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clinical articles • management advice • practice profiles • technology reviews


2 AO

March/April 2019 – Vol 10 No 2 •


PROMOTING EXCELLENCE IN ORTHODONTICS Using 3D CBCT imaging in orthodontics Dr. Jay B. Burton

Treating chronic pain and breathing disorders with technology Dr. Steven R. Olmos

Product debut LightForce Orthodontics

Practice profile Dr. Todd Bovenizer



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Adapt and adjust to the changing environment

March/April 2019 - Vol. 10 No. 2 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS


t is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able best to adapt and adjust to the changing environment in which it finds itself.” This quote is often misattributed to Charles Darwin, and while it may have been inspired by Darwin’s theories, it was actually written by Louisiana State University business professor Leon Megginson. Regardless of the author, it seems to appropriately describe the characteristics that one should possess in order to flourish in the technological revolution, which just about every industry is currently Dr. Cory Costanzo encountering. Taxi drivers are adapting to a world in which their services are hailed by a smartphone rather than an outstretched arm on the sidewalk. House cleaners are adapting to a world full of robotic vacuums. Orthodontists are adapting to a world in which patient treatment is designed on a computer and then delivered to the patient with the aid of 3D printing. Of course, we’ve all heard “the only constant in life is change.” That quote goes all the way back to the Greek philosopher Heraclitus 500 B.C. This is certainly not the first time orthodontists have had to change. Edward Angle revolutionized how we deliver orthodontic treatment when he invented the edgewise appliance in the 1920s. Imagine being an orthodontist at that time. Imagine spending the previous 20 years mastering Angle’s E Arch appliance, only to have edgewise thrust upon you. I’m assuming there were those who resisted the new appliance. Resist or not, it wasn’t long before orthodontists adapted and embraced the technological benefits of edgewise, and the E Arch was relegated to a museum in St. Louis. Now, thanks to intraoral scanners and sophisticated software, the edgewise appliance is jumping out of our hands and into the computer. Brackets are positioned digitally and delivered to the patient with a 3D-printed indirect bonding tray. Integration of CBCT with digital models allows us to visualize roots and simulate how they will move. Archwires are bent by computer-guided robots. Despite these improvements to the edgewise system, we may be approaching a time when the use of fixed appliances becomes scarce. It may not be long before clear removable appliances created from a digital plan are the norm. Whether we choose to be on the leading edge, or perhaps more wisely follow closely behind, adapting to new technology can help maximize our ability to provide optimal treatment to our patients. We must, however, remain cautious as some advancements, like Internetordered DIY orthodontics, may simply be an attempt to maximize profits with little regard for patient health. Just about every orthodontist I know shares a common core value in that he/ she is always striving to idealize both oral health and esthetics. We need to continue to let that value guide us as we evaluate the technology that we are presented with. I’m reminded of a situation from my residency in the early 2000s. Computer-designed clear aligner therapy was in its infancy, and the chairman of our orthodontic department, Dr. Bob Boyd, was leading the charge. After a lecture he gave on the subject, someone in the audience came up and told him, “You’re ruining what we do.” He calmly asked, “What is it that we do?” The agitated spectator replied, “We bend wires.” Dr. Boyd’s response, “Oh, I thought we gave people great smiles.” Cory Costanzo, DDS

Cory Costanzo, DDS, completed his Doctorate of Dental Surgery at the University of the Pacific School of Dentistry and continued there to receive his orthodontic certificate and Master of Science in dentistry. Dr. Costanzo is a Diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontists, and the American Dental Association as well as state and dental societies. Dr. Costanzo maintains a private practice in Fresno, California.

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

© FMC 2019. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

ISSN number 2372-8396

2 Orthodontic practice

Volume 10 Number 2

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2015, 2016, 2017, 2018 Townie Choice Award Winner Accelerated Treatment Technology © 2019 OrthoAccel Technologies, Inc. 1 Based on doctor testimonials on file. 2 Based on company-sponsored, randomized-controlled, blinded clinical trials. One study results showed the AcceleDent group was significantly faster than the sham control group in moving teeth in the ITT and PP groups by 50% (p=0.0496) and 38% (p=0.0234), respectively. Gakunga, P., Anthony, R. OA-02 Effect of Cyclic Loading (Vibration) on Orthodontic Tooth Movement. 2011. Unpublished study used for FDA clearance. Another study ITT analysis showed an average monthly rate of tooth movement in the AcceleDent group was 1.16 mm/month (95% CI: 0.86-1.46; 48.1 ± 7.1% faster) compared to 0.79 mm/month (95% CI: 0.49-1.09) in the control group, with a mean difference of 0.37 mm/month (95% CI: 0.07-0.81, P = 0.05), while the PP analysis showed significantly faster movement of the retracting cuspids when vibration was applied (P = 0.02). Typodonts with mounted mini screws and bonded brackets were used during this study for measuring error relating to tooth movement. Pavlin, D., Anthony, R., Raj, V., Gakunga, P.T. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Semin Orthod. 2015;21:187–194. 3 Accelerated tooth movement does not necessarily correlate to shorter duration of treatment. Individual results may vary. 4 Based on a randomized, controlled and parallel group clinical trial conducted during a four-month period. Because of possible unwanted treatment effects of bite wafers on pain reporting, the authors chose not to use a sham device that may have a bite wafer effect. Therefore, this study cannot dismiss the possibility that a placebo effect from AcceleDent may have influenced the results. Lobre, W.D., Callegari, B.J., Gardner, G., Marh, C.M., Bush, A.C., and Dunn, W.J. Pain Control in Orthodontics Using a Micropulse Vibration Device: A Randomized Clinical Trial. The Angle Orthodontist, 2015.


Case report Orthodontic treatment with SureSmile® Aligners

Practice profile Todd Bovenizer, DDS, MS


Dr. Antonino G. Secchi details a patient’s treatment using aligners, integrating data from intraoral scanning and CBCT imaging..........................21

Rx for orthodontic success

Case study 24-hour “headgear effect” using temporary skeletal anchorage devices Dr. Jack Fisher discusses a treatment alternative to headgear.................... 24

Product debut LightForce Orthodontics First truly digital system for braces — from scan to production..................30

Case study


Situational extraction therapy with clear aligner therapy in complex malocclusions Drs. George J. Cisneros, Anderson T. Huang, and Darren Huang discuss a case that resulted in a stable, functionally, and esthetically balanced occlusion

Focus on: gummy smile The gummy smile dilemma Dr. Stuart Frost illustrates an innovative treatment for an often untreated condition......................................... 34

ON THE COVER Cover photo courtesy of LightForce Orthodontics. Article begins on page 30.

4 Orthodontic practice

Volume 10 Number 2





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Visit us at AAO Booth #1301 *Study conducted in 2014. Grünheid, T.; Patel, N.; De FelippeN.; Wey, A; Gaillard, P.; Larson, B: Accuracy, reproducibility, and time efficiency of dental measurements using different technologies. Am. J. Orthod., 157-164 ©2019 Dentsply Sirona. All Rights Reserved. RTE-032-19 Rev. 01 Issued 01/19 Dentsply Sirona Orthodontics • 7290 26th Court East • Sarasota, FL 34243


Continuing education Treating chronic pain and breathing disorders with technology Dr. Steven R. Olmos explores hightech solutions to treatment problems ....................................................... 47

Continuing education Using 3D CBCT imaging in orthodontics


Dr. Jay B. Burton discusses the aspects of CBCT imaging that improve treatment planning and diagnostics

Orthodontic perspective

Product spotlight Beyond braces: CBCT expands orthodontists’ capabilities Dr. Robert “Tito” Norris discusses Carestream Dental’s 3D modules and systems .......................................... 54

Product profile Henry Schein® Orthodontics™ SLX 3D: the complete PSL treatment solution Now with all-new, innovative archwires and standardized sequencing protocols..........................................56

Technology — the past, the present, and your future

PUBLISHER | Lisa Moler Email:

Dr. Terry Sellke discusses methods to help orthodontists go beyond surviving and get back to thriving................... 58

EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: | Tel: (727) 515-5118

Product profiles

VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email:

Built to Last. Built for You. Built by Boyd.............................. 62

NATIONAL ACCOUNT MANAGER | Celeste Scarfi-Tellez Email:

The SunClear advantage......... 63


Planmeca Creo™ C5 HighSpeed 3D Printer.......................64

Step-by-step EverSmile®................................... 66

Industry news............... 68

ASSISTANT EDITOR | Elizabeth Romanek Email:


MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 |

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The VPro Series devices are marketed as an aligner sealers. The Propel device is indicated for use as a tool to create micro-osteoperforations. '(1) Alikhani, Mani et al. Effect of micro-osteoperforations on the rate of tooth movement. American Journal of Orthodontics and Oentofacial Orthopedics, Volume 144, Issue 5, 639-648 (2) Alansari 5, et al., The effetcs of brief daily vibration on clear aligner orthodonti treatment, J World Fed Ortho 2018. 101016/j.ejwf.201810.002 (3) Alikhani M, et al. Vibration paradox in orthodontics: Anabolic and catabolic effects. PloS ONE 2018. 13(5) e0196540


Todd Bovenizer, DDS, MS Rx for orthodontic success

Dr. Christopher Baker (left) and Dr. Todd Bovenizer (right)

What can you tell us about your background? I grew up in rural Virginia where much of my family worked in the healthcare/medicine industry. I come from a long lineage of pharmacists, starting with my grandfather and grandmother, and continuing to my father, sister, uncle, and cousin. The unique aspect here is that they worked in family-owned and operated pharmacies. I spent my adolescent years pricing all the merchandise, loading the pop machine, and sweeping the floors. It literally was a family business. I distinctly remember when Walmart opened in the 1980s, which was the start of the corporate pharmacy influx in my small hometown of Bluefield, Virginia. My family was obviously worried about “big business” taking over our smaller drugstore — it can 8 Orthodontic practice

be near impossible to try and compete. My father, however, is an extremely hard worker and didn’t let this intimidate him. He stayed the course, and the pharmacy is still doing well today. I credit my love for small business to his success and my family’s legacy in pharmaceuticals. Because of this, I knew that I wanted to own and start a business someday.

Why did you decide to focus on orthodontics? I have always had an interest in science and pursued a science degree at Virginia Tech. I went into my senior year of undergrad trying to decide which degree path I should take, and my mother suggested dental school. At first, I thought she was crazy! I fought it but decided to take the DAT, and the rest was history.

Todd Bovenizer, DDS, MS

In my hometown, there were very few specialists, no oral surgeons, no pedodontists or endodontists. I went into it thinking I was just going to get a dental degree and that would be the end of it. My passion for Volume 10 Number 2


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PRACTICE PROFILE orthodontics, however, surfaced in my third year of dental school. I loved the transformations that were occurring over time and the detail of work that was involved. I also loved the vibe that came from the residents — they were always happy, self-motivated, and enthusiastic. At that point, my spark was ignited, and I am still passionate about helping people achieve the smile they have always been after.

How long have you been practicing, and what systems do you use? I have been in private practice at Bovenizer & Baker Orthodontics in Cary, North Carolina, for 13 years. I started using the Damon™ System in 2009, and since then, have used the system exclusively as a fixed appliance. I’ve enjoyed seeing its evolution over the past several years. The Damon System’s low-friction, passive self-ligating brackets, and minimally invasive treatment options have been valuable to the success of my practice — and patient satisfaction. We also use various clear aligner options for those not interested in fixed appliances.

What training have you undertaken? I went to West Virginia University for a 3-year orthodontic program and had the opportunity to learn from so many incredible full-time and part-time faculty and staff. I was also exposed to a variety of techniques including the McLaughlin, Bennett, and Trevisi system and the Andrews system. In terms of my professional career, I became board certified in 2006 and re-certified in 2011. And finally, on top of all that, I have trained extensively in diode laser technology,

temporary anchorage devices, and as I mentioned earlier, the Damon System.

be where I am today without the support of my wife, Megan.

Who has inspired you?

What is the most satisfying aspect of your practice?

My faith in Jesus Christ has been instrumental in shaping how I live my day-to-day life. I have quickly realized that I need to seek His will and not my own. Life can be challenging, and this relationship has been key. I have been through differing layers of success, and this does not bring happiness; in the end, my faith and family will be what counts. Additionally, my father has made many sacrifices throughout my life and remains one of my best friends. To see his heart and kindness at 72 years of age is inspiring to me. He has set a great standard for me to measure my own life. My wife and three daughters are also very instrumental. I do not think I would

The most satisfying aspect of my practice is being able to be authentic and real with our family of patients. Sharing my heart with this practice and building a relationship with them really makes me tick. Sometimes I have to pinch myself because it feels surreal.

Professionally, what are you most proud of? This is a difficult question to answer. Certainly, I am proud of a lot of things; however, I believe an overinflated sense of pride can taint an individual or organization. I really think it is the authenticity that I place into my practice. I am always seeking to improve myself from a professional and a personal standpoint. Although I am confident, I try to possess a quality of humility in everything I do.

What do you think is unique about your practice? My team is the most unique part of my practice. We have 21 team members who give it their all every single day. We are blessed with a great, hardworking, and supportive team. We also have one location and two doctors. Both Dr. Christopher Baker and I pour our lives into the office each day.

What has been your biggest challenge? Dr. Todd Bovenizer with his family 10 Orthodontic practice

My biggest challenge has been myself. Although I am always eager to learn and change, I find that the limiting factor is Volume 10 Number 2

Your expertise. Our technology. A powerful combination. It takes insight and skilled hands to turn technology into a powerful tool. When you use the Invisalign® system and an iTero® scanner to create amazing smiles, that’s exactly what you do. With more than 6 million* cases and counting, the mission is clear: Let’s do amazing things together.

Brett Gluck, DMD, MS Alpharetta, GA

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Visit us at Booth #2001 during the 2019 AAO Annual Session.

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PRACTICE PROFILE always myself. I am the one who becomes stubborn and complacent at times. Or often I need to look in the mirror and recognize that there are limitations but to never rest on getting better and striving for excellence. 

What would you have become if you had not become a dentist? I really believe with all my heart that God placed me in the field of orthodontics. I am exactly where I need to be. If I had to pick one, I would have been a landscape architect on a farm. I love plants and trees. It is a lot like orthodontics, with very meticulous cultivation of soil and watching the product grow.  

What is the future of orthodontics and dentistry? I think our profession is very cyclical. Now, with that said, things are changing, and practices must adapt. We now have a digital platform on which to practice — we scan and print 3D models. Practices are using more clear aligner therapy options as well. I believe that there will always be room for orthodontic practices that are striving to provide high-end and quality treatment for their patients.

What are your top tips for maintaining a successful practice?

Top 10 favorites

The number one piece of advice for maintaining a successful practice is honesty. Honesty with patients, staff, and everyone in between can help build up your reputation. Remembering that each person on your team is valuable and treating him/her with respect is important in creating a prosperous work environment. In terms of orthodontic treatment, I recommend practices using Phase I sparingly. This is because in many cases, dental correction achieved in Phase I may have to be corrected again in Phase II. To prevent this, I advise allowing all teeth to erupt into the oral cavity prior to beginning orthodontic care.

peers, which is the key to leadership development and reputation establishment.

What advice would you give to budding orthodontists?

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

In addition to the previously mentioned advice, I recommend budding orthodontists maintain a sense of humility as they train for a professional career in orthodontics. Learning to become humble, in addition to honesty, helps build trust among both colleagues and

1. 2. 3. 4. 5. 6. 7. 8.

My faith and family The Damon™ Q2 bracket Dave Matthews Chipotle The water iTero® Ted Baker™ clothing My Big Green Egg® charcoal grill and pork 9. Spectralase diode laser 10. Traveling

I enjoy spending time outside, whether that’s traveling with my family or working in the yard. I also enjoy playing tennis and staying active. During my downtime, I love to read and study up on the latest in orthodontia. OP

Orthodontic Practice US 3 REASONS TO SUBSCRIBE • 24 CE credits available per year • 1 subscription, 2 formats – print and digital • 6 high-quality, clinically focused issues per year

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Situational extraction therapy with clear aligner therapy in complex malocclusions Drs. George J. Cisneros, Anderson T. Huang, and Darren Huang discuss a case that resulted in a stable, functionally, and esthetically balanced occlusion Abstract Complex malocclusions requiring atypical extractions have conventionally been treated with fixed appliances. However, there has been an increasing concern regarding the viability of clear aligner therapy for the treatment of extraction cases. This case report illustrates the treatment with clear aligner therapy of a patient where atypical extractions are required. The patient was a 12-year-old boy with a Class I malocclusion, an ectopically erupted maxillary left canine, dental midline deviation, and proclined maxillary incisors. Our treatment plan involved the exclusive use of clear aligner therapy. We planned for the extraction of the maxillary right first premolar in order to correct the maxillary midline and facilitate the eruption of the maxillary left canine. After 17 months for the initial course of aligners, we prepared adequate space for the maxillary left canine, erupted the maxillary left canine further into the arch, and improved midline coordination. Following a total of 26 months of treatment, in which we performed a single refinement course, we achieved ideal overjet and overbite, proper interdigitation of the maxillary left canine, coordination of maxillary and facial

midlines, and Class I canine and molar occlusion bilaterally. Radiographs showed root parallelism between the teeth adjacent to the extraction site. The case report describes the biomechanics behind ClinCheck® (Invisalign®) development for extraction cases treated with clear aligner therapy. We demonstrate that our approach toward extraction therapy produced a stable, functionally, and esthetically balanced occlusion for the patient.

Introduction Since the introduction of the Invisalign appliance to orthodontics, there has been an increasing interest regarding its use for the successful treatment of complex malocclusions. Early studies described the limitations of Invisalign, including deficiencies in the correction of large anteroposterior discrepancies and occlusal contacts, and unreliability in achieving certain movements, such as bodily translation during space closure, root torque, extrusion, and rotations of premolars and canines.1,2 Nevertheless, recent protocols and innovations in the appliance have allowed for improved adaptability to a wider range of malocclusions. There have been reports of

George J. Cisneros, DMD, received his dental degree from the University of Pennsylvania School of Dental Medicine and earned specialty certification in both Pediatric Dentistry and Orthodontics, as well as, a Master of Medical Science degree (MMSC) in Oral Biology at Boston’s Children’s Hospital Medical Center, the Forsyth Dental Center, and the Harvard School of Dental Medicine, respectively. Dr. Cisneros developed and established postgraduate training programs in Orthodontics at Albert Einstein College of Medicine/Montefiore Medical Center and Saint Barnabas Hospital in New York, and served as Chair of Orthodontics at New York University College of Dentistry. He is a Diplomate of the American Board of Pediatric Dentistry and the American Board of Orthodontics and has served as an ABO board examiner and on the ABPD Advisory Committee. He also was elected to and served on the American Academy of Pediatric Dentistry Board of Trustees.

successful treatment with Invisalign in single mandibular incisor extraction cases,3,4,5 symmetrical two or four premolar extraction cases,6,7,8 and cases involving orthognathic surgery complemented with clear aligner therapy.9 A recent randomized clinical trial has shown similar objective grading system scores between Invisalign and fixed appliances in the treatment of Class I adult extraction cases.10 Despite such advances, there remains a great degree of uncertainty regarding the effectiveness of the Invisalign appliance in complex malocclusions, particularly those requiring extractions.11,12,13 Certain extraction patterns, such as unilateral patterns for dental or skeletal asymmetries, require particularly judicious space management and have not been illustrated in previous studies.14 In light of the lack of evidence on Invisalign-treated complex malocclusions in the current literature, we present the following case report to demonstrate the effective management with Invisalign therapy of a case where atypical extractions are indicated.

Diagnosis and treatment plan A 12-year-old male presented with Class I malocclusion, Class I molars bilaterally, Class I canine relationship on the right, an unclassifiable canine relationship on the left, shallow overbite, and less than normal overjet (Figure 1). The maxillary arch presented with 6 mm of

Anderson T. Huang, BDS, DDS.ABO, FACD, FICD, is a faculty member, Department of Orthodontics, New York University College of Dentistry, New York City, and Department of Orthodontics, Taipei Medical University, Taipei, Taiwan. Dr. Huang is a Diplomate of American Board of Orthodontics (ABO). He is an Invisalign top 1% Platinum Plus provider and treating a wide range of orthodontic cases with clear aligner therapy, including Invisalign®, 3M™ Clarity™ aligners and SureSmile® aligners. He has orthodontic practices in Flushing, Great Neck, and Manhattan, New York. Dr. Anderson Huang was recently appointed as a board examiner of American Board of Orthodontics (ABO). Darren Huang, BS, DDS, is a postgraduate orthodontic resident, New York University College of Dentistry. He will join Dr. Anderson T. Huang’s practices in the summer of 2019. He has co-authored numerous articles with Dr. Anderson Huang during his tenure in the DDS program and postgraduate orthodontic residency. Disclosure: The authors, their opinions, and their research have not been endorsed by the companies mentioned in the article or any other organization that provides clear aligner therapy.

Figure 1: Pretreatment intraoral photographs 14 Orthodontic practice

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CASE STUDY crowding, while the mandibular arch showed 5 mm of crowding. The maxillary left canine had ectopically erupted, leading to a maxillary midline deviation to the left of about 3 mm. Initial cephalometric analysis showed a Class I skeletal pattern, hyperdivergence, flared maxillary incisors, mandibular incisor inclination within normal range, and less than normal overjet and overbite as shown in Figure 2. The initial panoramic radiograph showed the ectopic eruption of the maxillary left canine and erupting third molars in all four quadrants (Figure 3).

We treatment planned for the extraction of the maxillary right first premolar to facilitate maxillary midline correction and the eruption of the maxillary left canine. We also planned for interproximal reduction in the mandibular arch to allow for decrowding and midline coordination.

Figure 2: Pretreatment cephalometric radiograph

Figure 3: Pretreatment panoramic radiograph

Treatment Objectives Our central treatment objective was to create space for the eruption of the maxillary left canine. Other treatment objectives included coordinating maxillary and mandibular midlines, creating ideal overjet and overbite, correcting maxillary and mandibular crowding, establishing Class I canines, improving maxillary incisor inclination, and creating balanced facial esthetics.

ClinCheck design Our ClinCheck plan involved an initial course of 35 aligners and a refinement course of 16 additional aligners for a total treatment time of 26 months (Figure 4). We planned for the extraction of the maxillary right first premolar to facilitate the movement of the maxillary midline to the right. We incorporated a gable bend in the extraction space between the maxillary right second premolar and maxillary right canine to optimize root parallelism during space closure. About 1 mm of distalization was planned in the maxillary left segment to create additional space for the maxillary left canine. We requested that the aligners not cover the maxillary left canine, so we could employ auxiliaries to extrude the tooth into the arch during the initial course. In the mandibular arch, we planned for a total of 3 mm of interproximal reduction from the distal of the mandibular right second premolar to the distal of the mandibular left canine. We incorporated a button cutout on the mandibular left first premolar for the future placement of an auxiliary to assist in the extrusion of the maxillary left canine. Class II precision cuts were applied to counteract side effects from distalization on the left side and facilitate maxillary right canine retraction.

Figure 5: Photograph of auxiliary employed to extrude the maxillary left canine. A button has been bonded to the mandibular left first premolar. The patient is instructed to run vertical elastics from the maxillary left canine attachment to the mandibular left first premolar attachment 24 hours per day Figure 4: ClinCheck plan showing first course of aligners. Final tooth positions have been superimposed on initial tooth positions

Figure 6: ClinCheck plan showing refinement course of aligners. Final tooth positions have been superimposed on initial tooth positions 16 Orthodontic practice

Figure 7: Posttreatment intraoral photographs (following 26 months of treatment) Volume 10 Number 2


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Figure 9: Posttreatment panoramic radiograph

Figure 10: Intraoral photos following 1-year posttreatment

Figure 11A: Photograph showing inadequate application of a virtual gable bend during extraction space closure between the maxillary right canine and maxillary right second premolar

Figure 11B: Photograph showing successful extraction space closure between the maxillary right canine and maxillary right second premolar

Figure 8: Posttreatment cephalometric radiograph

During the course of treatment, we bonded metal buttons on the maxillary left canine when there was sufficient crown area and on the mandibular left first premolar, and we instructed the patient to wear vertical elastics full-time to facilitate extrusion of the maxillary left canine (Figure 5).

Treatment progress and refinement Following the initial course of aligners, the maxillary and mandibular midlines were markedly improved. The space for the maxillary left canine was adequately prepared. However, the maxillary left canine erupted rotated distolabially and required further extrusion for ideal placement into the arch. In the refinement course, we completed the extrusion of the maxillary left canine and perfected the interdigitation of teeth in the posterior segments (Figure 6). Interproximal reduction was performed mesial and distal to the maxillary left canine and mandibular left first premolar to achieve extrusion of both teeth and ideal interdigitation.

Treatment results We achieved a final occlusion with Class II molar on the right, Class I molar on the left, and Class I canine relationships bilaterally (Figure 7). The profile was balanced with harmonious soft tissue contours. Both overjet and overbite were ideal. The maxillary left canine was extruded to an esthetically and functionally balanced position and occluded with the mandibular left first premolar. Maxillary and mandibular alignments were close to ideal. The maxillary midline was coincident with the face, while the mandibular midline was 1 mm deviated to the left. Final cephalometric analysis showed that maxillary incisor inclination was normalized, and mandibular incisor inclination was maintained (Figure 8). 18 Orthodontic practice

The panoramic radiograph showed optimal root parallelism between the teeth adjacent to the extraction site (Figure 9). The retention protocol required the patient to wear maxillary and mandibular Essix retainers 14 hours per day for the first year. At 1 year after debonding, the occlusion showed stability (Figure 10). Maxillary and mandibular alignment were maintained, overbite and overjet were stable, and maxillary and mandibular arch forms were preserved.

Discussion In the previous case, we achieved our treatment objectives and finished in functionally balanced occlusion. Careful planning during the ClinCheck development stage was critical for the effective closure of all extraction spaces. We observed that in the case above, we did not receive the G6 maximal anchorage protocol for extraction space closure due to anchorage loss of greater than 2 mm. We note that the ClinCheck plans for extraction cases are frequently disqualified from the G6 maximal anchorage protocol and require the clinician to further design extraction space closure to optimize clinical results. We also recommend the use of a half-sized pontic for the extracted tooth so that the adjacent teeth can receive maximal coverage with the aligner material. In our previous study regarding patients with restorative and prosthodontic needs, we have demonstrated that the design of attachments on the adjacent teeth of extraction spaces is especially important.15 Extraction space closure often requires careful manipulation of tooth

Figure 12: Panoramic radiograph. Note the root parallelism achieved between the maxillary right canine and maxillary right second premolar following extraction space closure

movement because the Invisalign appliance has been shown to be less effective at root tipping and at moving roots bodily through bone.10 When the G6 maximal anchorage protocol was not triggered, we employed either conventional vertical beveled attachments or default optimized attachments on the teeth adjacent to the extraction spaces. In the previous case, we have shown that the addition of a virtual gable bend (VGB) is essential for ideal root parallelism during extraction space closure with clear aligner therapy. In the left figure, the maxillary right canine, maxillary right second premolar, and maxillary right first molar have been reciprocally moved into the maxillary right first premolar extraction space without adequate VGB application (Figure 11A). We can observe the unfavorable tipping of the maxillary right second premolar and maxillary right first molar. In Figure 11B, the VGB has been applied in the extraction space between the maxillary right canine and maxillary right second premolar during space closure. Ideal root Volume 10 Number 2

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CASE STUDY parallelism was achieved, as also demonstrated on the panoramic X-ray (Figure 12). During ClinCheck development, the VGB allows for the movement of teeth adjacent to extraction spaces in a more practical manner. In particular, the VGB tips then uprights the roots of the adjacent teeth rather than moving them in a random fashion. The addition of the VGB will typically increase the total number of aligners during treatment. We expect an increase of 10-15 aligners in a clear aligner extraction case when the VGB has been incorporated. Nevertheless, we believe its addition significantly improves outcomes in clear aligner extraction therapy. In their randomized clinical trial, Li, et al., demonstrated that clear aligner therapy could achieve root angulation as successful as fixed appliances in extraction cases.10 The authors postulated that optimal attachment placement contributed to improved root control during treatment. Midline correction can be sensitive to the development of particular side effects, such as undesired root tipping. In the case previously mentioned, optimized root control attachments were added on the maxillary central incisors to provide for ideal movement of the two roots during midline correction. The previous case shows an instance where an auxiliary was necessary to supplement a difficult movement for the Invisalign appliance. Historically, extrusion has been demanding, and interarch elastics have been often used as a supplement to achieve ideal occlusal contacts.16 In the presented case, we incorporated a gradually enlarging pontic to simulate the eruption of the maxillary left

canine into the arch. The timing for the addition of the auxiliary can be decided on the basis of tracking for the tooth in question. We have observed that significant extrusion — i.e., 3 mm or greater — often requires an additional refinement course to perfect interdigitation. Total treatment time for the case above was comparable to that which would be necessary had the case been treated with conventional fixed appliances. This result is coincident with the finding of Gu, et al., that on average, Invisalign patients finished 5.7 months faster when compared to matched patients in fixed appliances.17 In refinement courses, we routinely shorten the wear time for each aligner from 2 weeks to 1 week because typically less tooth movement is performed within each aligner.

Conclusion • In this case report, we have shown that with a combination of meticulous diagnosis and treatment planning along with judicious ClinCheck development, complex extraction cases can be treated to a level of excellence. • Although G6 technological developments have targeted moderate and maximal extraction cases, atypical extraction cases, such as the case previously mentioned, require innovative measures for the optimization of treatment results. • We recommend that more randomized clinical trials be performed to gather evidence regarding the viability of clear aligner therapy for extraction cases. OP

REFERENCES 1. Boyd RL. Esthetic orthodontic treatment using the Invisalign appliance for moderate to complex malocclusions. J Dent Educ. 2008;72(8):948-967. 2. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel, C. Treatment outcome and efficacy of an aligner technique — regarding incisor torque, premolar derotation, and molar distalization. BMC Oral Health. 2014;14:68. 3. Zawawi, KH. Orthodontic Treatment of a mandibular incisor extraction case with Invisalign. Case Rep Dent. 2014;2014:657. 4. Giancotti, A, Garino, F, Mampieri G. Lower incisor extraction treatment with the Invisalign® technique: three case reports. J Orthod. 2015;42(1):33-44. 5. Needham R, Waring DT, Malik, OH. Invisalign treatment of Class III malocclusion with lower-incisor extraction. J Clin Orthod. 2015;49(7):429-441. 6. Womack, WR. Four-premolar extraction treatment with Invisalign. J Clin Orthod. 2006;40(8):493-500. 7. Honn M, Göz, G. A premolar extraction case using the Invisalign system. J Orofac Orthop. 2006;67(5):385-394. 8. Giancotti A, Greco M, Mampieri, G. Extraction treatment using Invisalign Technique. Prog Orthod. 2006;7(1):32-43. 9. Boyd RL. Surgical-orthodontic treatment of two skeletal Class III patients with Invisalign and fixed appliances. J Clin Orthod. 2005;39(4):245-258. 10. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign appliance in extraction cases using the ABO model grading system: a multicenter randomized controlled trial. Int J Clin Exp Med. 2015;8(5):8276-8282. 11. Phan X, Ling PH. Clinical limitations of Invisalign. J Can Dent Assoc. 2007;73(3):263-266. 12. Lagravere MO, Flores-Mir C. The treatment effects of Invisalign orthodontic aligners: a systematic review. J Am Dent Assoc. 2005;136(2):1724-1729. 13. Ko HC, Liu W, Hou D, et al. Recommendations for clear aligner therapy using digital or plaster study casts. Prog Orthod. 2018;19(1):22. 14. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J. Orthod. Dentofacial Orthop. 2005;28(3):292-298. 15. Huang AT, Huang D. Space management with Invisalign for interdisciplinary orthodontic treatment. J Clin Orthod. 2018;52(4):219-226. 16. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85(5):881-889. 17. Gu J, Tang JS, Skulski B, et al. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. Am J. Orthod. Dentofacial Orthop. 2017;151(2):259-266.

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20 Orthodontic practice

Volume 10 Number 2

Dr. Antonino G. Secchi details a patient’s treatment using aligners, integrating data from intraoral scanning and CBCT imaging


atient Amy N., a 45-year-old female, consulted for orthodontic treatment with the chief complaint of “my back teeth are leaning inward; I have spaces when I smile.” The patient had braces several years ago. At the time of the consultation, she had a lower fixed lingual bar and no upper retainer. The patient had no discomfort, pain, or any functional problems with the way her teeth were occluding. She was looking for a cosmetic solution to improve her smile. After further clinical examination and discussion with patient, we agreed to start orthodontic treatment using SureSmile® Aligners. Records were taken, including initial photos, a scan of the upper and lower arch with bite registration, and a set of digital X-rays (panoramic and lateral ceph). After uploading all the required information to SureSmile Ortho, a Therapeutic Model was developed. In the Therapeutic Model, upper and lower canines, premolars, and molars were tipped buccolingually in order to upright them between 1.5 mm to 2 mm per side. Minor crowding was resolved, and the upper and lower arch were coordinated. Once the Therapeutic Model was finished and approved, stages for the upper and lower arch were developed based on the amount and type of movement required. Thirteen upper and 15 lower clear aligners were made. SureSmile clear aligners were delivered to the patient with the instruction of wearing them for about 20 hours every day

Figures 1A-1C: Initial extraoral photos. On Figure 1C, notice the “narrow” smile and “black corridors,” which were the main chief complaints of the patient

Figures 2A-2C: Initial intraoral photos. On Figure 1B, notice the lingual tipping of all posterior teeth from canines to molars on both arches

Figures 3A-3B: Initial intraoral occlusal views showing also the lingual tipping of most of the posterior teeth. The lower arch has a lingual fixed retainer from previous orthodontic treatment

Antonino G. Secchi, DMD, MS, is an alumnus of the University of Pennsylvania School of Dental Medicine, where he received his Doctorate of Dental Medicine, Certificate in orthodontics, and a Master of Science in oral biology. Dr. Secchi is a Diplomate of the American Board of Orthodontics and member of the prestigious Edward H. Angle Society of Orthodontists. He also holds membership in various local, national, and international dental and orthodontic societies and was the 2016 President of the Greater Philadelphia Society of Orthodontists. Dr. Secchi is the founder of the Complete Clinical Orthodontics System™ (CCO System), which he teaches to orthodontists in the United States and worldwide. He is currently in practice in Pennsylvania. Disclosure: Dr. Secchi is a lecturer for the Dentsply Sirona Complete Clinical Orthodontics courses.

Volume 10 Number 2

Figures 4A-4C: Progress intraoral photos showing both upper and lower clear aligners in place Orthodontic practice 21


Orthodontic treatment with SureSmile® Aligners


Figures 5A-5C: Final intraoral photos

Figures 6A-6B: Final intraoral occlusal views. Notice the improved arch form, uprighting of posterior teeth, as well as the alignment of upper and lower incisors

Today SureSmile Ortho 7.5 allows the integration of intraoral scan data and CBCT data, which makes the software incredibly powerful for treatment planning of more complex cases.

with weekly aligner changes. The patient used the VPro5™ intraoral high frequency vibrator (PropelŽ Orthodontics) every day for 5 minutes to help seat the aligners. Figures 7A-B and 8A-B show the before and after occlusal views of the upper and lower arch with measurements for intercanine, inter-premolar, and inter-molar distances. It is important to emphasize that no skeletal transverse correction was aimed for or achieved. Before and after changes represent only tooth movement in a buccolingual direction planned to be within the boundaries of the existing alveolar bone. At the time of treatment planning this case in the version of the SureSmile software I used, the integration of the scanned images with the CBCT data of the patient was not possible. Today SureSmile Ortho 7.5 allows the integration of intraoral scan data and CBCT data, which makes the software incredibly powerful for treatment planning of more complex cases. The treatment progress was uneventful, the patient had no complaints, aligners fit very well, and she was particularly pleased with the clearness of the aligners and the almost invisible look they had. Treatment time was 15 weeks. OP

Figures 7A-7B: Upper arch before and after treatment dental transverse measurement

Figures 8A-8B: Lower arch before and after treatment dental transverse measurement 22 Orthodontic practice

Figure 9: Final smiling photo. Needless to say, patient is delighted by her new smile! Volume 10 Number 2

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24-hour “headgear effect” using temporary skeletal anchorage devices Dr. Jack Fisher discusses a treatment alternative to headgear Introduction For many years, orthodontists have used cervical-pull headgear to treat Class II patients. However effective headgear can be, most patients hate the idea of wearing this appliance. This has led to an increase in the use of functional appliances as well as Class II corrector, all of which inevitably procline mandibular anterior teeth. After looking at many CBCTs, with particular interest in the alveolar boundaries of mandibular incisors, it is noted that often there is little-to-no bone into which to procline mandibular anterior teeth, which is one reason that gingival grafting is so common in adults who have had treatment when they were younger (Figure 1). The perio/ortho relationship is now at the forefront of most orthodontic practices looking at CBCT as well as the potential need for augmentation of the mandibular

anterior region, which is being discussed more frequently. In a Class II situation where clinicians want to maintain or improve the mandibular incisor angulation, they must depend upon growth as well as a distalization effect of the maxillary arch.

Case study This case will look at a situation where a “24-hour headgear” was used. This treatment modality employs the use of skeletal anchorage devices to distalize the maxillary arch and to allow for mandibular growth to occur. In this case, a 12-year 8-month-old male presented with the chief complaint of “I have crooked teeth and an overbite” (Figure 2). His medical history was insignificant, and he had no previous orthodontic treatment. He presented with a mild Class II brachycephalic

skeletal profile (ANB 4°) with mild maxillary prognathia (SNA 86°). Dentally, he presented with a Class I Division 1 incisor relationship. Midlines are coincident, and the mandibular left first molar was in buccal crossbite. He has 5 mm of overjet and 5 mm of overbite. The patient had mild crowding in the maxillary anterior and no crowding in the mandibular anterior. The curve of Spee is 2 mm, and the mandibular incisors were proclined (IMPA 106). He had a concave facial profile and an obtuse nasolabial angle. A TMJ exam revealed no joint sounds, and joints were asymptomatic. The patient had balanced maxillary and mandibular facial heights, and his lips were competent. He showed 100% of incisors upon smiling with 1 mm of gingival display and a concave facial profile with an obtuse nasal labial angle of 103°.

Figure 1

Jack Fisher, DMD, completed his orthodontic training at the Medical College of Georgia in 1982. Since then he has been in the fulltime practice of orthodontics in Kentucky and Tennessee. He has lectured both in the United States and internationally. Dr. Fisher is a member of the Southern Association of Orthodontics and the American Association of Orthodontics. He is presently a faculty member in the orthodontic department at The University of Tennessee. Dr. Fisher has taught a 2-day cadaver course for the insertion and use of temporary skeletal anchorage devices for 8 years. He has written several articles on the use of these devices. He recently has developed and taught a course on the use of CBCTs for the diagnosis and treatment of orthodontic patients. Disclosure: Dr. Fisher is a key opinion leader for Planmeca.

Figure 2 24 Orthodontic practice

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CASE STUDY Radiographic analysis Once the patient exam had been completed, it was determined that a CBCT should be taken to evaluate bone dimensions for diagnostic purposes and to identify the best location for TSAD placement. CBCT analysis revealed limited alveolar boundaries on the buccal and lingual of the mandibular anterior teeth. The buccal and lingual cortical plates of the alveolar processes were generally thin, particularly around canines and mandibular anterior teeth (Figure 4). Thicker cortical regions were present palatal to maxillary incisors. Currently, the author is using the Planmeca ProMaxŽ 3D Mid, which allows for an Ultra Low Dose™ CBCT Full Field Of View (FFOV) to be taken with less radiation (~15 microsieverts) than traditional 2D pan/ ceph radiography. A lateral cephalometric radiograph was reconstructed. Cephalometric analysis revealed a hypodivergent mild Class II skeletal pattern with well-balanced maxillary and mandibular facial heights, increased concavity, and moderately proclined man-

dibular incisors with maxillary incisors in a relatively normal position (Figure 3). The panoramic radiograph was reconstructed from a CBCT. Panoramic analysis revealed no pathology, and third molars were developing normally. Model analysis revealed a Class II molar relationship on the left and right with moderate overbite and overjet. The maxillary midline is coincident with facial midline, and the mandibular midline is coincident with the maxillary midline. The curve of Spee is moderate. Transversely, the mandibular left first molars and buccal crossbite.

Treatment objectives The treatment objectives established were to maintain the transverse and vertical dimensions as well as A-point other than where normal growth would be concerned, as well as to reduce increased over jet and overbite while alleviating the crowding present. The treatment aimed to correct the Class II molar relationship to a Class I molar relationship and maintain coincident

midlines. Treatment planned for improved facial profile and to allow for growth of the mandible to occur.Â

Treatment alternatives Three treatment options were presented to the patient: 1. Traditional headgear to restrain maxillary growth and to allow for mandibular growth to occur. 2. Extract maxillary first premolars and close space. 3. Place temporary skeletal anchorage devices to distalize/restrain the maxillary arch while allowing for mandibular growth.

Treatment plan/progression The above treatment options were presented to the patient, and risks and benefits of each option were discussed. The patient opted for non-extraction treatment with placement of temporary skeletal anchorage devices to hold the maxillary arch during the peak adolescent growth phase

Figure 4

Figure 5A: Initial records Figure 3

Figure 6 26 Orthodontic practice

Figure 5B: Final records Volume 10 Number 2

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Figure 7

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allowing for a “headgear effect” to occur. The bracket prescription used was MBT. Maxillary archwires were progressed to a 20 stainless steel with cinch backs. It was at this time that the skeletal anchorage devices would placed and 200g springs used with sliding yokes bilaterally (Figure 6). This was left in place for 5 months until the Class II molar relationship was corrected. At this point, the mandibular arch was bracketed, and wires were progressed. Before moving to stainless steel in the mandibular arch, an Ultra Low Dose dental-only (LFOV) scan was taken to evaluate the roots and bracket placement after level and aligning had occurred prior to moving to stainless steel posted archwire 28 Orthodontic practice

with tie backs. The case was finished with a 16 x 16 heat active NiTi wires with common ties from canine to canine, 20 segmental stainless. The case was finished with vertical elastics in the pyramid configuration, and the case was finished as planned. The total treatment time was around 17 months. (Figure 7) Cephalometric superimposition revealed that the maxillary molar position was relatively maintained with slight distalization, while the maxillary incisors were retracted bodily, slightly. In the mandibular arch, molar position was maintained, and the mandibular incisors were retroclined from 106° to 92° IMPA due to the coupling effect of the maxillary and mandibular incisors as a result of mandibular growth. Growth was a major factor in this case; both the vertical and sagittal dimensions revealed normal growth (Figures 8-10). The case was evaluated for four first bicuspid extractions as well as headgear

and/or the removal of only first bicuspids. The non-extraction treatment using skeletal anchorage to the maxillary arch was successful. This technique would not have been as successful in a dolichofacial skeletal pattern. The mandibular incisors retroclined unexpectedly. This occurred due to the strong muscle pattern and the horizontal growth pattern, which was very good. Analysis of final records reveal that the posterior crossbite was eliminated. Class I occlusion was achieved, and mandibular incisor position was improved. Overjet and overbite were both reduced. Upon review of final records, the clinician can see the patient’s chief complaint has been resolved, and posterior crossbite has been alleviated. Critically speaking, I would say one of the major factors for success in this case was mandibular growth. OP Volume 10 Number 2

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he success of orthodontic treatment depends on a final attention to detail and esthetics, precise tooth movement, and a dedication to finding the best materials, equipment, and software for treatment. At the heart of orthodontic diagnostics and treatment is the knowledge that each patient is an individual with specific anatomy and needs. When individualizing treatment, LightForce 3D-printing technology enables the clinician to tailor braces to the patient’s unique dental anatomy and treatment plan. LightForce offers a fully digital, 100% customized bracket system from scan to production. The brackets and indirect bonding jigs are 3D printed as direct outputs of your treatment plan ensuring that the precision of digital case setup and patient-specific bracket design is fully realized in the actual devices. Recent studies have demonstrated brackets customized to a patient’s anatomy increase treatment efficiency reducing treatment time by an average of 37%.1

Bracket Customized to individual patient’s teeth LightForce introduces a truly individualized approach to orthodontic treatment, providing 100% customized braces based on the patient’s anatomy and tooth morphology. Unlike today’s conventional braces that have generic predetermined prescriptions and are manufactured with a fixed-base shape, LightForce is as unique as each individual patient. Offering patient specific solutions incorporating digital treatment planning and custom braces differentiates your practice from those that use a standard approach for every patient. Slot precision and accuracy In an article entitled “An evaluation of slot size in orthodontic brackets — are standards as expected?” Drs. Cash, Good, Curtis, and McDonald noted the measurement of the slots of five upper left central incisor brackets from 11 commercially available bracket systems: “Results indicate that all bracket slots are oversized … [compared to] their stated dimensions.” The authors also reported, “Inaccurate machining of bracket slot dimensions and the use of undersized archwires may directly and adversely affect three-dimensional tooth positioning.”2 30 Orthodontic practice

Slot precision is critical to efficiently delivering the desired prescription. Using stateof-the-art 3D printing technology, LightForce is able to manufacture brackets with slot dimensions that are precise and accurate time after time. Anatomical fit as a result of next-generation, highly accurate 3DP Better-fitting braces have long been recognized as improving bonding characteristics and treatment efficiency. Until LightForce, compound contouring was the industry’s attempt to better match bracket bases to tooth morphology. Now using stateof-the-art 3D printing technology and digital treatment planning capabilities, LightForce is able to create bases that are fully customized, mirroring each individual tooth and resulting in an even more anatomical fit. Consistent cement layer for more predictable bond strength With standard brackets, the cement layer thickness varies to compensate for mismatches between the bracket base and the patient’s tooth anatomy. Thick or uneven cement distribution at the brackettooth interface can negatively impact bond integrity as well as proper expression of the bracket prescription.

In an in vitro study, Drs. Jain, Shetty, Mogra, Shetty, and Dhakar said, “The thickness of the adhesive layer under a bracket may be an important factor that affects the final tooth position and bond strength. With increasing use of preadjusted brackets, it is important to ensure that a consistently even layer of composite is placed under each bracket to take full advantage of bracket design and to avoid the need for compensatory bends to be placed in the archwire.”3 Because LightForce brackets are customdesigned to match each tooth’s particular morphology, brackets can be bonded with a uniformly consistent cement layer. Proprietary mechanical base designed for greater retention and more predictable debonding The LightForce 100% Mechanical Base was designed for reliable bonding, and debonding. The proprietary under-loc™ retention mechanism provides deep undercuts for a reliable and predictable bonding experience. Volume 10 Number 2

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Low profile for patient comfort with highly contoured edges and smooth tie-wings Patient comfort with brackets — while tooth-movement technology has helped clinicians to reach orthodontic goals, patients will also measure their orthodontic experience by the amount of comfort or discomfort that they experience throughout the process. This is integral to non-relative patient referrals, multi-sibling referrals, and the wordof-mouth reputation of the office. In their marketing strategies, orthodontists who are vying to attract patients in this competitive marketplace can shine a bright spotlight on the comfort aspect of patient treatment when using these unique brackets. LightForce Brackets are designed with patient comfort in mind. Our polycrystalline material and custom base provide the necessary strength in a low-profile bracket designed to minimize contact with soft tissues. Additional comfort features include smooth contoured edges and tie wings.

Software Simple interface Orthodontists want to maximize time spent with patients, not time in front of a computer screen. LightForce’s simple and intuitive online interface is designed for fast and efficient treatment planning.

32 Orthodontic practice

Cloud-based review and approval Simple easy to use treatment planning software allows for review and approval from virtually anywhere. Flexible bracket positioning while maintaining optimal treatment goals The fully digital design and manufacturing provides the ability to vary bracket positioning as needed based on each patient’s unique treatment plan. The software compensates dynamically to modify the bracket programming to maintain the straight wire goal while positioning to avoid occlusal interference. Creates an ideal occlusion Utilizing the perfect blend of software and technology along with clinical expertise, the LightForce system offers the 3D skeletal information and landmarks needed for the orthodontist to create an ideal occlusion. The LightForce system creates the suggested ideal occlusion based on skeletal information from images and dental landmarks on each tooth. The doctor then has the opportunity to make adjustments to the occlusion based on individual clinical considerations and treatment preferences. Complete control of all aspects of treatment After approval of the initial treatment plan, the clinician will receive an email

from LightForce letting him/her know that the patient’s case is ready for evaluation. Because the LightForce treatment planning software is real-time, 3D, and interactive, the doctor has control over virtually every aspect of the case. Approval to delivery in 7 to 10 days The LightForce platform allows for fast delivery of the patient’s custom appliance. Just 7 to 10 busines days from approval, the customized appliances are on the way. Precise control of final tooth position The LightForce system provides precise control over the final tooth position at the planning stage to help you achieve your treatment goals. Make precise adjustments directly on the 3D model and visualize the impact on the finish in real time. OP

REFERENCES 1. Weber DJ 2nd, Koroluk LD, Phillips C, Nguyen T, Proffit WR. Clinical effectiveness and efficiency of customized vs. conventional preadjusted bracket systems. J. Clin Orthod. 2013;47(4):261-266. 2. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets--are standards as expected? Angle Orthod. 2004;74(4):450-453. 3. Jain M, Shetty S, Mogra S, Shetty VS, Dhakar N. Determination of optimum adhesive thickness using varying degrees of force application with light-cured adhesive and its effect on the shear bond strength of orthodontic brackets: an in vitro study. Orthodontics (Chic.). 2013;14(1):e40-e49.

This information was provided by LightForce Orthodontics.

Volume 10 Number 2

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The gummy smile dilemma Dr. Stuart Frost illustrates an innovative treatment for an often untreated condition


ummy smile patients have always presented orthodontists with a huge dilemma. For many years, I would feel that churn in my stomach when a gummy patient would show up to my practice for a consultation because the only clear path to truly correct the gumminess was braces and surgery. My choices were to mention it to the patient or choose to just ignore the gumminess and present a treatment plan that just lines the teeth up. The majority of gummy smile patients that came for consultations didn’t really list their gummy smile as a chief complaint because most didn’t know there was something that could be done about it. Until the last decade, correction of the gummy smile has been underresearched and lacking in innovation.   Often these patients are treated by lining up the teeth and creating a beautiful straight smile, leaving the gumminess and feeling bested when the patient really smiles and shows an acre of gums. Just a few millimeters of gum-show can distract even the most beautifully treated orthodontic case. Herein lies the dilemma; treat it or ignore it! For orthodontists, do we offer an invasive treatment plan because we know how it can positively affect the patient’s life but run the risk of them declining treatment? Or do we settle with routine care, doing the best we can without addressing the elephant in the room? These cases have always been extremely difficult to treat, and even when we attempt to treat them, the path of treatment can seem unclear on how to achieve a desirable finish without compromising the smile for less gum-show. Historically, the only effective option for correcting gummy smile cases has

been jaw surgery, specifically taking a wedge out of the maxilla in order to impact via LeFort surgery, thus eliminating excess gum-show. When most patients are presented with this type of treatment plan, most decline after hearing the word “surgery.” This may be due to high risks associated with surgical intervention, high cost, or a combination of these objectives. So, from the patients’ standpoint, correcting their gummy smiles feels hopeless. An alternative method of treatment should be considered to obtain impaction and correct the gummy smile with less cost, less risk, and stunning results. It should also be noted that other nonorthodontic treatment methods have been attempted, including the neuromodulator BOTOX®, that paralyzes the muscle, or parts of the levator labii, levator labii superioris, and and parts of the zygomaticus minor muscles, and crown lengthening with gingivoplasty. BOTOX treatment can be effective, keeping up on quarterly maintenance can be costly and does not solve the source of the problem. Crown lengthening

and gingivoplasty is only an option for a few patients depending on crown height and amount of gingival attachment. Over the past decade, we have had pioneers in China, Japan, Korea, and in our own backyard (Drs. John Pobanz and John Graham) who have shown beautifully treated gummy smile cases using TADs to impact the maxilla and correct the gummy smile with very little invasiveness. It must be noted that with over a few decades of sound research and hundreds of successfully treated cases, it can be difficult at best to reduce the gummy show and create a beautiful smile at the same time. As I’ve jumped into the deep end of this huge pool of gummy smile patients, I’ve found that they have become the most rewarding types of cases I treat, and the smile transformations on these patients has been emotionally and physically life-changing for these individuals. I see people all the time in my exam room with gummy smiles, and when I tell them we can fix this non-surgically, most of them are shocked because they’ve

Stuart L. Frost, DDS, received his dental degree at the University of the Pacific School of Dentistry. Following a 1-year fellowship in temporomandibular joint dysfunction (TMJ), he completed a 2-year residency in orthodontics and dentofacial orthopedics at the University of Rochester. Dr. Frost practices in Mesa, Arizona. He is currently a part-time associate clinical professor at the University of the Pacific orthodontic program and has lectured on the Damon™ System at several Damon Forums and other Ormco-sponsored events, including the national American Association of Orthodontists Annual Session, component meetings, and his own Damon in-office seminars.

Figure 1: Initial photographs 34 Orthodontic practice

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FOCUS ON: GUMMY SMILE dismissed it as a possibility without going through a painful surgery. I love seeing their eyes light up as they consider the possibility of having their life transformed through a noninvasive orthodontic treatment that usually takes less than 24 months. This case study will discuss a patient I treated with my gummy smile protocol and demonstrate just how spectacular these treatments can be with the right simple protocols.

Diagnosis The first step to treating a gummy smile is accurate diagnosis. Most people who show a lot of gums upon smiling are usually very good at hiding them. In the initial exam, it is critical to have the patient smile with his/her authentic smile, not a posed or hidden smile. Furthermore, when obtaining records and photographs, it is important to obtain a truly authentic smile with accurate representation of gingival display. Besides getting the patients to share their authentic smile to assess gum-show, it is important to assess upper lip length, and the amount of incisor show at rest. One of the worst things we could do as practitioners would be to impact the maxilla and age a smile by eliminating incisor-show at rest, which is associated with a youthful smile. To assess incisor show at rest, I will have the patient repeat the word Emma and have them keep the lips parted. Normal incisorshow at rest can be categorized in millimeters or percentage of enamel-show to the lip. Ideal incisor-show at rest should be 2-3 mm or one-third enamel-show. If the patient shows 50% or more of their central incisors at rest, I investigate further to see how far the upper lip retracts on smiling and measure the amount of gum-show upon smiling.  The decision to treat the gummy smile is easier knowing these findings. The case presented is my treatment coordinator, Brooke (32 years old). After working in my office for 2 years, she asked me to correct some crowding and give her a beautiful “Frost smile.” Interestingly enough, she did not mention anything about correcting her gummy smile. Upon looking at her case, I noticed that she has great facial features at rest, a little bit of asymmetry in her lower jaw, but good vermillion display. From her profile, she appears to have good upper lip projection but has a slight chin button and might be slightly retrognathic. In her smiling photograph, she shows 100% of her incisors, plus an additional 4 mm–6 mm of gum-show. (With this 36 Orthodontic practice

much gum-show, I would consider this case to be a moderate-to-extreme example of a gummy smile.) Often, patients have a posed or guarded smile when they have excess gum-show, so I make sure to crack a joke in the consult room to get an authentic smile and see how much gum tissue they actually show. Based on how her eyes light up in the photograph, I would consider this picture to be her authentic smile. It’s the smile I imagine she shows when seeing her children after a great day at work. You’ll see that her front teeth are on the midline of her face, and at lip rest she shows 100% of her incisors. Looking at her smiling photo, I also notice that her posterior teeth are slightly dumped in and that her two front teeth have all of the dominance of the smile. She has a slight smile arc, which is good. I notice slight wear on her cuspids and see that she is Class I molar and canine, with about 3 mm of space between the upper left 2 and 3. Looking at her arches, her upper arch seems to be asymmetric, and she has a mild amount of crowding on the lower. Her cone beam scan shows that she has normal

root length and height. She has never had orthodontic treatment before, so I thought this would be an amazing experience for her.

Treatment plan Brooke chose to have the Damon™ Clear 2 bracket for her treatment. The protocol for this case would be to place low torque brackets upper 2-2 to keep them from flaring when intruding, and standard torque on the cuspids because they are severely dumped in. On the lower, I chose regular torque 2-2 with high torque on the 3s. When placing the brackets, I bond for an exaggerated smile arc because once we have finished intrusion, it’s very common for a smile to appear pretty flat. We want to keep that natural look of the upper teeth following the lower lip line. So, for a normal case, I would bond the cuspids at 5 mm from the cusp tip to the slot, but for a gummy smile, I bond them at 6 mm. For the centrals and laterals, I bond at 6.5 mm. With a case like this where we are intruding both the posteriors along with the anteriors, many orthodontists would

Figure 2: 4 weeks prior to TADS

Figure 3: Day of TADs placement Volume 10 Number 2




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FOCUS ON: GUMMY SMILE use a transpalatal arch to hold the molars in place while intruding to keep them from rolling out and flaring. However, I like to keep the mechanics simple in these cases and approach it slightly differently. The protocol I use is to place two anterior TADs for intrusion, place bite turbos on the occlusal of the lower 7s, and have the patient do a squeeze exercise that consists of 60 squeezes per day, really concentrating on engaging the posterior fibers of the temporalis muscle to impact the posterior arch, keeping it upright as we intrude the anterior. What I’ve found is that for cases like Brooke’s, where there is 4 mm–6 mm of gum-show, it takes about 10 months of intrusion to get full gummy smile correction. Figure 2 shows Brooke about 4 weeks before I placed the TADs. As you can see, we’ve progressed through our beginning wires to correct rotational and torque issues. At this point, she is in a 16x25 SS wire upper and lower. We will advance to a 19x25 for the majority of intrusion to keep the anterior torques under control while intruding the maxilla. Figure 3 shows Brooke the day we put the TADs in. As you can see, I placed them distal to the 2s and mesial to the 3s. Something to note: It is extremely important not to use too heavy forces. If you do, the upper incisors will flare, and it will be really hard to regain control of the case. There are two ways I attach the TADs to the wire for intrusion force. The first method I use is seen here in Brooke’s case. I took a 5 mm 150g double delta closing spring from the TAD, looped it around the wire, and hooked the other end to the TAD. Using a closing spring is great because the clinician can hook it up once and leave it in for the duration of the intrusion. The only issue with using springs is that it can cause inflammation in the gum tissue and can sometimes embed in the tissue. If that ever happens in a case, I switch to the second method I use, which is power chain. Power chain is great because it’s much lower profile, and clear power chain isn’t nearly as noticeable as the unsightly closing spring. The only downside is that you have to change them out as they lose their elasticity. Figure 4 shows Brooke 3 months into intrusion. Now that the springs have had a chance to start working their magic, the protocol is to start triangle anterior elastics to keep the lower arch coming forward and up to meet the impaction. Brook wore her elastics from the upper post to the lower 3-4 on both sides. 38 Orthodontic practice

Figure 4: 3 months into intrusion

Figure 5: 10 months of intrusion

Figure 5 shows Brooke at 10 months of intrusion. This is about the time when I take a look at the photos to see what’s left of the gummy smile. Keep in mind when evaluating at this point that any patient who is treated like this for a gummy smile will need gingival contouring at the end of treatment. Everyone loses his/her gingival architecture to some degree after impacting the maxilla. At this point, Brooke’s gummy smile is no longer looking gummy! I decided to take the TADs out and work on the finishing touches for her case.

Summary The total treatment time for this case was 22 months. (We spent 10 of those months intruding.) Brooke was hesitant about the idea of TADs, so we started intruding a little

later than usual. If we would have started earlier, I could have finished her a little sooner. Figures 1 and 6 show the before-andafter comparison of Brooke’s case. What a great transformation! Notice how her smile now lights up her face. There are several things I want to point out looking at her before-and-after comparison. In her smiling photographs, notice how her smile doesn’t draw attention to any part of the smile anymore. Before, her smile was dominated by her front teeth. Notice that there is about 1 mm of gum-show from anterior to posterior, which is perfect for a youthful smile. Remember that as women age, the upper lip tends to lengthen so we want to treat for graceful aging as well as beautiful esthetics. Notice how wide and broad her smile is now. The buccal corridors are now Volume 10 Number 2

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Volume 10 Number 2

Orthodontic practice 39


filled with beautiful teeth, which, in turn, gives her more upper facial support. She has even more vermillion display, and her upper lip projection from her profile picture appears enhanced. Because we impacted the maxilla, the lower jaw followed and came forward and up. Notice how that gave her better chin features as well. All of these changes can be seen as well on a 3D superimposition. Notice how you can see the 4 mm-5 mm of impaction and the new angle of the mandible. You can also see the gain of arch width in the posterior segment. All around, this is an amazing transformation that has changed Brooke’s life. These are the kinds of cases that we are missing out on if we choose to just ignore the problem of excessive gingival show in our patients who show up to our office. We now live in the day and age where these types of cases are now an opportunity for practice growth, rather than a dilemma. Go change someone’s life by treating a gummy smile! OP

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Using 3D CBCT imaging in orthodontics Dr. Jay B. Burton discusses the aspects of CBCT imaging that improve treatment planning and diagnostics


BCT has changed everything in my practice life — from treatment planning to treatment options to mechanotherapy, and even evaluation of treatment results. At this point, it is honestly difficult for me to imagine practicing without it. In discussions with other doctors about using CBCT, the topic of impacted canines frequently arises, even though less than 5% of orthodontic patients have an impacted tooth.1 It seems unnecessary to purchase a CBCT machine if this is the primary or only reason. If this is the case, patients with impacted teeth could be sent to an oral surgeon who has a CBCT and will share his/her copy of the volume, which usually will already be captured as a part of treatment protocol. Some of the most obvious uses for CBCT technology are in maxillofacial dysmorphology and orthognathics. These applications include craniofacial and orthognathic issues, TMJ, airway, and cases involving pathology. Other indications focus on the anomalies of dentition — specifically, indications for impacted teeth, supernumerary teeth, and wisdom teeth evaluation/impactions. Another more recent application since the advent of skeletally fixated expanders are for patients with transverse discrepancies. Of particular concern, and perhaps even overlapping with the topic of dentoalveolar boundaries, would be whether or not orthodontists are able to use traditional rapid maxillary expanders in patients needing expansion or whether a skeletally fixated expander should be used. These decisions can now be made with information regarding the amount of

Jay B. Burton, DMD, completed his undergraduate education at Bethel University and earned an MBA from The University of Tennessee at Martin, before achieving his Doctor of Dental Medicine degree at the University of Louisville. While in dental school, Dr. Burton served as class president and conducted dental mission work in Belize and the Philippines. Dr. Burton subsequently completed his Orthodontic Residency at the prestigious New York University (NYU) in Manhattan before achieving certification from the American Board of Orthodontics. Aside from his passion for making healthy smiles, Dr. Burton enjoys spending time with his wife, Sarah, and their children, Nora, Baker, and Charlotte. Dr. Burton can be reached through Disclosure: Dr. Burton is receiving an honorarium from Planmeca for this article.

42 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss the aspects of CBCT imaging that improve treatment planning and diagnostics.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 46 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the uses of CBCT technology.

Identify common rendered images.

Realize why using CBCT technology would be beneficial in patients with dentoalveolar boundaries.

Recognize the importance achieving low radiation dose for CBCT imaging without losing diagnostic image quality.

Realize the different aspects of multi-planar reconstruction.

Identify various diagnostic aspects of 3D analysis.

bone located on the buccal of the teeth to which the appliance would be attached. The question of these dentoalveolar boundaries is significant as we can now consider the limitations to treatment specifically in the AP and transverse dimensions. One example is the patient who may need extractions due to bimaxillary protrusion. Orthodontists can consider the amount of bone available in the direction the teeth are to be moved and even simulate the tooth movement revealing exactly how much bone would be present if that treatment plan were carried through. Orthodontists must also now consider the possibility and/ or reality that, in many cases, there may be a lack of bone in the direction we would like to move the teeth, resulting in the question of whether or not the patient should be treated. When considering these boundaries, we also must consider morphology for cases that will involve dental implants, bone grafts, or temporary skeletal anchorage devices.

Radiation dose Radiation dose is always a concern for orthodontists, especially since many orthodontic patients are children. CBCT in orthodontics has become more of a possibility since the advent of Ultra Low Dose™ (ULD) technology developed by Planmeca — one example of a manufacturer that offers this type of low dose imaging while maintaining the diagnostic image quality necessary for effective treatment planning.2 CBCT offers more information about the patient than 2D radiography is able to

provide. While under our care, the less radiation that the patient is exposed to, the better. It is now possible to take a full field of view (FFOV) CBCT with less radiation than a traditional 2D digital pan and ceph.2 The 3D unit from Planmeca that uses Ultra Low Dose technology has changed the way I personally approach orthodontic treatment. The Ludlow, Koivisto 2014 study noted, “An average reduction in dose of 77% was achieved using ULD protocols when compared with standard protocols. While this dose reduction was significant, no statistical reduction in image quality between ULD and standard protocols was seen. This would suggest that patient doses can be reduced without loss of diagnostic quality.”2 It is important to me to have the ability to use and maintain ALARA protocols, while retaining as much image quality as possible. Just because a lower radiation dose may be achievable, it does not mean that it is diagnostically acceptable. Many of the treatments discussed in this article become relevant only after obtaining the information garnered by a CBCT. Some would say that 2D should be used first, and when indicated, a 3D CBCT should be taken. My response to that is, “Why would you over-irradiate your patients when you can take a 3D CBCT with less radiation than even a 2D pan?” This article focuses on the practical and beneficial uses of this technology. The discussion will focus on the use of multiplanar reconstruction (MPR) for general diagnostics/pathology/incidental findings. Volume 10 Number 2


Attention will be given to when and how this technology can be used and recommended. A fully integrated intraoral scan, taken with an intraoral scanner (Emerald™ by Planmeca in my office), allows for a streamlined approach to diagnosis and treatment planning as well as the ability to virtually simulate treatment with respect to the patient’s individual anatomy.

Rendered/reconstructed images The number of different types of reconstructed images possible is limited only by the clinicians’ need and imagination. Orthodontists can view any part of the volume in three planes of space to localize and better visualize that which they are interested in seeing. Specific rendered images useful for orthodontic diagnosis and treatment planning purposes will be discussed as well.

Figure 1

Multiplanar reconstruction (MPR)

Figure 3 shows a multiplanar reconstruction (MPR) view in three planes of space: coronal, sagittal, and axial as well as a 3D reconstructed view of the skull. This is really the starting point from which to begin examining each case. Many orthodontists who use 3D-imaging technology begin their diagnostic/treatment planning process by first examining the information from all of the slices in each plane prior to even thinking about orthodontic diagnosis and treatment decisions (as these can be distractions while the clinician is looking for incidental findings and pathology). This is done for the same reasons that pans are reviewed for pathology prior to determining treatment. It is important to point out that the clinician can easily become distracted by the 3D reconstruction. When reviewing a CBCT for pathology, it is important to spend time appreciating the sagittal, axial, and coronal views. The lure of the wow factor of the 3D rendering, if the clinician is not used to manipulating these images, can be quite enticing/distracting. Reviewing a CBCT: when and how  With regard to when and how, the author likes to review the CBCT at three distinct time points. 1. Immediately after the scan is taken (quick review). 2. During diagnosis and treatment planning (case workup). 3. During the treatment plan consult with the patient. By reviewing the CBCT at these three time points, clinicians can reduce the likelihood that any potentially important detail/ finding will be missed. Figure 3 shows the traditional MPR view revealing the coronal, axial, and sagittal Volume 10 Number 2

Figure 2

Figure 3 Orthodontic practice 43

CONTINUING EDUCATION planes. Most orthodontists are familiar with the collapsed version of these images as the PA cephalometric radiograph, the submentovertex radiograph, and the lateral cephalometric radiograph. Essentially, CBCT allows the clinician to expand out the 2D images and look at specific areas of interest as a result of being able to scroll through the various planes and slices.

CBCT for orthodontic purposes

There has been a lot of discussion and training available to practitioners on recognizing incidental findings and pathology, but little to no training as to how to use CBCT for orthodontic diagnostic purposes. The remainder of this article will focus on meeting this need and discussing some of the important diagnostic capabilities unique to CBCT.

Figure 4

Integration of I/O scans into volume

A beneficial feature is registration of an intraoral scan or model scan into the CBCT volume. Given the speed with which the clinician can take an intraoral scan now, it only makes sense to do so on all new patients. With this information, we truly have a “digital patient” to treatment plan the case with, and if needed, even perform treatment simulations.

Common rendered images Rendered panoramic view The reconstructed panoramic view is probably the most common reconstructed image from a CBCT volume that is used for dental purposes. A point of contention regarding rendered 3D pans has been the image quality/sharpness. The quality of the rendered pan is dependent upon the resolution at which the 3D volume was taken. A traditional 2D panoramic radiograph is typically not taken with the patient in occlusion due to the limited focal trough necessary for a quality 2D panoramic radiograph. With the 3D volume for orthodontic purposes, the CBCT is generally taken with the patient in centric occlusion. This can be done because of a feature available with most 3D-imaging programs, which allows the ability to manipulate the focal trough and further refine the width of that trough to make sure that all dental structures are included. This functionality helps the clinician achieve a more meaningful image and, as a result, have fewer retakes, thereby further reducing radiation levels as a result of poor patient positioning. The benefit of the 3D pan in orthodontics specifically is that clinicians can determine the molar class and midline as a result of the volume being taken and occlusion. Granted, at the resolution of ULD/LD setting, the panoramic reconstruction won’t 44 Orthodontic practice

Figure 5

be as “pretty” as a 2D image, but the amount of information available from the volume will be substantially more than that of a traditional 2D pan. This brings me to the question, Why do we as orthodontists take a panoramic radiograph anyway? Generally speaking, the purpose of the panoramic image is to provide a general overview of the teeth and bony structures, which will be involved in treatment. It is also used to confirm the presence/ absence of teeth, including supernumerary/ impacted teeth and for a very cursory view of the TMJ to determine if further imaging of the joint might be needed.3 Rendered lateral cephalometric view When we think about a rendered image from a 3D volume, it is important that there

is no magnification error in these images.4 Because magnification errors exist in 2D images, many of the norms that are used will have this error as part of the norm. The significance of this is minimal, though, if it is important to the clinicians that they should know that most 3D-viewing software will allow the creation of a rendered image with synthetic magnification error added. Figure 5 shows the difference between a volume rendered both with and without magnification error. Another benefit of rendered images is that the clinician no longer has to retake an image due to poor patient positioning. This is because the 3D volume can be reoriented in any position desired by the clinician, with the most common being based on natural head position. With the rendered lateral ceph, the Volume 10 Number 2


Figure 6

orthodontist can use a photo taken in natural head position to manipulate the orientation of the rendered image.  

3D analysis

Orientation of the 3D volume When reviewing the 3D volume in the multiplanar reconstruction view, it is important to first orient the volume in all three planes of space. For orthodontic purposes, the clinician should try to get this as close as possible to the patient’s natural head position. Once the volume is oriented, I begin by reviewing the coronal and axial views, primarily looking for symmetry and/or asymmetry. Many times, pathology will reveal itself in an asymmetrical manner. Lastly, I review the sagittal view, and many times, if I see something of interest, I will hone in on that area in all three planes of space. One of the last details I look at is the 3D reconstruction to confirm what I have already seen in the sagittal, axial, and coronal views. This cannot be stressed enough. The old adage that says, “Don’t miss the forest for the trees,” is one that comes to mind when thinking of what can happen upon opening a 3D volume. There is so much information that it is very easy to get distracted. Immediately after the volume has been taken, it should be reviewed. It is very important that all three planes of space are looked at, and that vital tissues are examined. This is where many orthodontists and dentists get intimidated. Orthodontists are traditionally Volume 10 Number 2

trained to look at PA cephs, lateral cephs, and a submentovertex in 2D. When reviewing sagittal, axial, and coronal views, the clinician is simply looking at slices within that 2D film. When it comes to 3D analysis, the clinician soon begins to realize the need to treat to the individual anatomy of a patient versus the historical 2D norms with which orthodontists are trained. Some university programs as well as other individuals have developed 3D analyses that pool specific views with which they have developed 3D norms. I find that it is more important to treat to the individual anatomy rather than available ethnic norms. In Figure 6, you will see views or images that I create on a regular basis, which are beneficial for diagnostics and treatment planning purposes. The top left of Figure 6 shows solid body views of the skull in the left frontal and right side orientations. Other images in the figure show intermolar and intercanine angulations and interarchcanine angulation, interincisal angles as well as alveolar bone boundaries. Also important for diagnosis and treatment planning is the reconstructed pan and reconstructed lateral ceph. Coronal reconstructions of the dentition will allow the clinician to measure intermolar and intercanine distances as well as a multitude of other images that can be used for treatment decisions. An important point to take note of is simply the amount of information clinicians are faced with once this technology is adopted. It becomes very important to

develop a systematic approach for both the review of the CBCT for incidental findings/ pathology as well as for treatment planning decisions.


I hope that this article has provided a better understanding of the need for CBCT in orthodontics as well as how this technology can be used to better visualize anatomy for proper diagnosis and treatment planning. The comment that most frequently comes up in conversation with an orthodontist considering the purchase of a CBCT machine is not whether or not they will adopt the technology, but when they will do so. As was my personal experience, I believe that once orthodontists have used the technology on a regular basis, it becomes easy to see why they would not want to practice without it. Now that radiation dose for 3D is less than that for 2D, it is really not a question of technology for technology’s sake; rather, it is a radiation hygiene issue that must be answered. OP REFERENCES 1. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial. Orthop. 1992;101(2):159-171. 2. Ludlow JB, Koivisto J. Dosimetry of Orthodontic Diagnostic FOVs Using Low Dose CBCT protocol. University of North Carolina/University of Helsinki. Charlottesville: UNC/UH. (2014). 3. Proffit, WR, Fields HW, Sarver, DM. Contemporary orthodontics. St. Louis, Mo: Mosby Elsevier; 2007 4

Mah JK, Yi L, Huang RC, Choo H., Advanced Applications of Cone Beam Computed Tomography in Orthodontics. Semin Orthod. 2011,17:57-71

Orthodontic practice 45



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 24 CE credits for only $149; call 866-579-9496 or visit to subscribe today. 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.





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Using 3D CBCT imaging in orthodontics BURTON

1. In discussions with other doctors about using CBCT, the topic of impacted canines frequently arises, even though less than _______ of orthodontic patients have an impacted canine. a. 5% b. 25% c. 45% d. 50% 2. When considering these boundaries (such as lack of bone), we also must consider morphology for cases that will involve _______. a. dental implants b. bone grafts c. temporary skeletal anchorage devices d. all of the above 3. ___________ is always a concern for orthodontists, especially since many orthodontic patients are children. a. Informed consent b. Undiagnosed caries c. Radiation dose d. Bone loss 4. The Ludlow, Koivisto 2014 study noted, “An average reduction in dose of ________ was achieved using ULD protocols when compared with standard protocols. (For the Ultra Low

46 Orthodontic practice

Dose™ scan captured by the Planmeca unit). a. 10% b. 25% c. 50% d. 77% 5. Looking forward, CBCT might help us with risk assessment by assessing ________. a. bone density b. visualizing root proximity and resorption c. providing the imaging data to support treatment simulation and technology-aided treatment d. all of the above 6. Many orthodontists who use 3D-imaging technology begin their diagnostic/treatment planning process by first _______ prior to even thinking about orthodontic diagnosis and treatment decisions (as these can be distractions as the clinician is looking for incidental findings and pathology). a. examining the information from all of the slices in each plane b. taking digital 2D images anyway c. only looking at the 3D reconstruction d. only looking at the sagittal view 7. With regard to when and how, the author likes to review the CBCT _______.

a. immediately b. during diagnosis c. during the patient consult d. at three distinct time points (at the quick review, the case workup, and during treatment plan consult) 8. A traditional 2D panoramic radiograph is typically ________ due to the limited focal trough necessary for a quality 2D panoramic radiograph. a. taken with the patient in occlusion b. not taken with the patient in occlusion c. taken with the patient standing d. none of the above 9. With the 3D volume for orthodontic purposes, the CBCT is generally taken with the patient in ______. a. centric occlusion b. maximum protrusion c. right lateral or left lateral occlusion d. edge-to-edge occlusion 10. When we think about a rendered image from a 3D volume, it is important that there is/are no _________ in these images. a. artifacts b. magnification error c. over-resolution d. pathology

Volume 10 Number 2



Dr. Steven R. Olmos explores high-tech solutions to treatment problems Background My interest in patients suffering from chronic pain originated in dental school. I remember a woman who was being treated by a faculty dentist in the TMJ Department. She was given a nightguard and told to wear it all day. She was on medications for muscle relaxation and anti-anxiety. There was a certainty that these problems were of psychosocial origin at the time, so she was told to take an extended vacation. I was walking by when she tearfully said, “I’m wearing the appliance, taking the medication, and just returned from two months of vacation, and nothing has changed.” In the early 1980s, there were many joint surgeries for these failed patients. Treatment was based on symptom management before, and certainly after, joint surgery. Long-term outcomes were not good. In the mid-1990s, I sold my dental practice and limited my practice to craniofacial pain (head, face, jaw pain, and headaches). There was always an overlap with pain patients and poor sleep. In 1981, the CPAP was developed as the first nonsurgical and still most frequent treatment for obstructive sleep apnea (OSA). I started to treat patients that had OSA with oral appliances. I had patients with OSA who suffered from chronic craniofacial pain and vice versa. Current literature demonstrates a high comorbidity.1,2,3,4 My dental education focused on the orthopedic function of the jaw and occlusion. In my search for an easy and noninvasive way to know the health of the joints, I investigated Joint Vibration Analysis (JVA) (BioRESEARCH Inc.). It dynamically measures the vibration of soft and hard tissues to determine perforations — when

Educational aims and objectives

This clinical article aims to discuss how to treat chronic pain and breathing disorders with technology.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 52 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize how 3D imaging can be beneficial for evaluation of chronic pain and breathing disorders.

Realize the role that low-level laser therapy can play in chronic pain treatment.

Realize how orthodontic appliance therapy can help in treatment of chronic pain, sleep-breathing disorders, and orthopedic/orthodontic therapy.

Identify some testing methods for these chronic pain and breathing disorder issues.

Figure 1

Figure 2

and where the TMJ disc is recaptured or displaced.5,6,7,8 My search for novel ways of using technology to treat chronic pain and breathing disorders continues.

3D imaging 3D imaging of the head is essential when evaluating for chronic pain and dysfunctional breathing. An article published in The Journal of the American Dental Association (2013) recommends “the need for complete and proper review of the entire image, regardless of field of view or region of interest.”

Steven R. Olmos, DDS, DABCP, DABCDSM, DAAPM, DABDSM, FAAOP, FAACP, FICCMO, FADI, FIAO, has been in private practice for more than 30 years, with the last 20 years devoted to research and treatment of craniofacial pain, temporomandibular disorder (TMD), and sleep-related breathing disorders. He obtained his DDS from the University of Southern California School of Dentistry and is board certified in both chronic pain and sleep-breathing disorders by the American Board of Craniofacial pain, the American Academy of Integrative Pain Management, the American Board of Dental Sleep Medicine, and the American Board of Craniofacial Dental Sleep Medicine. Dr. Olmos is the founder of TMJ & Sleep Therapy Centres International, with 50 licensed locations in seven countries dedicated exclusively to the diagnosis and treatment of craniofacial pain and sleep disorders. Disclosure: Aqualizer, Mute, and Max-Air are sponsors for Dr. Olmos’ courses.

Volume 10 Number 2

Figure 3

The reason is that incidental findings (IFs) “are detected relatively frequently in CBCT imaging, and considerable variation is evident in their frequency and nature.”9 Case example One example of how 3D imaging can make a difference in diagnosis is the case of a 12-year-old boy, whose mother brought him in for his chronic face and jaw pain and severe fatigue. A dentist had recommended a bite splint, and a physician had prescribed Orthodontic practice 47


Treating chronic pain and breathing disorders with technology


Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

antibiotics and steroid nasal spray for him. Neither practitioner had performed imaging. After my clinical exam, I prescribed a CBCT image only to find an enormous spaceoccupying lesion that required immediate hospitalization and surgery. CBCT is important in evaluating condyle regeneration using appropriate decompression appliance therapy and laser rehabilitation.10 Oral orthotic treatment for craniofacial pain and sleep-breathing disorders have been demonstrated to be effective.11,12

injuries, as all other treatments are palliative, while the laser therapy is truly therapeutic. Classical trigeminal neuralgia (TN) is a disease of severe, stabbing neuropathic facial pain of the second and third divisions of the trigeminal nerve.24 It is estimated that one in 15,000 people suffer from trigeminal neuralgia; however, numbers may be significantly higher due to frequent misdiagnosis.15 The incidence is greatest in people more than 50 years old, and in women more frequently than men.25 I authored a case study titled “Chasing Pain: Diagnosing and Treating Trigeminal Neuralgia in General Dentistry.�26 The patient was treated unsuccessfully for 4 years with Tegretol. I found the patient to have OSA and treated with an oral appliance and a cold laser (Mphi 5, BioRESEARCH), which uses two wavelengths of light (808 and 905) with a synchronized delivery of both continuous and pulsed modes. The pain was resolved, and the patient was able to discontinue the Tegretol pain-free in 8 weeks. LLT therapy has been demonstrated to move teeth between 30% and 50% faster with reducing pain by 50% with either straight wire or InvisalignŽ techniques.27,28,29,30

Figures 9 and 10: 9. Start of treatment. 10. 12 weeks MMI

Chronic facial pain and low-level laser therapy

Figure 11 48 Orthodontic practice

One in six adults who visited a general dentist during 2015 experienced chronic facial pain.13 Pain in the muscles and temporomandibular joints was reported as frequently as that in the teeth and surrounding tissues in patients visiting general dentists. Pain in the orofacial regions affects 21.7% of the population in the United States and costs more than $32 billion each year.14 The clinical efficacy of low-level laser therapy (LLT) in the treatment of neuropathic pain is well established in many studies.15-23 This is a very important tool for the treatment of nerve

Volume 10 Number 2

Figure 14

Figure 15

Figure 16


Figure 13

Figure 12

Orthodontic appliance therapy I reviewed the history of appliance therapy in a previous issue of Orthodontic Practice US “Oral appliances — past, present, and future” (July/August 2018).31 Digital scanning and fabrication of appliances for chronic pain, sleep-breathing disorders, and orthopedic/ orthodontic therapy are now done on software in the laboratory. New printed materials (Type 12 Nylon) are crafted from lightweight, flexible, biocompatible materials that are inert and unreactive to soft and hard tissue, in contrast to methyl methacrylate either layered or milled: Both are now available. This technology allows for the first vertical titratable appliance for sleep-breathing disorders (Diamond Digital Sleep Orthotic [DDSO]/ Diamond Orthotic Laboratory LLC).32 Finding the optimal 3D mandibular position to produce appliances for both orthopedic function and minimizing pharyngeal collapse of the airway for sleep-breathing appliances can be accomplished utilizing the sibilant phoneme registration (SPR) protocol or phonetic bite technique. Acoustic pharyngometry is used to measure the baseline and collapse of the pharyngeal muscles of the airway in patients with OSA (Figure 21).33,34 This device allows for evaluation of the bite registration for restoration of tonus. Utilizing the sibilant phoneme registration requires vertical titration as opposed to protrusive for the George Gauge technique. The SPR technique will reduce the chances of TM disc dislocation. (See Figure 22 for airway volume and TM joint position comparisons for the same patient.) Studies have shown that the two biggest factors in mandibular advancement device (MAD) treatment success are body mass index (BMI) and nasal airway resistance (NAR).35 Nasal dilators have become a very important part of OSA therapy. Nasal valve dilation has been shown to decrease intraluminal pressures in the oropharynx, which Volume 10 Number 2

Figures 17 and 18

Figure 19

reduces apneic events, via the Starling resistor model (Figure 23).36 The volume of the nose can be measured using acoustic rhinometry (Figures 24-26), and the flow rate of the nose can be measured by acoustic rhinomanometry (Figures 27-29).37,38 This allows for evaluation of normalization of the airway using OTC nasal sprays (Xlear®), nasal dilators (Mute, Max-Air nose cones), and nasal surgery. Changes to occlusion can occur with or without the use of oral appliances when treating sleep-breathing disorders and/or chronic pain. A study using only nasal CPAP for greater than 2 years produced the same

Figure 20

Figure 21. Acoustic pharyngometry Orthodontic practice 49


Figure 23: Starling resistor model.

Figure 22: Airway volume/TM joint position comparison in same patient

Figure 24: Acoustic rhinometry (volume of the nose)

Figure 25

Figure 27: Acoustic rhinomanometry

Figure 26

Figure 28: Volume of the nose

Figure 30

Figure 29

changes as using oral appliances in studies evaluating these appliances changes over 10 years. The changes are correction of anterior rotations, reductions of open bite and overjet (Class II patients), and increase in canine width.39,40,41,42 Postural changes such as leg length discrepancy can result in changes to occlusion.43,44 Inflammation (capsulitis), osteoarthritis, and disc displacement also can result in changes to occlusion. The T-Scan (Tekscan) (Figure 33) — a device that measures the timing, force, and distribution of tooth contact in real time utilizing a digitized wafer and software — is useful in quantifying occlusion. Figures 34 and 35 show scan of a seated patient with and without foot orthotics. Note the heavy occlusal forces on the left side without and the normalized occlusion with the foot orthotics in place. It is necessary to quantify the efficacy of treatment for OSA via an at home sleep testing (HST) device during treatment. The MediTouch is an effective tool for adult and pediatric OSA patients.45,46


Figure 31 50 Orthodontic practice

Figure 32

Quantifying each step of treatment is the bridge between clinical practice and science (reproducible steps). I am certain that due to our increase in knowledge of the comorbidity Volume 10 Number 2

Figure 35: Balanced occlusion with foot orthotic

Figure 33: T-Scan connects to computer for real-time occlusal analysis

Figure 36: Diagnostic PSG (severe sleep apnea)

of chronic face pain and sleep-breathing disorders and the technology that exists, I would now be able to help that woman who was suffering way back in my dental school education. OP REFERENCES 1. Smith MR, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32:779-790. 2.

Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. 2013;92(suppl 7):70S-77S.


Wickwire E, Bellinger K, Kronfli T, et al. Relations between objective sleep data, sleep disorders, and signs and symptoms of temporomandibular joint disorder (TMD). J Pain. 2008;9(4)(suppl 2):14.

4. Olmos S. Comorbidities of chronic facial pain and obstructive sleep apnea. Curr Opin Pulm Med. 2016;22(6):570-575 5.


Ishigaki S, Bessette RW, Maruyama T. Vibration of the temporomandibular joints with normal radiographic imagings: comparison between asymptomatic volunteers and symptomatic patients. Cranio. 1993;11(2):276-283. Sharma S, McCall WD, Crow H, Gonzalez-Stucker Y. Reliability and Diagnostic Validity of Joint Vibration Analysis. Presentation at 2015 IADR Meeting, Boston, MA, Based on Master’s Thesis of S. Sharma. School of Dental Medicine, State University of New York(SUNY) Buffalo: Buffalo, NY.

7. Radke JC, Kull RS. Comparison of TMJ vibration frequencies under different joint conditions. Cranio. 2015;33(3):174-182. 8.

Sharma S, Crow HC, Kartha K, McCall WD Jr, Gonzalez YM. Reliability and diagnostic validity of a joint vibration analysis device. BMC Oral Health. 2017;17(1):56.

9. Edwards R, Altaligbi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of the head and neck region: a systematic review. J AM Dent Assoc. 2013;144(2):161-170. 10. Olmos S. Airway Centered Dentistry: (The A, B, C’s of Treatment for Chronic Face Pain/OSA and Closing Anterior Openbite Without Ortho). J Oral Health. 2017;44-56. 11. Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J AM Dent Assoc. 2012;143(8):847-857.

Figure 37: Titration HST titration study with hybrid therapy (normal respiration) Dentistry research network. J Am Dent Assoc. 2015;146(10):721 -728. 14. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey Data. 2002. Accessed February 20, 2019. 15. Iijima K, Shimoyama N, Shimoyama M, et al. Effect of repeated irradiation of low-power He-Ne laser in pain relief from postherpetic neuralgia. Clin J Pain. 1989;5(3):271-274. 16. Walker J, Akhanjee L, Cooney M, et al. Laser therapy for pain of trigeminal neuralgia. Clin J Pain. 1988;3:183-187. 17. Iijima K, Shimoyama N, Shimoyama M, Mizuguchi T. Evaluation of analgesic effect of low-power He:Ne laser on postherpetic neuralgia using VAS and modified McGill pain questionnaire. J Clin Laser Med Surg. 1991;9(2):121-126. 18. Walker J. Relief from chronic pain by low power laser irradiation. Neurosci Lett. 1983;43(2):339-344. 19. Eckerdal A, Bastian H. Can low reactive-level laser therapy be used in the treatment of neurogenic facial pain? A double- blind, placebo controlled investigation of patients with trigeminal neuralgia. Laser Therapy. 1996;8:247-252. 20. Moore KC, Hira N, Kramer PS, Jaykumar CS, Ohshiro T. A double blind crossover trial of low level laser therapy. Laser Therapy. 1989;1(1):7-9. 21. Samosiuk IZ, Kozhanova AK, Samosiuk NI. [Physiopuncture therapy of trigeminal neuralgia]. Vopr Kurortol Fizioter Lech Fiz Kult. 2000;6:29-32. 22. Vernon LF, Hasbun RJ. Low-level laser for trigeminal neuralgia. Practical Pain Management. 2014;8(6):56-63. 23. Kim HK, Jung JH, Kim CH, Kwon JY, Baik SW. The effect of lower level laser therapy on trigeminal neuralgia. Journal of the Korean Pain Society. 2003;16:37-41. 24. Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol. 1991;27(1):89-95.

Orthop. 2018;154(4):535-544. 31. Singh D, Olmos S. Use of a sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007;11(4):209-216. 32. Olmos SR, Rago M. Oral appliances — past, present, and future. Orthodontic Practice US. 2018;9(4):32-37. 33. Gelardi M, Del Giudice AM, Cariti F, et al. Acoustic pharyngometry: clinical and instrumental correlations in sleep disorders. Braz J Otorhinolarngol. 2007;73(2):257-265. 34. Deyoung PN, Bakker JP, Sands SA, et al. Acoustic pharyngometry measurement of minimal cross-sectional airway area is a significant independent predictor of moderate-to-severe obstructive sleep apnea. J Clin Sleep Med. 2013;9(11):1161-1164. 35. Zeng B, Ng AT, Qian J, et al. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep. 2008;31(4):543-547. 36. Michels Dde S, Rodrigues Ada M, Nakanishi M, Sampaio AL, Venosa AR. Nasal involvement in obstructive sleep apnea syndrome. Int J Otolaryngol. 2014;2014. 37. Corey JP. Acoustic rhinometry: should we be using it? Curr Opin Otolaryngol Head Neck Surg. 2006;14(1):29-34. 38. Roithmann R, Cole P, Chapnik J, et al. Acoustic rhinometry, rhinomanometry, and the sensation of nasal patency: a correlative study. J Otolaryngol. 1994;23(6):454-458 39. Pliska BT, Almeida FR. Tooth movement associated with CPAP therapy. J Clin Sleep Med. 2018;14(4):701-702. 40. Venema J U, Stellingsma C, Doff M, Hoekema A. Dental Side Effects of Long-Term Obstructive Sleep Apnea Therapy: A Comparison of Three Therapeutic Modalities. Journal of Dental Sleep Medicine. 2018;5(2):39-46.

25. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD.

41. Ueda H, Almeida FR, Lowe AA, Ruse ND. Changes in occlusal contact area during oral appliance therapy assessed on study models. Angle Orthod. 2008;78(5):866-872.

26. Almos, S. Chasing Pain: Diagnosing and Treating Trigeminal Neuralgia in General Dentistry. Dentaltown Magazine. 2016; 35-40.

42. Pliska BT, Nam H, Chen HN, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints. J Clin Sleep Med. 2015;11(4):503-504.

27. Doshi-Mehta G, Bhad-Patil WA. Efficacy of low-intensity laser therapy in reducing treatment time and orthodontic pain: a clinical investigation. Am J Orthod Dentofacial Orthop. 2012;141(3):289-297.

43. Sakaguchi K, Mehta NR, Abdallah EF, et al. Examination of the relationship between mandibular position and body posture. Cranio. 2007;25(4):237-249.

28. Cruz DR, Kohara EK, Ribeiro MS, Wetter Nu. Effects of low-intensity laser therapy on the orthodontic movement velocity of human teeth: a preliminary study. Lasers Surg Med. 2014;35(2):117-120.

12. John CR, Gandhi S, Sakharia AR, James TT. Maxillomandibular advancement is a successful treatment for obstructive sleep apnoea: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2018;47(12):1561-1571.

29. Qamruddin I, Alam MK, Mahroof V, et al. Effects of low-level laser irradiation on the rate of orthodontic tooth movement and associated pain with self-ligation brackets. Am J Orthod Dentofacial Orthop. 2017;152(5):622-630.

13. Horst OV, Cunha-Cruz J, Zhou L, et al. Prevalence of pain in the orofacial regions in patients visiting general dentists in the Northwest Practice-based Research Collaborative in Evidence-based

30. Varella AM, Revankar AV, Patil AK. Low-level laser therapy increases interleukin-1β in gingival crevicular fluid and enhances the rate of orthodontic tooth movement. Am J Orthod Dentofacial

Volume 10 Number 2

Figure 38: Level 3 HST setup

44. Maeda N, Sakaguchi K, Mehta NR, et al. Effects of experimental leg length discrepancies on body posture and dental occlusion. Cranio. 2011;29(3):194-203. 45. Driver HS, Pereira EJ, Bjerring K, et al. Validation of the MediByte® type 3 portable monitor compared with polysomnography for screening of obstructive sleep apnea. Can Respir J. 2011;18(3):137-143. 46. Pereira EJ, Driver HS, Stewart SC, Fitzpatrick MF. Comparing a combination of validated questionnaires and level III portable monitor with polysomnography to diagnose and exclude sleep apnea. J Clin Sleep Med. 2013;9(12):1259-1266.

Orthodontic practice 51


Figure 34: Heavy occlusion left without foot orthotic



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 24 CE credits for only $149; call 866-579-9496 or visit to subscribe today. 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 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.

Your CE certificate(s) will be emailed to the address you provided above. Please add to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Treating chronic pain and breathing disorders with technology OLMOS

1. An article published in the Journal of the American Dental Association (2013) recommends “the need for complete and proper review of the entire image, regardless of field of view or region of interest.” The reason is that incidental findings (IFs) “are detected relatively frequently in ________, and considerable variation is evident in their frequency and nature.” a. traditional 2D X-ray b. panoramic imaging c. cephalometric imaging d. CBCT imaging 2. Pain in the orofacial regions affects ________ of the population in the United States and costs more than $32 billion each year. a. 11% b. 21.7% c. 57% d. 63% 3. This (low-level laser therapy) is a very important tool for the treatment of nerve injuries, as all other treatments are ________, while the laser therapy is truly therapeutic. a. palliative b. experimental c. risky d. painful

52 Orthodontic practice

4. It is estimated that ________ people suffer from trigeminal neuralgia; however, numbers may be significantly higher due to frequent misdiagnosis. a. one in 100 b. one in 1,600 c. one in 15,000 d. one in 300,000 5. The incidence (of trigeminal neuralgia) is greatest in people more than 50 years old, and ________. a. in women more frequently than men b. in men more frequently than women c. equally divided between women and men d. found only in women 6. Low-level laser therapy (LLT) has been demonstrated to move teeth between 30% and 50% faster with reducing pain by _______ with either straight wire or Invisalign® techniques. a. 30% b. 50% c. 64% d. 75% 7. Finding the optimal 3D mandibular position to produce appliances for _______ can be accomplished utilizing the sibilant phoneme registration (SPR) protocol or phonetic bite technique. a. orthopedic function

b. minimizing pharyngeal collapse of the airway for sleep-breathing appliances c. increasing intraluminal pressures d. both a and b 8. _________ is used to measure the baseline and collapse of the pharyngeal muscles of the airway in patients with OSA. a. A CPAP machine b. Anthropometry c. Acoustic pharyngometry d. Polysomnography 9. Studies have shown that the two biggest factors in mandibular advancement device (MAD) treatment success are body mass index (BMI) and ________. a. size of the rima glottidis b. nasal airway resistance (NAR) c. postural changes d. none of the above 10. This (volume of the nose and the flow rate of the nose) allows for evaluation of normalization of the airway using _______. a. OTC nasal sprays b. nasal dilators c. nasal surgery d. all of the above

Volume 10 Number 2




Beyond braces: CBCT expands orthodontists’ capabilities Dr. Robert “Tito” Norris discusses Carestream Dental’s 3D modules and systems


veryone knows what orthodontists do: braces. From a patient’s perspective, orthodontists simply straighten teeth, and that’s it. But if they only knew what orthodontists could do for them thanks to advancements in digital technology such as cone beam computed tomography. While admittedly clear aligners are making the image of brackets slowly fade in patients’ minds, straightening teeth in general is just the tip of the iceberg of what CBCT allows orthodontists to do for their patients.

and enlarged tongues. We’ve known since the 1960s that expanding the maxilla can increase nasal air volume significantly. Airway has gained national attention in orthodontics over the past 5 years as a movement of “airway-friendly” orthodontics has emerged.

In fact, the entire 2019 AAO Winter Conference lecture series revolved around the topic. Though these concepts are still relatively new within the specialty, orthodontists play a critical role in recognizing signs of airway problems, and patients are frequently

Airway visualization I’ve been looking at airways for about the past 15 years, trying to educate and elicit the support of local ENTs to assist in opening airways constricted by tonsils, adenoids, polyps, swollen turbinates, deviated septa,

Figure 1: Patients with a posterior crossbite often have nasal constriction, leading to mouth breathing, a low tongue posture, and lack of maxillary support by the tongue, resulting in narrowing of the maxilla. These patients will usually have well-developed mandibular arches with minimal crowding Figure 2: Many patients with anterior open bites have narrow pharyngeal airway space, often exacerbated by enlarged tonsils. The anterior tongue posture is the frequently the body’s natural effort to open the pharyngeal airway

Dr. Robert “Tito” Norris completed dental school at the University of Texas Health Science Center, San Antonio, and did a general practice residency at the Washington DC VA Medical Center, followed by an orthodontic residency at Howard University. He then served 3 years in the Air Force as an orthodontist in Misawa, Japan, before opening his practice in 1998 in San Antonio. Dr. Norris was board certified in 2003 and has served as a clinical consultant for numerous technology companies along the way. Disclosure: Dr. Norris is a key opinion leader for Carestream Dental.

54 Orthodontic practice

Figure 3A: This patient with an anterior and posterior crossbite also had a constricted pharyngeal airway. A skeletally anchored expander with protraction headgear allowed transverse and anterior correction of the maxilla while improving the airway Volume 10 Number 2

Figure 3B

continue to take the lead in this area because constricted airways are simply not on the radar for most physicians, and patients are suffering because of it.

Micro-implant assisted rapid palatal expansion (MARPE) Though this technique has a history of inconsistent results and significant morbidity, in the past couple of years, these issues have been resolved, and it has now become an effective and predictable method to get true parallel (not trapezoidal) skeletal expansion in all teens and even most adult females. We’ve been using the MARPE technique that was developed at UCLA for over a year now with amazing success. Having a CBCT in-house (CS 9300 system, Carestream Dental) is critical to the success of the technique because the micro-implant placement must be extremely accurate, and bicortical engagement of the micro-implants must be verified via CBCT before the patient can begin expansion. Using MARPE, we have been able to increase nasal airway volumes; increase oral cavity volumes to improve tongue posture; and develop maxillae not only laterally, but also anteriorly via a facemask therapy or mandiublar Bollard plates applied to a skeletally anchored maxillary expansion appliance, which has just loosened all five maxillary sutures. As more orthodontists adopt in-house CBCT systems, the MARPE technique will spread in orthodontics,

giving clinicians the ability to solve a number of complaints for their patients

TMJ discomfort Most orthodontists have some basic understanding of TMJ but many are simply too busy straightening teeth to deal with it. Imaging of the joint with a CBCT system plays an important role in properly managing these patients. With a large FOV CBCT system like the CS 9300, orthodontists are able to offer an interdisciplinary solution for patients in TMJ discomfort.

Dentofacial orthopedics It’s time that we started living up to our name as specialists in orthodontics and dentofacial orthopedics. By using the latest knowledge and technology, we have the ability to help patients breathe, sleep, and focus better. We can help alleviate the suffering of most TMJ patients as well. Spread the word — let your patients know you invested in them by investing in advanced technology. Let referrals know that they can send their patients to you for 3D scans rather than an imaging center (especially helpful for doctors practicing in rural areas). Let everyone know that orthodontics is so much more than straight teeth; it’s life changing. OP

REFERENCES 1. Kumar SA, Gurunathan D, Muruganandam E, Sharma S. Rapid Maxillary Expansion: A Unique Treatment Modality in Dentistry. Journal of Clinical and Diagnostic Research. 2011;5(4) 906-911.

Figure 4 Volume 10 Number 2

Orthodontic practice 55


surprised when an orthodontist recognizes an airway issue that has been missed by multiple physicians over the patient’s lifetime, often with significant sequelae. In addition to large tonsils, narrow palates, open bites, tethered tongues, anterior spacing, dento-alveolar extrusion, high mandibular plane angles, short upper lips, anterior tooth wear, and narrow nares — just to name a few — orthodontists now have the ability to send patients off with a home sleep study and utilize important visualization tools such as the CS Airway module (Carestream Dental) to quantify the minimum axial airway area. These two tools have been critical in getting patients to actually go to the ENT specialist for evaluation. The CS Airway module alone is used in my practice multiple times a day to quickly analyze the airway in 3D. The color coding of the pharyngeal region highlights constrictions, so I can effectively communicate concerns with patients. As a specialty, orthodontists must


Henry Schein® Orthodontics™ SLX 3D: the complete PSL treatment solution Now with all-new, innovative archwires and standardized sequencing protocols


he Carriere® SLX 3D™ Appliance system, when powered by the SAGITTAL FIRST™ Philosophy, is the most comprehensive and technologically advanced PSL treatment solution we’ve ever designed. Engineered to address all case types, the system offers efficient, no-compromise finishes with the superior esthetics patients value today. The core of the system is the uniquely redesigned, feature-rich SLX 3D Self-Ligating Brackets — metal and ceramic. The highly acclaimed engineers of Henry Schein® Orthodontics™ collaborated with worldrenowned orthodontists to ensure its development and met the highest standards for patient comfort, esthetics, and clinical control. Completing the system are self-ligating buccal tubes, easy-to-use instruments, and intuitive packaging, and now a revolutionary new series of archwires with standardized

Primary Carriere SLX 3D System Components

Just some of the amazing features of the SLX 3D Bracket EZ Twist open/close. A feather touch and slight twist of the instrument propels the slide to the open and locked position.

Full M/D slot coverage. For unmatched rotational control. Helps ensure you finish faster! Superior esthetics. Smoothest contours ever. Looks and comfort for what patients want.

Proven slot geometries. Tight tolerances. Exacting torque values, in/out thicknesses, and slot depths mean less wire bending for faster, more high-quality finishes.

56 Orthodontic practice

sequencing protocols for accelerated treatment. In addition to the notable features highlighted here, the SLX 3D boasts full metal/ceramic bracket compatibility with brackets sized appropriately for each tooth. The cross-hair color coding offers a new level of visual cues for precise bracket placement, and the compound-contoured bases just fit right. Bracket base edges are beveled for quick, clean removal, and intelligent numbering makes ordering and inventory control a breeze. Integral to the Carriere approach is the paradigm-shifting SAGITTAL FIRST philosophy. Carriere Motion 3D™ Appliances power sagittal movement prior to bonding brackets, eliminating competing force vectors and minimizing patient compliance issues inherent in traditional Class II and Class III correction. Rounding out the system are the new, revolutionary Carriere M-Series™ Archwires and wire sequencing protocols — just three

wires for metal brackets — designed to standardize and simplify archwire progression. The M-Series Wires have been engineered in tandem with the SLX 3D Brackets to fit the shape of the bracket slot accurately and precisely. The goal is to consistently achieve total treatment times of 12 months or less.

Building a future together As with all our offerings, the care with which we designed the Carriere System reflects the very nature of our relationship with you, your staff, and patients. Every customer is important, and we work hard to earn your trust by continuing to develop new and innovative products that fuel your success and practice growth by giving your patients great smiles and total health solutions. From clinician to staff member, you can “Rely on Us.” OP

This information was provided by Henry Schein® Orthodontics™.

Volume 10 Number 2

Not Just Another Clear Aligner The SLX ™ Clear Aligner system by Henry Schein® Orthodontics™ incorporates the paradigm-changing SAGITTAL FIRST ™ Philosophy with Carriere® MOTION 3D CLEAR ™ for ultimate aesthetic and efficiency.

To learn more, contact your Henry Schein ® Orthodontics ™ Sales Representative call 888.851.0533 or visit

MOTION 3D Clear Appliance and SLX Clear Aligners

© 2019 Ortho Organizers, Inc. 1822 Aston Ave., Carlsbad, CA 92008-7306, USA. All rights reserved. M1494 01/19 U.S. Patent No. 7,621,743; 7,238,022; 7,618,257; 6,976,839 and foreign patents.


Technology — the past, the present, and your future Dr. Terry Sellke discusses methods to help orthodontists go beyond surviving and get back to thriving Background I have been in practice for a long time. My initial orthodontic training involved treatment with stainless steel bands and wires. There were no brackets, no superelastic wires, and no computers. In my early years, our time at orthodontic meetings involved discussions of whose mechanics to follow, and what would produce stable treatment. They were simpler times. Then technology began to play a part in orthodontics. Technology brought us brackets, better brackets, better wires, and computers. We used computers to improve our business skills, to speed our communication, to aid diagnosis, and to visualize treatment outcomes. Our times at orthodontic meetings were then spent debating bracket systems, learning about the next generation of computer programs to make us more effective and efficient as practitioners. By the 1980s we began to talk about third parties that were attempting to affect our domain and our practices. How dare dentists do orthodontics, and how dare entrepreneurs and corporations infringe on the profession of orthodontics. So here we are today. We are blessed with innovations that make our treatment easier, faster, more predictable, and more profitable. But we are faced with third parties that plan not only to profit from our great profession, but also to own the delivery system. Orthodontics is experiencing a paradigm shift it has never known in its 100-plus years of its proud existence. How can we meet the challenges presented by third parties? The answer is to embrace change and to embrace new technology. Technology is, and will continue to be, rapidly adopted by those who would turn the profession of orthodontic

care into the business of orthodontic delivery. Our patients’ chief complaints are emotional and difficult to “upload” direct from consumer. Our advanced training on the biology and mechanics of tooth movement offer improved diagnosis and treatment plans compared to nonspecialists. Adjunctive technologies in our experienced hands will always deliver more when coupled with individualized treatment and superior biomechanics. This offers us the opportunity to stand out as providing “different and better” care than dated, or “cookie-cutter,” alternatives.

Three principles I have lectured internationally on the business aspects of orthodontics for decades. Our profession’s future lies in applying business principles to the clinical cottage industry we call orthodontics. We must continue to improve every day. There are three principles, that if applied consistently

Terry A. Sellke, DDS, is a native Illinoisan. His fervor for Illinois extends to his academic background, having enrolled in the University of Illinois undergraduate and dental school. He graduated with his Doctorate of Dental Surgery in 1971. Two years later, he achieved a specialty degree in orthodontics. In 1974, he received a Master’s degree in orthodontics, the same year that he opened the first office of what was to become Drs. Sellke and Reily, Ltd. In 1980, Dr. Sellke became a Diplomate of the American Board of Orthodontics. He still teaches orthodontics at the University of Illinois College of Dentistry, where he earned the titles of professor, master clinician, co-clinic director, and master’s thesis advisor. Dr. Sellke lectures domestically and internationally on clinical orthodontics as well as another of his passions, applying business principles to the practice of orthodontics. Disclosure: Dr. Sellke discussed his experience using various accelerated tooth movement technologies on a CE webinar hosted by Propel Orthodontics in January 2019. He has lectured previously on behalf of Dental Monitoring and SureSmile.

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to everyday challenges, will allow as to go beyond surviving and get back to thriving as a specialty. They are delegation, technology, and systems. 1. Delegation: We need to delegate to others (including computers) things that we currently do but that others can do equally, legally, and maybe even technically better. 2. Technology: We need to embrace technology that makes us not only better but also more efficient and can be used to enhance the experience of our patients while in our practices. 3. Systems: We need to develop systems that allow us to incorporate delegation and technology to the maximum possible without losing quality while enhancing the experience of patients we have the privilege to serve. Simple principles — but powerful! Given the state of orthodontics today, we need to look for things that “give us an edge.” Those that would replace us cannot compete with our diagnostic skills as true specialists. However, that is not nearly enough. Today, to compete, we must offer consumers a level of service they cannot and will not find in the corporate models. This is the key to our future. Technology can save the day and our profession. In recent years, I have had the honor and great fortune to be invited to speak Volume 10 Number 2

* See the full independent Clinicians Report at


# $500


# $500


# $500

Air/Water Disposable Syringe Tips Also available in White!

1600 pieces/box

Pointed Polisher

Tapered Brush

• Ideal for heavy stain removal • Great for ortho cleanings • Provides access under ortho wires and around brackets.

• Ideal for heavy stain removal • Great for ortho cleanings and applications • Provides access to oclusal pits and fissures




ORTHODONTIC PERSPECTIVE internationally on breakthrough technologies that accomplish the goals outlined previously. In my busy practice, these breakthroughs have allowed us to differentiate even as we provided improved care with less inconvenience to our patients. Here is what we have done.

The future In our practice with three locations, we have cone beam (CBCT), lasers, the latest computer innovations, and we use SureSmile® and Invisalign®. I believe in all of these technologies. But there are two technologies that have given us an unprecedented level of convenience, comfort, and clinical control. They are remote monitoring and accelerated orthodontics. If anything can differentiate a practice, it is convenience. Patients and parents want what can get them to “the promised land” in the fewest number of months, the fewest number of office visits, and with the least inconvenience. The office that can provide these consumer conveniences is the winner in the competition for patients. The practice that offers this can charge a premium fee for its services, as consumers will pay more for what they perceive as superior. Convenience is the number one differentiator for consumers — our patients. Remote monitoring Imagine a world where an orthodontist can remotely monitor treatment of any patient. They can be anywhere, and the doctor can be anywhere. The patient need only come to the office for necessary treatment appointments. Imagine the value proposition to patients of full, exceptional treatment in less than 10 appointments with braces and less than six with aligners. Think of the value to the practice! What will this yield in productivity? (What have I taught for decades?) What could this mean to your profitability? Could this be a key to competing on price? There is a company that offers remote monitoring. That company is Dental Monitoring. This is not a pipe dream. It is real. It is accurate. It works. I have been using this technology in my practice for over 2 years. How does it work? Artificial intelligence! Accelerated orthodontics I have studied and used accelerated orthodontics for many years. After accumulating hundreds of cases of hands-on experience using their products, I’ve found a company offering accelerated orthodontic technology that works very effectively for my 60 Orthodontic practice

Patients and parents want what can get them to “the promised land” in the fewest number of months, the fewest number of office visits, and with the least inconvenience. purposes and my patients’ lifestyles and clinical needs. The company that offers this technology is Propel®. Their products require minimal clinician, staff, or patient training, and they have in-office and at-home treatment options. They can be used independently, or in combination with each other. My main objective with using them isn’t simply to move teeth faster; rather, it is to move them better. High-frequency vibration (VPro+) operates at a very specific frequency and g-force specifically developed for dental purposes. The patient bites on a wafer that vibrates. It runs for 5 minutes and shuts off. We’ve observed the following benefits in our practice: • For aligner cases, the ability to prevent unseats is far superior to “chewies” and other methods we’ve tried. This is verified in our Dental Monitoring reports. • For braces and aligner cases, patients are consistently reporting less discomfort with VPro+ use. • Accelerated tooth movement. This is very easy to quantify with our remote monitoring service. We are witnessing verifiable aligner tracking

and predictably advancing aligners in 4-day intervals without modifying treatment velocity. Micro-osteoperforations (MOPs) is based on 100-year-old science behind the corticotomy technique. We expand the maxilla in a high percentage of our growing patients. Expansion offers the opportunity for reduced extraction, fuller smiles, better nasal respiration, and even Class II correction. The dilemma is that adults cannot have their “palates popped” without surgery. We have been using MOPs in adults to expand the maxillary dentoalveolar process to create space, improve smile arcs, correct crossbites, torque roots, etc. It works, and it works well! Looking back at the simpler times of my early career, I’m humbled to have learned from you all, and to realize all that I’ve learned along the way. I look to the future with optimism and excitement. The market will continue to evolve, becoming increasingly complex and competitive. I believe practicing with these three principles as a guide will allow our profession to thrive and our care to improve. By combining specialty tools with specialty care that simplify today’s challenges we can stay ahead. Have a great career! OP Volume 10 Number 2

The 5th Annual MKS Forum is the LARGEST Orthodontic Business Event in the U.S. October 24-26, 2019 Hilton Anatole Dallas The 5th annual MKS Forum will once again focus on the business of orthodontics. Thousands of attendees return to MKS each year to learn new ways to increase their practice growth and profits. New technologies, new competitive marketing tools, new financial tools and better ways to provide enhanced patient care. Orthodontics is under siege from several angles and doctors learn how to thrive and win from their most successful peers. Don’t miss the MKS Forum 5th anniversary party, Thursday, October 24, 2019! Also join us for an exclusive Invisalign event prior to the MKS Forum, Thursday, October 24, 2019. AAO Some of the surprising learning experiences over the last four years of MKS: Special: Save $150 for Doctors • Why growth into multi-specialty destroyed a great orthodontic practice. & $100 for Teams. • How the largest practice in a state competes with Smile Direct Club and wins. Discount Code: • The doctor who generates $6,000,000 in annual production due to the brackets he chose. MKSMAY2019 • How one practice gets 1000+ new patient referrals from nearby pedodontist practices every year. • How a doctor with a practice, appraised at a value of 80% of collections, sold it for 3.5X collections. • Why dealing with your escheatment issues now rather than later could save you $1,000,000 or more.

MKS 2019 Featured Speakers Peter Kierl Orthodontist

500+ Doctors

Chip Fichtner Large Practice Sales

24 Speakers

Donna Galante Orthodontist

Michelle Shimmin Ortho Consulting

Keith Dressler Orthodontist

Ed Lin Orthodontist

50+ 12+ Vendors CE Hours

To exhibit to this exclusive group of orthodontists, contact Susie Snow at 305-998-9893, or visit


Built to Last. Built for You. Built by Boyd.


uilt to Last. Built for You. Built by Boyd” is more than a tagline; it signifies the commitment that everyone at Boyd makes to each and every one of our customers. Best known for the durability and reliability of our award-winning products — including treatment chairs, mobile storage, and clinical cabinetry — we combine over 60 years of design and manufacturing expertise to perfectly fit your unique space and personal style. We take great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can take pride in your office for years to come.  

Learn more about our featured products

The M3000LC Exam and Treatment Chair is Boyd’s most popular option among orthodontists, combining affordability, function, and a wide variety of practical features including all-steel frame construction, ergonomically designed winged back, lowvoltage DC motor actuators, integrated full function foot control, snap-on upholstery, and choice of seven headrest styles. What makes the MC3000LC perfect for your everyday use? Its motorized column base with 8" vertical lift allows the chair’s height to be adjusted for maximum ergonomic positioning, ensuring your comfort as well as your patients’ comfort.

Perfect for orthodontic consultation rooms, the award-winning M3010 Series Exam and Treatment Chairs’ synchronized drop-toe design provides your patients with the most natural seated position during consultations or minor exams. Like the M300LC, these chairs come standard with all-steel frame construction, ergonomic winged backs, integrated full-function foot control, and more. Enhance these chairs with Ultraleather Pro™ upholstery and Memory Foam cushioning for maximum comfort. To complement your exam and treatment chairs, Boyd offers 10 standard Delivery Unit models for chairside, rear, or concealed delivery. With a nearly limitless selection of laminate colors and grains, these units combine functionality, efficiency, and style. Choose standard or square back models, depending on your unique storage and space requirements. We recommend starting your search with the CSU-356 Delivery Unit, which offers ample storage in a unit less than 25" wide. The  BOS-279, Boyd’s most popular  Doctor/Assistant Seat, offers an ergonomic saddle seat, adjustable seat height and tilt, and a floating lumbar-support back. You’ll find a perfect fit with the seat’s wide range of possible adjustments. Like our patient chairs, Boyd’s doctor/assistant seats are designed with your long-term comfort and spinal health in mind.

Vincent Team Orthodontics in Sandy, Utah

Once you’ve chosen your seating and storage solutions, complete the picture with Boyd’s LED Exam Lights, which provide the latest in operatory light technology. Their cool, power-efficient, and reliable LEDs emit clear and natural white light for maximum visibility. Choose the C300 LED Exam Light for its clear and natural regeneration light technology, with an IR sensor with intensity up to 30,000 LUX and 95Ra rendering, three-axis head movement, and adjustable, sterilizer-safe hand grips. Choose the C500 Camera Exam Light for its built-in HD video camera, hands-free operation, selection of three different color temperatures, and more. The Boyd team has made every effort to create specialized products that are truly “Built for You.” These featured orthodontic products can be combined with Boyd’s custom clinical and office cabinetry — with nearly limitless combinations of color and print laminates — to create a fully cohesive office space. When you work with the Boyd team, we recognize your unique needs and offer the widest range of personalization options in the industry, so feel free to consult your sales representative about your specific needs. Call today, or request a quote online to get started! To learn more, visit us at www.boyd You can also follow us on Instagram and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. OP   This information was provided by Boyd Industries.

62 Orthodontic practice

Volume 10 Number 2


The SunClear advantage


ore and more patients are asking for aligners, but due to costly aligner lab fees, many are forced to decline treatment or go online for do-it-yourself aligners. Thanks to SunClear 3D aligner design software and manufacturing solution, digital orthodontics has now become more affordable. SunClear aligners are the clear alternative to expensive and overpriced aligner systems. • Save up to 50% on aligner lab fees. • High-quality aligners design-ready for approval in a matter of days after the impression has been received by the lab. Sun Dental Labs now offers a doctorsupervised state-of-the-art comprehensive treatment that is safe and effective. Once the necessary records are uploaded, a custom and personalized aligner plan is generated by our team. Then you can use the SunClear 3D orthodontic software to review, modify, and accept the plan. We can accept digital STL files from any intraoral or desktop scanner for aligner treatment. The device is customized for each patient and follows a prescription as submitted by the dentist.

What does the SunClear Aligner fee include? The fee includes a full-customized aligner plan, including any number of revisions until approved. There are no setup fees ($95 value), and a free set of retainers ($99 value) is included. There is also one free refinement included during treatment. The base fee includes up to 20 aligners/trays, and only $15 per aligner above 20 aligners. We will charge your credit card when the case is completed and shipped out.

How does the process work? The process is the same as with traditional vendors. To create an account using the Google Chrome browser, please access; toward the bottom of the page there is a link to create your SunClear Account. On this page, you will fill out your practice information, and you will receive an emailed response back with your portal login information. Once

you receive your login information, using the Google Chrome browser again, you can log into your SunClear Account. This is where you will be able to enter patients and create cases for them by uploading their records, including a panoramic X-ray, digital models (if applicable), and the patient photos. Once the patient information is entered with the treatment objectives, we will create a treatment plan for you to approve using the information that was provided to us. Once the treatment plan is created, you will be able to share the simulated tooth movement with the patients enabling them to see how their teeth will look once treatment is completed.

The straight talk Poorly aligned teeth can put extra stress and pressure on your teeth and jawbone, which can cause: • Receding gums and gum disease • Chipping and wearing of teeth • Food traps, bad breath, and difficulty flossing • Jaw pain and headaches • Sleep apnea It’s easier to brush and floss around properly aligned teeth, and you are less likely to have pockets between gums and teeth that trap bacteria and food that may cause plaque, decay, and bad breath. Properly aligned teeth reduce plaque, tooth decay, and the risk of gum disease. Now thanks to SunClear aligners, patients who were previously unable to complete an aligner plan due to cost or complexity can enjoy the health benefits of aligned teeth. OP This information was provided by Sun Dental.

Volume 10 Number 2

Orthodontic practice 63


Planmeca Creo™ C5 High-Speed 3D Printer


any 3D printers being used in dental offices today were originally made for other uses by designers who had little to no experience or background in the dental industry. Planmeca has been a dental manufacturer for over 45 years with numerous digital workflows. Stepping into the additive 3D-printing market was a natural progression. Planmeca Creo™ C5 is a high-speed 3D printer to help you complete your

digital workflow. Planmeca Creo C5 is custom-engineered for dental professionals and specified for use in high-speed printing of surgical guides and dental models. Planmeca Creo C5 uses LCD Photomask Technology to create a uniform layer of light that virtually eliminates imperfections when printing. LCD technology is more accurate and has a faster build speed than other Digital Light Projection (DLP) systems making Planmeca Creo C5 one of the fastest 3D printers currently on the market. Planmeca Creo C5 delivers extraordinary precision and impeccable resolution under 50 microns. The capabilities of this revolutionary high-speed printer include a surgical guide or a dental model in less than 15 minutes, and printing up to five full arches in one print.

Ease of use As with all Planmeca products, Planmeca Creo C5 is open so you can work with STL and PLY files for a seamless experience when completing your digital workflow. An easyto-use touch display with pre-programmed settings and medically approved resin cartridges makes Planmeca Creo C5 simple to operate. Materials for Planmeca Creo C5 come in convenient resin cartridges that eliminate waste. The capsules ensure that the valuable resin inside is always utilized efficiently. This compact, self-cleaning 3D printer does not require calibration — just plug and print.

Applications Planmeca Creo C5 offers high-speed printing to support your specialty procedures regardless of whether you are printing dental models for a treatment plan or performing implant surgery. Planmeca Creo C5 guides you through every step to reach the optimal resolution so you can provide better care for your patients.

Features Key product features of Planmeca Creo C5 include: • LCD Photomask Technology — provides a uniform light source by layer to reduce distortion and better 64 Orthodontic practice

print quality for higher resolution and precision • Resin cartridge — cartridge dosing of medically approved resins eliminates excess waste of costly resins • No calibration needed — plug-n-play • Touch display — easy-to-use display with pre-programmed material settings • Open STL and PLY files — most commonly used file formats by CAD programs for seamless integration • Compact design — small footprint for desktop use • Self-cleaning For more information about the Planmeca Creo C5 High-Speed 3D Printer, visit OP This information was provided by Planmeca.

Volume 10 Number 2

have a big impact. At Planmeca, we’ve built our solutions on the smallest details.

Planmeca ProMax® 3D

imaging and low dose radiation for patient safety

Jaw motion technology for real-time visualization of mandibular jaw movements in 3D

Fast and accurate full arch scanning including automatic bite alignment

Orthodontic software for digital dental models including clear aligners, indirect bonding, Bolton analysis, and measurements Planmeca Romexis® 3D Ortho Studio

The small things form the big picture – delivering treatment and care your patients deserve. Learn more about Planmeca products today.


© Planmeca U.S.A. Inc. 2019. All Rights Reserved

Planmeca Emerald™




few years ago, an orthodontist approached EverSmile® at a trade show and asked if we could develop a product that would enhance patients’ brushing while wearing fixed orthodontic appliances. We had already developed an aligner and tooth cleaner called EverSmile WhiteFoam, which was a big success with aligner patients, but had never thought about a product to enhance the cleaning efficiency of toothpaste and mouthwash. Dr. Michael Florman, our research and development specialist, decided to take on the challenge. Knowing that oral hygiene issues with braces patients was one of the top problems facing the orthodontic profession, he began testing formulations that would achieve a list of the following objectives: 1. Safe for children of all ages since the majority of patients wearing braces are children; 2. Effective by killing bacteria and breaking down biofilm; 3. Used with toothpaste and/or as a booster to toothpaste by enhancing toothpaste’s cleaning characteristics; 4. Able to fight gingivitis associated with patients wearing braces; 5. Last but not least: Taste good and be fun for kids to use. Dr. Florman began gradually testing various low levels of hydrogen peroxide on patients wearing braces, and found that he was able to increase the percentage of hydrogen peroxide close to 4% without any patients experiencing tooth sensitivity or negative soft tissue effects. At this level of hydrogen peroxide, Dr. Florman noted decreased plaque around brackets and wires,

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Volume 10 Number 2

OrthoFoam step-by-step instructions Brushing Dispense 1/2 to 1 full pump of foam inside the mouth or on your toothbrush. Brush teeth for up to 60 seconds. Spit out foam, and rinse mouth with water. Can be used as a stand-alone cleaner/whitener or in combination with any fluoridated toothpaste. Add OrthoFoam to your toothbrush (with toothpaste), or pump directly into your mouth as you brush. Rinsing Dispense 1/2 to 1 full pump of foam inside mouth and swish for up to 60 seconds. Then spit out foam, and rinse mouth with water. In trays (custom or disposable) Dispense 1 or 2 full pumps of foam into trays, and apply to teeth for 3 minutes. Stand over sink during treatment, spitting out excess foam. Do not swallow. After 3 minutes, rinse with water. Repeat once or twice daily. Trays are available at

Get in touch To learn more about EverSmile® products, get free patient coupons (available at CVS), or to place an order, visit doctors. with the passcode “orthofoam” to enter our Doctor’s Portal. Or you can send us an email at info@ever, or give us a call Monday through Friday 8 a.m. to 6 p.m. Pacific time at 855-595-2999. OP This information was provided by EverSmile®.

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improved gingival health, and tooth whitening over and under the composite resin used to affix the brackets, as compared to a control product using 1.5% hydrogen peroxide with the same surfactants and cleaners. In a retrospective study that Dr. Florman performed on aligner patients with composite resin attachments (buttons), using the formula in EverSmile’s WhiteFoam, it was noted that teeth whitening occurred even under the attachments. OrthoFoam was soon launched in the dental market in 2017. OrthoFoam allows patients to brush with the product alone, or in conjunction with their favorite toothpaste. OrthoFoam can also be used as a therapeutic mouth rinse alone and can be placed into custom or foam trays for patients to apply at home on a daily basis. Doctors who use OrthoFoam report that after 4-6 weeks of use, a noticeable plaque reduction is noticed with improvements in gingival inflammation and reduction in gingivitis.

INDUSTRY NEWS Dr. Carl Gugino receives Dawson Academy Lifetime Achievement Award Great Lakes Dental Technologies (formerly Great Lakes Orthodontics) is pleased to congratulate its co-founder, Dr. Carl Gugino, for receiving the prestigious Dawson Academy Lifetime Achievement Award in recognition of his significant contributions to the dental profession. The award was presented at the January 2019 Dawson Airway Symposium in Saint Petersburg, Florida. Dr. Gugino graduated in 1953 from the University of Buffalo School of Dentistry. He established a local practice and eventually specialized in orthodontics in 1961. Dr. Gugino co-founded Great Lakes Orthodontics with Peter R. Breads in 1967. After years of expansion, the team eventually sold the company to its employees. Dr. Gugino currently serves as a member of the Great Lakes Dental Technologies Board of Directors and belongs to numerous American and European societies of orthodontists, has practiced orthodontics exclusively, and held lectures on this subject throughout the world. Dr. Gugino is the author of the next-generation Bioprogressive™ Philosophy, ZeroBase Orthodontics™, which combines treatment planning and diagnosis into time-efficient treatments. Dr. Gugino also developed the first computerized cephalometric and visual treatment objective program available in orthodontics, and his patient management and teaching philosophies are used by practicing orthodontists around the globe. For more information, visit

Carestream Dental expands its global leadership team Carestream Dental has welcomed Greg Marko as its new global chief marketing officer as part of its ongoing commitment to transforming dentistry, simplifying technology, and changing lives. In this role, Marko will drive global marketing strategy and product promotion across all Carestream Dental’s regions. Marko joins Carestream Dental with a robust healthcare/medical device background. Most recently, he served as a leader within Johnson & Johnson Vision. Previously, he was the vice president of marketing at National Vision and served as a marketing director for Asia-Pacific and North America at Transitions Optical in both Singapore and the United States. Marko is a graduate of Florida State University and the Masters of Leadership Strategies and Strategic Marketing programs (PPG with the Katz Graduate School of Business) and is fluent in both English and Hungarian. For more information, call 800-944-6365, or visit www.

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3Shape TRIOS® now integrated with 3M™ Clarity™ Aligners 3Shape TRIOS® users can now submit their digital scans to the 3M™ Oral Care Portal for treatment planning and delivery of its Clarity Aligners™. The portal integration enables professionals to cloud-send their 3Shape TRIOS intraoral scans with just a click to the Oral Care Portal. Clarity Aligners join the more than 50 orthodontic treatment solutions, sleep device providers, and 500-plus bracket libraries integrated with the 3Shape TRIOS intraoral scanner. Before sending 3Shape TRIOS intraoral scans to 3M for Clarity Aligner production, professionals can take advantage of the 3Shape TRIOS Treatment Simulator app to first excite their patients and promote acceptance of the proposed treatment. Using the app, professionals can show onscreen the envisioned results of the orthodontic treatment. 3M’s portal is web-based, HIPAA compliant, easily accessible from anywhere, and supports treatment for aligners, combination treatment, and retainers. Orthodontists using the 3M Oral Care Portal have access to its updated toolset, which displays 3-dimensional, cross-sectional views of the teeth, with and without overlays. Key to ensuring treatment success, the workflow further enables patient progress scans at each treatment step. These scans show how well the patient is tracking to the treatment, and they allow the orthodontist to refine a treatment plan if the patient isn’t tracking according to plan. For more information, visit or

G&H Orthodontics all smiles with announcement of John Voskuil as CEO G&H Orthodontics, provider of clinical solutions for the orthodontic community, announced the appointment of John Voskuil as Chief Executive Officer. He joins G&H with more than 20 years of experience delivering solutions to patients and doctors in the dental and orthodontics industry. Prior to G&H, Voskuil held a number of senior leadership positions at Dentsply Sirona and earned a Bachelor of Science in Industrial Technology Management from the University of Wisconsin-Platteville and an MBA from Northern Illinois University. For more information, visit

Volume 10 Number 2

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Orthodontic Practice US March/April 2019 Vol 10 No 2  

Orthodontic Practice US March/April 2019 Vol 10 No 2  

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