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clinical articles • management advice • practice profiles • technology reviews Spring 2021 – Vol 12 No 1 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS How LightForce and digital appliances are transforming orthodontics Drs. Alfred Griffin and Maz Moshiri

Company profile Who we are: 3DISC

A protocol for inverting upper incisor brackets Dr. Chad Foster

Practice profile Drs. W. Keith Harvey and B. Carter Thomas




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Pandemic startup practice — how we survived and thrived

Spring 2021 - Volume 12 Number 1



f someone were to tell me a year ago that I was going to open a startup orthodontic practice in the middle of a pandemic, I would never have believed it in a million years. Here we are, 6 months into our practice, and we can reflect back on all of the challenges we faced, and what has set us apart. We could have let the overwhelming circumstances own us and bring us down, but we didn’t. Being a startup, we had no choice but to embrace the challenge. We encouraged parents to get their children started with treatment while they were out of school and sports, offering a COVID-19 friendly environment with only a few families in the office at a time. Marketing was targeted through social media and created Miriam Hall, DMD a large increase in adult patients, wanting braces or aligners, who were previously self-conscious and could now hide it with masks. “When is a better time to consider fixing your teeth than when you are wearing masks for the unforeseeable future?” The staff and I gave out custom Hall Orthodontic masks ordered through Rafael Nadal to every patient and parent — our walking brand on people’s faces. I designed our modern and tech-advanced clinic, built by Boyd Industries, with each side unit fully equipped and organized for every type of appointment, making the clinic much more efficient. Our utilization of technology with cloud-based Wave software has allowed us to become a patient-centric practice with convenient online scheduling, virtual consultations, electronic new patient forms, and texting communication capability. Our iTero® scanner and SprintRay 3D printer offer an entirely digital and impression-less workflow. We use the iTero scanner during every new patient appointment and effectively improve patient conversion by showing the patient simulation and the changes that would be made possible with treatment. After using alginate for several years as an associate, going completely impression-less was the best decision that we have ever made. Parents who once had braces are always impressed and thankful for the technology because the appliances fit perfectly every single time. This new technology has allowed us to completely eliminate a band-fit appointment since the NEOLab indirectly fits the bands for us. As a mother of four young children, I found it difficult to travel to advanced continuing education courses and would often ask the lecturers if the courses were recorded. COVID-19 has disrupted the traditional on-site conferences and has forced us all to embrace virtual learning. From treatment-coordinating courses to advanced learning courses, these platforms are now at our disposal from the comfort of our homes. We took advantage of this during the pandemic to ensure we were staying current on the latest technologies to offer the best care for our patients. I cannot stress enough the importance of showcasing your orthodontic work. For years, I diligently took records and stored every single type of case treatment and created a portfolio book for both referring dentists and our waiting room and consultation rooms. The portfolio book has allowed us to show patients and parents what a finished case would look like with confidence. It includes the most complex and beautifully finished cases, and we have even given every dentist in the area a copy of the book. The response exceeded my expectations, and it has given dentists the confidence to refer to our practice when they didn’t even know me. In the midst of the unforeseeable future, we must look within ourselves to find what sets us apart, always putting our best foot forward and always, as author Stephen Covey says, “Begin with the end in mind.” Miriam Hall, DMD, received her dental training at the University of Pennsylvania in Philadelphia and was inducted into the Omicron Kappa Upsilon and the Matthew Cryer National Dental Honor Societies in 2008. She furthered her education in the specialty of Orthodontics at the University of Pennsylvania and received her postdoctoral specialty certificate in Orthodontics in 2010. Dr. Hall was honored by being published in the American Journal of Orthodontics. Her publication is entitled “Effects of Rapid Palatal Expansion on the Sagittal and Vertical Dimensions of the Maxilla.” Dr. Hall thrives to stay up-to-date on the latest technology and advancements in orthodontics, and she opened Hall Orthodontics in June of 2020. Outside of the office, Dr. Hall spends her time with her husband, Tom, and four children: Jacob, Mila, Easton, and Renna. She was captain of her women’s soccer team at Lafayette College and enjoys coaching her kids’ soccer teams. Dr. Hall remains an avid runner and loves to stay active to keep up with her kids and busy schedule. She loves to cook for her family and share the culture in which she was raised. Dr. Hall is an active member in the community and has made it her mission to give back to the community in which she serves.

Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth 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

© MedMark, LLC 2021. 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 12 Number 1

Boyd Industries’ award-winning operatory equipment for the orthodontic industry is designed to ensure comfort for both your patient and you. With workplace efficiency and comfort in mind, Boyd has introduced our latest operatory chair: M3000LS. Our newest chair is identical to our most-loved M3000LC but starts 2.5” lower and reclines nearly 40% faster, making it more ergonomically effective and efficient for all of your office staff. Additionally, this new seating position makes it easier for your smaller patients to get in and out of with ease.

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TABLE OF CONTENTS Publisher’s perspective Renewed energy in 2021 Lisa Moler, Founder/CEO, MedMark Media................................8

A conversation with ... Alfred Griffin, DMD, PhD, MMSc and Maz Moshiri, DMD, MS, FICD


Company spotlight Smile Stream Solutions — Everything you need to create a beautiful smile.........................16

Two orthodontic trailblazers discuss how LightForce and digital appliances are transforming orthodontics

Company profile Who we are: 3DISC ....................................................... 18

Continuing education Evaluation of adverse physiological events during Invisalign® treatment: part 1

Practice profile W. Keith Harvey, DMD, and B. Carter Thomas, DMD Doing the right thing for the right reasons


Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi explore the literature regarding clear aligners as compared to traditional braces..............................................19 ON THE COVER Cover image courtesy of LightForce Orthodontics. Article begins on page 10.

4 Orthodontic practice

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TABLE OF CONTENTS Technology The InBrace™ system: a new category of treatment Dr. Hany Youssef discusses a new lingual braces system with increased efficiency and profitability..................32

Product spotlight Knowing more means doing better Suzanne Wilson discusses how Gaidge prepares for a successful and profitable future for orthodontic practices..........36

Product profile Boyd Industries — featured orthodontic products................ 37

Continuing education A protocol for inverting upper incisor brackets


Dr. Chad Foster illustrates a technique for patients with moderate-to-severe crowding or protrusion

Technology/case study Patients gain early rotation correction and improved torque control Dr. Michael Bicknell discusses how harnessing advancements in technology can satisfy core values and lead to improved patient experiences, simplification of treatment, and improved clinical outcomes.............38

Industry news............... 43 Going viral Practice development Virtual patient monitoring Dr. Christopher Cosse discusses how virtual patient monitoring can bring efficiency and convenience to the orthodontic practice........................ 44

Is your orthodontic practice a target for cybercriminals in today’s COVID-19 workplace? Cybersecurity expert Mark Pribish says that awareness of data breaches is imperative in today’s technologically active practice.................................46

www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

6 Orthodontic practice

Volume 12 Number 1

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Renewed energy in 2021

Published by


o here we are in 2021. While the challenges of 2020 have not completely disappeared, we can definitely see healing and hope on the horizon. Personally, I am energized — looking forward to seeing all of you at in-person conferences and meetings, setting new goals, and finishing some that were put on hold. What does this mean for MedMark and all of its publications? Since we thrive when you thrive, it means that we need you to share all of your thoughts with us. During the pandemic shutdowns, what ideas did you have for improving your office procedures and your clinical protocols when you returned? What are you doing to make those plans into actions? How are Lisa Moler Founder/Publisher, MedMark Media you focusing your renewed energy into more thriving practices? What were your challenges, and how are you going to make your practices more resistant to future forces that can get in the way of forward movement? We want to be the publication that brings you new techniques, cutting-edge technologies, innovative products, and articles that start conversations about how your dental talents can change lives for the better. Because of our readers, people overcome life-threatening sleep disorders, teenagers can smile without being self-conscious, and adults can obtain some orthodontic, implant, and endodontic treatments that weren’t even an option when they were teens. As we discover and spotlight new products and techniques, patients will not think of their dentist as just doing a root canal or implant but as being synonymous with healing and overall good health. In this issue of Orthodontic Practice US, Dr. Chad Foster’s CE explores a protocol for inverting upper incisor brackets. Part 1 of our CE by Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi compares physiological effects of Invisalign® and traditional braces on patients. Subscribers can take the quizzes to obtain 2 credits each! “A Conversation with...” column features Drs. Alfred Griffin and Maz Moshiri discussing their views on how technologies like LightForce’s 3D-printed tooth-moving tools and aligners fit into the contemporary orthodontic practice. Our article by Dr. Chris Cosse on virtual patient monitoring is especially relevant in these times when virtual consultations and virtual exams have already received so much attention. We greet 2021 with so much hope, ideas, and energy. The MedMark team is ready to help you reach positive goals that exceed your expectations. With articles written by experienced and knowledgeable dental leaders and advertisements from technology and service leaders that involve all areas of dentistry, we aspire to be part of your healing, a source of your inspiration, and a vehicle for your success! All the best, Lisa Moler Founder/Publisher MedMark Media

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com WEBMASTER Mike Campbell webmaster@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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Alfred Griffin, DMD, PhD, MMSc and Maz Moshiri, DMD, MS, FICD Two orthodontic trailblazers discuss how LightForce and digital appliances are transforming orthodontics


rs. Alfred Griffin and Maz Moshiri share their views on aligners and the customized, 3D-printed tooth-moving tools provided by LightForce. Dr. Alfred Griffin (AG): Maz, you are easily one of the foremost authorities in the aligner world. I’ve been in the audience for your lectures for over half a decade now. I’ve been looking forward to this conversation. Dr. Maz Moshiri (MM): Thanks, Alfred. I’ve been equally as impressed with your vision to improve our profession. Your foresight has been incredible with regards to customizing braces within the digital workflow. My experience with the system has been amazing so far.

Beyond aligners AG: As someone steeped in the aligner world, where does LightForce fit into your practice? MM: I was waiting for brackets with a truly digital workflow to mirror my aligner workflow. Consistency in our practice is Alfred C. Griffin III, DMD, PhD, MMSc, is the cofounder and CEO of LightForce Orthodontics, a digital platform providing orthodontists with fully customized, 3D-printed tooth-movement tools. Dr. Griffin received his BS in Biochemistry from the University of Virginia and completed his DMD and PhD in Craniofacial Biology at the Medical University of South Carolina in 2014. He earned his Masters of Medical Research and Certificate in Orthodontics from the Harvard School of Dental Medicine in 2017. In addition to leading LightForce, Dr. Griffin practices in the Boston area and teaches at Harvard School of Dental Medicine. Dr. Griffin, along with Lou Shuman, DMD, founded LightForce Orthodontics in 2015 with the mission to revolutionize the specialty through advanced manufacturing and technology. After 4 years of extensive research and development, LightForce launched its first product to the orthodontic market — the world’s first and only fully customized 3D-printed bracket system and digital treatment software. Learn more at www.lightforceortho.com. Maz Moshiri, DMD, MS, FICD, maintains his private practice in St. Louis, Missouri, alongside his father and sister. In addition to leading multiple Ask the Expert webinars, Dr. Moshiri was a lead educator for Class II Kit solutions for Invisalign and the Deep Bite Solutions of Invisalign G5. He is an Assistant Clinical Professor at the Saint Louis University Center for Advanced Dental Education, where he teaches with a clinical focus on the use of Invisalign. Dr. Moshiri is a Diplomate of the American Board of Orthodontics and Fellow in the American and International College of Dentists. He is the founder of the Aligner Intensive Fellowship, a 17week online course that teaches orthodontists how to properly treatment plan with aligners.

10 Orthodontic practice

very important to me. I feel like it makes me a much better orthodontist to see the treatment plan on a screen. I can really visualize things much better when they’re magnified. Combine the digital workflow with the unmatched level of customization, and it was a no-brainer.

Finding your practice’s Zen AG: Talk about your journey to finding balance in your practice as it relates to business and clinical efficiencies. MM: First, as a practice owner, I’m constantly thinking about monitoring those things. Looking back, our practice was getting busier, and we needed to take some of the load off of our lab because it was labor intensive to do indirect bonding with our lab technician. Second, not surprisingly, I didn’t like carrying stock bracket inventory. To be honest with you, when 3M™ stopped supporting SmartClip™, I could not receive some of my variable torque brackets. Thankfully, the switch was a seamless and enjoyable transition. LightForce plugged right into our workflow without increasing duress or time spent within the practice.

An end-to-end digital practice AG: Most of us have a digital and an analog workflow depending on the tool we’re using for that patient. In your hands, what is the best workflow for your patients/ outcomes? MM: I feel like I’m actually a better orthodontist digitally. It makes me see things in 3D spatial relation better. LightPlan, LightForce’s Treatment Software, gives me a simulation of how the teeth are moving. I can start anticipating anchorage needs, visualize how teeth are predicted to fit together, and overall see the beginning with the end in mind. Being able to see the finish, along with the ability to anticipate things happening along the way, provides me with the main advantages of digital treatment planning. Furthermore, a nice advantage with LightPlan is that it is generally accepted faster than clear aligner plans with regards to doctor time.

Dr. Alfred Griffin, upper left, and Dr. Maz Moshiri, lower right

We scan a patient in, confirm with our TC that this is a LightForce patient, and then seamlessly transition into a LightPlan. Within no time at all, I’m able to make any changes I need. The simplicity is fantastic. It’s not as nuanced as it would be in terms of having an Invisalign technician because I’m not worried about AI and/or what attachments I’m getting, among other things. We know every tooth has a handle on it, which decreases the need to anticipate push surfaces for movement or anchorage.

It’s just braces AG: Great point — for a new fixed appliance system to add value to a practice, it should reduce your time spent as much as possible — the nice thing about LightPlan and braces is that we’re able to leverage their biomechanical efficacy to minimize doctorcompany cycles. This obviously impacts lead time, a doctor’s time, and ultimately patient scheduling. So now that you’ve experienced digital brackets and aligners, are there any major deviations in your practice or lab workflow? MM: It’s been great. The doctor’s time spent detailing brackets on the model for traditional indirect bonding is now translated into digitally placing the brackets in the digital realm, which has the added advantage of substantial diagnostic tools to further aid in treatment planning. Of course, the decreased strain on our in house lab has been a significant added bonus. This has seamlessly integrated into our digital workflow, which we were so accustomed to due to the high level of Invisalign that we have historically provided. Volume 12 Number 1

AG: One of the reasons why we placed so much emphasis on the indirect bonding process is because we believe it’s the linchpin in any custom system. How do custom brackets change the indirect bonding experience? MM: We’re all striving to have the right bracket in the right spot. For example, it defeats the whole force system if you don’t have the aligner attachment in the right spot. I’ve been amazed by LightTrays, LightForce’s 3D printed jigs. In my opinion, they are printed beautifully. I think “foolproof” might be a strong word because it indicates it’s at 100%, but with the combination of custom bases and this IDB tray, it’s near spot-on like a lock in key. You’re getting that bracket in the right spot every time, whether that’s on FA point or not.

United systems unite teams AG: At LightForce, we think a lot about the whole system — not only the brackets, but also the software, the IDB tray, and bite turbos. Everything should work better if it’s all designed to meet a common clinical goal. MM: Agreed! We see that with the indirect bonded turbos. Before LightForce, I was personally having to reposition the lower brackets quite a bit to open up the bite more to accommodate deep bite correction during leveling in order to adjust for the thickness of the bracket. Having custom-designed turbos for a given IDB setup minimizes so many of these workflow issues. We routinely use them to disclude posterior teeth and add elastics to open deep bites with LightForce.

The Sarver school of esthetics AG: A mentor I know we both share is Dr. David M. Sarver. He was probably ahead of his time in addressing the importance of esthetics when the orthodontic world was obsessed with occlusion. How important is the face and smile arc in your setups? MM: It’s everything. My traditional approach to treatment planning is to plan the custom the torque prescription based on our cephalometric analysis to address any compensations or decompensations I’m aiming to provide for any given patient. Then, when I pull up the patient’s smile photo, I’m carefully looking at the upper incisors. I’m looking at the position relative to the lip, and that’s affecting my whole setup in terms of bonding. That dictates how the lower incisors are going to go because I have to make room for what just happened on the upper. Dr. Sarver taught me that. I was a big Sarver supporter starting back in residency, reading everything he put out there. It was all ahead of its time, but very relevant. Volume 12 Number 1

Face mapping the future MM: Regarding esthetics, it’s been fascinating being a beta tester of the Face Map technology, the new software feature from LightForce. I’ve enjoyed collaborating with LightForce engineers, designers, and product managers. AG: Thanks, it’s the accumulation of a lot of discussions with LightForce users like you, Drs. Sarver, Waldman, Wheeler, Nobrega, and Shuman, my dad, and so many others. I believe firmly that our close partnership with our user community, orthodontists, is part of our secret sauce as a company. We’re all taught that a key component of smile arc depends on the upper incisor’s vertical position and torque, which are both tough to achieve at the same time with existing appliances. Fully custom braces enable such movements predictably and in concert. Now with Face Map, you get a better diagnostic tool to even further improve smile arc plans and outcomes. For those readers that don’t know, Face Map allows orthodontists to use their phone or tablet to scan a 3D model of their patient’s face, which gets stitched to their intraoral scan, and then the doctor can use that extra diagnostic information to treatment plan for the most precise esthetic outcome from all facial angles without a crazy expensive 3D-photometry machine. MM: One of the biggest things I’ve been excited about is actually seeing how different my setup is with Face Map. I thought I was setting everyone up for smile arc properly; however, the difference has been eyeopening. Without Face Map, I’m just doing my best by looking at the patient’s smile photographs and comparing them to the floating model. That was the way it was done.

But now with Face Map, it’s awesome. It’s just so different, in terms of seeing how much more I’m actually extruding the upper teeth to get them to touch the lower lip, which affects my bracket position. It also affects what’s happening on the bottom arch. That’s what we want. We want to give patients the eye-popping smile that they came to us for. I’ve also been amazed at how popular this 3D-scanning feature has been with patients. The act of scanning their face and explaining how it will improve their treatment really resonates and helps differentiate our practice. When we show patients their actual face on a LightPlan, it becomes very clear these braces and our treatment plan are only for them.

Map your face MM: Alfred, I’m sure a lot of people would love to see Face Map in action. I know you’re currently in beta testing, but is there a way any orthodontist reading this can see it for themselves? AG: We are in beta testing right now with a select group of LightForce providers; however, our team does have a short demo of the technology, which you can access at www.lightforceortho.com/facemap AG: Maz, thanks for taking the time to speak with me and for being an essential part of LightForce’s growth and development. MM: Thank you, Dr. Griffin, for the work you and your team are doing to push the specialty forward. It’s been nice to work with a company that really listens to orthodontists and has the prowess to make enhancements. I’m excited about where LightForce is going. OP This information was provided by LightForce Orthodontics.

Orthodontic practice 11


Bonding with indirect bonding


W. Keith Harvey, DMD, and B. Carter Thomas, DMD Doing the right thing for the right reasons


rs. W. Keith Harvey and B. Carter Thomas operate three orthodontic practices in Mobile, Alabama. All locations have six clinic chairs with two treatment consultation rooms and a records area. They have a staff of 23 with approximately 11 administrative and 12 clinical assistants. This practice is more than 50 years old. Dr. Harvey joined Dr. Fred Cushing in 1986 and worked together for 10 years before Dr. Cushing retired. Dr. Harvey worked by himself for 20 years, and then Dr. Thomas joined him in 2015.

What can you tell us about your background? WKH: I was born in Mobile, Alabama, as an only child in a blue-collar family. My mom was a registered nurse, and my father was a mechanic. BCT: I was born and raised in Mobile, Alabama, as the youngest of three boys. My father is a pediatric dentist, and my mother was one of the sweetest and toughest ladies I’ve known. I had loving parents who taught me the value of family and hard work.

When did you become a specialist, and why?

Drs. Keith Harvey and B. Carter Thomas

WKH: I became a specialist in 1986. I loved the problem-solving nature of orthodontics and its life-changing effect on patients. BCT: I became a specialist in pediatric dentistry in 2013 and orthodontics in 2015. In dental school, I enjoyed treating younger patients and became very interested in growth and development, changing faces, occlusion, beauty, and facial esthetics. Orthodontics is fun and attractive from a problem-solving and mechanical standpoint.

Why did you decide to focus on orthodontics? WKH: I am analytical and a problem solver. I also love the fact that you can establish long-term relationships with patients and families. BCT: I enjoy the analytical aspect of orthodontics. Every patient is a new puzzle to solve. Orthodontics can have such a positive impact on people’s lives. I love the relationships I get to form with patients and their families. 12 Orthodontic practice

Harvey & Thomas Orthodontics Snow Road office clinic area Volume 12 Number 1

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PRACTICE PROFILE Do your patients come through referrals? WKH and BCT: Most of our new patients come through word-of-mouth referrals from their pediatric or general dentist, or from existing or former patients. Some find us through online searches.

Professionally, what are you most proud of? WKH: I am most proud of having the opportunity to teach at the orthodontic graduate level at the University of Alabama at Birmingham (UAB). BCT: The lifelong relationships with my team and our patients in the community.

How long have you been practicing orthodontics, and what systems do you use? WKH: I have been practicing for 34-plus years. We use the Damon™ System in clear and metal as well as various clear aligner systems. BCT: I’ve been practicing for 5½ years. We use the Damon System, Invisalign, and Spark aligners.

What training have you undertaken? WKH: I am a graduate of the Louisiana State University (LSU) School of Dentistry

Orthodontic Specialty Program and have taken years of continuing education courses. BCT: I am a graduate of the Tufts University School of Dental Medicine Orthodontic Specialty Program. When it comes to continuing education, I most frequently attend the Damon Forum and the Southern Association of Orthodontics conference. I have really enjoyed furthering my clear aligner education with a series of different courses put on by Dr. Regina Blevins and Dr. Barry Glaser. I love Dr. Stuart Frost’s stuff and whatever course he is lecturing. My partner, Dr. Harvey, was a Damon mentor for several years, and working with him gave me hands-on training within our practice. I am in a number of online orthodontic groups — I love those!

Stuart Frost, Giorgios Kanavakis, Moon Young Lee, Carl Carlamari, and Charlie Ruff. Personally — my wife, my late mother, my father, and Jesus Christ.

What do you think is unique about your practice? WKH: The way we value our patients and our amazing staff! BCT: I think our focus on clinical excellence as well as the atmosphere you feel when walking in our office is refreshing and fun, which is kind of unique in healthcare.

What is the most satisfying aspect of your practice? WKH: The relationships we form are the most satisfying. BCT: The relationships I have with my team and with my patients.

Who has inspired you? WKH: Dr. Jim Bordelon, Dr. Dwight Damon, and Dr. J.M. Chadha BCT: Professionally — Dr. W. Keith Harvey (partner), plus Drs. Todd Bovenizer,

Harvey & Thomas Orthodontics Snow Road office exterior

Drs. Harvey and Thomas with their staff of administrative and clinical assistants 14 Orthodontic practice

Volume 12 Number 1


Dr. Thomas with his family

Dr. Harvey with his family

What has been your biggest challenge? WKH: Treating children with a cleft lip or palate. (Editor’s note: Dr. Harvey is an active member of the Cleft Palate Team in South Alabama, where he and Dr. Thomas serve as their only orthodontists.) BCT: Building an amazing team. Like most businesses, managing people. While that is one of our greatest challenges, I think it is one of our greatest successes. Our team is incredible!

What would you have been if you did not become a dentist? WKH: I would have been a fighter pilot or a musician. BCT: I may have started a business right after high school … maybe HVAC … it’s mechanical, helps folks, and it’s hot down here!

What is the future of orthodontics and dentistry? WKH: The future of orthodontics is bright. We live in a very self-aware world where there is a lot of emphasis on self-improvement. BCT: The future for orthodontics and dentistry is bright. We have an obligation to maintain the highest quality of treatment by serving patients in person — being the beacon of excellence as specialists. The technological advances with braces and clear aligners is amazing, and it’s allowing us to provide treatments never before possible in orthodontics. It’s a fun time! Volume 12 Number 1

Drs. Harvey and Thomas’ top favorites • Cloud 9 Software • Damon™ System (Damon Q2 and Ultima Braces) • Invisalign® • Spark™ clear aligners • uLab aligners • iTero Element® 3 scanner • EnvisionTEC 3D printer • i-CAT™ FLX 3D • Vatech 2D imaging • Spectralase Soft Tissue Laser • Reliance Orthodontics Bonding and Ortho-FlexTech • Gaidge Impact360 Dr. Thomas and his wife, Amelia, boating

What are your top tips for maintaining a successful specialty practice? WKH: Stay up-to-date, provide outstanding customer service, and hire great people. BCT: Serve your patients with the highest level of care and customer service. Produce beautiful smiles. Take care of your team.

What advice would you give to a budding orthodontist? WKH: Always do the right thing for the right reason. BCT: Finding a mentor outside of your local bubble to be able to bounce ideas around is very important. Become part of some orthodontic group, whether it be online, like Facebook, or in person. Sharing and asking questions are what helps us learn constantly. Invest in yourself and have fun at work!

Dr. Harvey and his wife, Ashley, traveling abroad

What are your hobbies, and what do you do in your spare time? WKH: I spend my spare time hunting, fishing, and playing guitar. My wife, Ashley, and I love to just hang out with our family. BCT: I have three kids under 5, so most of my time outside of a busy practice is spent with them and my beautiful wife. I love spending time with my babies, boating, and deer hunting. I love gathering at the beach/ bay with family and friends. OP Orthodontic practice 15


Smile Stream Solutions — Everything you need to create a beautiful smile

Our History Smile Stream Solutions, Inc. is a privately owned company that started as a strategic sourcing supplier to some of the largest single- and group-orthodontic practices in the country. By delivering extremely high value and an exceptional customer experience, Smile Stream Solutions grew and is now positioned and prepared to expand its model to the greater dental market.

Our Mission At Smile Stream Solutions, we believe our best customer is a vital customer — informed, efficient, profitable, and fortified against risk. However, we also see our responsibility as one to the greater Orthodontic-care-providing community as well.

Our Value Proposition Our Value Proposition rests upon four pillars that, together, directly supports our

Our mission is to enhance the vitality of the orthodontic community through savings and efficiencies in clinical supplies. Traditional braces for the modern age

Mission. These pillars also serve as symbols of every product, service, and Best-in-Class partnership we procure, and secure, for You. In this way, we see ourselves serving as a Strategic Supplying Partner in the growth of Your business.

Products – Services – Partnerships Everything you need to create beautiful smiles can be sourced from Smile Stream Solutions, from traditional braces for the modern age, to the most comprehensive aligner platform in the marketplace. What’s even better is that we afford you access to all of the products and information you need 24/7, from any device, and from anywhere in the world, all through our e-commerce website. And if you want a human touch, 16 Orthodontic practice

we have a staff of RDA Certified Account Managers and Sales Agents who are ready to support you and ensure that you have an exceptional experience. But we haven’t stopped there. Beyond our core product lines, we have also assembled what we call our Value-Added Partnership Group to serve as Best-In-Class providers of key products and services. Together, we are able to afford you access to the latest information, technology, and materials with the highest level of convenience and savings. In this way, we collectively strive to provide solutions that further enhance the vitality of your practice. This Value-Added Partnership Group is led by our recent acquisition of OrthoEssentials, a fullservice provider of high-quality, high-value Volume 12 Number 1


advanced, automated solutions for printing, polishing, marking, packaging & labeling.


GT FLEX clear aligner material 100-sheet box

orthodontic products with a relationshipbased approach to doing business that is consistent with our own core values. From there, we recognized the need for greater control and security over your businesses most critical processes and assets. This is why we partnered with CureMint, Inc.®, the most advanced e-procurement enterprise solution available, topsOrtho practice management software that significantly increases workflow efficiencies while reducing exposure to spyware and ransomware driven outages, and The Fortune Law Firm, whose legal and financial services team can consult with you on asset management and liability mitigation best practices. Next, we developed the most comprehensive Aligner Services platform in the market with our Stream Ligners brand; as under the Stream Ligners umbrella, you have a single point of sourcing for everything from Aligners to Retainers, to Thermoforming Plastics, to Aligner Sterilization and Cleaning supplies, to Aligner Instruments, Accessories and Personal Care. This all reinforced further through our exclusive and preferred distribution rights of Good Fit Technologies’ GT-Flex thermoform plastics,

DB Orthodontic’s Ixion Instruments, and Steraligner’s family of hygiene products.

They Smile. You Smile. We Smile. At Smile Stream Solutions, we are all about positive treatment outcomes and the self-esteem and self-confidence that comes from a beautiful smile. We know that when your patients smile, it makes you smile. And when you’re smiling, we’re then smiling too. Moving forward, Smile Stream Solutions will remain committed to the orthodontic care providing community, and the patients who seek treatment from it. This through the distribution, innovation, and partnerships that then deliver quality, efficacious, and high value products and services to you every day. For more information regarding Smile Stream Solutions, Stream Ligners, OrthoEssentials and our Value-Added Partnership Group, and all other information or events, please go to our completely redesigned website at www.smilestream solutions.com. OP This information was provided by Smile Stream Solutions.

Ixion instruments

Desktop and mobile friendly website for easy ordering

Volume 12 Number 1

Orthodontic practice 17


Solutions that enhance the vitality of your practice.


Who we are: 3DISC

Company overview Founded in 2007, 3DISC started off as an R&D company but quickly matured into an agile American manufacturer and global provider of digital-imaging solutions for dental practices. Fourteen years later, 3DISC is a privately owned company with headquarters based in the United States and France with a diverse team of digital experts curated from a variety of high-tech backgrounds for one mission — to pioneer the digital dentistry landscape of tomorrow. Our goal is to deliver relevant clinical benefits to doctors through inclusively digital solutions, specifically intraoral scanners. When dental clinics choose 3DISC, they’re taking digital beyond; they can trust our commitment to the continuous innovation of our solutions that will help bring simplicity to their workday and empower doctors to provide the highest quality treatment to their patients. That’s why we created the Heron IOS.

Solution overview The Heron™ IOS is a digital 3D-imaging solution bringing simplicity to the beauty of

18 Orthodontic practice

“The Heron has arrived, and it has set a new bar for all other scanners. The choices among optical scanners have become vastly overwhelming. In its inception clinicians demanded quality scans and simplified workflow. The Heron from 3DISC not only has those qualities but is unsurpassed in ergonomics and accessibility. Finally, we have a comfortable lightweight scanner that feels like it belongs in the palm of your hand.” – Isaac Tawil, DDS, MS your work as a medical professional. One of the most ergonomic and easy-to-use scanners on the market, the Heron weighs in at 150 grams with a compact, streamlined design for more efficient scanning and increased patient comfort. For an allinclusive price, the Heron IOS is presented as a turnkey solution that takes less than 10 minutes to unbox and set up — including a pre-calibrated scanner, three autoclavable tips, and optimized acquisition PC equipped with HeronClinic Software. Using the HeronClinic Software, your team can easily navigate the intuitive, user-friendly interface to meet all your restorative, orthodontic, and implant needs. With clear workflows and a cloud platform, the Heron IOS makes it easier than ever to create or browse patient cases, scan, and share with your labs. Our team is committed to providing superior service and support, so you can trust that when you introduce a Heron IOS into your practice, we will be there providing thorough in-office training as well as a variety of online resources. Our optimized acquisition PC automatically deploys software

updates as they are released to ensure that you always have the latest as well as instant remote access capabilities when you have questions or need help.

Why go digital? Digital impressions have a number of advantages over traditional techniques. The increased accuracy of a digital impression results in fewer lab remakes and better-fitting crowns and appliances. Intraoral scanners (IOS) are also faster and more cost-efficient for users, while being less intrusive and uncomfortable for patients. Traditional impression taking methods may be triedand-true, but the reliability and performance intraoral scanning for digital impressions have increased dramatically in recent years. Switching to intraoral scanning has never been easier or more reliable than it is today. The Heron IOS is a fast and easy-to-use system that provides reliable and accurate results every day — take advantage of this technology in your own practice today. OP This information was provided by 3DISC.

Volume 12 Number 1

Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi explore the literature regarding clear aligners as compared to traditional braces Experimental hypotheses Based on an extensive review of the literature, the experimental hypotheses state that 1. Patients being orthodontically treated with Invisalign® experience less discomfort than patients being treated with traditional fixed appliances. 2. Patients being orthodontically treated with Invisalign experience fewer issues with periodontal health than patients being treated with traditional fixed appliances 3. Patients being orthodontically treated with Invisalign experience fewer issues with caries/demineralization periodontal health than patients being treated with traditional fixed appliances

Bridgette Jones Brooks, DMD, is a graduate of Spelman College with a Bachelors’ degree in Psychology. She attended East Carolina University School of Dental Medicine where she obtained her Doctorate of Dental Medicine and then completed a General Practice Residency at Mountain Area Health Education Centers. She completed her orthodontic training at the Georgia School of Orthodontics where she received a certificate in Orthodontics and Dentofacial Orthopedics. She currently practices in the metropolitan Atlanta, Georgia, area. Bryan Keith Blankenship, DDS, is an alumnus of The Ohio State University (DDS) and Bachelor’s and Master’s degrees in Microbiology. He is a graduate of the Georgia School of Orthodontics (Class of 2020). Dr. Blankenship currently practices orthodontics in Palm Coast, Florida. Jared Stasi, DDS, earned a Bachelor of Science and his dental degree from Creighton University. He received a certificate in Orthodontics and Dentofacial Orthopedics from the Georgia School of Orthodontics (Class of 2020). Dr. Stasi currently practices orthodontics in Centennial, Aurora and Silverthorne, Colorado. Disclosure: None of the authors has any financial interest in Invisalign® (Align Technology Inc.).

Volume 12 Number 1

Educational aims and objectives

This article aims to study the differences in discomfort, periodontal health, or caries/ demineralization experienced by patients who are being orthodontically treated with Invisalign® as compared to traditional fixed appliances.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 23 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize some basic benefits and challenges of clear aligner and braces orthodontic treatment.

Realize what some studies have found regarding orofacial pain/discomfort with clear aligners or traditional braces.

Realize what some studies report regarding maintain an appropriate level of oral hygiene with either clear aligners or traditional braces.

Identify some challenges in avoiding dental caries and demineralization when using clear aligners or traditional braces.

Purpose/abstract The aim of this study is to review the appropriate literature concerning adverse physiological events experienced by patients being treated with Invisalign appliances and comparing this literature to that of patients’ adverse physiological events when undergoing fixed orthodontic appliance therapy.

Introduction/literature review Invisalign removable orthodontic therapy was introduced in 1999 and serves as an alternative to traditional fixed orthodontic appliances. Invisalign claims to improve esthetics and to be more convenient for patients by allowing aligners to be removed during eating and drinking.1 Patients treated with Invisalign have reported greater satisfaction during orthodontic therapy2 and fewer negative impacts on their lives during the initial stages of their orthodontic treatment.3 As more adults are seeking orthodontic treatment, the popularity of clear aligners as a substitute for fixed orthodontic appliance therapy has increased.4 With the advent of Invisalign therapy, there has been a parallel increase in research regarding Invisalign treatment. Initially, research was done primarily in the areas of treatment efficacy, effectiveness, and oral hygiene.5 Significant research on the gingival

outcomes using Invisalign has also been conducted and evaluated.6 Studies have found varying psychosocial effects of Invisalign treatment.7 Few studies, however, have evaluated adverse effects of Invisalign use, including the effects of Invisalign treatment on patients’ perceptions of pain and impacts on systemic health. In 2007, Allareddy, et al., conducted a comprehensive literature search of the Manufacturer and User Facility Device Experience (MAUDE) database (U.S. Food and Drug Administration) for pertinent medical reports associated with Align Technologies products. They found that there were 173 medical device reports from 2006-2016. Forty-five (26%) of these reports dealt with adverse physiological events associated with Invisalign therapy, and the nature of these events ranged from irritation of the tongue and lips to anaphylactic reactions.8 In recent years, Invisalign continues to introduce new products into the market, including Invisalign® First. Invisalign First is Phase 1 orthodontic treatment specifically targeting patients aged between 6 and 10 years.9 As this technology will begin to impact more of the consumer market, it seems logical and appropriate that more research is needed regarding possible complications that can be associated with Orthodontic practice 19


Evaluation of adverse physiological events during Invisalign® treatment: part 1

CONTINUING EDUCATION Invisalign treatment, especially side effects such as those highlighted in the Allareddy, et al., study. Based upon informed consent and risk/benefit patient education presented by the dental practitioner prior to treatment, it then becomes the educated responsibility of the parents/patients to determine which treatment modality may be best suited for themselves and their children. Parameters, including pain experienced while undergoing treatment, changes in periodontal health, and caries experienced during treatment, will need to be thoroughly explored prior to the consumer making the best treatment modality decision.

Orofacial pain/discomfort Orofacial pain encompasses many facets of pain in the head and neck region. It occurs within the trigeminal complex and encompasses dental pain (odontogenic), and hard tissue and soft tissue pain.10 With orthodontic treatment, patients are most likely to experience odontogenic pain. This pain is defined as being derived from the teeth and/or its supporting structures.11 Inflammatory mediators are released when orthodontic forces are applied. These mediators not only aid in tooth movement, but also are associated with a pain-like sensation perceived by the patient. The perception varies among subjects, but in general, it has been described as beginning within a few hours of orthodontic treatment being initiated, peaking after 1 day, and subsiding within 7 days.12 Pain perception can vary among individuals relative to factors such as gender and age, but adolescents (ages 14 to 17) reported more severe pain during orthodontic treatment when compared to preadolescents (ages 11 to 13) or adults (ages greater than 18).7 Most studies have focused on pain reported after separation of teeth for orthodontic banding or the bonding of traditional fixed orthodontic appliances.7,12 With the increased use of clear aligners, studies have also begun to compare pain experienced with Invisalign versus traditional fixed appliances. In a study of 60 adult orthodontic patients, Miller, et al.,4 found that significantly less pain was associated with Invisalign than with traditional fixed appliances during the first week of treatment. They also found that patients treated with Invisalign reported taking less pain medication during the first week of treatment than the fixed orthodontic appliance group. In another study, Shalish, 20 Orthodontic practice

et al., compared patients’ perception of recovery from pain/discomfort in the first few days after insertion of lingual fixed orthodontic appliances, or traditional fixed orthodontic appliances and Invisalign appliances. However, in this study, Invisalign patients not only reported more severe pain compared to patients with labial fixed appliances, but also reported the lowest level of oral symptoms.13 Fujiyama, et al., noted in a study of 145 cases that Invisalign may result in less pain/ discomfort than fixed orthodontic appliances during initial stages, but care must be taken to avoid deformation of the Invisalign trays that could result in pain and discomfort.14 As mentioned earlier, many of the studies investigating pain/discomfort in Invisalign treatment and fixed orthodontic appliance treatment have targeted the early or initial phase of treatment, but few studies have targeted pain incurred during different time points during orthodontic treatment. White, et al., conducted a randomized prospective trial in which patients received orthodontic treatment with Invisalign or with traditional fixed appliances. They assessed patients during the week after bonding, and again after the first and second monthly adjustment. They found that patients being treated with fixed orthodontic appliances had more pain in the first week than the Invisalign group, and there were similar findings for subsequent adjustments with the Invisalign group experiencing less pain than the fixed group.15

Periodontal health As more teenagers and adults are beginning to use Invisalign for their orthodontic

treatment, more research is being done on the impact of Invisalign therapy and patient periodontal health and hygiene. Traditional fixed orthodontic appliances may make it more difficult for patients to maintain an appropriate level of oral hygiene. Periodontal health can be measured using many different parameters, including oral hygiene, bleeding on gingival probing, gingival inflammation, plaque index, gingival index, biofilm mass, papillary bleeding, and others.16 Miethke, et al., reported that patients treated with Invisalign may not have an increased risk of negative periodontal effects despite the trays remaining on the teeth throughout the day and night (exceptions are meals and sports) and cover both the teeth and gingiva.6 Azaripour, et al., studied the impact of treatment appliances on hygiene, periodontal health, and quality of life.2 Patients’ periodontal health and oral hygiene levels were assessed before and during orthodontic treatment with either traditional fixed appliances or Invisalign. Upon final assessment, there was a significant difference in the increase in bleeding and gingival inflammation when the traditional fixed appliances group and Invisalign group were compared with the Invisalign group demonstrating better gingival health. Rossini, et al., also sought to determine if clear aligner treatment has negative effects in periodontal health. They conducted a systematic review of the literature and were able to use five studies in their meta-analysis of the data to help answer this question. The results of the studies suggested that there were significantly less plaque, less bleeding on probing, better probing pocket depths, less plaque Volume 12 Number 1

Parameters, including pain experienced while undergoing treatment, changes in periodontal health, and caries experienced during treatment, will need to be thoroughly explored prior to the consumer making the best treatment modality decision. patients’ dental health if a significant consumption of these fluids occurs during Invisalign in the absence of adequate dental and gingival cleansing resulting in an increase in acid-producing plaque.20 While it is standard operating procedure to instruct patients in proper oral hygiene and in avoidance of wearing the trays while eating or drinking, patients are too often noncompliant to these suggestions, and the resultant side effects concerning dental and gingival health can become problematic. Several articles have shown the effects of caries and demineralization with clear aligner appliances.21 Nontypical areas of decalcification generally cleansed with saliva, such as cusp tips and incisal edges, have been associated with higher caries indices when aligners are worn during food and drink consumption.22 Regardless of the appliances used in orthodontic therapy, patient education is a must especially in high-caries risk and poor oral hygiene patients.

Dental caries and demineralization

Interproximal reduction (IPR): adjunct in Invisalign therapy and its impact upon oral health

Since their inception in orthodontic treatment, it has been touted that clear aligners (Invisalign) are more hygienic than fixed orthodontic appliances. The ease of removing the trays during treatment for oral hygiene purposes is a major consideration. However, the evidence for clear aligners being more hygienic or caries-preventive has never been demonstrated. The design of the aligners prevents the normal, self-cleansing salivary flow, thus preventing the natural cleansing and remineralization of teeth.2 Addition of composite attachments to the Invisalign trays may provide an increase in caries index and demineralization areas of the patient especially since the trays are designed to be worn for approximately 22-23 hours per day. Cariogenic, sugar, and carbohydratebased drinks can significantly affect the

Interproximal reduction (IPR), also known as interproximal enamel reduction (IER), involves removing enamel from the interproximal surfaces of teeth. This technique provides an alternative to extraction treatment by allowing for reduction of tooth mass and the resultant increase in interproximal space23 and is a technique frequently used during Invisalign treatment. Both anterior and posterior teeth may be designated for IPR, with as much as 7 mm of total interproximal reduction possible in the posterior teeth (premolar and first molar region) and another 2.5 mm of reduction in the anterior teeth (cuspid to cuspid). It also has been suggested that IPR can reduce treatment time by removing the exact amount of tooth structure needed to resolve crowding in cases where it is used.24 IPR can be done

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using several techniques, including air-rotor stripping (ARS) with diamond or carbide burs, handpiece-mounted diamond discs, and motor- or hand-driven interproximal diamond strips. Some have suggested that IPR abrades the enamel surface of the designated teeth, resulting in dental surfaces that are more susceptible to plaque and bacterial accumulation.25 Different IPR instruments have been found to produce different amounts of enamel surface abrasion, with diamond burs creating the roughest surface and diamond discs creating the least abrasion (as measured by nanotopography).26 Polishing is a strategy that is used to reduce this surface roughness and reportedly restores the tooth to a surface that is smoother than untreated enamel.24 Several authors have studied the risks of IPR on caries formation and ways to mitigate this risk. Twesme, et al., found that there was an increase in demineralization of tooth structure when IPR was performed using an air-rotor device, but when topical fluoride was applied after the procedure, the penetration of the lesion was diminished.27 Several other studies determined that there is not an increased caries risk associated with IPR.23,24,25 To summarize, IPR as an adjunct in Invisalign therapy is a viable non-extraction procedure, but the clinician must be judicious in its use so as not to result in patient pain, discomfort, or reduction in acceptable periodontal and dental health.

Materials and methods A variety of methods and materials were used in the selected studies for this systematic review. Many studies of orofacial pain have utilized self-report questionnaires 4,7,12,13,14,15 and visual analog scales12,14,15 in the assessment of pain, while others had patients completed a diary of their experience with the fixed orthodontic appliances and Invisalign trays. When assessing periodontal Orthodontic practice 21


biofilm mass, and better gingival index and papillary bleeding in the clear aligner groups when compared with the fixed appliance groups.16 Another periodontal assessment during Invisalign therapy and fixed orthodontic appliance therapy involves plaque biofilm levels. Low, et al.,17 found no significant difference in amounts of plaque biofilm among clear aligner wearers throughout their treatment when compared to fixed orthodontic appliance therapy patients. Levrini, et al., reported significantly different amounts of plaque biofilm between the Invisalign and fixed orthodontic appliance groups and also significantly different levels of bacteria in the plaque biofilm between the two groups, with the traditional fixed orthodontic appliance group having higher amounts of periodontal disease-causing bacteria in the biofilm.18 When comparing different fixed orthodontic appliance therapies relative to periodontal health parameters, self-ligating brackets have been reported to accumulate less plaque than elastomeric (rubber elastic) ligated traditional fixed appliances. Chibber, et al., studied the differences among the self-ligating brackets, Invisalign, and elastomerically ligated traditional fixed appliances and their effects on gingival index, papillary bleeding index, and plaque index.19 They found that although there were short-term significant differences between gingival index and papillary bleeding index between the clear aligner group and the self-ligating group and the elastomerically ligated group, there were no long-term significant differences between the three groups after 18 months.

CONTINUING EDUCATION changes, clinical examinations were often performed using various indices, including plaque index, gingival index, bleeding on probing, papillary index, periodontal bleeding index, and periodontal probing depths.2,6 Several studies were structured as clinical trials with differing levels of blinding and controls.18,19 Other studies analyzed the aligners or aligner materials directly using Polymerase Chain Reaction and Scanning Electron Microscope,17,18 and one study used a systematic review for comparison of the two different orthodontic treatment modalities.16 Caries and demineralization were often assessed using radiographs and clinical examination of patients who had undergone IPR in the past.23,24,25 For some of the in-vitro studies, extracted teeth were treated with IPR directly and demineralization was simulated in the lab.26,27

of all participants in these 5 studies are female (199 female). The follow-up time of patients after the procedure in these studies ranged from 1 to 14 days. Periodontal health outcomes (periodontal health) were measured in these studies by using plaque index, gingival index, bleeding on probing, papillary index, periodontal bleeding index, and periodontal probing depths. Caries21, 24, 25, 26, 27 A total of five studies addressed the issue of caries. Among these one study is a case report, one study followed patients longitudinally, and one study involved radiography and imaging. A total of four studies used adult patients, and two studies utilized premolars. The sample sizes in these studies ranged from 40 to 61. The age of the sample of patients selected in these studies ranged

from 19-70 years of age. A total of 60% of all participants in these five studies are male (126 patients). A total of 40% of all participants in these five studies are female (83 patients). The follow-up time of patients after the procedure in these studies ranged from 1 to 10 years. Caries were measured per radiographic assessment. Part 2 of this article will continue with the Discussion and Findings of the studies and some conclusions regarding orofacial pain, periodontal health, and caries/ demineralization.

Acknowledgments The authors would like to extend their appreciation to Dr. Harish Parihar (the biostatistician) and Dr. John Stockstill, Professor and Director of Dental Research at the Georgia School of Orthodontics, for their valuable guidance and contributions to this article. OP

Data analysis and results Orofacial pain4, 13,14,15 A total of four studies addressed orofacial pain. Among these four studies, all are prospective in nature, and all studies evaluated patients’ experience with the treatment longitudinally. All of the four studies used only adult patients. The sample sizes in these studies ranged from 41 to 145. The age of the sample of patients selected in these studies ranged from 18 to 60 years with a mean age of 28. A total of 32% of all participants in these four studies are male (67 patients ). A total of 67.6% of all participants in these four studies are female (140 patients). The follow-up time of patients after the procedure in these studies ranged from 1 to 60 days. Among those six studies, four studies used a self-reported questionnaire to understand the experience of patients and four studies used a visual analog scale to measure pain level experienced by patients. Periodontal health2,6,16,17,18,19 A total of six studies addressed periodontal health. Among these six studies two are a prospective cohort, one crosssectional study, one RCT by design, and one study is a systematic review of literature. All studies used adult patients. Three studies also utilized adolescent patients. The sample sizes in these studies ranged from 11 to 63. The age of the sample of patients selected in these studies ranged from 11 to 63 years. The average of the two studies reporting patients’ age means was 24 years old. A total of 41% of all participants in these 5 studies are male (135 male). A total of 59% 22 Orthodontic practice

REFERENCES 1. Phan X, Ling PH. Clinical limitations of Invisalign. J Can Dent Assoc. 2007;73(3):263-266. 2. Azaripour A, Weusmann J, Mahmoodi B, et al. Braces versus Invisalign®: gingival parameters and patients’ satisfaction during treatment: a cross-sectional study. BMC Oral Health. 2015;15:69. 3. Miethke R, Vogt S. A comparison of the periodontal health of patients during treatment with the Invisalign system and with fixed orthodontic appliances. J Orofac Orthop. 2005;66(3):219-229. 4. Miller K, McGorray S, Womack R, et al. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. Am J Orthod Dentofacial Orthop. 2007;131(9):302. 5. Gu J, Tang J, 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. 6. Miethke R and Brauner K. A comparison of the periodontal health of patients during treatment with the Invisalign system and with fixed lingual appliances. J Orofac Orthop. 2007;68(3):223-231. 7. Brown D, Moerenhout R. The pain experience and psychological adjustment to orthodontic treatment of preadolescents, adolescents, and adults. Am J Orthod Dentofacial Orthop. 1991;100(4):349-356. 8. Allareddy V, Nalliah R, Lee M, Rampa S, Allareddy V. Adverse clinical events reported during Invisalign treatment: Analysis of the MAUDE database. Am J Orthod Dentofacial Orthop. 2017;152(5):706-710. 9. Blevins, R. Phase I orthodontic treatment using Invisalign First. 2019. J Clin Orthod. 52(3):73-83. 10. Kandasamy S, Greene C, Rinchuse D, Stockstill J. TMD and Orthodontics. Springer International Publishing Company: New York, NY; 2016. 11. Renton T. Dental (Odontogenic) Pain. Rev Pain. 2011;5(1):2-7. 12. Sandhu S, Leckie G. Orthodontic pain trajectories in adolescents: Between-subject and within-subject variability in pain perception. Am J Orthod Dentofacial Orthop. 2016;149(4):491-500. 13. Shalish M, Cooper-Kazaz R, IvgiI et al. Adult patients’ adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign. Eur J Orthod. 2011;34(6):724-730. 14. Fujiyama K, Honjo T, Suzuki M, Matsuoka S, Deguchi T. Analysis of pain level in cases treated with Invisalign

aligner: comparison with fixed edgewise appliance therapy. Prog Orthod. 2014;15(1):64. 15. White D, Julien K, Jacob H, Campbell P, Buschang P. Discomfort associated with Invisalign and traditional brackets: A randomized, prospective trial. Angle Orthod. 2017;87(6):801-808. 16. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi C. Periodontal health during clear aligners treatment: a systematic review. Eur J Orthod. 2014;37(5):539-543. 17. Low B, Lee W, Seneviratne C, Samaranayake L, Hagg U. Ultrastructure and morphology of biofilms on thermoplastic orthodontic appliances in ‘fast’ and ‘slow’ plaque formers. Eur J Orthod. 2010;33(5):577-583. 18. Levrini L, Mangano A, Montanari P, Margherini S, Caprioglio A, Abbate G. Periodontal health status in patients treated with the Invisalign system and fixed orthodontic appliances: A 3 months clinical and microbiological evaluation. Eur J Dent. 2015. 9(30);404-410. 19. Chibber A, Agarwal S, Yadav S, Kuo C, Upadhyay M. Which orthodontic appliance is best for oral hygiene? A randomized clinical trial. Am J Orthod Dentofacial Orthop. 2018;153(2):175-183. 20. Moshiri M, Eckhart J, McShane P, German D. Consequences of poor oral hygiene during clear aligner therapy. J Clin Orthod. 2013;47(8):494-498. 21. Birdsall, J and Robinson, S. A case of severe caries and demineralization in a patient wearing an essix-type retainer. Prim Dent Care 2008. 15(2);59-61. 22. Sheridan, John J., et al. Avoiding demineralization and bite alteration from full-coverage plastic appliances. J Clin Orthod. 2001;35(7):444. 23. Zachrisson B, Minster L, Øgaard B, Birkhed D. Dental health assessed after interproximal enamel reduction: Caries risk in posterior teeth. Am J Orthod Dentofacial Orthop. 2011;139(1):90-98. 24. Jarjoura K, Gagnon G, Nieberg L. Caries risk after interproximal enamel reduction. Am J Orthod Dentofacial Orthop. 2006;130(1):26-30. 25. Zachrisson B, Nyøygaard L, Mobarak K. Dental health assessed more than 10 years after interproximal enamel reduction of mandibular anterior teeth. Am J Orthod Dentofacial Orthop. 2007;131(2):162-169. 26. Meredith L, Farella M, Lowrey S, Cannon R, Mei L. Atomic force microscopy analysis of enamel nanotopography after interproximal reduction. Am J Orthod Dentofacial Orthop.2017;151(4):750-757. 27. Twesme D, Firestone A, Heaven T, Feagin F, Jacobson A. Air-rotor stripping and enamel demineralization in vitro. Am J Orthod Dentofacial Orthop.1994;105(2):142-152.

Volume 12 Number 1



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 www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to orthopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260 To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. 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 medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Evaluation of adverse physiological events during Invisalign® treatment: part 1 BROOKS, ET AL.

1. Invisalign removable orthodontic therapy was introduced in 1999 and serves as an alternative to _______. a. traditional fixed orthodontic appliances b. retainers c. extractions d. orthognathic surgery 2. Invisalign claims to ________ by allowing aligners to be removed during eating and drinking. a. improve esthetics b. be more convenient for patients c. be slower but better d. both a and b 3. With orthodontic treatment, patients are most likely to experience ______. a. TMJ pain only b. odontogenic pain c. migraines d. self-esteem issues 4. The perception varies among subjects, but in general, it (orthodontic pain) has been described as beginning within a few hours of orthodontic treatment being initiated, _______. a. peaking after 1 day, and subsiding within 7 days b. peaking after 2 days, and subsiding within 4 days c. peaking after 1 day, and subsiding within 5 days

Volume 12 Number 1

d. peaking after 3 days, and subsiding within 10 days 5. Pain perception can vary among individuals relative to factors such as gender and age, but adolescents (ages 14 to 17) reported ______ during orthodontic treatment when compared to preadolescents (ages 11 to 13) or adults (ages greater than 18). a. less pain b. equal pain c. more severe pain d. slower tooth movement 6. Periodontal health can be measured using many different parameters, including oral hygiene, _______, gingival index, biofilm mass, papillary bleeding, and others. a. bleeding on gingival probing b. gingival inflammation c. plaque index d. all of the above 7. Regardless of the appliances used in orthodontic therapy, patient education is a must _______. a. only in older patients b. only for adolescent patients c. especially in high-caries risk and poor oral hygiene patients d. especially with newer patients


Both anterior and posterior teeth may be designated for IPR, with as much as _____ of total interproximal reduction possible in the posterior teeth (premolar and first molar region) and another 2.5 mm of reduction in the anterior teeth (cuspid to cuspid). a. 3 mm b. 4 mm c. 7 mm d. 10 mm


Different IPR instruments have been found to produce different amounts of enamel surface abrasion, with _______ (as measured by nanotopography). a. diamond burs creating the least abrasion and diamond discs creating the roughest surface b. diamond burs creating the roughest surface and diamond discs creating the least abrasion c. separating discs used to smooth the area d. carbide burs used to reduce roughness instead of diamond burs

10. To summarize, IPR as an adjunct in Invisalign therapy is a viable non-extraction procedure, but the clinician must be judicious in its use so as not to result in _______. a. patient pain b. patient discomfort c. reduction in acceptable periodontal and dental health d. all of the above

Orthodontic practice 23




A protocol for inverting upper incisor brackets Dr. Chad Foster illustrates a technique for patients with moderate-to-severe crowding or protrusion


stablishing proper labiolingual inclination of the upper anterior teeth is considered a high esthetic priority in orthodontic treatment. Significant crowding and protrusion of the upper anterior teeth are two of the more common motivating factors for patients seeking orthodontic treatment.1 The final antero-posterior (A-P) position and inclination of the maxillary anterior teeth play a major role not only in smile esthetics, but also in facial profile and the position of the lips.2 Achieving proper labiolingual inclination has even been shown to be more important esthetically than the A-P position of the anterior teeth.3 Treatment planning with this end in mind, particularly in cases with significant pretreatment crowding or protrusion, can be quite a challenge. The traditional orthodontic approach when significant crowding or protrusion exists involves creating space within the dental arch, which can then be consolidated to allow alignment of crowding or retraction of the proclined anterior teeth. Often this creation of space is achieved through a bicuspid extraction pattern. Other than creating arch length via extractions, there are various other methods at the orthodontist’s disposal in these types of cases. These include manually adjusting torque in the archwire, variable torque brackets, interproximal reduction, expansion of the dental arch, auxiliary torqueing springs, and others. Another technique that has been popular for some time is “inverting” incisor brackets (placing them upside-down) to reverse the prescription torque from positive to negative. Dr. Earl Johnson recommended this as

Chad Foster, DDS, MS, is a Board-certified orthodontist and owner of Butterfly Orthodontics in Phoenix, Arizona. A graduate of Chapman University, he earned his Doctor of Dental Surgery and a master’s degree in craniofacial biology, and completed his orthodontic residency at the University of Southern California (USC). Dr. Foster loves orthodontics and supporting his orthodontic colleagues. He is an avid reader, a prolific writer, and lectures internationally, most often on the topic of orthodontic esthetics. He serves as the Directing Editor of Orthotown magazine.

24 Orthodontic practice

Educational aims and objectives

This article aims to discuss “inverting” incisor brackets (placing them upside-down) to reverse the prescription torque from positive to negative.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 30 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the traditional orthodontic approach when significant crowding or protrusion exists.

Realize methods other than creating arch length via extractions when significant crowding or protrusion exists.

Identify the method of “inverting” incisor brackets (placing them upside-down) to reverse the prescription torque from positive to negative.

Realize that because of prescription requirements, when inverting brackets, the orthodontist must compensate in some way in order to achieve the intended tooth position.

Observe the setups referred to as “Inverted A” and “Inverted B.”

a technique to exert labial root torque when upper lateral incisors are blocked out to the lingual.4 Dr. Tom Pitts has coined the term “flipping” to refer to this technique when it is applied to the upper incisors as a group and has advocated its clinical use for many years.5 The protocol to be described in this article is submitted as a means to maximize the efficacy of inverting upper incisor brackets in cases exhibiting moderate-to-severe crowding or protrusion. This approach is most beneficial in cases where the orthodontist is on the fence between an extraction or non-extraction treatment approach, commonly referred to as “borderline cases.” An important note — while many of the concepts to follow are universal in application, the protocol discussed is specific to a traditional 0.022 rectangular slot appliance.

“Inverted A” versus “Inverted B” — understanding prescription consequences and compensations When inverting U2-2, an understanding of the prescription of these brackets is important. The straight-wire appliance, developed by Dr. Larry Andrews, relies on brackets designed to achieve precise, three-dimensional control of crown and root position.6 The prescription is specific and requires that each bracket is applied to the correct tooth in normal orientation. Brackets are not designed to perform with the same degree of

accuracy or control when they are inverted. Inverting brackets often comes with clinical consequences that require some type of compensation by the orthodontist in order to achieve the intended tooth position. Regarding tooth alignment, it is considered ideal for the upper central incisor crown to have slightly greater positive labiolingual inclination relative to the upper lateral incisor; hence, the greater positive torque prescription for U1 brackets versus U2 brackets. However, in an inverted setup where the upper incisor brackets are inverted on their correct teeth (U1s on U1s and U2s on U2s), the upper central incisors will now have a slightly stronger effective negative torque applied to them relative to the upper lateral incisors. I will refer to this, the most common inverted setup, as “Inverted A.” In my experience, this unfavorable relative torque discrepancy can become visually evident in larger dimensional wires. It might be hard to believe that this slight difference in torque would express itself, but the reason it does has to do with the archwire “engaging the low couple” of the inverted bracket (discussed in the next section), which effectively removes “slop” and works toward complete expression of prescription torque. The orthodontist’s compensation in an “Inverted A” setup is to either place very slight additional positive torque to the U1s or very slight additional negative torque to the U2s via third order adjustments to dimensional Volume 12 Number 1

Volume 12 Number 1

the slot of the bracket relative to the long axis of the tooth.

Understanding “low couple” activation in an inverted U2-2 bracket setup The following may harken back to physics class, but a refresher is helpful! A simple couple is a pair of equal and opposite forces whose lines of action do not coincide. These forces have a turning effect (moment) called torque, about an axis which is perpendicular to the plane of the forces. Simply put, torque is the turning effect that occurs when the corners (diagonal dimension) of the archwire engage a couple in the walls (also known as a lock point) of the bracket slot. When rotating the archwire within the bracket slot, larger dimensional wires will engage a high couple on one lock-point end range and a low couple on the other lock-point end range (Figure 1). When the corners of the archwire are engaging the couple, there is very little “slop,” and the prescription in the bracket will theoretically be expressed very accurately. You can test this out with a larger dimensional wire in the slot of an incisor bracket. At the top end or low end of where you can rotate the wire to simulate torque (Figures 1A and 1C), there is almost no “slop” or play in the wire in rotation (first order) or tip (second


order). But in between these high and low couple lock points, the corners of the wire do not fill up the slot, and there is excess first order and second order “slop” (Figure 1B). Understanding the following concept is key to understanding the activation at work in an inverted incisor setup. When a large enough dimensional archwire is inserted into inverted brackets on upper incisors that are excessively proclined (either because they started in this position or because alignment of significant crowding takes them to this position), the corners of the wire will engage the slot at the low couple lock point. This occurs when the degree of labiolingual inclination of the crown of the tooth is greater than the degree specifically limited by the low couple lock point (Table 1). In this scenario, the torquing moment is now active and will be expressed in tooth movement. Theoretically, the excessive labiolingual inclination of the tooth will be reduced until the degree limited by the low couple lock point is reached. In other words, the proclined tooth will rotate until it reaches the position allowed by the low couple at which point the torqueing moment is no longer active. In an inverted setup, the goal is to have the torqueing moment cease when the inclination of the tooth has been reduced to the desired position. Thus, targeting an endpoint that leaves the incisors in an ideal esthetic



Figures 1A-1C: 1A. High-end lock point. 1B. Between lock points. 1C: Low-end lock point

Table 1: “Inverted B” low couple lock point

Archwire size

Slot play in each direction

Maximum incisor inclination allowed (as limited by low couple lock point with inverted MBT U2 of 10 degrees)

Maximum incisor inclination allowed (as limited by low couple lock point with inverted Roth U2 of 8 degrees)

Maximum incisor inclination allowed (as limited by low couple lock point with inverted Andrews U2 of 3 degrees)

16X16 (0.018 slot)





14X25 (0.018 slot)





16X22 (0.018 slot)





14X25 (0.022 slot)





16X22 (0.022 slot)





16X25 (0.022 slot)





18X25 (0.022 slot)





19X25 (0.022 slot)





20X20 (0.022 slot)





Orthodontic practice 25


archwires. These adjustments can be in the form of wire bending or “bleeding torque” by very slightly reducing the corners of the rectangular wire in the area of the upper centrals with a handpiece. My preference when inverting U2-2 brackets is to place lateral incisor brackets on all four of the upper incisors. I will refer to this setup as “Inverted B.” I find this effective for two main reasons. First, while negative torque is the goal, the negative torque provided by the inverted U2 bracket is less likely to be excessive compared to the inverted U1 bracket. Expression of excessive negative torque is typically the most unfavorable risk of using an inverted setup. The fact that it is the lesser of the two negative torques also allows the setup to have a bit more range to advance into larger dimensional wires (18 X 25 and above,) which permits greater third order control of the U3-7 brackets, which are in normal orientation. An “Inverted B” setup still has a prescription consequence that requires compensation. While this setup has less of a third order (torque) consequence compared to an “Inverted A,” there is instead a first order error introduced that now needs to be compensated for. An U2 bracket has a greater labiolingual offset built into the base of the bracket to allow the facial surface of the lateral to be very slightly lingually positioned relative to the central for ideal tooth position. The compensation here is small first order bends to the archwire between the U1 and U2 to step the U1 slightly out toward the facial (an amount equal to the base depth difference between an U1 and U2 bracket). I personally find this compensation much easier than the torque compensation required in an “Inverted A” setup, and this is the second reason that I prefer “Inverted B.” Additionally, this very slight first order archwire bend has a beneficial collateral effect on the relative torque between U1 and U2. As with any first order bend, there will be a minimal collateral effect on torque. In this case, even though the inverted U2 brackets on all four upper incisors are delivering the same negative torque, the addition of the first order bend between U1s and U2s will result in slightly less negative torque applied to the U1s, which is closer to the ideal relative labiolingual inclination difference between these teeth. It is also important to note that there is a slight second order (tip) difference between an U1 bracket and an U2 bracket. This however is easily seen and compensated for in bracket placement when visualizing

CONTINUING EDUCATION position should be the goal. This has everything to do with selecting the right dimensional archwire. For perspective, Andrews states that the ideal crown inclination of an upper central incisor is 7 degrees.6 Another study found that an inclination of less than 5 degrees is relatively more preferable.2 Table 1 is a helpful guide to estimate the resulting labiolingual inclination of the incisors after an "Inverted B" setup has completed its activation. This theoretical endpoint obviously varies depending on bracket torque and archwire size. My reference for slot play in Table 1 is Earl Johnson’s article,4 which takes into consideration that wires are typically undersized, and slots are typically oversized. However, true slot sizes and wire sizes can vary greatly so these numbers should be used only as a theoretical guide. Additionally, throughout expression of the torqueing moment and also at its endpoint, there will be almost zero “slop” in the system in regards to rotation or tip. This means that any consequences in the altered (inverted) straight-wire prescription will also be equally well expressed. As previously discussed, in an “Inverted A” setup, the unfavorable relative torque differences between U1s and U2s will probably be observed within a few months. In an “Inverted B” setup, the unfavorable in/out relative position of U1s to U2s within will most likely be seen in a few months. Even slight archwire adjustments made to the upper incisors in this setup are likely to be well expressed in tooth position.

Archwire progression It is important for archwire progression in an inverted U2-2 setup to be strategic. Obviously, round wires will not engage a couple in either normal or flipped orientation. In cases with normal orientation, I most often use a three-wire sequence of 14N, 20N X 20N, and a third and final wire that may be anywhere from 16N X 25N to 19N X 25N in dimension and of either stainless steel or TMA. The 20N X 20N wire is used throughout the pano/repo appointment in normal orientation setup. In an inverted U2-2 setup, however, I will opt to use a 16N X 22N as the second (middle) wire in the upper arch instead of the 20N X 20N. I use the 16N X 22N wire here because in the flipped setup (assuming some degree of proclined incisors), it is large enough to allow the low couple lock point to provide acceptable first order and second order control for pano/repo purposes. Additionally, the 16N X 22N is small enough in dimension to not significantly engage the low couple. Generally speaking, I prefer to not significantly engage 26 Orthodontic practice

the low couple to produce the desired negative torque until after the pano/repo appointment is complete, and the patient is in more full size dimensional stainless steel wires. The reason for this is explained in the next section. If a different dimensional wire such as 20N X 20N or 16N X 25N were used as a middle wire in the inverted setup, the low couple would be more actively engaged.

Finishing wires and interproximal reduction (IPR) Reducing upper incisor proclination to establish ideal labiolingual inclination is typically the goal in an inverted U2-2 setup. In larger dimensional wires when the low couple is engaged, the moment created will begin to produce a combination of labial (positive) root torque and lingual (negative) crown torque. In an effort to tip the scales toward greater lingual crown torque, my preference is to not significantly engage the low couple until I have performed IPR in the upper arch. The interproximal space created prevents proximal contact binding between the anterior teeth as the torqueing moment is created, which allows a greater expression of the lingual crown torque component. In the absence of this space, the binding of the incisors at their contact points, below the incisors’ center of resistance, will allow a relatively greater degree of labial root torque. This is often less favorable depending on the amount of bone labial to the roots of the incisors within the alveolus. In anticipation of significant IPR (regardless of normal or inverted setup), it is important that the pano/repo is completed first. This is important for two reasons that have to do with posttreatment relapse. First, it is important that first order rotation issues are normalized so that the new interproximal contacts are as close to 90 degree abutments as possible. IPR done prior to this, when rotations still remain, are very likely to create angled contact points that are readymade for relapse of the original rotation. I call these “relapse contacts.” Second, if root position (tip/second order) is not ideal, and IPR contacts are created in this position, there is a tendency after treatment that these roots will naturally attempt to upright to their ideal positions, which could unfavorably alter the esthetic contacts of the anterior teeth. If early IPR prior to ideal alignment and root position is necessary, it is important to consider performing it again later once these issues are idealized. Following pano/repo, I will advance from the 16N X 22N to a 16 X 25 SS archwire

and perform IPR. Depending on the case, IPR will be performed from U2-2, U3-3, or U4-4 depending on the amount of protrusion present. My preferred IPR tool is a 0.3 mm rigid coarse disc in a slow -speed handpiece. Additionally, unless there is excess overjet present, I will typically perform IPR in the lower arch at the same time. One key concept to keep in mind is that while the low couple moment is active, do not run out of overjet! While the moment is active, if the upper incisors are in contact with the lower incisors (preventing lingual crown torque), there will obviously be relatively greater labial root torque expressed. If further retraction is needed, and if the micro-esthetic tooth form allows for additional IPR (larger barrel or triangular shaped incisors), I will perform a second IPR session. Two factors are considered in regards to how much IPR should be performed. First, I do not like to appreciably compromise micro-esthetic tooth form, so I will do less on smaller teeth. Second, I will not remove more than 50% of proximal enamel,7 which varies depending on tooth size, but typically not exceeding .75 mm at each contact point of the lower incisors (slightly more at upper incisors) as recommended by Sheridan.8 An additional tactic when further reduction of protrusion is needed is to progress to a larger archwire to create a stronger moment from greater low couple engagement. From a 16 x 25 wire this progression is most often to an 18 X 25 SS or 19 X 25 SS. If progression into a larger dimensional wire is indicated, it is important to monitor the patient closely to make sure that the roots of the upper incisors do not violate the labial aspect of the alveolar housing. This is an active appliance, and if the patient is not seen for an extended period of time while in larger dimensional wires, there is risk of overcorrection and periodontal consequences. This is why, except for select cases, I often do not progress past a 16X25 dimension archwire. The best way to monitor root position is with CBCT sectional images, but palpation of the upper anterior alveolus and cephalometric radiographs can help in this regard as well. Once the ideal labiolingual inclination is achieved, the moment producing the torque can be deactivated by reducing the size of the archwire or by “bleeding torque” off the wire by lightly reducing the corners of the wire in the U2-2 area with a high speed. In certain cases it is even necessary to reposition the inverted incisors to normal orientation if negative torque seems at all overexpressed. Volume 12 Number 1


Figure 2: Case 1 — initial photos

Figure 3: Case 1 — final photos

Case report No. 1 I am a proponent of orthodontic diagnosis from “Outside-In” as recommended by Dr. David Sarver.9 In regards to the macroesthetics (facial) of this case, I was concerned with what I viewed as a deficient midface, unfavorable tight/thin lips, and a relatively flat profile. In regards to mini-esthetics (smile), I felt that the patient would benefit from increasing esthetic projection of arch width via mild arch expansion of posterior teeth. In regards to micro-esthetics (teeth), I knew that IPR would be a great benefit due to his mild triangular incisor shape and to address the appearance of dark gingival embrasures as

Figure 5: Case 1 — 12 months' retention Volume 12 Number 1

Figure 4: Case 1 — final CBCT

Figure 6: Case 1 — pano comparison Orthodontic practice 27


Figure 7: Case 1 — ceph comparison

the severe crowding aligned. I chose not to extract in the upper arch due to my macroesthetic soft tissue concerns, which I viewed as very sensitive to over-retraction. In the lower arch, I think this case could have been well treated with a lower incisor extraction, but my plan did not include this. Instead, over the first 4 months of treatment as the crowding aligned, the patient was seen every 3-4 weeks to perform very light hand-strip IPR on the lower arch (less than 0.1 mm per contact each time). This was done in an effort to reduce proximal binding of the lower anteriors as the alignment of their severe crowding unraveled. His U6s had prominent lingual cusps that, even when reduced, prevented full non-working (buccal) cusp seating (evident pre- and posttreatment). The case was treated in 22 months. “Inverted B” setup with 0.022 MBT Alpine brackets (Rocky Mountain Orthodontics) was used and approximately 0.75 mm IPR

Figure 10: Case 2 — initial photos 28 Orthodontic practice

Figure 8: Case 1 — smile comparison

Figure 9: Case 1 — final headshot

Figure 11: Case 2 — final photos Volume 12 Number 1


Figure 12: Case 2 — ceph comparison

Figure 13: Case 2 — profile comparison

Figure 14: Case 2 — pano comparison

This approach is most beneficial in cases where the orthodontist is on the fence between an extraction or non-extraction treatment approach, commonly referred to as “borderline cases.”

was performed at each contact U3-3 and L4-4. Mild arch expansion was achieved through use of Norris extra broad NiTi archwires (DynaFlex®) in sizes 14N and then 16N X 22N. Then, 16 X 25 SS archwires were used in finishing.

Case report No. 2 In my opinion, the macro-esthetics (facial) presented a bit of a conundrum. Obviously, correction of the protrusive upper incisors to establish ideal labiolingual axial inclination was of primary importance in this case (to patient and parents as well). However, I very much liked the presentation of her lips, and did not wish for their retraction. Also, the strong chin prominence esthetically requested that the lips remain close to where they were so as not to further relatively highlight this prominence. In regards to the vertical of the lower facial one-third, I felt that Volume 12 Number 1

decreasing would further project the chin via autorotation of the mandible. My decision was to treat without extractions which I viewed as having greater potential for overretraction of uppers and also slight risk of vertical decrease. The case was treated in 22 months. “Inverted B” setup with 0.022 MBT Alpine brackets (Rocky Mountain Orthodontics) was used along with Class II elastics and approximately 0.4 mm IPR was performed at each contact between U3-3 and L3-3. Mild arch expansion was achieved through use of Norris extra broad NiTi archwires (DynaFlex) in sizes 14N and then 16N X 22N. Then 16 X 25 SS archwires were used in finishing. OP REFERENCES 1. Samsonyanova L, Broukal, Zdenek. A systematic review of individual motivational factors in orthodontic treatment: facial attractiveness as the main motivational factor in orthodontic treatment. Intl J Dent. 2014;2014:938274.15

Figure 15: Case 2 — final headshot

2. Ghaleb N, Bouserhal J, Bassil-Nassif N. Aesthetic evaluation of profile incisor inclination. Eur J Orthod. 2011;33(3):228-235. 3. Cao L , Zhang K, Bai D, et al. Effect of incisor labiolingual inclination and anteroposterior position on smiling profile aesthetics, Angle Orthod. 2011;81(1):121-129. 4. Johnson E. Selecting custom torque prescriptions for the straight-wire appliance. Am J Orthod Dentofacial Orthop. 2013;143(suppl 4):S161-S167. 5. Pitts TR. Bracket Positioning for Smile Arc Protection. J Clin Orthod. 2017;51(3):142-156. 6. Andrews LF. Straight wire: the concept and appliance. L.A. Wells Co.: San Diego, CA; 1989. 7. Pinheiro MLR. Interproximal Enamel Reduction. World J Orthod. 2002;3(3):223-232. 8. Sheridan JJ. Guidelines for contemporary air-rotor stripping. J Clin Orthod. 2007;41(6):315-320. 9. Sarver, David. Dentofacial Esthetics: From Macro to Micro. Quintessence Publishing Co.: USA; 2020.

Orthodontic practice 29



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 www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to orthopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260 To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. 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 medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

A protocol for inverting upper incisor brackets FOSTER

1. The final antero-posterior (A-P) position and inclination of the maxillary anterior teeth play a major role in ________. a. smile esthetics b. facial profile c. position of the lips d. all of the above 2. Achieving proper labiolingual inclination has even been shown to be ________ esthetically than the A-P position of the anterior teeth. a. more important b. less important c. more difficult to achieve d. less difficult to achieve 3. Often this creation of space (when significant crowding or protrusion exists) is achieved through _______. a. IPR b. a bicuspid extraction pattern c. using clear aligners first d. robotic archwires 4. _______ recommended this (inverting incisor brackets) as a technique to exert labial root torque when upper lateral incisors are blocked out to the lingual. a. Dr. Tom Pitts

30 Orthodontic practice

b. Dr. Larry Andrews c. Dr. Earl Johnson d. Dr. John J. Sheridan 5. _______ has coined the term “flipping” to refer to this technique (inverting incisor brackets) when it is applied to the upper incisors as a group and has advocated its clinical use for many years. a. Dr. Tom Pitts b. Dr. Larry Andrews c. Dr. Earl Johnson d. Dr. John J. Sheridan 6. An important note — while many of the concepts in the article are universal in application, the protocol discussed is specific to a traditional ________ rectangular slot appliance. a. 0.018 b. 0.022 c. 0.025 d. 0.028 7. The straight-wire appliance, developed by _______ , relies on brackets designed to achieve precise, three-dimensional control of crown and root position. a. Dr. Tom Pitts b. Dr. Larry Andrews

c. Dr. Earl Johnson d. Dr. John J. Sheridan 8. In an inverted setup where the upper incisor brackets are inverted on their correct teeth (U1s on U1s and U2s on U2s), the upper central incisors will now have a ________ applied to them relative to the upper lateral incisors. a. slightly stronger effective negative torque b. slightly stronger effective positive torque c. slightly weaker effective negative torque d. none of the above 9. For perspective, Andrews states that the ideal crown inclination of an upper central incisor is ______. a. 5 degrees b. 7 degrees c. 8 degrees d. 9 degrees 10. My reference for slot play in Table 1 is _______ article, which takes into consideration that wires are typically undersized, and slots are typically oversized. a. Dr. Tom Pitts’ b. Dr. Larry Andrews’ c. Dr. Earl Johnson’s d. Dr. John J. Sheridan’s

Volume 12 Number 1



AUTHOR GUIDELINES Orthodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 12 Number 1


Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript review All clinical and continuing education manuscripts are peer-reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact Mali Schantz-Feld, managing editor, with any questions via email: Mali@medmarkmedia.com

Orthodontic practice 31


The InBrace™ system: a new category of treatment Dr. Hany Youssef discusses a new lingual braces system with increased efficiency and profitability Introduction A goal of orthodontic treatment is to achieve excellent treatment outcomes with optimal efficiency. Treatment efficiency may be measured by several different metrics such as chair time, doctor time, and overall treatment time. Often once treatment efficiency metrics are determined, they can then be used to calculate treatment profitability. Many orthodontic practices may then evaluate and use this information to adjust their treatment modalities, mechanics, and/or workflows to optimize their efficiency and profitability. In the current orthodontic landscape, many orthodontic practices have started moving toward a more digital and proactive treatment workflow using computer-aided design and computer-aided manufacturing (CAD/CAM) technology to improve their clinical predictability and treatment efficiency.1–4 A new CAD/CAM orthodontic treatment modality to penetrate the orthodontic market is the InBrace™ system, which was designed with treatment efficiency in mind.5 This article will explore the different features of InBrace that improve treatment efficiency and will present a hypothetical treatment efficiency and profitability model to compare InBrace with other standard orthodontic treatment modalities.

Programmed Non-Sliding Mechanics (PNM) The InBrace system is a new category of orthodontic treatment that fundamentally diverges from the traditional edgewise or straight-wire appliances, which use sliding mechanics. While sliding mechanics works efficiently on the labial side with traditional braces, a general consensus is that optimal treatment efficiency has not been achieved with sliding mechanics on the lingual side as it is more difficult and time-consuming because of inaccurate bonding, difficulty with

Dr. Hany Youssef is a Board-certified orthodontist. He obtained his Doctor of Dental Surgery from University of Southern California (USC), completed his residency in orthodontics at USC, and is currently a clinical adjunct professor for USC’s graduate orthodontics department. He is in private practice in Tustin, California. Disclosure: Dr. Youssef is a speaker for InBrace™.

32 Orthodontic practice

insertion, ligation, adjustment, and disengagement of the archwire, limited visibility, and small interbracket distance.6–12 To resolve some of these inconveniences with early iterations of lingual appliances, CAD/CAM technology was applied to fabricate customized lingual brackets and archwires.13–15 However, this generation of lingual orthodontic treatment still did not resolve the issue of small interbracket distance and introduced a new complication of inefficient bracket replacement, which required a new custom bracket to be ordered, refabricated, and shipped if a replacement bracket was needed. In addition, customizing both the bracket and archwire led to significantly higher lab and hardware costs compared to any other treatment modality, including clear aligners. These higher fees were often passed on to patient fees, which decreased the economical access patients had to this treatment modality. Thus, even with the introduction of CAD/CAM technology, there was minimal adoption of these previous versions of lingual appliances.16 The InBrace system was designed as a behind-the-teeth treatment modality that resolves the inconveniences of all previous versions of lingual appliances. The InBrace system significantly improves treatment efficiency and minimizes clinician intervention by using their proprietary Gentleforce™ technology to apply a new paradigm in orthodontic mechanics that has been termed Programmed Non-Sliding Mechanics (PNM). With PNM, light and continuous forces are generated from a shape memory change that is programmed into nickel-titanium (NiTi) archwires that are capable of simultaneously moving each tooth to their digitally planned position in all 6 degrees of freedom: in/out, up/down, rotation, tip, torque, and even open or closed spaces. This leads to automation in treatment and minimizes the need for clinician intervention. In contrast, sliding mechanics often relies on a more inefficient force mechanism, heavy and interrupted forces in order to overcome unpredictable frictional forces. Heavy and interrupted forces lead to undermining resorption, which is a more inefficient mode of tooth movement compared to the light and continuous forces used in PNM, which results in frontal resorption.17

Designed for efficiency Another component of PNM that improves treatment efficiency is the InBrace appliance design. The InBrace archwire, termed a Smartwire®, is a programmed, multi-loop, NiTi archwire that is custom designed and digitally produced for each patient using the provider’s approved InBrace Digital Setup. Smartwires are comprised of two types of customized loop systems: Locking Loops and Interproximal Loops (Figure 1). Locking Loops are designed to fit within the InBrace bracket, and it is surrounded by walls on the mesial and distal surfaces, unlike a traditional edgewise bracket with a horizontal slot. Because of the interaction of the Locking Loop with the mesial and distal walls of the bracket, the Locking Loop does not slide when opening or closing spaces resulting in friction-free tooth movement (Figure 2). This non-sliding and friction-free tooth movement potentially improves treatment efficiency by removing the unpredictable force loss due to the variable of friction.18 In addition, Locking Loops create a thirdorder couple with the InBrace brackets, resulting in torque expression from the beginning of treatment.5 The Interproximal Loops are located in between each tooth, and they effectively increase the length of the Smartwire between brackets by greater than 3 times that of a normal lingual straight-wire appliance. This significantly increases wire flexibility and solves one of the major pain points of traditional lingual appliances: short interbracket distance.8 With the increased wire flexibility, it improves handling during engagement and disengagement of the Locking Loops and brackets. In addition, this increased wire flexibility enables light and continuous forces in all 6 degrees of freedom, including opening and closing spaces, which has the potential to be far more efficient than heavy, interrupted forces that often require more frequent and manual activations (Figure 3). A final benefit of the Interproximal Loops is that they allow patients to floss normally with no interproximal wire obstruction. In addition to being designed to prevent sliding and enable friction-free tooth movement, the InBrace brackets have several other features that support treatment efficiency. Volume 12 Number 1

The InBrace bracket is self-ligating and designed with a vertical insertion channel, which improves visualization and handling during the engagement and dis-engagement process leading to swift Smartwire changes. Also, all InBrace brackets are designed with zero prescription since all customization is built into the Smartwires. This allows for immediate and simple bracket replacement when needed, whereas other customized lingual bracket systems require a much more complicated process because the custom bracket would need to be ordered, refabricated, and shipped to an office. The zeroprescription nature of the InBrace brackets also allow them to be designed as low profile as possible which maximizes tongue space and minimizes speech impediments and tissue irritations. Furthermore, the use of zero-prescription brackets significantly reduces the lab cost to a comparable price to clear aligners, which greatly improves the economical access of behind-the-teeth orthodontic treatment to potential patients.

Treatment efficiency and profitability comparison In recent years, the two major categories of orthodontic treatment that have dominated the current orthodontic market are traditional braces and clear aligner therapy (CAT). The treatment efficiency between these two categories has been compared in several studies with findings that typically show CAT is more efficient but has significantly greater material costs.19–21 These studies also concluded that treatment efficiency and profitability with these two treatment modalities are also dependent on the experience of the orthodontist. Based on these conclusions, a reasonable speculation is that there is not a significant difference in profitability between traditional braces and CAT on average. A significant difference in profitability is likely seen only in orthodontic practices that specialize more heavily in one treatment modality over the other. With the automation and treatment efficiency built into the InBrace system that has been described thus far, a potential Volume 12 Number 1

Figures 3A and 3B: 3A. UL 2/3 Interproximal Loop compressed and UL 3/4 interproximal loop stretched. 3B. Interproximal Loop activation to create space and de-rotate the upper left canine

Table 1: Hypothetical Chair Time / Doctor Time Analysis Treatment Time / Doctor Time (minutes) Appointment Types

Traditional Braces


Clear Aligner Therapy (CAT)

Noncompliant Clear Aligner Therapy

Initial Consult

30 / 5

30 / 5

30 / 5

30 / 5

Initial Records

30 / 0

30 / 0

30 / 0

30 / 0

Treatment Planning/Digital Setup Review


0 / 20

0 / 20

0 / 30

Initial Bonding

75 / 10

75 / 5

60 / 5

60 / 5

Regular Appointments

420 / 56

270 / 27

270 / 27

420 / 42

Repositioning Brackets/Attachments

45 / 10

15 / 5

30 / 10

60 / 15

Emergency Appointments

30 / 10

30 / 10

15 / 5

15 / 5


60 / 10

60 / 10

60 / 10

60 / 10

Total Treatment Time





Total Doctor Time





Total Staff Time





hypothesis is that there is also no significant difference in profitability between InBrace, traditional braces, and CAT on average, and orthodontists who specialize more in InBrace could even see a greater profitability than with the other two treatment modalities. This hypothesis is further supported by the compliance-free nature of InBrace compared to CAT, which will have a mixture of compliant and noncompliant patients that will affect its average efficiency and profitability. To examine and illustrate this hypothesis, hypothetical chair time, doctor time, and profitability analyses were performed. In this hypothetical chair time analysis of the average 18-month orthodontic case, total chair time was modeled for all three treatment modalities (Table 1). Because CAT is highly dependent on compliance, and most orthodontists have experienced a small but significant number of patients who are noncompliant with their clear aligner wear, noncompliant CAT was also modeled. In this model, consistent with previous reports, chair time was significantly higher

for traditional braces primarily based on the number of regular appointments modeled for each category (14 for traditional braces and noncompliant CAT and 9 for InBrace and CAT).19–21 All regular appointments for each treatment modality were modeled to take 30 minutes. InBrace and CAT were modeled to have fewer appointments because CAD/ CAM orthodontic treatment modalities tend to reduce the number of appointments and allow for longer appointment intervals.1–5,19 Other significant differences in treatment time between the treatment modalities include repositioning brackets/attachments and emergency appointments. Traditional braces often require some bracket repositions since the original bracket position is often manually placed based off of clinical judgment, while CAT typically requires removing and replacing attachments at refinements. In contrast, InBrace, which has digitally positioned brackets transferred by an indirect bonding tray, typically requires minimal repositioning. However, InBrace as a fixed appliance system will likely experience Orthodontic practice 33


Figures 1 and 2: 1. InBrace Smartwires have two customized loop systems – Locking Loops and Interproximal Loops. 2. The Locking Loop (blue) does not slide, resulting in friction-free tooth movement

TECHNOLOGY Table 2: Hypothetical Profitability Analysis Fee Types

Traditional Braces


Clear Aligner Therapy (CAT)

Noncompliant Clear Aligner Therapy

Patient Fees





Hardware/Lab Fees





Staff Fees





Net Profit Per Patient





Net Profit Per Hour





Dcotor Profit Per Hour





a similar number of emergency appointments as traditional braces, while CAT rarely experiences emergency appointments.15 In this hypothetical analysis of the average 18-month orthodontic case, doctor time was also modeled (Table 1). Similarly, the major difference is found at the regular appointments where on average, 4 minutes per appointment was modeled for traditional braces and 3 minutes per appointment was modeled for InBrace and CAT. Traditional braces were modeled as having more average doctor time per appointment because manual adjustments to the archwires are often needed toward the end of treatment. The other significant difference in doctor time was in the treatment planning/digital setup review. CAT likely requires the most time for this step because additional factors need to be evaluated such as clear aligner staging and attachment design. Based on the calculated doctor time, total staff time can also be calculated by subtracting the total doctor time (minus treatment planning/digital setup review time, which the staff is not involved with) from the calculated total chair time shown in Table 1. Based on the hypothetical chair time and doctor time models for the average 18-month orthodontic case, profitability can be calculated for each treatment modality (Table 2). An equal patient fee of $5,500 was modeled for all three treatment modalities, though InBrace and CAT can generally command a higher patient fee in the orthodontic market. An equivalent lab fee was modeled for InBrace and CAT, and the same staff fee per hour ($25/hour) was modeled for all three treatment modalities. With the exception of noncompliant CAT, this model showed that traditional braces, InBrace, and CAT all potentially have a similar net and doctor profit per hour once hardware/lab and staff fees were accounted for. InBrace could potentially see a greater doctor profit per hour because of reduced digital setup review time needed compared to CAT, especially when CAT and noncompliant CAT are averaged together. 34 Orthodontic practice

While this is only a hypothetical model, based on the thoughtful development of PNM and the InBrace appliance design to maximize treatment efficiency, InBrace has the potential to achieve a similar or better profitability than traditional braces and CAT as shown in this hypothetical model.

Conclusion Previous iterations of lingual orthodontic treatment likely have not been able to penetrate the orthodontic market due to decreased treatment efficiency and profitability for orthodontists, especially if pricing patient fees at costs similar to traditional braces or CAT.22 As described in this article, InBrace is a fundamentally different category of behind-the-teeth treatment through its use of Gentleforce technology to apply PNM, so its proposed treatment efficiency has the potential to achieve a similar profitability to traditional braces and CAT on average, and orthodontists who specialize more in InBrace could even see a greater profitability than with the other two treatment modalities. As evidenced by the growing number of starts in the United States, the orthodontic market is not a zero-sum game, and there are countless prospective orthodontic patients that are currently not being captured by traditional braces and CAT. InBrace was developed by orthodontists, for orthodontists, to help expand their patient pools through its new “Smile Now” category of orthodontic treatment that potentially provides orthodontists a behind-the-teeth treatment option with improved efficiency, predictability, and profitability. From a patient perspective, InBrace serves the needs of countless unserved patients who have previously opted out of orthodontic treatment because they either did not want a visible appliance or did not want the commitment of compliance. Therefore, this “Smile Now” category may bring in a new group of patients into orthodontic offices that were not interested in traditional braces and CAT because it provides these

new patients with a more hidden and compliance-free option where they can continue smiling immediately after InBrace bonding without their peers knowing that they are undergoing orthodontic treatment. This expansion of the orthodontic patient pool should not only help grow InBrace patient starts, but also could potentially have a ripple effect to grow traditional braces and CAT patient starts. Overall, the InBrace system has the potential to benefit the orthodontic community and expand the orthodontic patient pool by providing orthodontists with a new and efficient category of orthodontic treatment. OP

REFERENCES 1. Brown MW, Koroluk L, Ko C-C, et al. Effectiveness and efficiency of a CAD/CAM orthodontic bracket system. Am J Orthod Dentofac Orthop. 2015;148(6):1067-1074. 2. Moreira FC, Vaz LG, Guastaldi AC, English JD, Jacob HB. Potentialities and limitations of computer-aided design and manufacturing technology in the nonextraction treatment of Class I malocclusion. Am J Orthod Dentofac Orthop. 2020;159(1): 3. Aldrees AM. Do customized orthodontic appliances and vibration devices provide more efficient treatment than conventional methods? Korean J Orthod. 2016;46(3):180. 4. Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World J Orthod. 2010;11(1):16-22. 5. Tong H, Weissheimer A, Pham J, Lee R, Redmond WR. Lingual Orthodontics Redefined with Automation and Friction-Free Mechanics. J Clin Orthod. 2019;53(4):214-24. 6. Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed appliances. Am J Orthod Dentofac Orthop. 1991;99(3):202-9. 7. Gorman JC. Treatment of adults with lingual orthodontic appliances. Dent Clin North Am. 1988;32(3):589-620. 8. Moran KI. Relative wire stiffness due to lingual versus labial interbracket distance. Am J Orthod Dentofac Orthop. 1987;92(1):24-32. 9. Geron S, Romano R, Brosh T. Vertical forces in labial and lingual orthodontics applied on maxillary incisors--a theoretical approach. Angle Orthod. 2004;74(2):195-201. 10. Ye L, Kula KS. Status of lingual orthodontics. World J Orthod. 2006;7(4):361-368. 11. Ackerman JL. The challenge of adult orthodontics. J Clin Orthod. 1978;12(1):43-47. 12. Creekmore T. Lingual orthodontics--its renaissance. Am J Orthod Dentofac Orthop. 1989;96(2):120-137. 13. Wiechmann D, Rummel V, Thalheim A, Simon J. Customized brackets and archwires for lingual orthodontic treatment. Am J Orthod Dentofac Orthop. 2003;124(5):593-599. 14. Dalessandri D, Lazzaroni E, Migliorati M, et al. Self-ligating fully customized lingual appliance and chair-time reduction: a typodont study followed by a randomized clinical trial. Eur J Orthod. 2013;35(6):758-765. 15. Mujagic M, Fauquet C, Galletti C, et al. Digital design and manufacturing of the Lingualcare bracket system. J Clin Orthod. 2005;39(6):375-382. 16. Keim RG, Gottlieb EL, Vogels DS, Vogels PB. 2014 JCO study of orthodontic diagnosis and treatment procedures, Part 1: results and trends. J Clin Orthod. 2014;48(10):607-630. 17. Proffit WR Jr, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St. Louis, MO: Mosby Elsevier; 2006. 18. AlSubaie M, Talic N, Khawatmi S, Alobeid A, Bourauel C, El-Bialy T. Study of force loss due to friction comparing two ceramic brackets during sliding tooth movement. J Orofac Orthop. 2016;77(5):334-340. 19. Buschang PH, Shaw SG, Ross M, Crosby D, Campbell PM. Comparative time efficiency of aligner therapy and conventional edgewise braces. Angle Orthod. 2014;84(3):391-396. 20. Zheng M, Liu R, Ni Z, Yu Z. Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis. Orthod Craniofacial Res. 2017;20(3):127-133. 21. Ke Y, Zhu Y, Zhu M. A comparison of treatment effectiveness between clear aligner and fixed appliance therapies. BMC Oral Health. 2019;19(1):24. 22. Keim RG, Gottlieb EL, Vogels DS, Vogels PB. 2017 JCO Orthodontic Practice Study. J Clin Orthod. 2017;51(10):639-656.

Volume 12 Number 1


Knowing more means doing better Suzanne Wilson discusses how Gaidge prepares for a successful and profitable future for orthodontic practices


ooking back on 2020, all of us were faced with unexpected impacts on our businesses and communities. Successful practices were able to weather the storm, and many saw a healthy 3rd and 4th quarter that helped level a declining year. There has never been a more important time to have laser-focused attention on business performance. Practices that pay attention to their performance have a strategic advantage over those that do not. Gaidge provides practices with automation, time savings, and clarity for the most successful and profitable path forward. Gaidge is a tool that helps practice owners get a pulse on their essential performance metrics providing the information required to run their businesses better. In one comprehensive, cloud-based software platform, orthodontists have access to review their key performance indicators across all areas of the practice with easy-to-understand charts, summaries, trends, industry benchmarks, and practice comparisons. Gaidge provides automation with direct integration to the leading practice management systems (Cloud9, Dolphin, Ortho2, CS OrthoTrac, topsOrtho™). This means no added data entry, and all your practice data flows seamlessly into Gaidge where you can see historical and current performance in both charts and visual graphics. The software comes with preloaded benchmarks and tips on achieving industry standards, but each practice can also create, set, and track its unique goals.

Operational and financial visibility The new Executive membership access gives users all of the standard Gaidge tools plus the ability to track their spending, forecast their future, and gain access to new metrics such as marketing ROI and PPErelated expenses. New Financial Tools The Overhead Expense Tracker™ and Practice Projections™ modules provide a comprehensive look back and the ability to

Gaidge Overhead Expense Tracker™

look forward and create a plan for the future. This further enhances the value of Gaidge providing practice owners with the ability to see a clear, end-to-end picture of the practice’s business performance conveniently all in one place.

Expenses Leveraging integration with accounting software, the Overhead Expense Tracker features automated reporting of your overhead expenses, including budget tracking, profitability, benchmarks, and trends. Controlling overhead represents a wealth of opportunity for increasing net income. Having a simple view and easy access to monitor what’s happening brings visibility on a regular basis rather than waiting for quarterly, biannual, or annual reviews. In addition, having the budgeting tool with the progress tracker allows you to keep tabs on spending, detect areas of concern, and have better

Suzanne Wilson joined Gaidge as the Chief Marketing Officer in September 2018. She has held leadership positions in operations, marketing, and business development in the oral care industry over the past 20 years. She earned her Bachelor of Arts in English and Executive MBA from the University of Utah. Learn more: https://www.linkedin.com/in/suzanne-wilson-8a158b1a/.

36 Orthodontic practice

chances of hitting your profitability goals throughout the year. The module is fully integrated and automated with QuickBooks® Desktop and Online, including pulling through retroactive adjustments. For offices using other accounting software, Gaidge also offers a file upload and manual entry option.

Forecasting Using Practice Projections, users can play with interactive sliders to determine which areas to focus on in order to reach desired goals. Looking for a 10% increase in production dollars? Use the sliders or enter the digits, and watch how the information cascades to other related metrics such as collections, based on historical productioncollection ratios, number of exams, starts, and more. Using this tool means you can create a plan to set specific, achievable goals by month, quarter, and year. Save and share with your team to gain alignment, achieve and celebrate wins. Contact us today for a free online demo. Email info@gaidge.com, visit www.gaidge. com, or call 800-287-3396. OP Volume 12 Number 1


uilt to Last. Built for You. Built by Boyd” is more than a tagline. It signifies the commitment that the Boyd team 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 custom cabinetry — we combine over 60 years of design and manufacturing expertise to perfectly fit your unique space and esthetic preferences. We take great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can have confidence in your equipment for years to come.  

Learn about our featured products 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. These series of 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. As anxiety for dental appointments has increased since COVID-19 disrupted our daily lives, doctors and their staff started looking for ways to ease patients’ nerves during an appointment. Boyd has developed products to help doctors fight the spread of harmful viruses and airborne diseases with the introduction of the Patient Divider and

C510 LED Exam Light. Volume 12 Number 1

Dental Aerosols Collector

Dental Aerosols Collector. The decorative Patient Dividers serve as a great option for privacy as well as a barrier against potential airborne pathogens between patients. Our Aerosols Collector is a top choice among the dental industry as it’s a low-cost and highly effective solution that collects droplets during operations. To complement your exam and treatment chairs, Boyd offers a series of standard Delivery Unit models for chairside, rear, or concealed delivery. With a limitless selection of laminate colors and grains, these units combine functionality, efficiency, and style. Choose standard or square back models to accommodate your storage and space requirements. 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. 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 plus an IR sensor with intensity up to 30,000 LUX and 95Ra rendering, three-axis head movement, and adjustable, sterilizer-safe hand grips. The C500 Camera Exam Light features a built-in HD video camera, hands-free operation, selection of three different color temperatures, and more. Want the same great lighting technology in the C500 without the HD camera? Ask about our C510 LED Exam Light. 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 new project. Start the conversation today! To learn more, visit us at www.boyd industries.com. You can also follow us on Instagram and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. OP This information is provided by Boyd Industries.

Orthodontic practice 37


Boyd Industries — featured orthodontic products


Patients gain early rotation correction and improved torque control Dr. Michael Bicknell discusses how harnessing advancements in technology can satisfy core values and lead to improved patient experiences, simplification of treatment, and improved clinical outcomes

Introduction “Perception is reality” is a phrase that floats around in all areas of life. In today’s society, this holds even more weight due to the easy access to information, obsession with social media, and all-things advertising. When I think of a phrase like this and try to understand how it can help me to best understand my patients, I formulate questions. How do we present ourselves to our prospective patient base? How do our teams view us as both practitioners and leaders? How do our colleagues and peers evaluate our commitment to excellence and the progression of our profession? These questions and many others are quickly answered by the core values held by an organization’s leadership. Core values drive our decisionmaking process in all areas of life and are the most important attribute we can express to create trust in serving our patients. Additionally, core values set and enforce our teams’ culture that creates the environment in which we provide care. If the leadership’s core values are clear and the decisions made support these values, many things happen: • Patients feel the message presented is the one delivered. • The teams become harmonious and loyal to the mission of the practice. • Emotional conflict is reduced because everyone is operating in an Michael Bicknell, DDS, MS, earned his DDS and completed a residency in orthodontics at the University of Illinois at Chicago College of Dentistry where he also received a MS in oral biology. He is a former clinical instructor at the university and continues his involvement there by lecturing to dental students and orthodontic residents throughout the year. In private practice in Elmhurst, Illinois, he is a Diplomate of the American Board of Orthodontics and is an internationally recognized educator, presenting to thousands of orthodontists on subjects such as efficient treatment, esthetics, leadership, and creating a culture of excellence. Disclosure: Dr. Bicknell is a Damon™ System Mentor and paid consultant of Ormco™.

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Figure 1

Figure 2

environment within the parameter of their value sets. When all these occur, perception does become a reality. The reason for the discussion of core values is that it prefaces how and why we make decisions for the services we provide as orthodontists. In my practice, three core values are held and must be satisfied with each decision made: 1. We will always work to improve the patient experience. 2. We must progress our profession by using advancements in technology. 3. We must simplify treatment while improving our outcomes. Suppose we can find ways to improve the patient experience by using technology and, at the same time, simplify the treatment process and improve outcomes. In that case, we will create improved office cultures, less stressful workplaces, and an overall better environment to treat patients and provide world-leading care.  One of the choices in today’s marketplace that seems to satisfy these core values is the newly designed Damon Ultima™ System by Ormco™ Corporation, which is an advanced bracket-wire system that has been in the making for many years. It is not only a modification of a current bracket design, but also an entirely new product engineered from the ground up to help solve the current problems associated with the inefficiency

inherent in all products on the market. The significant difference is that the newly engineered brackets and wires were designed concurrently as an integrated system. The Ultima bracket slot is parallelogramshaped and fits with the Ultima wire — a rectangular wire with round wire edge characteristics — to deliver direct engagement at vertical and horizontal contact points. This integrated system design virtually eliminates play, resulting in precise control of rotation, angulation, and torque. In almost all orthodontic systems, the orthodontist accepts timepoints in the treatment process where less desirable tooth movement occurs. When I was able to examine and understand the new Damon Ultima System, it appeared to be a more natural continuous movement in all three dimensions, designed to allow for a more efficient, simplified treatment while obtaining improved outcomes in a shorter time frame — all this while maintaining the core principles of PSL as it pertains to low force and friction. There are numerous differences to the Damon Ultima System compared to current market options. The most profound is the change made to the bracket slot geometry. Until now, when variable torque brackets were used, the slot lineup between the differential torques results in vertical discrepancy along the centerline. The change in torque led to a vertical discrepancy with both positioning and expressed tooth movement (Figure 1). Volume 12 Number 1

The orthodontist would compensate with a bend that could further complicate the issue, resulting in concerns about finishing PSL cases. The modification to the slot geometry is simple but profound. Rather than being a rectangle cut into a bracket then placed on the base, the slot is a parallelogram carved into the bracket face itself. With the new design, regardless of the variable torque bracket selected, the slot’s centerline remains level among all the brackets. This provides the orthodontist with increased bracket torque choices for creating efficient tooth movement without the undesirable side effects (Figure 2). Key advancements in technology with this system are not only an improved bracket but also a specifically designed set of wires, which is the engine that drives the system. When the Ultima wire is paired with the newly designed Damon Ultima bracket, they work symbiotically to improve force application in all three planes of space. The wire set is designed as a rectangular wire with full rounded sides, which provides the advantages of rotation and torque control of rectangular wires and the comfort and ease of inserting a round wire (Figure 3). These illustrations show the wire and bracket in a passive state. However, in Figure 4, the wire is paired with a variable torque bracket showing the bracket-wire interactions in an active state. The couple produced results in an improved torque expression throughout the entire Ultima wire range. The wire’s new design allows for rotation, space closure, and torque to be applied much earlier and more effectively than in the past. A redesign of the bracket also allows for improvement in tooth movement. Changing the slot dimension to accept the Ultima wires in increasing sizes maintains passivity and ease of insertion, but eliminates much of the wire bracket play that has been previously observed. Correcting first-order movements much earlier and having precise rotation control in the beginning stages are some of the early benefits observed in my practice. Furthermore, torque expression at a greater Volume 12 Number 1

Figure 4

level with the initial Ultima wires results in moving teeth purposefully from the beginning without having to wait for a previous stage to be completed. With the engineering of the Damon Ultima System, we now have a tool that can improve the patient experience and harness technology advancement to simplify treatment and improve outcomes.

Case 1: Figures 5 and 6 Diagnosis A 48-year-old female presented with a Class I crowded malocclusion with moderate maxillary and mandibular crowding. The facial profile was convex with a slightly retrusive mandible due to a vertical mandibular pattern. Normal lip strictures were noted with slight strain on closure due to the strong

Figure 5 Orthodontic practice 39


Figure 3

TECHNOLOGY/CASE STUDY vertical pattern. A constricted arch form with tapered buccal segments resulted in poor smile width and dark buccal corridors. This, along with a reverse smile arc due to insufficient incisor eruption, resulted in poor smile esthetics.  Objectives/plan The objectives were to create space while maintaining maxillary incisor position, to improve the smile arc by erupting incisors, and to develop the posterior segments for increased arch length as well as improved smile width. Resolving crowding through arch development with proper torque control was a key objective since incisor advancement and increased angulation would lead to further lip strain. A non-extraction plan was chosen using Damon Ultima System, along with the use of light vertical elastics for early overbite correction and smile arc improvement.  Case setup The brackets chosen were Damon Ultima PSL brackets with neutral torque on the upper and retroclined torque on the lower 2-2. All permanent teeth were bonded, the bite was disarticulated, and 2 oz. 3/16 elastics were started from the U3’s to the L3-4’s at night only. Case progression Stage 1: (0-5M) Bracket placement for improved smile arc with initial 0.013 CuNiTi U/L and an early elastic protocol was started using 2.0 oz. 3/16 Class 1 triangles from the U3’s to the L3-4’s part-time to help with the eruption of the maxillary incisors and overbite. After 4 weeks, wires were changed to 0.014 CuNiTi and then to 0.018 CuNiTi extending to the U/L 7’s. Wires were again changed 4 weeks later to 0.014 x 0.0275 CuNiTi Ultima U/L. These were to be maintained for 8 weeks but were extended by a few months due to the COVID-19 shutdown.  Stage 2: (5-10M) Upon returning, the wires were changed to 0.018 x 0.0275 CuNiTi UIltima U/L. The upper 3-3 were laced to avoid space opening, and the elastics were changed to Class II full-time. A few brackets were repositioned, and the U/L 3’s were changed to proclined torque to improve angulation. The case was left for an additional 4 weeks before progressing to final wires.  Stage 3: (10-13M) The finishing wires were 0.019 x 0.0275 stainless steel (SS) Ultima upper and 0.016 x 0.0275 SS Combi lower. The patient was seen on 40 Orthodontic practice

Figure 6

4-week intervals for shaping of wires and instructions for Class II box elastics to begin bite closure on the right side. Case completion: Finishing details along with posterior elastic were completed in the last 2 weeks. The retention plan included direct placement of an upper 2112 braided SS fixed retainer and a digital scan for U/L Essix retainers with a custom-made 0.025 x 0.019 gold fixed L3-3. Retainers were provided along with tooth whitening gel with instructions for full-time wear for 1 week and then nights only moving forward.   Overview An overview of the case resulted in the Damon Ultima PSL brackets with variable torques utilized correcting the malocclusion with resolution of the significant crowding and lack of overbite along with substantial

arch development. Maxillary incisor position and angulation were maintained due to significant posterior arch development and anterior torque control. Overall, the patient was extremely compliant with elastics from the beginning to the end of treatment. From a clinical efficiency standpoint, the patient had 11 treatment visits and completed treatment in 13 months.

Case 2: Figures 7 and 8 Diagnosis A 14-year-old male presented with a Class I constricted malocclusion with a posterior unilateral crossbite with a notable functional shift along with a partial anterior crossbite. Due to the crossbite, a slight maxillary dental cant was noted with the incisors on the left side being less erupted than the right. The facial profile was orthognathic Volume 12 Number 1


with a well-positioned mandible. Radiographic analysis shows well-positioned maxillary and mandibular incisors. Lips were well supported, but slightly retruded relative to the facial structures. Additionally, tapered buccal segments were observed, and a poor smile arc was noted due to insufficient incisor display when smiling. Objectives/plan The objectives were to maintain maxillary incisor position through torque control of anterior, to improve the smile arc by erupting incisors, and to develop the posterior segments for improved smile width. A non-extraction plan using Damon Ultima System was chosen along with the use of posterior crossbite elastics for early posterior development and crossbite correction. Case setup The brackets chosen were Damon Ultima PSL brackets with neutral torque on the upper and lower. All permanent teeth were bonded with buttons on the palatal of the U6’s for crossbite elastics. The bite was disarticulated, and 3.5 oz. 3/16 elastics were started from the U6’s to the L6’s. Case progression Stage 1: (0-5M) Bracket placement for improved smile arc with initial 0.014 CuNiTi U/L and an early elastic protocol was started using 3.5 oz. 3/16 Class crossbite elastics from the U6’s to the L6’s full-time. The occlusion was disarticulated by placing bite stops on the U6’s to reduce the effect of incline planes and allow for easier correction of the crossbites. After 4 weeks, wires were changed to 0.018 CuNiTi extending to the U/L 7’s. Wires were again changed 4 weeks later to 0.014 x 0.0275 CuNiTi Ultima U/L. These were to be maintained for 8 weeks but were extended by a few months due to the COVID-19 shutdown.   Stage 2: (5-10M) The next visit back, wires were changed to 0.018 x 0.0275 CuNiTi Ultima U/L. The upper 3-3 segment was laced to avoid space opening, and the crossbite elastics were discontinued since the corrections were observed. A few brackets were repositioned, and the U1’s were changed to proclined torque to gain inclination. The case was left for an additional 4 weeks before progressing to final wires.  Stage 3: (10-14M) The case was finished in 0.019 x 0.0275SS Ultima upper and 0.016 x 0.0275 SS Ultima lower. The patient was seen on 4-week intervals for shaping of wires and instructions for vertical elastics to begin Volume 12 Number 1

Figure 7

bite closure after crossbite correction. Light buccal root torque was added to the final wires; however, the posterior bite stops were not removed until case competition resulting in lack of occlusion of the U6’s. These were corrected by changing the position of the U/L 6’s in the digital software prior to fabrication of retainers.   Case completion: Shaping of archwires and minor details, along with posterior elastic, was completed in the last 2 weeks. The retention plan included direct placement of the upper 2112 braided SS fixed retainer and a digital scan for U/L Essix retainers with digital correction of the 6’s with a custom-made 0.025 x 0.019 gold fixed L3-3. Once the 6’s have improved occlusion,

the case will be scanned for fabrication of final Essix retainers.    Overview An overview of the case resulted in the Damon Ultima PSL System with proclined torque on the upper 1’s, and neutral torque on the lower incisors show correction of the anterior and posterior crossbites, improvement of arch form with correction of the functional shift. Maxillary incisor position and angulation were maintained even with the significant amount of posterior width achieved while the smile arc and width were enhanced, resulting in a much more visible and natural smile. After evaluating the case, some improvements would have been Orthodontic practice 41

TECHNOLOGY/CASE STUDY observed if I would have used retroclined torque on the U3’s and removed bite stops earlier in treatment, resulting in better angulation of the 3’s and a more settled occlusion of the 6’s, respectively. From a clinical efficiency standpoint, the patient had 11 treatment visits and finished treatment in 14 months.

Conclusion The two case examples presented highlight the outcomes that become possible with a commitment to improved patient experiences by harnessing technology advancements. It was impressive to see the effects of the Damon Ultima System. With early rotation correction and improved torque control with the Ultima wires, the final wires required very few adjustments. The benefits to the patients were less discomfort, shorter overall treatment time, and a fantastic outcome. Just a short time ago, a 27-month treatment plan was acceptable for one case; now we can compete two challenging cases in the same time combined. This truly demonstrated how we are progressing as a profession, and how technology and the pursuit of improved patient care are really improving the patient experience. We live in a world where constant change and improvements, and “upgrades” are synonymous with progress. By continually advancing our profession and keeping it at the forefront of technology, we also help ensure that the orthodontist will be the best option when it comes to choosing a provider to deliver orthodontic treatment. OP Figure 8

THE DENTAL CLINICAL COMPANION PODCAST Bringing together the world’s leading clinicians and experts to optimize your treatment, educate, and inspire and energize your professional goals. Hosted by: Dr. Richard Mounce Listen now at www.dentalclinicalcompanion.com

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Vivos Therapeutics, Inc. — a medical technology company focused on developing and commercializing innovative treatments for patients suffering from sleep-disordered breathing, including mild-to-moderate obstructive sleep apnea (OSA) — has opened the first Pneusomnia clinic, a clinician-owned, integrated medicaldental sleep center featuring the Vivos System through its Medical Integration Division. The clinic, located in Del Mar, California, is owned and operated by a diverse group of local physicians led by Dr. Mimi Guarneri, cardiologist, founder, and president of The Academy of Integrative Health and Medicine, and an award-winning physician and researcher. The company formally launched its Medical Integration Division in early 2020 to foster an environment where more medical doctors could work directly with dentists (including dentists who participate in the Vivos® Integrated Practice Program) for treating sleep disorders in patients. As part of the new sleep medicine center, patients receive treatment with the Vivos System, a clinically effective, nonsurgical, noninvasive, non-pharmaceutical oral appliance treatment for mild-to-moderate sleep apnea. Unlike traditional solutions, the Vivos System typically does not require lifetime usage since it addresses sleep apnea’s underlying cause with a treatment plan that, on average, lasts only 18 to 24 months. In addition to the Del Mar facility, new centers are currently being developed in Johnstown, Colorado; Modesto, Ladera Ranch, Encino, and Beverly Hills, California; Las Vegas, Nevada; and Morristown, New Jersey. For more information, visit www.vivoslife.com.

Henry Schein® Medical helps physician practices mitigate risk of ransomware attacks and lost revenue Henry Schein® Medical has entered into a distribution agreement with Black Talon Security, LLC, provider of cybersecurity solutions and data breach security for the healthcare market. The cybersecurity company is focused on protecting healthcare providers and practices from cybersecurity incidents and data breach security while helping practitioners with compliance through education, training, cyber investigations, and documentation. Black Talon offers advanced solutions that can help mitigate ransomware attacks and encrypt critical files while also helping to avoid local and cloud backups from being destroyed or data from being stolen, resulting in lost revenue and productivity for physician practices. In addition, Black Talon offers three specific capabilities to help protect practice data, including: vulnerability management tools that locate known vulnerabilities on external and internal network devices; penetration tests (performed by Black Talon’s ethical hackers) to help identify exploitable systems not detected by vulnerability scans; and use of its predictive threat intelligence software that enables Black Talon to proactively find “unlocked doors and windows” on a network. To find out more about Black Talon’s cybersecurity solutions distributed by Henry Schein, visit Henry Schein Medical’s new SolutionsHub website: https://www.henryscheinsolutionshub.com/.

Dentsply Sirona acquires Byte®, a direct-to-consumer, doctor-directed clear aligner company Dentsply Sirona has acquired Byte®, a rapidly growing clear aligner company. Dentsply Sirona’s R&D capabilities and commercial expertise offer significant potential to drive additional growth of the Byte clear aligner solutions. The combination with Dentsply Sirona will focus on expanding the market for orthodontic care by connecting additional patients with dental professionals and helping them access quality oral healthcare. For more information, visit www.dentsplysirona.com

Volume 12 Number 1

Ultradent partners with American Orthodontics Ultradent Products, Inc., and American Orthodontics have announced a partnership in which American Orthodontics will exclusively distribute Ultradent’s Opal Orthodontics-branded products to orthodontists in the United States. Both American Orthodontics and Ultradent share similar corporate values, cultures of continuous improvement, and commitment to their customers, employees, and communities. These similarities present a unique opportunity to complement the shared ideal of promoting the orthodontic and dental professions. For more information about Ultradent, call 800-552-5512, or visit ultradent.com.

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Vivos Therapeutics opens first Pneusomnia-integrated medical-dental sleep center


Virtual patient monitoring Dr. Christopher Cosse discusses how virtual patient monitoring can bring efficiency and convenience to the orthodontic practice


oday orthodontists are reevaluating their practice procedures in order to do more with less. Providing exceptional patient care without overstretching resources is on everyone’s mind. Thanks largely to recent advancements in telehealth technology and modalities, virtual consultations and virtual exams have gotten a lot of attention. Not to be outdone, their younger sibling — virtual patient monitoring — has been growing and may outshine the other two in no time at all.

What is virtual patient monitoring? Virtual patient monitoring utilizes digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmits that information securely to a different location for assessment, recommendations, and advancement of treatment from a provider. The COVID-19 pandemic forced this technology into relevancy in 2020, and it will be a necessity for practices to offer this convenient service in order to stay relevant in 2021 and beyond. Fortunately, this is a win-win for patients and practices alike. Patients want this service for the convenience and safety that it offers, and practices benefit by decreased chair time and expenses, and an overall increase in efficiency and profitability. I take great pride in my office and staff’s reputation of being very personable and welcoming. Initially, it was hard to shake the fear of losing the “personal touch” that our patients have grown to love and expect from our office by incorporating virtual

appointments. However, I have found that providing this extra convenience has actually improved overall patient satisfaction. They are still getting one-on-one communication with me; it is just done virtually (which Millennials and Gen Z are used to anyway). With COVID-19 still lurking, patients are leery of being around strangers and being in public places that have certain amounts of people moving through them on a daily basis. If patients aren’t necessarily worried about exposure, then I guarantee they are busy. Taking off work, taking the kids out of school, commuting to your office, and waiting in your reception area (or their car) to have a one-minute-of-doctor-time appointment telling them to continue what they were already doing, doesn’t rank too highly on their list of satisfying experiences. These days it is hard to think of a good or service that isn’t offering some sort of virtual option for their business. Your patients expect this as an option — and will soon demand it. Dr. Bill Dischinger, an orthodontist in Oregon, has stated that he doesn’t plan on doing aligner checks anymore. “I’m really excited to implement [virtual patient monitoring] to help me get through this time, but I’m more excited for its future.” Within a practice, the decrease in chair time naturally creates an increase in capacity.

Figure 1: Showing filter to divide patients that are new versus in treatment — It then further breaks down the choices to determine what type of treatment the patient is in

Open chairs allow more space for new patients, or more time for virtual consultations. It has been estimated that every time a patient sits in your clinic chair, it costs the practice somewhere between $100 and $300. A decrease in costs and an increase in new patient starts lead to an increase in the profitability of the practice. Not to mention, the orthodontist can monitor their patients from home or the beach! Dr. Palasz from Lititz Orthodontics in Pennsylvania has eliminated 20% of his

Christopher Cosse, DDS, is a graduate of Louisiana State University School of Dentistry, and he completed his orthodontic training at Oregon Health Science in Portland. He is regularly invited to speak about orthodontics nationally and internationally. He is married and has four children. Dr. Cosse is a Damon Premier Provider and Educator and is in private practice in Shreveport, Louisiana. For more information about virtual consults/appointments, visit Dr. Cosse’s FaceBook group VirtuOrtho. Disclosure: Dr. Cosse is the founder of Braces Academy — the prescriptive patient education™ system and OrthoScreening.™

Figure 2: Showing customizable template to monitor patient in braces 44 Orthodontic practice

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Figure 3: Showing customizable template of pictures needed for each type of patient

continues to the next virtual appointment or hops back in to seeing in-office patients if needed. With the benefits that virtual patient monitoring provides, you may be wondering how to get started. There are several companies that specialize in virtual patient monitoring. OrthoScreening™, of course, is the one that we use. Other market options include Dental Monitoring and ClearPG. There are pros and cons with any of them, so it is important to find what fits best with your practice. Start by comparing the features, cost, and connectivity to what you

are already using with each service provider. While special features such as Artificial Intelligence are cool, be sure to really evaluate the value of the features each company includes. You don’t want a line item of your expenses to show a huge number when a more practical approach could have made that number much smaller. Start now with implementing this technology into your daily office schedule. You won’t regret it, and you won’t get left behind — the benefits are too great for both patient and provider. Virtual patient monitoring is here to stay! OP

“THE ZZZ PACK” PODCAST The prescription for dental sleep we have all been waiting for. Uncensored, real talk with hosts… Lisa Moler: DSP Publisher, Sleep Apnea Slayer, and Patient Dr. Erin Elliott: The fearless OSA doctor aka “The Queen of Good Air” Jason Tierney: Multi-syllabic thought provoker in all things sleep Listen now at www.zzzpack.com

Volume 12 Number 1

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in-person appointments in his office. “We now have a whole column in our PMS just for virtual appointments,” Dr. Palasz said. “It is filling up fast with all those RPE, elastic, OH checks, aligner checks, etc.” Similarly to virtual consultations, the patients are given an appointment time and simple instructions on how and when to submit photos for their virtual consultation. The web-based and HIPPA-compliant software we use in our office has easy-to-follow prompts that carry patients through the entire submission process. Our patients send in the required appointment information and any questions or concerns they may have entirely from their cellphone, using the phone’s internet browser and camera. Since it is not a realtime system, the patients are able to submit throughout the day when it is convenient for them, and our office is able to respond between already scheduled in-office patients.  Once received, our designated virtual appointment assistant updates the patient’s chart and notifies the doctor that the images are ready to view. The doctor will then dictate what information needs to be reciprocated, what actions the patient needs to take, and what kind of appointment is needed next. The assistant ensures all communication and documentation is completed, and either


Is your orthodontic practice a target for cybercriminals in today’s COVID-19 workplace? Cybersecurity expert Mark Pribish says that awareness of data breaches is imperative in today’s technologically active practice

Introduction Most small- to medium-sized businesses, including orthodontic practices, do not believe their orthodontic practice is a target for cybercriminals and/or the insider threat. Unfortunately, the cyber-risk threat landscape keeps expanding and evolving with hackers and the insider threat contributing to an endless number of data breach events and even regulatory actions. And now the new COVID-19 working environment has businesses and consumers becoming more reliant on technology than ever before — which makes having an incident response plan to respond and recover from a data breach event more important than ever. In just the past 4 months, these five news headlines and notifications rocked the business world, including the dental business sector. • One Million US Dental Patients Impacted by Data Breach https:// www.infosecurity-magazine.com/ Mark Pribish is the VP and ID Theft Practice Leader at Phoenix, Arizona-based Merchants Information Solutions, Inc. — an identity theft and data breach risk management firm. He has authored hundreds of articles and is frequently interviewed by local and national media as an ID theft and data breach risk management expert. He is a member of the Identity Theft Resource Center Board of Directors and is a graduate of the University of Dayton.

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news/1m-us-dental-patientsimpacted-by/ FireEye, a Top Cybersecurity Firm, Says It Was Hacked by a Nation-State https://www.nytimes. com/2020/12/08/technology/fireeyehacked-russians.html New McAfee report estimates global cybercrime losses to exceed $1 trillion https://www. financialexpress.com/industry/technology/cybersecurity-the-hiddencosts-of-cybercrime/2153819/ Risk Based Security releases its Year-End 2020 Data Breach Report https://www.securityinfo watch.com/cybersecurity/pressrelease/21207207/riskbased-security-risk-based-security-releases-itsyearend-2020-data-breach-report FBI Private Industry Notification: Cyber Criminals Exploit Network Access and Privilege Escalation https://www.ic3.gov/Media/News/ 2021/210115.pdf

Summary: cyber-related news headlines and notifications In October 2020, Dental Care Alliance This dental support organization — with more than 320 affiliated dental practices across 20 states working with more than 700

dentists — started notifying over 1 million dental patients that their data may have been exposed as the result of a cyberattack. While Dental Care Alliance discovered that it was a victim of a hacking event on October 11, the hack itself had begun on September 18. When Dental Care Alliance finally contained the cyber intrusion by October 13, a total of 26 days gave hackers the time to steal patient data, including names, addresses, patient account numbers, billing information, bank account numbers, the name of the patient’s dentist, and health insurance information. Surprisingly, Dental Care Alliance saw no need to offer remediation services such as credit monitoring to patients impacted by the data breach event since the company saw “no specific evidence that personal information was used for malicious purposes.” Unfortunately, when a breached organization states that it has no specific evidence showing personal information was used for malicious purposes, it is shortsighted and careless. The final story for most data breaches rarely reflects the initial forensic assessment and news report and speaks of what’s known at the moment, but never follows up and discusses the long-term impact to affected individuals such as these dental patients. The fact is that the threat of a data breach or an identity theft event can be a lifelong problem Volume 12 Number 1

In December 2020, FireEye FireEye — one of the leading international cybersecurity firms in the world with $3.5 billion in annual sales — reported that it was hacked by a nation-state. The big and shocking news is what was hacked — digital tools that replicate the most sophisticated hacking tools in the world — where most of the tools are based in a digital vault that FireEye closely guards. The company said “hackers used “novel techniques” to make off with its own tool kit, “which could be useful in mounting new attacks around the world.” This was a stunning cyber intrusion for a company known for identifying some of the elite cybercriminals in the world and for managing some of the most well-known data breaches such as Equifax and Sony. Essentially, FireEye, which is a network security company that prides itself on providing automated threat forensics and dynamic malware protection against advanced cyber threats, could not protect itself from being hacked. In December 2020, McAfee McAfee, a leading cybersecurity firm, released a report titled “Cybersecurity: The Hidden Costs of Cybercrime” on the significant financial and unseen impacts of cybercrime. The report, conducted in partnership with the Center for Strategic and International Studies (CSIS), concludes that cybercrime costs the world economy more than $1 trillion annually. In addition, the report stated that 56 % of organizations said they do not have a plan to prevent and respond to a cyber incident. Key findings in the McAfee report included two-thirds of surveyed companies reported some kind of cyber incident in 2019 Volume 12 Number 1

Global Cybercrime Damage Costs: • • • • • • •

$6 Trillion USD a Year* $500 Billion a Month $115.4 Billion a Week $16.4 Billion a Day $684.9 Million an Hour $11.4 Million a Minute $190,000 a Second

All figures are predicted by 2021 * Source: Cybersecurity Ventures

with an average interruption to operations at 18 hours and average cost more than half a million dollars per incident. The survey also revealed 92% of businesses felt there were other negative effects on their organizations beyond financial costs and lost work hours after a cyber incident such as lost revenue, lost customers, and negative public relations. As a sidenote, Cybersecurity Ventures, a leading researcher for cybersecurity facts, figures, and statistics, states that McAfee vastly underestimates the cost of cybercrime at $1 trillion annually and that the number is closer to $6 trillion a year (https://cyber securityventures.com/mcafee-vastly-underestimates-the-cost-of-cybercrime/). In January 2021, Risk Based Security Risk Base Security — a global leader in vulnerability intelligence, breach data, and risk ratings — released its 2020 Year End Data Breach QuickView Report, revealing that “the volume of publicly disclosed data breaches fell by 48% in 2020 compared with the previous year, leading to 3,932 in total.” That was the good news. “However, the volume of records that were compromised by these breaches jumped by 141% to a whopping 37 billion records, the largest number seen by Risk Based Security since 2005.” That was the bad news. Part of the reason for the staggering increase in breached records of our personally identifiable information (PII) can be attributed to the COVID-19 pandemic

as numerous organizations relaxed their security policies for employees to work from home and students to study remotely and unwittingly exposed their networks to compromise. Interestingly enough, Inga Goddijn, Executive Vice President at Risk Based Security, commented: “We do not believe fewer breaches are happening.” Instead, “disruptions at certain governmental sources, delayed reporting, and declining news coverage have all contributed to fewer breaches coming to light in 2020, but that is only a part of the story. More complex and damaging attacks have also contributed to lengthy and complex investigations.” In my view, the single largest highlight from this year’s Risk Based Security report is that healthcare was the most victimized sector in 2020, accounting for 12.3% of reported breaches. In January 2021, the FBI Released Private Industry Notification (PIN) In PIN notification 20210114-001, the Federal Bureau of Investigation (FBI) Cyber Division issued a warning of vishing attacks stealing corporate accounts. Vishing (also known as voice phishing) is a social-engineering attack in which attackers impersonate a trusted entity during a voice call to persuade their targets into revealing sensitive information such as banking or login credentials. The notification warned of ongoing vishing attacks attempting to steal corporate accounts and credentials for network Orthodontic practice 47


that may affect you (and me) long into the future and in ways you (and I) likely haven’t even thought about. As a sidenote, the Dental Care Alliance data breach happened 2 months after a medical software company’s database containing the personal information of more than 3.1 million patients for medical and dental practices was left exposed online without the need for a password or other authorization (https://healthitsecurity.com/ news/medical-software-database-exposespersonal-data-of-3.1m-patients).

GOING VIRAL access and privilege escalation from U.S. and international-based employees. According to PIN 20210114-001, “The threat actors are using Voice over Internet Protocol (VoIP) platforms (aka IP telephony services) to target employees of companies worldwide, ignoring their corporate level.” In addition, this is the second warning alerting of active vishing attacks targeting employees issued by the FBI since the start of the pandemic after an increasing number of employees began working remotely from home. In August 2020, the FBI and the Cybersecurity and Infrastructure Security Agency (CISA) issued a joint advisory warning remote workers of an ongoing vishing campaign targeting companies from several U.S. industry sectors as cybercriminals mined the victim company databases for their customers’ personal information to leverage in other attacks.

So what can be done? Your orthodontic practice needs to create a new security culture with a new sense of urgency for both your business and its employees. First, understand that cyber thieves and ID theft criminals are constantly evolving and diversifying to find new ways to monetize the phishing (fraudulent emails), vishing (fraudulent phone calls and voicemail messages), and smishing (fraudulent text messages) threat landscape. Second, ask the orthodontic practice that you work for what is the formal response and recovery plan that is in place in the event of a data breach event? With more people working from home due to the COVID-19 crisis, the risk of financial and non-financial identity theft, fraud, and scams for both individual consumers and small businesses have significantly increased. To help your orthodontic practice learn more about common scams and crimes, I have included this FBI link (https://www.fbi. gov/scams-and-safety/common-scamsand-crimes/internet-fraud) with a focus on internet fraud, including several high-profile fraud methods provided by the FBI. • Business Email Compromise (BEC): A sophisticated scam targeting businesses working with foreign suppliers and companies that regularly perform wire transfer payments. The scam is carried out by compromising legitimate business 48 Orthodontic practice

email accounts through social engineering or computer intrusion techniques to conduct unauthorized transfers of funds. Data Breach: A leak or spill of data which is released from a secure location to an untrusted environment. Data breaches can occur at the personal and corporate levels and involve sensitive, protected, or confidential information that is copied, transmitted, viewed, stolen, or used by an individual unauthorized to do so. Denial of Service: An interruption of an authorized user’s access to any system or network, typically one caused with malicious intent. Email Account Compromise (EAC): Similar to BEC, this scam targets the general public and professionals associated with, but not limited to, financial and lending institutions, real estate companies, and law firms. Perpetrators of EAC use compromised emails to request payments to fraudulent locations. Malware/Scareware: Malicious software that is intended to damage or disable computers and computer systems. Sometimes scare tactics are used by the perpetrators to solicit funds from victims. Phishing/Spoofing: Both terms deal with forged or faked electronic documents. Spoofing generally refers to the dissemination of email which is forged to appear as though it was sent by someone other than the actual source. Phishing, also referred to as vishing, smishing, or pharming, is often used in conjunction with a spoofed e-mail. It is the act of sending an e-mail falsely claiming to be an established legitimate business in an attempt to deceive the unsuspecting recipient into divulging personal, sensitive information such as passwords, credit card numbers, and bank account information after directing the user to visit a specified website. The website, however, is not genuine and was set up only as an attempt to steal the user’s information. Ransomware: A form of malware targeting both human and technical weaknesses in organizations and individual networks in an effort to deny

the availability of critical data and/or systems. Ransomware is frequently delivered through spear phishing emails to end users, resulting in the rapid encryption of sensitive files on a corporate network. When the victim organization determines they are no longer able to access their data, the cyber perpetrator demands the payment of a ransom, typically in virtual currency such as Bitcoin, at which time the actor will purportedly provide an avenue to the victim to regain access to their data. Lastly, help your employees and patients respond to the threat to their personal information in 2021 by considering these personal privacy tips. • Cut your cyber- and identity-theft risks by learning about the Internet of Faking and Extortion occurring through social media, as it has become a new profit center for ID theft criminals. • The Internet of Things or “IoT” adds tremendous benefits through devices and apps, but these “things” also create opportunities for hackers and ID theft criminals to steal and use your information. • While IT and hacking are the sizzle that continues to create data-breach headlines, most data-breach events are caused by lost devices, human error, and malicious intent. Only 50% of breaches are caused by IT and hacking. • As the use of Telehealth and healthrelated services and information via electronic information and telecommunication technologies increases, medical ID theft will continue to increase. Be more vigilant in securing and monitoring your medical information. • The use of apps and social media are priority targets for cybercriminals, and you need to limit the information you share. • No password is “unbreakable,” but do not make it easy for ID theft criminals to get a pass into your personal information with weak or overused passwords. Why is all of this important? Because cyber-thieves and ID theft criminals never rest, and they continue to stay ahead of law enforcement, businesses, and consumers. OP Volume 12 Number 1

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Orthodontic Practice US Spring 2021 Vol 12 No 1  

Orthodontic Practice US Spring 2021 Vol 12 No 1  

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