clinical articles • management advice • practice profiles • technology reviews
PROMOTING EXCELLENCE IN ORTHODONTICS Early interceptive treatment of impacted and potentially impacting permanent teeth Dr. Bradford Edgren
BioDigital Orthodontics part 17
An orthodontic perspective on white spot lesions: part 2 Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA
Treatment of asymmetrical Class II malocclusion Dr. Todd Bovenizer
READY TO TAKE CONTROL?
Practice profile Dr. L. Douglas Knight
Go to page 31
Drs. Rohit C.L. Sachdeva, Steven Moravec, Takao Kubota, and Jun Uechi
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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon
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Volume 6 Number 5
Time as a measure of quality?
hat are the hallmarks of quality orthodontic treatment? You would have to search far and wide to find an orthodontist who does not claim to provide quality treatment. Quality is not easily defined in orthodontics, and to date, a standard has not been established that the general public can understand. The American Board of Orthodontics has helped quantify quality for orthodontists in that we can measure occlusal relationships, marginal ridge relationships, alignment of teeth, buccolingual inclinations, and occlusal contacts. More recently, the subjective evaluation of smile arcs and smile lines has become a prevalent measure and is more readily identified by patients. Jeffrey G. Johnson, DDS, MS One of the most easily measured metrics by anyone is time, which never seems to be mentioned in the same breath as quality treatment. Ironically, the first question a patient and/or parent almost always asks during the consultation is, “How long will it take?” Their assumption is that, as specialists, we will strive to achieve the aforementioned measures of quality. To the patient, time in treatment is related to discomfort, less-than-desired esthetics, and the nuisance of appliances. To parents, time means listening to their child complain about discomfort and nuisances associated with orthodontic appliances, trips to visit the orthodontist, and reminding/nagging their child to be compliant. Not only is the length of treatment time important, but the predictability of it is as well. Undoubtedly, patients do not like to exceed proposed treatment time estimates. This is the value proposition associated with time. Over the previous 12 years, we have transitioned our practice to complete utilization of digital technologies, including our patient management system, two- and three-dimensional radiography, intraoral scanning, and clinical patient management and virtual treatment planning system. It was at that time we introduced suresmile® technology as our digital treatmentplanning platform. We have been able to diagnose, treatment plan, and prescribe mechanics and wires to reduce treatment times by 35% as measured in more than 3,000 patient histories. The effects of predictably reduced treatment times have several effects: reduced treatment visits, dramatic reductions in hypocalcified teeth as subjectively evaluated at debonding, improved patient compliance as aggressive treatment goals are set and tracked, an increase in the capacity to treat patients, and an increased pool of patients willing to undergo treatment. Three-dimensional treatment planning also offers a powerful way to convey your vision to the patients. They can actually see their planned quality outcome and are undoubtedly impressed with the application of advanced technologies to their care. Furthermore, it allows the orthodontist and staff to demonstrate the need for auxiliaries and adjunctive procedures (elastics, TADs, Class II correctors, etc.) as the patient can visualize that brackets and wires alone are not sufficient to achieve a quality outcome. Technology is not the answer in and of itself. Plenty of practitioners have technology in their offices, yet so much of it remains underutilized and almost exists for the sake of it. Furthermore, when technology is employed, its fullest capabilities are often not used. It is up to each one of us for the sake of our patients and our profession to use whatever we deem appropriate to the extent of our abilities and the capabilities of each technique or technology. The technology we profess to use has to evolve beyond a fancy gadget that wows the patient into a tool that we can utilize to best plan for and execute the care for our patients within their biological and physiological tolerances.
Dr. Jeffrey G. Johnson
Jeffrey G. Johnson, DDS, MS, graduated from the University of Iowa with a BS in Biomedical Engineering and his DDS. Baylor College of Dentistry at Texas A&M University Health Systems was where he received his Orthodontic Certificate and MS in Oral Biology. He has served on the American Association of Orthodontists Council on Orthodontic Practice and the suresmile Advisory Board. He has practiced in Dallas, Texas, for the past 19 years with a pediatric dental partner.
Orthodontic practice 1
September/October 2015 - Volume 6 Number 5
TABLE OF CONTENTS
Case study Integrating efficient systems to complete a challenging Class II Division 2 in 16 months Dr. Anoop Sondhi illustrates innovative treatment for a teenage patient........ 18
Practice profile L. Douglas Knight, DMD
Treatment of asymmetrical Class II malocclusion Dr. Todd Bovenizer presents treatment of a challenging asymmetrical Class II malocclusion utilizing Damon™ Q selective torques and early light elastics............................................21
Case review Active self-ligation for better control throughout treatment Dr. Luis Nelson Núñez illustrates treatment phases that lead to precision, predictability, and efﬁciency ....................................................... 24
Orthodontic concepts BioDigital orthodontics Management of skeletal deformities with orthognathic surgery — Direct (CBCT) (2): part 17
Case study About F.A.C.E
Drs. Rohit C.L. Sachdeva, Steven Moravec, Takao Kubota, and Jun Uechi continue their exploration of management of skeletal deformities using suresmile® technology............ 28
Drs. Straty Righellis and L. Douglas Knight illustrate an advanced treatment for the entire dental and facial system ON THE COVER Cover photo courtesy of Dr. Bradford Edgren Article begins on page 43.
2 Orthodontic practice
Volume 6 Number 5
Stop Following the Crowd and Start Following the Leaders
Hollywood, FL Diplomat Resort and Spa January 27 – 29 Wednesday, January 27, 2016
Friday, January 29, 2016
• Evening Poolside Welcome Reception
• Clinical Insights General Session • Breakout Sessions • Closing Reception and Dinner at Marlins Stadium
Thursday, January 28, 2016 • Business Insights General Session Featuring Best Selling Business Authors & Industry Experts • Happy Hour
This year’s list of world-class keynote speakers include John DiJulius, Mark Jeffries and Jim Abbott.
TABLE OF CONTENTS
Propelling orthodontics The Propel® System: the next generation orthodontic disruptor Dr. Gary Brigham discusses faster orthodontic movement without compromising clinical outcomes .......................................................36
Continuing education An orthodontic perspective on white spot lesions: part 2 Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA, discuss various ways to reduce the occurrence of demineralized white spot lesions (DWSL)........................39
Continuing education Early interceptive treatment of impacted and potentially impacting permanent teeth
Dr. Bradford Edgren illustrates cases where early treatment avoided later complications
Going viral Infection control — how equipment plays a role Adrian E. LaTrace offers advice on controlling pathogens in the practice .......................................................50
Technology Gentle, effective, and efficient Class II correction that sets a new standard for treatment The Jasper Vektor™ — the first edgewise Class II corrector..............53
Research The value of orthodontic study models for diagnosis and treatment planning: a survey Drs. Nathan Yetter and Donald J. Rinchuse investigate whether orthodontic e-models and/or plaster models are useful........................... 56
4 Orthodontic practice
Herbst appliance update
AOA, customizing the MARA™ since 1994....................................68
A review of the Herbst appliance and the design evolution of the last 30 years..........................................60
Industry news...............63 Product spotlight The all-new Carriere® Motion™ Class III Appliance A remarkable breakthrough in Class III correction........................................64
New product announcement 3DiB: 3-Dimensional Intelligent Bonding........................................70
Product profile Planmeca Romexis® software Open architecture, endless possibilities .......................................................71
Product profile American Orthodontics Tanzo™ Premium Heat Activated Arch Wire.....................................66
Volume 6 Number 5
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Designed to increase case starts, this new interactive tool educates patients on the benefits of orthodontia and the Damon System including Damon Clear. • 25+ videos and numerous photos • For use before, during and/or after the consultation • Customizable with your practice branding, patient photos and patient testimonials • Free service for orthodontists treating with the Damon System
Visit ormco.com to learn more about the Damon System and My Smile Consult. © 2015 Ormco Corporation
L. Douglas Knight, DMD Knight life What can you tell us about your background? Following dental school, I completed a General Practice Residency and spent 7 years practicing dentistry in the Army Dental Corps. I became very active in the Academy of General Dentistry and earned my Fellowship in the AGD. My time in the military gave me a great foundation and an appreciation for interdisciplinary dentistry. It was also during my time in the Army that I first met my future mentor, Dr. Ron Roth. He inspired me to pursue a career in orthodontics. After attending one of his lectures at Walter Reed Army Medical Center, I applied to orthodontics.
Why did you decide to focus on orthodontics? I was inspired by Dr. Rothâ€™s passion to treat the entire dentofacial complex and not just straighten the teeth. Orthodontics requires an understanding of the dental and skeletal system, growth, airway, and facial esthetics. It requires thought! Thus, no two patients are the same, and no two days are the same.
How long have you been practicing, and what systems do you use? I just celebrated my 20th year in practice. I have been using self-ligating brackets for the past 16 years. For the last 6 years, I have been using a hybrid system, passive in the posterior and active in the anterior. Reviewing diagnostic records prior to a consultation
Several members of the Louisville Interdisciplinary Team 8 Orthodontic practice
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PRACTICE PROFILE What training have you undertaken? During my orthodontic residency, I began the Roth Williams Course on Functional Occlusion for Orthodontists. Upon completing this 2-year course, I began assisting in teaching the course. The course has now been enhanced to incorporate additional training in facial esthetics and airway management, but still remains true to the Roth Williams treatment philosophy. I now teach the course with two of my best friends, Dr. Straty Righellis and Dr. Carl Roy.
Who has inspired you? Several people have provided a great deal of inspiration and education throughout my career. Dr. Bill Arnett has shared his knowledge of orthognathic surgery, Dr. David Hatcher on radiology, Dr. Jeff McClendon on bioesthetic dentistry, and Dr. Rick Roblee on accelerated orthodontics.
Teaching partners Dr. Bob Williams and Dr. Carl Roy 10 Orthodontic practice
Volume 6 Number 5
THE SECRET TO ORTHODONTIC LAB SURVIVAL IN THE NEXT DECADE? GO DIGITAL.
For an orthodontic lab to survive in today’s market you need to expand your reach. Win new customers. Open fresh markets. In short – you need to go digital. 3D printing helps you better plan and execute your digital workflow. Now you can digitally manufacture stone models, orthodontic appliances, delivery and positioning trays, clear aligners and retainers faster than ever. Labs like ClearCorrect and ClearStep have already transitioned to a digital workflow and have done away with bulky physical model storage. So why wait? Contact Stratasys to find out why now is the right time to move to digital production with Stratasys Objet 3D Printers.
Visit www.stratasysdental.com ©2015 Stratasys, Inc.
PRACTICE PROFILE What is the most satisfying aspect of your practice? Finishing difficult cases and achieving the goals, while pleasing the patients’ desires. It doesn’t get any better than that. Happy patients; happy practice!
Professionally, what are you most proud of? I’ve been fortunate to work with a great group of dedicated dentists and specialists in my area (Louisville, Kentucky), and together we’ve been able to generate a lot of nice cases, which have been good for teaching. It makes going to the office each day purposeful, and both my patients and students benefit.
What do you think is unique about your practice? In addition to straightening teeth, we strive to provide bites, which are functional as well. Condylar position, guidance, airway, and facial esthetics all have measurable goals, and we place great emphasis on improving with treatment.
Top 10 favorites
Celebrating the 20th Anniversary of Knight Orthodontics with his wonderful staff
1. Skeletal anchor plates 2. Dentoalveolar distraction osteogenesis (DDO) procedure 3. Pre-torqued archwires 4. i-CAT™ 3D cone beam imaging 5. Anatomodels (Anatomage) 6. Functional and Cosmetic Excellence (FACE) hybrid appliance 7. Dolphin 3D imaging 8. Panadent articulator 9. Guys I teach with 10. The knowledge and friendships I’ve gained from my association with Roth Williams International Society of Orthodontists
What is the future of orthodontics and dentistry? I think the future is bright if we can continue to provide a high level of service that is more than just esthetics.
What has been your biggest challenge?
What are your top tips for maintaining a successful practice?
I’m probably my own biggest critic. I feel anything is possible if you believe in yourself, and you can envision your goal. When things don’t turn out as I might wish they would, I can usually look in the mirror to see who is at fault.
Treat your patients as you would want to be treated. Don’t drive yourself crazy concerning yourself with production. Focus on quality of treatment and putting the patients’ care first. Everything else really does take care of itself.
What would you have become if you had not become a dentist?
What advice would you give to budding orthodontists?
I’m not sure; I never really had a fallback plan. I had always pursued a career in dentistry.
Continue your education past your residency. There is so much to learn. You owe it to yourself and your patients.
What are your hobbies, and what do you do in your spare time? I enjoy, of course, spending time with my family, but I also enjoy teaching. OP
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12 Orthodontic practice
Volume 6 Number 5
FACE Evolution System
“Finally we have an appliance focused not only on aesthetics, but takes into account aesthetics and function as a means to longevity and stability of the stomatognathic system.” The FACE Group
Dr. Domingo Martín , Dr. Jorge Ayala, and Dr. L. Douglas Knight.
For detailed information on FACE visit us on www.forestadent.com/face
About F.A.C.E Drs. Straty Righellis and L. Douglas Knight illustrate an advanced treatment for the entire dental and facial system What is F.A.C.E, and what does it stand for? No longer is orthodontic treatment just treating the smile by straightening teeth. Building on the principles established and practiced by renowned dental and orthodontic leaders (Drs. Ronald Roth, Bob Williams, Bill Arnett, and David Hatcher) the FACE (Functional and Cosmetic Excellence) program provides a comprehensive study in orthodontics and interdisciplinary dentistry. The FACE philosophy incorporates comprehensive diagnostics, efficient treatment mechanics, and the latest orthodontic advancements for treating the entire dental and facial system. FACE orthodontists seek a marriage between the goals of orthodontics and comprehensive dentistry. These goals are similar for patients of all ages: beautifully aligned teeth that fit harmoniously with properly positioned jaw joints — promoting healthy tissue, efficient chewing, proper lip support, and ideal facial balance. By establishing and sharing these goals, your team — the orthodontist, dentist, and/or specialist — work closely together to provide outstanding results in beauty, health, and function. Since excellent results require careful planning, FACE doctors believe in visualizing the final outcome before commencing
The FACE philosophy incorporates comprehensive diagnostics, efficient treatment mechanics, and the latest orthodontic advancements for treating the entire dental and facial system.
treatment. Thorough and accurate diagnostic records, detailed study, and a comprehensive treatment plan can also yield shorter treatment times, better results, and improved stability. The FACE philosophy trains orthodontists how to implement this treatment process while maintaining a productive and profitable practice.
FACE diagnosis and treatment philosophy The FACE approach has measurable evidenced-based goals for the occlusion, face, airway, and TMJ as well as understanding the biology of the periodontium and the elements for long-term stability of the results. The criteria for an optimal occlusion are to have even and simultaneous contacts of all possible teeth when
Straty Righellis, DDS, is a Diplomate of the American Board of Orthodontics, graduated from UCLA Dental School, and received his orthodontic specialty certification from University of California at San Francisco. He maintains a private practice in Oakland, California, while serving as an Associate Clinical Professor at the University of the Pacific and University of California, at San Francisco, Schools of Dentistry. Dr. Righellis is on the Editorial Review Board for the American Journal of Orthodontics, and has lectured extensively to over 250 national and international groups on Excellence and Clinical Orthodontics. He is a member of the American Association of Orthodontists, faculty member at the FACE USA postgraduate teaching program, and is past President of the Edward H. Angle Society, Northern California. Dr. Righellis is a chapter contributor on “Treatment Efficiency and Excellence” in the textbook Goal-Directed Orthodontics. L. Douglas Knight, DMD, ABO, FAGD, is a graduate of the Roth/Williams 2-year program for Functional Occlusion and was on the faculty at the Center for Functional Occlusion from 1997 to 2000. He is the recipient of the Roth Williams International Society of Orthodontists Pacesetter Award. Most recently, he was honored by the Hardin County School System with a Distinguished Alumni Award. Dr. Knight is a graduate of the University of Kentucky College of Dentistry and the Army Dental Corps 1-year General Practice Residency. In addition, he is a Diplomate of The American Board of Orthodontics and a Fellow of the Academy of General Dentistry. Dr. Knight completed his orthodontic training at New York University in 1995. Dr. Knight has published several articles in the Academy of General Dentistry and the Journal of Clinical Orthodontics. Dr. Knight founded an interdisciplinary team training group with teams from around the country. Besides operating two offices, Dr. Knight lectures on a broad range of topics to study clubs and residency programs. He has been appointed as Director of the Roth Williams International Society of Orthodontists for the United States.
14 Orthodontic practice
condyles are positioned forward against the eminence as far superior as possible and centered mid-sagittally with a healthy disc interposed. Dr. Jorge Ayala, a FACE educator, has quantified the range of optimal facial balance elements of various ethnicities, which are essential to strengthen our ability to apply the highest standards of care across various cultures. From the clinical research from leaders of the FACE teaching group, comes a refreshing approach to lifelong learning that is not only didactic, but also clinically realistic. It can be readily applied to day-to-day practice.
Case examples The pre- and-posttreatment cases illustrate FACE principals for occlusion, facial esthetics, and facial balance. The four case examples presented illustrate different treatment plans to achieve predictable occlusal goals, optimal facial balance, enhanced periodontal health, and maintenance of TMJ health while achieving dental stability with minimal long-term retention. The FACE teaching team, together with Forestadent, has introduced the FACE prescription in a new self-ligation bracket. Alterations in canine inclination and angulation, molar rotation, and inclination are a few of the improvements over the original Roth prescription. Other improvements include an improved contoured base for added retention and a more durable clip. Volume 6 Number 5
Diagnosis: Class I, moderate upper arch crowding. Inadequate overbite with minimal chin projection. Upper midline to patientâ€™s right. Treatment Goals: Mutually protected occlusion and enhance soft tissue chin projection. Treatment Plan: .022 Active/Passive Self-Ligation Bracket System. Four second bicuspid extractions with reciprocal space closure to control midlines, improve overbite, and mild incisor retraction to relieve mentalis muscle strain. Treatment Results: Mutually protected occlusion, midlines centered, and enhanced facial balance. Treatment Time: 21 months with 13 office visits. Retention: Nightly use of removable retainers. No lingual bars!
Case 2 Diagnosis: Class II right side malocclusion. Minimal upper arch crowding. Good chin projection. Treatment Goals: Mutually protected occlusion. Maintain soft tissue and chin projection. Treatment Plan: .022 Active/Passive Self-Ligation Bracket System. Initially segmental Class II right side elastics. As Class I approached, complete upper arch appliance placement. Treatment Results: Class I occlusion; mutually protected occlusion; maintained facial balance
Volume 6 Number 5
Orthodontic practice 15
CASE STUDY Case 3 Diagnosis: Class III malocclusion. Prognathic profile. Anterior crossbite. Left posterior crossbite. Upper and lower spacing. Narrow upper lateral incisors. Unerupted 8’s. Treatment Goals: Mutually protected occlusion. Balance soft tissue profile. Treatment Plan: .022 Active/Passive Self-Ligation Bracket System. Lefort I – maxillary advancement. Move maxillary anterior down and forward
Case 4 Diagnosis: Class I malocclusion. Anterior open bite. Tongue thrust habit. TMJ symptoms. Slightly retrusive profile. Treatment Goals: Close anterior open bite in order to achieve a mutually protected occlusion. Treatment Plan: .022 Active/ Passive Self-Ligation Bracket System. Maxillary anchor plates
Commitment to teaching and mentoring (F.A.C.E. Courses) — Partnership with teaching centers During the comprehensive FACE program, participants develop a solid foundation of skill sets taught by practicing orthodontists in the following areas: • In-depth evaluation of joint function and occlusion • Analytical techniques to assess facial balance, correct tooth position, and 16 Orthodontic practice
esthetic smile design • Computer-assisted treatment planning and case presentation • Multidisciplinary case diagnosis and steps to follow for successful outcomes • Efficient treatment mechanics with the latest in accelerated and skeletal anchorage techniques • Guidelines for establishing your interdisciplinary team
• Practice management and marketing techniques • Develop a never-ending quest for continued improvement in practice efficiency. Finishing “on time” with predictable results allows the orthodontist to provide optimal results that meet or exceed patients’ expectations. For FACE Course information, click www.fullfacecourse.com OP Volume 6 Number 5
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Integrating efficient systems to complete a challenging Class II Division 2 in 16 months Dr. Anoop Sondhi illustrates innovative treatment for a teenage patient
16-year-old male patient presented for orthodontic treatment with an atypical Class II Division 2 malocclusion. Although the overall dental and skeletal pattern featured a Class II Division 2 discrepancy, tooth No. 9 demonstrated a significant labial inclination, as opposed to a lingual inclination. Given the patientâ€™s age, it was evident that the Class II correction would prove to be a challenge. The treatment plan, therefore, called for the integration of various systems, including Variable Prescription Appliances, self-ligation, and Class II Correctors. As seen in the diagnostic records (Figures 1A-1C), the anteroposterior discrepancy was a full-cusp Class II malocclusion. Given the patientâ€™s facial and lip profile, extractions were considered undesirable. It was also quite evident that the correction of the Class II
Figure 1A: Initial facial records
Figure 1B: Initial lateral cephalometric X-ray
Dr. Anoop Sondhi, DDS, MS, received his dental degree from the Indiana University School of Dentistry and his postgraduate certificate and MS in orthodontics from the University of Illinois in 1977. He practices in Indianapolis and is a visiting professor for several graduate programs in orthodontics. He has presented seminars and continuing education courses to several dental and orthodontic organizations all over the world. Dr. Sondhi devotes a significant amount of his work to the development of effective and efficient treatment systems, indirect bonding, interceptive treatment of complex malocclusions, and the orthodontic management of temporomandibular disorders. Disclosure: In the past, Dr. Sondhi has received honoraria from 3M.
Figure 1C: Initial panoramic X-ray 18 Orthodontic practice
Volume 6 Number 5
mandibular anterior segment, Low Torque brackets were placed in the mandibular arch. Figure 2 shows the initial placement of the maxillary and mandibular fixed appliances. The case was treated with Clarity™ SL Self-Ligating Brackets (3M Oral Care) on the maxillary arch, and SmartClip™ SL3 Self-Ligating Brackets (3M Oral Care) on the mandibular arch. Resin-reinforced glass ionomer cement was placed on the occlusal surfaces of the maxillary first molars to disarticulate the patient and to avoid traumatic contact between the maxillary incisal edges and the mandibular incisor brackets.
Volume 6 Number 5
Once initial alignment of the arches had been obtained (Figure 3), rectangular wires were inserted to begin expression of the maxillary and mandibular torque. As soon as the curve of Spee had been leveled to an acceptable degree, Forsus™ Class II Correctors (3M Oral Care) were engaged to begin the Class II correction (Figure 4). The Forsus Correctors were activated by the addition of 1 mm spacers at 6-week intervals. Figure 5 shows the status of the case following completion of the Class II correction with Forsus Correctors. At this time,
Orthodontic practice 19
discrepancy would require a fixed Class II corrector. The panoramic radiograph reveals an impacted tooth No. 32. Due to the proximity of the roots to the inferior alveolar canal, the oral surgeon opted to defer extraction of tooth No. 32. The tooth was kept under observation. The Variable Prescription Orthodontics technique (VPO – 3M) was used for this case. The maxillary arch called for Medium Torque brackets on all the teeth except tooth No. 8, where a High Torque bracket was placed. Because the fixed Class II correctors generally cause some proclination of the
Figure 7A: Final facial records
Figure 7B: Final lateral cephalometric X-ray
the finishing archwires were placed, and finishing elastics were engaged to complete the detailing required. Figure 6 demonstrates the finishing archwires as we approached the completion of treatment, and Figures 7A-7C show the posttreatment records, and the cephalometric and panoramic radiographs. Because of the efficiency afforded by the use of Variable Prescription brackets, selfligation, as well as the enhanced efficiency of the Class II correction with Forsus Correctors, the patient’s total treatment time was 16 months. This is quite remarkable, given that we were dealing with a patient who was essentially non-growing. The archwire sequence was as follows: • 9/19/11 – 2/1/12: Maxillary .012 Nitinol/Mandibular .014 Nitinol 20 Orthodontic practice
Figure 7C: Final panoramic X-ray
... the patient’s total treatment time was 16 months. This is quite remarkable ...
• 2/1/12 – 3/28/12: Maxillary .014/.014 Nitinol Tandem Archwires/Mandibular .014/.014 Nitinol Tandem Archwires
• 3/28/12 – 5/23/12: Maxillary .016 x .025 Beta III Titanium Archwire with enhanced curve of Spee/Mandibular .016 x .025 Beta Titanium w/ exaggerated curve of Spee • 5/23/12 – 11/29/12: Engagement of the Class II Corrector; inserted .016 x .025 Beta III Titanium archwires • 11/29/12 – 1/22/13: Class II Corrector removed; inserted .016 x .025 Beta III Titanium archwires • 1/22/13 – 2/27/13: Placement of a finishing .016 x .025 Beta Titanium wire in the mandibular arch, with finishing elastics • 2/27/13: Case complete OP Volume 6 Number 5
Dr. Todd Bovenizer presents treatment of a challenging asymmetrical Class II malocclusion utilizing Damon™ Q selective torques and early light elastics
ompliance is paramount to a satisfactory orthodontic finish. Treatment results are only as good as the level of participation a patient provides. Specifically when determining what type appliance to employ for A/P correction, it is necessary to evaluate the psychological commitment each patient will likely exhibit. Good oral hygiene, negligible appliance breakage and debonding, and consistent elastics wear, if applicable, are all critical to an excellent result. Without compliance, treatment success is significantly lessened. In the following case, I demonstrate how a sound diagnosis and careful treatment planning can positively affect case development and the eventual outcome. Orthodontists must evaluate each case with the end result in mind in order to select the proper torques that will achieve the desired result. Difficult Class II cases may also need A/P correction (with elastics or a fixed appliance, such as AdvanSync™), which determines incisor torque selection. I evaluate the malocclusion and skeletal pattern to determine which appliance is best suited to correct a Class II, taking into consideration my estimation of the patient’s proclivity for compliance. In this particular case, I surmised that compliance would be a non-issue, so I proceeded with an elastics-only treatment plan. The Damon™ Q bracket system offers selective torque values that are vital for effective treatment planning.
Todd Bovenizer, DDS, MS, is a Diplomate, American Board of Orthodontics, recertified in 2010, who maintains a full-time practice in Cary, North Carolina. He serves as President of the North Carolina Association of Orthodontists and is also actively involved with many study clubs, locally and nationally. His practice has been selected as a test site for practice management software, and he participates in clinical evaluations to assess appliances in development. Dr. Bovenizer earned his DDS and MS in Orthodontics from West Virginia University.
Volume 6 Number 5
Figure 1: Pretreatment records that exhibit patient’s narrow maxillary/ mandibular arches, moderate overjet, and a near full-step Class II dental malocclusion on the right side
Figure 2: Pretreatment ceph
Figure 3: Pretreatment pano
It is only through use of passive Damon™ System technology and its reduced friction would I treatment plan with only light elastics. Using light elastics that begin at bonding is kinder to tissues. Beginning A/P correction concurrent with leveling and aligning also speeds treatment time and allows me to start finishing mechanics much earlier, providing additional time to detail the occlusion when necessary. I also like to remain in stainless steel wires for 6 months for arch coordination and stability.
Case presentation: diagnosis A 13.6-year-old adolescent male presented with no significant dental history, complaining that he did not like his smile or midlines. He exhibited a Class I skeletal relationship with narrow maxillary/mandibular arches, moderate overjet, and a near full-step Class II dental malocclusion on the right side (Figures 1-3).
Treatment plan In assessing the case, I had a very important decision to make — whether to use Orthodontic practice 21
Treatment of asymmetrical Class II malocclusion
Orthodontists must evaluate each case with the end result in mind in order to select the proper torques that will achieve the desired result.
elastics or a fixed Class II dental corrector. In my practice, this choice dictates torque selection because I pay particular attention to axial inclination of maxillary incisors. I determined that elastics therapy would be the right treatment plan choice in this case because the examination had gone well, and I anticipated compliance from both the patient and his parents. It has been my experience that using fixed Class II correctors, such as Forsus™ or Herbst® therapy, results in retroclination of the incisors, which dictates high-torque incisor brackets. Given that I had decided to employ early light elastics therapy (beginning with 2 oz. elastics and progressing from there), I chose low-torque Damon Q selfligating brackets U/L 2-2 and high-torque brackets for the U/L 3s. I would expand the buccal segments, coordinate the arch forms, and be careful to assess incisal angulation, the smile arc and transverse expansion at every appointment to ensure their proper development.
Treatment progress At the start of treatment, I indirect bonded the patient with Damon Q low-torque appliances U/L 2-2 and hightorque brackets on the U/L 3s. Figure 4: Midtreatment pano appointment. Repositioned upper incisor brackets 2-2 to improve the smile arc I placed Ormco’s .014" Damon ® Copper Ni-Ti wires and began short Quail 3/16" 2 oz. Class accommodate bracket repositioning, I left II elastics (from Ormco) U4-L6, bilaterally, the .018" x .025" Copper Ni-Ti wires in place full time until 6 weeks prior to engaging the for 6 more weeks prior to engaging finishing finishing wires. The patient remained on short wires. I make the determination about how Class II elastics for 16 weeks — the amount long to leave the rectangular Copper Ni-Ti of time spent in .014"/.018" round Copper wires engaged on a case by case basis; I Ni-Ti wires. At this point, I bonded the 7s, do not prescribe to a “one fits all” approach. transitioned to rectangular .014" x .025" Copper Ni-Ti wires and began Parrot 5/16" Finishing 2 oz. Class II elastics on the right side U3-L6, At 10.6 months after bonding, the keeping the short Class II configuration (Quail finishing wires were placed — U: .019" x 3/16" 2 oz.) on the left side. After 10 weeks, .025" Damon stainless steel; L: .016" x .025" I moved to .018" x .025" Copper Ni-Ti wires Damon stainless steel with Impala 3/16" 6oz. (upper and lower) and attached Bear ¼" 4.5 elastics U3 to L4-6. I chose not to employ a oz. elastics on the right side, continuing the TMA wire in the upper arch because I did not Quail 3/16" 2 oz. on the left side. After 8 anticipate any wire manipulation and desired weeks in these wires (at the midtreatment the transverse aspect of the arch form to pano appointment), I repositioned the maxildevelop even more fully. The stainless steel lary upper incisors 2-2 because his smile wires would remain in place for 5.6 months arc was flatter than desired, then specified prior to debonding. We saw the patient for nighttime only elastics wear with the same two more visits during this time — one for sizes/weights/attachments (Figures 4). To a retie and then the appointment 6 weeks further develop the transverse arch and
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22 Orthodontic practice
Volume 6 Number 5
Figure 5: Posttreatment images exhibit an excellent result with improved transverse width, an appreciable increase in incisor display upon smiling, and a pronounced smile arc with excellent interdigitation of the teeth, a mutually protected occlusion, complete cuspid rise with no interferences, and superior anterior guidance
Figure 6: Posttreatment ceph
prior to bracket removal to place 3/16” 6 oz. settling elastics, U3-L3-4 on the left side and U4-5-L4-5 on the right side. Thanks to Dr. Stuart Frost (Mesa, Arizona) for the protocol of maintaining finishing wires for 6 months for adequate arch development and coordination. I always try to treatment plan with this time frame in mind, which helps case management when starting treatment with 7s erupted and with treatment time estimates.
Results Due to the patient’s exceptional response from both compliance and biological perspectives, the A/P was corrected using only light elastics begun at bonding. These mechanics negated the need for a fixed Class II appliance that can cause iatrogenic maxillary incisor retroclination. The variable torque brackets selected reduced proclination of the mandibular incisors and kept the maxillary incisors upright. I feel one of the most important aspects of beautiful treatment is not only a pleasing smile arc, but the proper inclination of the incisors. These are just two reasons why the Damon Q bracket is so helpful in treating cases. I feel I can gain control from the start of treatment, even during the round-wire phase. This patient’s arches rounded out nicely, and his buccal corridors improved Volume 6 Number 5
Figure 7: Posttreatment pano
dramatically. There was also an appreciable increase in his incisor display upon smiling and a pronounced smile arc with excellent interdigitation of the teeth. He finished with a mutually protected occlusion and complete cuspid rise with no interferences. He also now benefits from superior anterior guidance (Figures 5-7).
Conclusion The key to this case was the diagnostic treatment planning and indirect bonding setup. I selected the incisor torque values based on the force patterns of the planned elastics. Had a different appliance been
selected for A/P correction, different torque choices would have been made. I also positioned the brackets at the FA point (at the center of the clinical crown) and bonded the brackets from the posterior to the cuspids to take advantage of the “wedge effect” that Dr. Dwight Damon (Spokane, Washington) discusses, which dramatically improves smile arc design. Not every patient in my practice can commit to the level of compliance this patient did. Because he did so, the case finished in 16.2 months and 10 appointments (including bonding and debonding and one repair) rather than the 18-20 months it could easily have gone. OP Orthodontic practice 23
Active self-ligation for better control throughout treatment Dr. Luis Nelson Núñez illustrates treatment phases that lead to precision, predictability, and efﬁciency
hile self-ligating brackets have proven efﬁcacious in treating a wide variety of malocclusions, they are especially proﬁcient in treating crowding. Active self-ligation has been widely proven to provide better control throughout treatment, and the In-Ovation® line of products is undoubtedly the best. In this review, you will notice how effectively and efﬁciently In-Ovation® C brackets performed. I’ve had the opportunity to work with many different appliances during my professional career, and I’ve found the In-Ovation brackets give me everything I need to ﬁnish cases with precision, predictability, and efﬁciency. One of the most controversial points about self-ligating brackets is the torque expression during the ﬁnal phase of treatment. However, Dr. Celestino Nobrega has proven that In-Ovation active SL brackets express 100% of their torque values when combined with a .019 x .025 stainless steel archwire.1 In my daily practice, I want to be as efﬁcient as possible, avoiding complications and enjoying the day with my patients. During this article, we will explore a brief description of the treatment phases related to the archwire sequence.
Figure 1: Pretreatment, skeletal Class I malocclusion
Figure 2 A.
Class I with severe lower crowding and upper central incisors uprighting This male adult patient has a brachicephalic biotype with a skeletal Class I malocclusion. The frontal image shows an asymmetry, with his left hemi face higher Dr. Luis Nelson Núñez, DMD, MS, graduated from the Uruguayan Public University, UDELAR, where he also received his Orthodontic training. He is a graduate of the Roth/Williams Center at the Uruguayan Catholic University. Currently, Dr. Núñez is an Assistant Professor at the UDELAR Orthodontics and Dento-Facial Orthopedics Department, a position he has held for the last 10 years. He also teaches the short-term Orthodontics courses at the NYU for Latin American Doctors. Dr. Núñez is a member of the Uruguayan Orthodontists Society, Latin American Orthodontists Association, and the World Federation of Orthodontists. Dr. Núñez serves as the Latin American consultant for DENTSPLY GAC. He runs a private practice in Montevideo, Uruguay.
24 Orthodontic practice
and behind the contra-lateral side. The proﬁle image shows a bi-retrusion of the lips, resulting in a concave proﬁle. On the pretreatment dental panoramic radiograph, the position of the third molars and the extrusion of the lower incisors can be seen. The third molars will be extracted after the orthodontic treatment.
After performing the Björk cephalometric and Ricketts analyses, we can see that the patient has a strong symphysis that is camouﬂaging a mandibular Class I. With the soft tissue tracing, we conﬁrm the bi-retrusion of the lips. Also, a high uprighting of the upper incisors can be diagnosed. Volume 6 Number 5
When mounting the model in centric relation, it’s evident that there’s a small opening of the bite generated by the premature contact between right second molars (a slight bilateral cuspids Class II). The initial pictures show good gingival health and oral hygiene. In OC, molars and cuspids are in Class I. The overjet is too tight, and the overbite is almost 3 millimeters. Both dental alveolar arches are square in shape, and in the lower one there is a negative discrepancy of 6 to 7 millimeters. The lower cuspids are proclined or tipped mesially, which makes us think about a fast protrusion of incisors and bite opening as soon as we introduce the preprogrammed appliance and ﬁrst archwire.
Diagnosis • • • • • • • •
Male adult patient Brachyfacial Skeletal Class I Good periodontal health TMJ without any dysfunctional sign Retrusion of both lips Prominent chin Molar Class I and cuspids in relative Class I in OC and slight Class II on the way to CR with premature contact between both right second molars • Square type dental arches • Uprighting of upper and lower incisors • Lower dentoalveolar discrepancy of 6 to 7 millimeters and peg upper lateral incisors
Treatment plan First stage Leveling and aligning: Level and align; begin giving ovoid shape to both dental arches; protrude and torque upper central incisors to make room for lower brackets; protrude lower incisors to move lower cuspids into the dental arch. Second stage Working stage: Give torque; level Volume 6 Number 5
occlusal plane until getting parallel archwires; fully express the prescription; reshape peg lateral upper incisors. It is important in this patient to get to full-size archwires and to reach our goal of a ﬂat occlusal plane and good overbite. Third stage Finishing stage: Seat the occlusion. Appliance: In-Ovation C Roth .022 Retention: Fixed 3 x 3 in the lower arch and ﬁxed 2 x 2 plus a Hawley retainer in the upper one.
Third stage A .021x.025 braided archwire is my preferred choice for ﬁnishing most cases. With its rectangular section and ﬂexibility, this archwire gives the orthodontist the possibility to seat the occlusion with elastics and to let teeth get their individuality back.
Archwire sequence First stage A .014 Sentalloy® (Dentsply GAC) superelastic nickel-titanium archwire was in place for 10 weeks until the leveling and aligning allowed me to move forward to the .020 x .020 Bioforce®. This second archwire is also a superelastic nickel-titanium wire, but with three progressive forces in its internal structure. The Bioforce archwire releases the appropriate force on the molars to prepare the anchorage, on the cuspids and premolars giving the ovoid shape to the dental arch, and a lighter force on the single-rooted teeth to correct their positions. The Bioforce archwire was in place for 8 weeks.
Figure 6: .014 upper Sentalloy
Figure 7: .020 x .020 upper Bioforce/.014 lower Sentalloy. No laceback ligatures were used
Second stage A .019 x .025 Neo-Sentalloy® superelastic nickel-titanium archwire was inserted to begin the working stage. This archwire had to give dental arches the ﬁnal ovoid shape, express the appliFigure 8: .019 x .025 upper NeoSentalloy/.020 x .020 lower Bioforce ance prescription, express any possible bonding mistake, and show the size discrepancy of the peg upper laterals. A As you may notice, the overbite almost .021 x .028 Neo-Sentalloy archwire and inverted at this point. Remember, we planned .021 x .025 stainless steel archwire shared to move forward in the archwire sequence the objective of ﬂattening the occlusal plane until we reached full-size wires in order to and closing the open bite generated during make the wires parallel and correct this treatment evolution. quasi-open bite. Orthodontic practice 25
Figure 9: .021 x .025 upper and lower stainless steel
Figure 10: Final intraoral images
The orthodontic correction achieved during treatment made it possible to get this ďŹ nal result on the face of the patient. The lower third (lips) had a nice improvement just by correcting the torque on the incisors. The results of this case were so satisfying that it helped convince me to use In-Ovation R and In-Ovation C Roth (and CCO) in all my cases. The secret to achieving results of this kind in all patients is to know the appliance we will be working with and the appropriate archwire sequencing for each case. Knowing the appliance will give us the chance to get the best out of it in regular situations and how to work with it to overcome any complications that may arise. OP
Figure 11: Final facial images
REFERENCE 1. Nobrega C. Biomechanical behavior of self-ligating interactive systems. Ortho CE â€“ North American Edition. 2014;3(1).
Figure 12: Final dental panoramic radiograph A.
Figure 13A-13C: A. Pre-cephalometric. B. Post-cephalometric. C. Superimpositions A.
Figure 14A-14B: A. Pretreatment. B. Posttreatment 26 Orthodontic practice
Volume 6 Number 5
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BioDigital orthodontics Management of skeletal deformities with orthognathic surgery — Direct (CBCT) (2): part 17 Drs. Rohit C.L. Sachdeva, Steven Moravec, Takao Kubota, and Jun Uechi continue their exploration of management of skeletal deformities using suresmile® technology Introduction Suresmile® technology is a total patient care management system that enables the orthodontist to provide personalized care to patients with a wide variety of malocclusions.1-16 These include patients with skeletal deformities requiring orthognathic surgery. In a previous article,16 three approaches to planning surgical care for a patient using suresmile were described. Each approach is distinguished by the type of the image taken for planning purposes. These are “Fusion” (CAT scan), “Direct” (CBCT), or OraScan (Sachdeva). Also, in a previous article,16 planning care with the “Fusion” approach was discussed. In this article, aided with an example of a patient history, the “Direct” method is described for planning orthognathic surgery and designing custom surgical archwires with the goal of providing effective and efficient care for a patient.
Patient C.H. Patient C.H., a 20-year-old female Caucasian patient, presented with a chief complaint of “I cannot bite into an apple, and I have a protruding lower jaw.” She had a previous
history of orthodontic treatment. Her oral hygiene was unremarkable, and she had all teeth present with the third molars unerupted. She demonstrated a skeletal Class 3 pattern with a maxillary deficiency and mandibular excess. No functional shifts were recorded. Her initial records with a cephalometric analysis are shown in Figure 1. Also, note that the Virtual Diagnostic Model (VDM) in this case is a suresmile post-processed CBCT scan. Currently, four systems are certified for use with suresmile: i-CAT™ Next Generation, i-CAT™, i-CAT™ FLX (Imaging Sciences International, Hatfield, Pennsylvania), and Kodak® CS 9300 (Carestream Dental LLC, Atlanta, Georgia). The images taken by these CBCT scanners are processed for surface data from the CBCT scan (Figure 1B). Since any tooth contact prevents the capture of the entire crown surface and leads to a distorted image during post-processing, the CBCT image is taken with mouth open with the patient requested to bite down on a piece of wax as the image is captured. A sagittal perspective of the volumetric image can be reconstructed to render the cephalometric view. Also, for the purposes of a cephalometric analysis, the tracing is
Rohit C.L. Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use. He also works with the dental industry in product design and development. He is the co-founder of the Institute of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder and former Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. In the past, he has held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.blogspot.com. Please contact firstname.lastname@example.org for access information. Dr. Takao Kubota is in private practice in Yours Orthodontic Clinic, 378-6 Motomura Yame City, Fukuoka 834-0063 Japan. He is also the co-founder of the Instiute of Orthodontic Care Improvement in Japan. Dr. Jun Uechi is from the Department of Orthodontics, School of Dentistry, Health Sciences University of Hokkaido, 1757, Kanazawa, Ishikari-Tobetsu, Hokkaido 061-0293, Japan. Dr. Steven Moravec is in private practice at Moravec Orthodontics, 23842 W. Main Street, Plainfield, Illinois.
28 Orthodontic practice
corrected for the open-mouth position by rotating the mandible around the condylar head to the point of first tooth contact in order to establish a better representation of the patient’s mandibular spatial relationship with respect to the rest of the craniofacial complex. The plan for patient C.H. was soft-tissue driven. Soft tissue changes were projected in response to maxillo-mandibular movements (Figure 2A). To achieve the best esthetic results, mandibular setback and maxillary advancement with a clockwise rotation was planned in 2D using WinCeph® Ver 9.0 software from Rise Inc. (www.risecorp. co.jp) (Figure 2). The displacement coordinates from the 2D simulation were used as a guideline to plan the skeletal movements in 3D with the Virtual Diagnostic Model (VDM) to create the Virtual Diagnostic Simulation (VDS). The VDS in Figure 3 shows the planned skeletal movements, and Figure 4 shows the planned pre-surgical and dental movements Treatment was initiated by bonding the patients with Strite Industries Speed Rhomboid (www.speedsystem.com) brackets with 0.022" slot width. The initial archwires used in both the upper and lower arches were .016x.022 CuNiTi AF 35°C. The patient was seen 10 weeks later, and a therapeutic CBCT scan was taken. The intraoral photos and X-rays at the time of therapeutic scan are shown in Figure 5. The superimposition of the VDS to VTM (Figure 6) shows that most of the presurgical treatment objectives were achieved. Note that the lower incisors demonstrate minimal bone on the labial aspect. The pre-surgical mechanics were designed to maintain the AP position of the lower incisors to minimize any further loss of labial bone as a result of flaring. The lower incisor position was maintained within the alveolar bone housing (Figures 6E and 6F). As can be seen in Figure 6G, the labiolingual thickness Volume 6 Number 5
Figures 1A-1D: Patient C.H. 1A. Initial intraoral photographs. 1B. suresmile Virtual Diagnostic Model (VDM). 1C. Lateral ceph and panorex. 1D. Initial ceph tracing and analysis
Figures 2A-2C: Patient C.H. 2D surgical treatment plan. 2A. Simulation of surgery on soft tissue. 2B-2C. Ceph tracing Volume 6 Number 5
Orthodontic practice 29
ORTHODONTIC CONCEPTS VDS (Surgery)
Surgery VDS (white) vs. VDM (green)
VDS (Post-surgery plan)
VDS (white) vs. VDM (blue)
Figures 3A-3D: Patient C.H. 3A. Virtual Diagnostic Simulation of the surgical plan. 3B. Virtual Diagnostic Simulation (VDS) vs. Virtual Diagnostic Model (VDM). 3C. Planned surgical displacements. 3D. Planned surgical simulation models shown superimposed on the patientâ€™s lateral ceph Dental movements VDS (white) vs. VDM (green)
Figures 4A-4D: Patient C.H. 4A. Virtual Diagnostic Simulation of the surgical and dental plan. 4B. Virtual Diagnostic Simulation (VDS) vs. Virtual Diagnostic Model (VDM). 4C. Planned orthodontic tooth movement (pre-surgical). 4D. Planned orthodontic tooth movements
Figures 5A-5B: Patient C.H. Therapeutic CBCT scan was taken 10 weeks after the patientâ€™s bonding. 5A. Intraoral photos. 5B. Pano at time of therapeutic scan 30 Orthodontic practice
Volume 6 Number 5
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ORTHODONTIC CONCEPTS VTM
VDS (white) vs. VTM (green)
Figures 6A-6G: Patient C.H. 6A. Virtual Therapeutic Model (VTM) with bone. 6B. Virtual Therapeutic Model (VTM) without bone. 6C and 6D. VTM (white) superimposed over VDS (green) showing that the planned tooth movement closely matched the initial plan. 6E and 6F. Pre-surgical mechanics were designed to maintain the AP position of the lower incisors. This minimized the risk of further loss of labial bone as a result of flaring. The lower incisor position was maintained within the alveolar bone housing. 6G. Thickness of the alveolar bone is a key factor that determines the AP boundary of the lower incisor position
Figures 7A-7H: Patient C.H. 7A. Pre-Surgical Virtual Therapeutic Model (VTM) with bone. 7B. Virtual Target Setup (VTS) with surgical and dental simulation with bone. 7C. VTM (green) vs. VTS (white) with bone. 7D. VTS with surgical and dental simulation shown without bone. 7E. VTM (green) vs. VTS (white) (bone not shown). 7F. Surgical segments selected for surgical simulation. Also shown are the values for the planned surgical movements. 7G. Shows the relationship of the incisors against the lip line prior to maxillary clockwise rotation (surgical). 7H. The negative smile line (incisor exposure) was corrected with the clockwise (downward) rotation of the maxilla and minimal dental movement
of the alveolar bone is the limiting factor in determining the AP position of the lower incisors. Planning with the surgical Virtual Therapeutic Model (VTM) was initiated by selecting the osteotomy segments. These are shown in Figures 7A and 7F. The surgical Virtual Target Setup (VTS) with and without bone and the accompanying tooth movement are shown in Figures 7B-7F. The smile 32 Orthodontic practice
line was planned by employing the superimposed image of the 3D maxillary segment with the facial image. (The suresmile digital lab as one of its services superimposes the 3D post-processed CBCT image to the 2D extraoral frontal smile image.) The maxillary segment was rotated clockwise to establish a better incisor-stomion relationship. (This can be seen in Figures 7G and 7H).
The Virtual Target Setup (VTS) was staged to design the suresmile archwires. The first setup was used to design the suresmile precision passive surgical archwire (.017x.025 CuNiTi) and the second for the post-surgical suresmile precision active archwire (.017x.025 CuNiTi AF 35째C) (Figure 8). The pre-surgical archwire was inserted 6 weeks post-therapeutic CBCT Volume 6 Number 5
Therapeutic wire Passive Surgical archwire
VTS (Therapeutic wire)
Figures 8A-8C: Patient C.H. 8A. The first archwire designed was the suresmile precision passive surgical archwire. The archwire is seen with respect to the VTM. 8B. The second archwire designed was the suresmile post-surgical active archwire. This is shown with respect to the VTM. 8C. Planned post-surgical orthodontic tooth movement
Figures 9A-9B: Patient C.H. Debonded at 39 weeks from start of treatment. 9A. Final extraoral and intraoral photos. 9B. Final lateral ceph and panorex Volume 6 Number 5
Orthodontic practice 33
ORTHODONTIC CONCEPTS VFM (without bone) 1-year post-surgery
VTS (green) vs. VFM (white)
Figures 10A-10F: Patient C.H. 10A and 10B. 3D CBCT 1-year post-surgery (VFM). 10C. Superimposition of the VFM to VTS (Virtual Target Setup) demonstrates that the treatment outcome closely matches the plan. 10D. Therapeutic CBCT scan. 10E. Virtual Target Setup (VTS) with bone. 10F. Post-surgical CBCT scan 1-year post treatment. Note that the bone levels were maintained in comparison to both the Therapeutic scan and the VTS. Also, fixation plates were removed due to irritation
Figures 11A-11C: Patient C.H. 11A. Initial. 11B. Prediction. 11C. Final 34 Orthodontic practice
scan. Because of schedule conflicts, the patientâ€™s surgery was performed 8-weeks post suresmile precision passive archwire insertion. Patient C.H. was seen 6 weeks post-surgery and the active post-surgical archwire inserted (Figure 9). The patient was asked to wear short Class 3 elastics and scheduled to be seen 6 weeks later. The patient was debonded a month after her last appointment. The final records are shown in Figure 9. Note the Virtual Therapeutic Simulation (VTS) versus the Virtual Final Model (VFM) superimpose very closely suggesting that the planned result was achieved (Figure 10). Also, note in Figures 10D-10F, the response of the alveolar bone to treatment is seen. The doctor can observe that generally bony architecture was preserved. The soft tissue changes were favorable. One can see the final changes were similar to the animated prediction (Figure 11). Volume 6 Number 5
Conclusions The total treatment time for patient C.H. was 9 months. However, treatment for patient C.H. could have been shortened by bonding the patient and taking a diagnostic/ therapeutic CBCT scan at the first appointment. The definitive surgical and orthodontic treatment plan with the surgical archwire could have been designed with this scan. This was possible since minimal pre-surgical tooth movement for the patient was required. In other words, the patient could have been set up for surgery within 6-8 weeks of initiating treatment and possibly debonded 10-12 weeks post-surgically. The total treatment time for this protocol would have been no greater than 20 weeks. Furthermore, had these clinical pathways been followed, we would have obviated the necessity of taking a second CBCT scan. This approach to care is similar to that described in an earlier paper by the senior author (Sachdeva) that describes fast-track treatment.4 The “Direct” method using CBCT and suresmile technology provides a reliable approach to plan and manage personalized care for the surgical patient. The postprocessed suresmile CBCT images allow visualization and planning of both roots and the bone position that can help the orthodontist to better plan care. Also, being able to design precision pre- and post-surgical archwires and to stage them provides unprecedented control of tooth movement. This results in a predictable treatment outcome. The “Direct” approach obviates the necessity of using the “Fusion” technique, which can be cumbersome and time-consuming. Lastly, planning with suresmile software can be performed interactively between the surgeon and orthodontist, minimizing any disconnect in treatment objectives between the caregivers. Currently, clinical testing by suresmile is underway to evaluate the suitability of using the post-processed CBCT image for designing splints directly and manufacturing them with sterolithography using a biocompatible material. OP
Acknowledgments Our sincere thanks are extended to Donald Kalant, DDS, MS, (Kalant and Associates Oral and Maxillofacial Surgery, Illinois), the surgeon on our team for his outstanding care of patient C.H. We also wish to thank Sharan Aranha, BDS, MPA, and Arjun Sachdeva for their help in the preparation of this manuscript. Volume 6 Number 5
Table 1: Surgical Clinical Pathway (Direct) with suresmile (Sachdeva) Phase
Patient’s chief complaint. Determining patient’s needs and wants
Diagnostic record coalition
2D photos, ceph, PA, and panorex (reconstruct from CBCT) 3D Virtual Diagnostic Model (VDM)
• • • • • •
Perform cephalometric analysis (correct for mouth-open position) Establish treatment objectives Simulate 2D surgical planning and use to guide 3D planning on fusion model Measure 3D displacement coordinates of surgical displacements on fusion models Transfer coordinates of surgical movements to suresmile VTM Plan dental movements on VTM
Therapeutic scan and design of customized suresmile archwires
Design virtual target setup and surgical archwires
Installation of suresmile pre-surgical archwires
Schedule surgery as per plan
Post-surgical orthodontic management
• • •
Place suresmile precision archwires within 4-6 weeks post-surgery Stage suresmile archwire use as per plan Evaluate patient in 4-6 week intervals
2D photos, ceph, PA, and panorex 3D Virtual Final Model (VFM) from OraScan or CBCT
2D cephalometric superimposition of initial versus final 3D superimposition of the VFM to VTS
* Note: Based upon the treatment plan designed by the doctor, pre-surgical wires may be continuous or segmental and designed to be passive, hybrid, or fully active. The type of wire used dictates the timing of surgery and treatment
REFERENCES 1. Sachdeva R. BioDigital orthodontics: Planning care with Suresmile technology: part 1 Orthodontic Practice US. 2013;4(1):18-23. 2. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with Suresmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 3. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with Suresmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30. 4. Sachdeva R. BioDigital orthodontics: Outcome evaluation with Suresmile technology: part 4. Orthodontic Practice US. 2013;4(4):28-33. 5. Sachdeva R. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Fast–Track”©– six month protocol: Part 5. Orthodontic Practice US. 2013;4(5):18-27. 6. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Standard– Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26. 7. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of space closure in Class I extraction patients with Suresmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 8. Sachdeva R, Kubota T, Moravec S. BioDigital orthodontics. Part 1-Management of Class 2 non–extraction patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16. 9. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 2-Management of patient with Class 2 malocclusion non–extraction: Part 9. Orthodontic Practice US. 2014;5(3):29-41. 10. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 3- Management of patients with Class 2 malocclusion extraction: Part 10. Orthodontic Practice US. 2014;5(4):27-36 11. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patients with class 3 malocclusion: Part 11. Orthodontic Practice US. 2014;5(5):28-38. 12. Sachdeva RCL, Kubota T. BioDigital orthodontics. Part 1 - Management of patients with openbite (1): Part 12. Orthodontic Practice US. 2014;5(6):22-31. 13. Sachdeva RCL, Kubota T,Lohse.J. BioDigital orthodontics. Management of patients with openbite (2): Part 13. Orthodontic Practice US. 2015;6(1):13-23. 14. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, Hasuda M. BioDigital orthodontics: Management of patients with transverse (midline) discrepancies: Part 14. Orthodontic Practice US. 2015;6(2):25-36. 15. Sachdeva RCL, Kubota T, Hayashi K, . BioDigital Orthodontics-: Management of Patients with Transverse (Midline) Discrepancies (2):part 15. Orthodontic Practice. US. 2015;6(3):28-44. 16. Sachdeva RCL, Kubota T, Hayashi K, Uechi J. BioDigital Orthodontics. Management of Skeletal deformities with Orthognathic Surgery: Part 1 (Part 16 of the series). Orthodontic Practice US. 2015;6(4):26-32.
Orthodontic practice 35
A summary of the clinical pathway developed by Sachdeva is shown in Table 1
The Propel® System: the next generation orthodontic disruptor Dr. Gary Brigham discusses faster orthodontic movement without compromising clinical outcomes
espite significant technological advances in the orthodontic industry over the past 2 decades, treatment length still remains one of the top patient concerns. As clinicians, we are continually faced with meeting patient expectations of shorter treatment times without compromising clinical outcomes. When Invisalign® (Align Technology) was first introduced in the late 1990s, although its efficacy was already clearly documented, it was still viewed by most clinicians as a “disruptor” to the profession. Invisalign immediately impacted both the scope and manner in which orthodontic treatment would be administered and delivered, permanently changing the nature of orthodontic treatment for the future. Many practitioners, including myself, were initially reticent to embrace this technology and skeptical that we could move teeth with removable aligners and expect the same clinical outcomes as we were seeing with fixed appliances. Due to the unprecedented patient interest and demand for this new treatment, I had little choice other than to adopt the modality as quickly albeit as cautiously as possible, to better serve the patients in my practice. To sustain my capacity to use Invisalign, I relied in large part upon the experience and expert guidance of the early adopters who had embraced this modality and generously shared their clinical experience. With Invisalign use in my practice expanding year after year, new challenges
Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a master’s degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States. for Align Technology since 2004 and is the recipient of Align’s first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health. He maintains a full-time practice in Scottsdale, Arizona.
36 Orthodontic practice
... the pertinent question is how to make treatment more efficient without sacrificing great clinical outcomes. with this treatment emerged. As Invisalign technology continued to evolve, and it began to be applied to more complicated cases, the number of aligners required to achieve these expanded treatment objectives increased. This translated into increased treatment time, often frustrating patients. As a result, I was faced with a newfound treatment dilemma. My choices were either to limit treatment goals to accommodate patients’ expectations of acceptable treatment time, or to spend an inordinate amount of time encouraging patients to remain in treatment until their original treatment objectives had been met. In the past few years, these challenges have been magnified by the emergence of teens with complicated lifestyles and schedules, and aging baby boomers with severely worn dentitions and craniomandibular complications. Now more than ever, the pertinent question is how to make treatment more efficient without sacrificing great clinical outcomes.
Propel as a proven orthodontic disruptor The Propel® Excelleration Drivers (Propel Orthodontics) have proven to be the answer to this dilemma in my practice by providing significantly faster orthodontic movement without sacrificing clinical outcomes. Texeira, et al., have documented that bone remodeling can be accelerated through the use of micro-osteoperforations that result in an increase in local levels of cytokine activity around a tooth.1 Through a scientifically proven and patented process called micro-osteoperforation, Propel stimulates the alveolar bone to induce an inflammatory response, accelerating tooth movement in the treated
areas (significantly increased the rate of tooth movement by 2.3-fold with no significant patient pain or discomfort2). After reviewing the clinical literature supporting the efficacy of micro-osteoperforations, I was intrigued by the promise of more efficient and predictable treatment. I was, however, still reticent to embrace what I considered to be an invasive technology, just as I had been during my early Invisalign experience. Once again, I followed the lead and guidance of the early adopters who had already embraced the technology and had well documented the positive impact micro-osteoperforation had made in their practices.3,4 I prefer Propel over other accelerated orthodontic options because it provides complete doctor control rather than relying on patient cooperation to affect results. Moreover, it is clearly the most cost-effective treatment modality when compared to other accelerated orthodontic devices. The case studies that follow present a few examples of the use of Propel with Invisalign treatment. Although these cases focus exclusively on clear aligner treatment, we also use Propel in my practice to reduce treatment time in fixed appliance cases, particularly in patients with space closure associated with extraction or missing teeth, as well as impacted tooth and severe rotation cases.
Case study 1 Case 1 represents one of my introductory applications of Propel. The patient, a 50-year-old female, presented with a Class I malocclusion characterized by severe mandibular incisor crowding with proclination of tooth No. 24 which created traumatic occlusion with tooth No. 9. The case was further complicated by the recent placement of a bridge to replace a missing tooth No.19, which eliminated the option of arch development to create space (Figure 1). The patient was seeking treatment to avoid further tooth extraction. The patient underwent an initial 7 months of aligner treatment during which she was instructed to exchange aligners every Volume 6 Number 5
Figure 1: Case 1 intraoral pretreatment photos
Figure 2: Case 1 intraoral posttreatment photos
2 weeks (14 of 42 total aligners). At this point, the patient expressed interest in accelerating her treatment, and Propel was recommended and performed on all 12 anterior teeth. The patient was then instructed to exchange the next 28 aligners weekly and completed her treatment in 14 total months rather than the 21 months initially anticipated (Figure 2).
Case study 2 Case 2, a 21-year-old male, presented with a Class II subdivision left malocclusion characterized by 50% overbite, crossbite of the left second bicuspids, and significant mandibular incisor crowding. The case was further complicated by a severely dysmorphic mandibular left first bicuspid (Figure 3). For this case, I proactively recommended Propel at the outset of treatment, and the micro-osteoperforations were performed immediately after the placement of the aligner attachments at the time of the first aligner delivery. Two to three micro-osteoperforations were performed at the dentoalveolar bone between each tooth from the mesial of the molar to the mesial of the opposite molar in both arches. This now represents our current Propel protocol. The patient was instructed to exchange aligners weekly (total of 32 aligners), and all orthodontic movements were completed in 8 months of treatment time (Figure 4). Volume 6 Number 5
Figure 3: Case 2 intraoral pretreatment photos
Figure 4: Case 2 intraoral posttreatment photos Orthodontic practice 37
Figure 5: Case 3 intraoral pretreatment photos
Figure 6: Case 3 intraoral posttreatment photos
Case study 3 Case 3, a 40-year-old female, presented with a Class I malocclusion characterized by bimaxillary arch constriction, mild mandibular incisor crowding, and crossbite of the right canines (Figure 5). The patient was anxious to complete treatment quickly and elected to include Propel as part of her treatment plan. Propel was initiated immediately after the placement of the aligner attachments, at the time of the first aligner delivery. The patient was initially instructed to exchange aligners every 7 days (26 total aligners). After 2 months of treatment (eight aligners into the planned treatment), the patient reiterated her desire to finish treatment as quickly as possible. As a result, I changed the aligner protocol and instructed her to exchange aligners every 3 days for the remainder of her treatment. All clinical movements were expressed, and the patient completed treatment in less than 5 months (Figure 6). Dr. Thomas Shipley (Peoria, Arizona) originally proposed the protocol of aligner exchange every 3 days, as opposed to the standard 7-day period recommended when using Propel. Dr. Shipley has documented numerous cases with exceptional results using this exchange protocol. 38 Orthodontic practice
Over the past several months, we have experienced significant success using Dr. Shipleyâ€™s 3-day aligner exchange protocol. For more challenging cases, we have found the greatest success when educating patients on how to identify and monitor their own aligner tracking and empowering them to determine their optimal aligner exchange rate (either a 3-, 5-, or 7-day aligner exchange). For example, when employing the Nicozisis Extrusion Protocol for extruding maxillary incisors to establish smile arcs (Dr. Jonathan Nicozisis, Princeton, New Jersey), patients often require 4-5 days of aligner wear to maintain tracking when extruding dysmorphic maxillary lateral incisors. The success of this patient-centric approach relies heavily on patient understanding of the critical importance of monitoring tracking, and this is emphasized at each appointment.
Conclusion Incorporating Propel into our practice has proven to be a positive disruptor and has provided a solution to the dilemma of how to shorten treatment times without compromising clinical outcomes. We have found success using Propel for both fixed appliance
and Invisalign cases, but the results achieved with aligners have been especially remarkable. The use of Propel has consistently improved our practice efficiency, increased our productivity, and is attracting patients to our office through new patient referrals. Accordingly, as more orthodontists discover its advantages, it is anticipated that Propel will be identified as one of the most significant positive disruptors of next-generation orthodontic treatment. OP
REFERENCES 1. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):1135-1141. 2. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. 3. Nicozisis J. Accelerated orthodontics with alveocentesis. Princeton Orthodontics Web site.http://www.princetonorthodontics.net/portals/0/alveocentesis_white_paper_ final_edit.pdf. Published December 19, 2012. Accessed January 18, 2015. 4. Shipley T. Proactive treatment with Propel. Ortho Practice US. 2015;6(2):38-39.
This information is sponsored and provided by Propel Orthodontics.
Volume 6 Number 5
Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA, discuss various ways to reduce the occurrence of demineralized white spot lesions (DWSL) Orthodontic perspective With the addition of fixed appliances, the risk of demineralization can only be compounded, as the presence of brackets, archwires, ligatures, and other orthodontic devices make maintaining proper oral hygiene even more difficult, leading to plaque accumulation and ultimately demineralization around brackets in as little as 4 weeks’ time. The prevalence of new enamel lesions among orthodontic patients treated with fixed appliances, even with the use of fluoride toothpaste, can range anywhere from 13% to 75%. Children aged 11–14 years are considered to be at greatest risk of developing caries.1 Studies have estimated the prevalence of white spot lesions (WSLs) after orthodontic treatment to be as high as 97%.2 WSLs are particularly detrimental in a field that focuses on the esthetic outcome of their patients, more so, as these lesions mainly occur in the maxillary anterior dental region3 (Figure 1). Several approaches can be employed to help reduce the occurrence of WSLs, such Shira Bernstein is a fourth-year dental student at NYU College of Dentistry. She has received honors from the OKU society for her academic achievements. Shira graduated from Queens College in 2011 summa cum laude. She hopes to pursue a postgraduate certification in orthodontics following her graduation from NYU. Dr. Matthew J. Miller is an orthodontic resident at NYU College of Dentistry. He graduated from NYUCD in 2012, completed a General Practice Residency at SUNY Stony Brook in 2013 and expects his certificate in orthodontics in 2016. Dr. George J. Cisneros received his BS from Manhattan College, DMD from the University of Pennsylvania School of Dental Medicine, and his MMSc from Harvard University School of Dental Medicine. He is a Professor of Orthodontics at New York University College of Dentistry and is a Diplomate of the American Board of Pediatric Dentistry and the American Board of Orthodontics, serving on both of their advisory committees. Dr. Cisneros is a reviewer for various journals, including the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the Journal of Dentistry for Children, and the Journal of Pediatric Dentistry where he also served as a member of the Editorial Board.
Volume 6 Number 5
Educational aims and objectives
This article discusses possible approaches for reducing the occurrence of demineralized white spot lesions (DWSL).
Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the prevalence of WSL among orthodontic patients. • Identify some possible approaches to reduce the occurrence of WSL. • Realize the advantages and disadvantages of using RMGI cements. • Recognize the efficacy of using fluoride varnish to prevent WSLs. • Read about research on fluoride rinses and toothpastes to prevent WSLs. • Read about the effectiveness of remineralization products.
as more frequent professional cleanings and reinforcing oral hygiene instructions, using applied behavior analysis (ABA), and the use of chemotherapeutic agents, which can also reduce the incidence of WSLs by means of specifically targeting the disease-producing microorganisms. The use of resin-modified glass ionomer (RMGI) cements has been investigated in the past as a means to prevent cavities. There have also been studies conducted using glass ionomer cements with cariesprevention capabilities to bond orthodontic brackets. In a study conducted by Kashani, et al., it was shown that when comparing enamel demineralization depths adjacent to bands cemented with zinc polycarboxylate, glass ionomer (GI) and RMGI, the use of RMGI cement seems to present significantly better prevention of enamel demineralization.4 Unfortunately, there is a downside to the use of RMGI cements. These materials have low bond strength, as demonstrated by the work of Bishara, et al.5 Their results showed significantly reduced shear bond strength when compared with that of the conventional composite resin adhesive system. Orthodontists and their patients are better served by an adhesive system that provides clinically reliable bond strength. The ideal preventative treatment is one that does not rely on patient compliance at
all. If there was a one-visit, cure-all prevention that could be implemented on the initial day of bracket placement and need no subsequent follow-up, no further research would be needed. Research has established that fluoride is a very effective means of caries prevention. Subsequent to water fluoridation, there was a decrease in childhood caries by 15%-40%. Fluoride rinses and toothpastes such as PreviDent® 5000 Plus® (Colgate®) contribute to additional reduction in caries. However, careful at-home flossing, brushing with fluoridated pastes, and using fluoride rinses rely heavily on meticulous compliance from children and adolescents. An alternative to these methods of fluoride administration is a longer lasting fluoride treatment done professionally to ensure that patients receive the appropriate amount of fluoride — i.e., fluoride varnish applications, provided by dentists who would ensure the varnish is applied properly to a dried tooth surface. But what do we already know about the prevention of WSLs using fluoride varnish? When plaque accumulates around orthodontic brackets, it causes a perfect storm. Plaque is a natural reservoir for cariogenic microflora, namely Streptococcus mutans and Lactobacilli.6 This leads to demineralization of the enamel around the brackets leading to white spot lesions. A particularly effective way to prevent WSLs, and ultimately decay, is to apply fluoride varnish to Orthodontic practice 39
An orthodontic perspective on white spot lesions: part 2
Figure 1: Examples of WSLs. Post-treatment intraoral frontal photographs of orthodontic patients demonstrating varying degrees of decalcification that can occur after orthodontic therapy from mild (left), to moderate (center), to severe (right). (Center photo courtesy of Dr. Michael Katz)
the enamel surface around the brackets7 (Figure 2). There are a multitude of companies that manufacture fluoride varnish. Some of the more popular brands are GC America that manufactures a 5% sodium fluoride varnish with CPP-ACP called MI Varnish™. Ultradent makes a varnish called FlorOpal® Varnish White. 3M ESPE is another company that makes a 5% sodium fluoride varnish (Vanish™). While there are quite a few companies manufacturing fluoride varnish, they all contain 5% sodium fluoride. Interestingly, Varnish America™ (Medical Products Laboratories, Inc.) contains the usual 5% sodium fluoride, but also has xylitol, a known anticariogenic agent.8 Research has shown the efficacy in using fluoride varnish to prevent WSLs. A study was conducted by Jablonski-Momeni, et al.,9 that assessed the initial caries lesions in 12-year-olds. The study was conducted in two regions of Hesse, Germany, with different group prevention programs. In Region 1, the children received fluoride varnish twice a year in schools; and in Region 2, there was no use of fluoride varnish in schools. The results showed that in Region 2, where there was no fluoride varnish administered, significantly more initial lesions were assessed (p = 0.01, D1+2FS). These results showed the impact fluoride varnish could have as a prevention of early demineralization. A randomized control trial was conducted by Divaris K., et al.,10 on 543 Australian children from the Aboriginal community who had white spot lesions. The study divided the subjects into a case group and a control group by village, where some villages were given fluoride varnish and some were not. The data concluded, like the previous studies, that there was a 25% decrease in the number of WSLs in the children who were exposed to fluoride varnish compared with the children who were not. Some research has focused on combined regiments, while others have evaluated the use of a single item alone. The drawback of studies that evaluated the effects of both 40 Orthodontic practice
Figures 2A-2B: Varnish application. A. 5% NaF varnish applied to an air-dried mandibular central and lateral incisor in a patient with fixed orthodontic appliances. B: After contact with saliva, the varnish begins to harden, in order to resist displacement and maximize fluoride delivery to the teeth. (Photo courtesy of Dr. Laura Edwards)
fluoride varnish and MI paste together is that we can never decipher the effect of either of these items alone. There are fewer studies that focus on the prevention of WSLs solely in the context of orthodontic treatment; however, there have still been quite a number of studies performed. In 1999, Todd, et al., conducted an in vitro study looking solely at the effects of fluoride varnish around orthodontic brackets.11 This study noted that while at-home topical fluoride applications such as rinses are effective, compliance was an issue in approximately 50% of patients. The purpose of the study was to evaluate an in vitro caries preventative measure that would not be dependent on patient compliance. Duraflor® fluoride varnish (Medicom®) was thought to have the advantage of reducing demineralization without being techniquesensitive. Varnish provides protection despite patient noncompliance and delivers fluoride in a sustained manner. It also has longer contact time when compared with APF gel and amine fluoride applications. Duraflor provides a type of waterproof coating against saliva that allows the fluoride to remain in contact with the enamel for a longer period of time. Studies have also shown that fluoride uptake from Duraflor increased significantly when applied to a dry surface. Thirty-six extracted, caries-free, human canines and premolars were used
in the study. The teeth were divided into three groups: • a control group with no treatment • a non-fluoridated varnish group • a Duraflor varnish group The teeth were placed in both artificial saliva solutions and solutions that simulated a carious environment. After 37 days, the brackets were removed, and the teeth were evaluated under polarized light microscopy. Statistically significant differences were found between all groups for both depth and area of lesions. The fluoride varnish group had approximately 50% less demineralization than the control group. The fluoride varnish group had the smallest lesions, followed by the placebo group, and the control group thereafter. White spot lesions can develop within 1 month of having brackets bonded; therefore, varnish should be applied before or at the time of bracket placement. The Todd, et al., study demonstrated that a single application of fluoride varnish was beneficial for reducing WSLs. It also demonstrated that nonfluoridated/placebo varnish was not effective in reducing WSLs, which tells us that there is nothing inherent in the varnish that is helping produce these positive effects; rather it is the release of fluoride that is beneficial. In comparison, Stecksén-Blicks, et al.,3 using an in vivo model, conducted a very Volume 6 Number 5
Volume 6 Number 5
WSLs are particularly detrimental in a field that focuses on the esthetic outcome of their patients, more so, as these lesions mainly occur in the maxillary anterior dental region. • amine fluoride and stannous fluoride toothpaste and rinse versus sodium fluoride toothpaste and rinse • intraoral fluoride-releasing glass bead device versus fluoride mouth rinse The results of the study comparing fluoride varnish versus placebo (253 participants) showed that when varnish was applied every 6 weeks, there was moderate quality evidence supporting an almost 70% reduction in WSLs. This review had a low risk of bias, as the study compared different formulations of fluoride toothpaste and mouth rinse and found no difference between an amine and stannous fluoride combination compared to sodium fluoride products for the outcomes of white spot index. The study comparing fluoride-releasing glass beads attached to the brace versus a daily fluoride rinse was a small study with only 37 participants and was assessed at high risk of bias due to substantial loss to follow up. In conclusion, this Cochrane review of all that has been published in this area found only one study of moderate evidence that the application of fluoride varnish every 6 weeks reduces the risk of developing white spots by 70%. Further well-designed RCTs are required to confirm this, and more studies are probably needed to show the best way of administering the optimal fluoride dose to patients wearing braces. Other research has looked at methods of treatment of these lesions once they do occur. Few in vivo studies have specifically looked at the effectiveness of remineralization products to address the appearance of WSLs after orthodontic treatment. Huang, et al.,12 compared two products: MI Paste Plus™ and PreviDent® fluoride varnish in a randomized controlled trial, in order to assess their effectiveness over an 8-week period. These two products were compared to a standard oral hygiene regimen with fluoridated toothpaste. The results of this trial showed that when comparing objective assessments (by two blinded examiners) of WSL improvement in 115 participants, there was no significant difference between active treatment and control groups. There was also no difference in subjects’ self-assessment between active
treatment and control groups. Other studies in the past have shown positive results from using MI paste and fluoride varnish; however, they were conducted over a longer time span of approximately 6 months, which may be impacting the results of this trial. Nonetheless, what is interesting to note from this research is, that in a well-conducted RCT, no difference was found in the effectiveness of MI Paste Plus or PreviDent fluoride varnish compared to a standard oral hygiene regimen for treating WSLs during an 8-week period. This highlights what a challenge treating these lesions can be and reinforces the need to prevent these lesions before they occur. Another interesting idea that has been researched is the use of sealants on the facial surface of anterior teeth surrounding the orthodontic brackets. In a study conducted by Benham, et al.,13 60 subjects between the ages of 11 and 16 had UltraSeal XT® Plus (Ultradent) clear sealant randomly allocated to a quadrant of their mouths. The sealant was applied to the incisors and canines, from the gingival surface of the bracket to the free gingival margin of the tooth. The control quadrant had brackets bonded with no sealant placed. A total of 360 maxillary teeth and 258 mandibular teeth were studied. The study found that the non-sealed teeth developed white spot lesions at a rate of 3.8 times greater than teeth with sealants. In this study, a smooth surface sealant provided a significant reduction in enamel demineralization during fixed orthodontic treatment and may be considered for use by clinicians to minimize white spot lesions.
Future considerations There has been a significant amount of research conducted in the area of prevention of white spot lesions, and while there have been studies that solely focus on the use of fluoride varnish as a preventative means, there are still holes to fill in this topic. In the RCT by Stecksén-Blicks, et al.,3 a significant reduction in WSLs was found, but why? Was it due to the 6-week reapplication of varnish throughout the 6 months? Is there anything known about what yields the best results? Would a 3-week intervention Orthodontic practice 41
similar study. In addition to the advantage of using an in vivo model, this research had the benefit of having a larger sample size: 302 healthy children between the ages of 12-15, compared to 32 extracted teeth. To be included in the study, the children had to be scheduled for orthodontic treatment for at least 6 months. The study was carried out in a double-blind fashion with a randomized placebo-controlled design. The subjects were treated with topical applications of either the active or the placebo varnish immediately after orthodontic appliance placement, and then at every 6-week follow-up visit. The incidence of WSLs during the treatment with fixed appliances in the fluoride varnish group was approximately one-third of that in the placebo group, 7.4 versus 25.7% with a P value of 0.05. The strengths of the study were the randomized double-blind design, the number of subjects, and the data being recorded by outside examiners, not the dentists who were involved. Photographs recorded the lesions, both before and after treatment. The researchers believed the key element behind the success of the fluoride varnish was the retention and subsequent slow release of fluoride over a prolonged period of time, securing low concentrations available in the liquid plaque-enamel interface. Although the fluoride varnish did not totally prevent WSL formation, the incidence was significantly reduced in the fluoride varnish group. A Cochrane review7 was conducted to examine what has been accomplished in existing research and to assess the effectiveness that fluoride has to offer in preventing WSLs. It also sought to determine the best means of administering the fluoride to achieve this goal. Previous studies looked at the effects of various modes of delivering fluoride; however, they didn’t study the effects on participants who were wearing braces. Randomized controlled trials were reviewed in which topical fluoride was delivered by any method. Participants could be any age, and were recruited at the start of their orthodontic treatment and followed until completion. Trials included had to assess enamel demineralization at the start and end of orthodontic treatment. The type of interventions ranged from mouth rinses, gels, fluoride-releasing bonding materials, etc. The control groups were given a placebo or no intervention at all. No split-mouth studies or in vitro studies on extracted teeth were included in the review. Trials were grouped into three comparisons: • fluoride varnish versus non-fluoride containing varnish
CONTINUING EDUCATION be better, or would that be too costly? Can we have similar results on a 10- or 12-week regimen? These are areas that have not been investigated in the realm of orthodontics. Also, can we get these same results of a 50% decrease in WSLs obtained by Todd, et al.,11 when using more than 36 extracted teeth? Additionally how do the results of his work correlate when using central and lateral incisors as well, as opposed to just canines and premolars as used in his study? Another thought is the combination of both fluoride varnish and sealants as a means of prevention. If each is effective on its own, can we see an even greater decrease in the number of WSLs using them together? These are all different paths to be explored, and with time there is hope that more can be discovered to aid in the prevention of WSL formation during orthodontic treatment. OP
42 Orthodontic practice
REFERENCES 1. Derks A, Katsaros C, Frencken JE, van’t Hof MA, Kuijpers-Jagtman AM. Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances. A systematic review. Caries Res. 2004;38(5):413-420. 2. Huang GJ, Roloff-Chiang B, Mills BE, Shalchi S, Spiekerman C, Korpak AM, Starrett JL, Greenlee GM, Drangsholt RJ, Matunas JC. Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2013;143(1):31-41. 3. Stecksén-Blicks C, Renfors G, Oscarson ND, Bergstrand F, Twetman S. Caries-preventive effectiveness of a fluoride varnish: a randomized controlled trial in adolescents with fixed orthodontic appliances. Caries Res. 2007;41(6):455-459. 4. Kashani M, Farhadi S, Rastegarfard N. Comparison of the effect of three cements on prevention of enamel demineralization adjacent to orthodontic bands. J Dent Res Dent Clin Dent Prospects. 2012;6(3):89-93. 5. Bishara SE, Gordan VV, VonWald L, Jakobsen JR. Shear bond strength of composite, glass ionomer, and acidic primer adhesive systems. Am J Orthod Dentofacial Orthop. 1999;115(1):24-28. 6. Struzycka I. The oral microbiome in dental caries. Pol J Microbiol. 2014;63(2):127-135. 7. Benson PE, Parkin N, Dyer F, Millett DT, Furness S, Germain P. Fluorides for the prevention of early tooth decay (demineralised white lesions) during fixed brace treatment. Cochrane Database Syst Rev. 2013;12:CD003809. 8. Sahni PS, Gillespie MJ, Botto RW, Otsuka AS. In vitro testing of xylitol as an anticariogenic agent. Gen Dent. 2002;50(4):340-343. 9. Jablonski-Momeni A, Lange J, Schmidt-Schäfer S, Petrakakis P, Heinzel-Gutenbrunner M, Pieper K. Dental health in 12-year-old children including initial lesions and dentine caries [in German]. Gesundheitswesen. 2014;76(2):103-107. 10. Divaris K, Preisser JS, Slade GD. Surface-specific efficacy of fluoride varnish in caries prevention in the primary dentition: results of a community randomized clinical trial. Caries Res. 2013;47(1):78-87. 11. Todd MA, Staley RN, Kanellis MJ, Donly KJ, Wefel JS. Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod Dentofacial Orthop. 1999;116(2):159-167. 12. Huang GJ, Roloff-Chiang B, Mills BE, Shalchi S, Spiekerman C, Korpak AM, Starrett JL, Greenlee GM, Drangsholt RJ, Matunas JC. Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2013;143(1):31-41. 13. Benham AW, Campbell PM, Buschang PH. Effectiveness of pit and fissure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod. 2009;79(2):338-345.
Volume 6 Number 5
Dr. Bradford Edgren illustrates cases where early treatment avoided later complications
n impacting tooth is any tooth that is unlikely to erupt into its normal position in the mouth prevented by the lack of space, tissue, bone, and/or by another tooth. When discussing early interceptive treatment of potentially impacting teeth, typically the maxillary canines are being addressed since they are most commonly impacted teeth, second only to third molars.1 The maxillary canine has the longest period of development with the most tortuous course of travel from its origin to full eruption of all maxillary teeth.2 Its calcification commences at 4 to 5 months of age, which is approximately the same age as the initiation of calcification of the maxillary central incisor and first molar.3 Eruption of the upper canine doesn’t occur until 11-12 years of age, much later than the eruption of the first molar (6 years of age) and the central incisor (7-8 years of age),3 and is one of the last teeth to erupt into the maxillary dental arch. It has been hypothesized that the permanent maxillary canine is more susceptible to ectopic eruption and impaction because of its development high up in the most concentrated portion of the alveolus and its relatively late age of eruption.2 A study by Coulter and Richardson4 found that the maxillary canine travels nearly 22 mm from its position at age 5 years to its final position at age 15 years. However, maxillary canines are not the only impacting permanent teeth that can benefit from early interceptive treatment. Premolars, molars, and incisors can also
Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a member of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in AJO-DO, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado. Disclosure: Currently, Dr. Edgren is not receiving compensation from RMO on this appliance.
Volume 6 Number 5
Educational aims and objectives
This article aims to discuss various advantages of early interceptive orthodontic treatment.
Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some developmental characteristics of specific teeth. • Realize the susceptibility of certain teeth to ectopic eruption and impaction. • Recognize the opportunity to reduce damage or loss of teeth in certain situations. • Realize how to use CBCT imaging as a key component to comprehending the full extent of a patient’s dentofacial anatomy and determining a diagnosis. • See how future dentofacial growth is a key factor in treatment for all young orthodontic patients.
become potentially impacted at an early age and respond well to early interceptive orthodontic treatment. In the young orthodontic patient, many of the permanent tooth roots are not fully formed, and the dentofacial skeleton is more amicable to dentofacial orthopedics. Addressing potentially impacting teeth early provides the opportunity to reduce damage or loss of adjacent permanent teeth, diminish the incidence of ankylosis, provide optimum alveolar bone support and morphology, improved buccal root torque/angulation, and an enhanced overall final result. Leaving a jaw condition untreated until after the eruption of the permanent teeth can result in a dental and/ or skeletal discrepancy that is too severe to achieve an ideal or even an acceptable orthodontic result. At that point, if treatment is initiated after all or most of the permanent teeth have erupted, the treatment regimen has to adapt to the already established or nearly established face.5 The keys to early intervention of patients with impacting and potentially impacting teeth include a clinical exam, cone beam computed tomography (CBCT) imaging, lateral and frontal cephalometric analyses, dentofacial growth analysis, consideration for maxillary skeletal expansion, diligent monitoring of all erupting teeth, and timely referral to an oral surgeon for tooth exposure as necessary. CBCT imaging is a key component to comprehending the full extent of a patient’s
dentofacial anatomy and determining a diagnosis before embarking on treatment. The better the radiographic imaging, the more complete the diagnosis and understanding of the complexity of the patient’s problem. The availability of CBCT imaging makes traditional panoramic radiography inadequate for evaluating and treating impacting or impacted teeth due to the inherent distortions associated with the traditional technique. Traditional panoramic images do not provide the subtle details of tooth position, root form, and dentoalveolar width necessary to diagnosis and treat impacting teeth.6 The “power of slices” provided by CBCT allows the clinician to thoroughly evaluate the mesiodistal, buccolingual, and vertical orientations of all unerupted teeth. Canines that might appear to be resorbing the lateral incisor roots on a traditional panoramic radiograph may actually be just buccally or palatally positioned to lateral incisor root with no resorption evident when analyzed with CBCT. Future dentofacial growth is another key factor that requires consideration for all young orthodontic patients. Patients with the potential for growth should always have lateral cephalometric and dentofacial growth analyses performed. Many of these patients with impacting maxillary teeth suffer from horizontal and transverse maxillary hypoplasia and therefore have the potential for relative excessive mandibular growth. McConnell, et al., established that patients with maxillary canine impactions Orthodontic practice 43
Early interceptive treatment of impacted and potentially impacting permanent teeth
CONTINUING EDUCATION Table 1: Early treatment of patients with impacting and potentially impacting teeth Key Steps
Reduce damage or loss of adjacent permanent teeth
Diminish the incidence of ankylosis
Lateral and frontal cephalometric analyses
Provide optimum alveolar bone support and morphology
Dentofacial growth analysis
Improved buccal root torque/angulation
Consideration for maxillary skeletal expansion because a significant maxillary constriction is often present
Enhanced overall final result
Diligent monitoring of all erupting teeth Early interceptive treatment is not complete until the impacted teeth have erupted or are erupting normally based upon clinical review and/or radiographic imaging Timely referral to an oral surgeon as necessary
demonstrated a profound transverse anterior arch deficiency.7 Schindel and Duffy also stated that patients possessing a transverse discrepancy are more likely to have an impacted maxillary canine than those without the transverse deficiency.8 They also stated that the early mixed dentition is the best time to assess a patient for potential canine impaction. Imprudent permanent maxillary tooth extraction can exacerbate anterior and posterior crossbites following the full expression of facial growth. Maxillary expansion should be routinely considered because of the high likelihood of a maxillary skeletal constriction and the need for a complete diagnosis, including the frontal analysis.5,9 Consequently, injudicious extraction of deciduous teeth in these young patients without early active orthodontic treatment is ill-advised. Bazargani, et al., found a significant decrease in maxillary arch length occurred at sites where deciduous canines were extracted with palatally displaced canines compared to controls.10 Active early interceptive treatment of patients with impacted and/or impacting teeth is not complete until the teeth are erupting normally based upon clinical review and/or radiographic imaging. If it becomes evident that the course of eruption of the teeth in question does not improve in a timely fashion, and damage to adjacent teeth is imminent, then a referral to an oral surgeon for early exposure and bonding with a gold chain for guided eruption techniques is warranted. Moreover, since these patients typically possess significant maxillary skeletal constrictions, diligent monitoring of all erupting teeth is necessary because additional permanent teeth can become impacted.
Figure 1: 8-year 4-month-old male with severely impacted maxillary right lateral and central incisors
Case report 1 This 8-year 4-month-old male presented with severely impacted maxillary right lateral and central incisors (Figures 1-2). His case 44 Orthodontic practice
Figure 2: Diagnostic CBCT panoramic image revealing the impacted maxillary right lateral and central incisors and potentially impacting right maxillary canine Volume 6 Number 5
CONTINUING EDUCATION Figures 3A and 3B: Diagnostic lateral cephalometric analysis and growth forecast to maturity without orthodontic treatment demonstrating the potential for excessive mandibular growth and severe Class III malocclusion
illustrates that maxillary permanent teeth can impact at an early age and benefit from a thorough diagnostic evaluation. This was his second opinion with the original treatment plan necessitating extraction of the impacted incisors and implant replacement after the completion of dentofacial growth. His CBCT scan, taken on an i-CAT™ Next Generation scanner (Imaging Sciences International), and Ricketts’ lateral and frontal cephalometric analyses and growth forecast, performed by Rocky Mountain Orthodontics Data Services® (RMODS®), indicated a potential for a severe skeletal Class III malocclusion due to the mandible and maxilla, a skeletal lingual crossbite pattern due to the maxilla, the need for extended treatment due to probable excessive mandibular growth resulting in an anterior crossbite, and severe Class III malocclusion (Figures 3-5). Extraction of the impacted right maxillary incisors would only have exacerbated the potentially developing Class III malocclusion, and would have had a devastating outcome for this patient. His early interceptive orthodontic treatment plan included maxillary expansion with a bonded expander, fixed appliances, and timely referral to the oral surgeon for exposure of the right central incisor and canine that were bonded with gold chains for guided eruption techniques. Shortly after the cessation of active maxillary expansion, Volume 6 Number 5
Figure 4: Diagnostic frontal 3D cephalometric image
Figure 5: Diagnostic axial 3D image illustrating the rotational orientation of the impacted right maxillary lateral and central incisors Orthodontic practice 45
Figures 6A-6B: 6A. In the progress CBCT panoramic image at 28 months, after the start of treatment, the right lateral incisor root appears to have resorbed. 6B. However, the arch sectional image of the maxillary right lateral illustrates an intact lateral incisor root
the right later incisor erupted, eliminating the need for surgical exposure. The expander was removed after 9 months, and the right canine and central incisor were exposed and bonded. After 15 months of treatment, the canine and central incisor erupted. Twenty-eight months after the start of treatment, a progress CBCT scan was taken. Initially, it appears as though the right lateral incisor root has suffered significant resorption (Figure 6A). Upon further inspection, via the â€œpower of slicesâ€? with CBCT imaging, it is evident that the lateral incisor root is severely proclined due to the initial positions of the canine and central incisor, but the root is fully intact with no resorption (Figure 6B). It would take a total of 46 months of orthodontic treatment to upright the right maxillary lateral incisor while competing against his excessive mandibular jaw growth (Figures 7 and 8). Follow-up care on this patient will only require comprehensive orthodontic treatment including additional maxillary expansion and fixed appliances. Timely early interceptive treatment, with guided eruption of the maxillary right canine and central incisor, no longer results in a severe skeletal class III malocclusion, anterior crossbite, damage to adjacent teeth, or the need for implants.
Figure 7: Progress photos 46 months after the start of treatment
Case report 2 This 8-year-old female initially presented with severe crowding, premature loss of the maxillary right deciduous canine and right first deciduous molar, and partial anterior crossbite (Figure 9). Review of her CBCT imaging, lateral, frontal, and dentofacial growth analyses revealed significant mandibular retrognathia, tendency for a skeletal open bite, and lingual crossbite pattern due to both 46 Orthodontic practice
Figure 8: Progress panoramic image 46 months after the start of treatment demonstrating intact right maxillary lateral incisor root Volume 6 Number 5
jaws, and potentially impacting maxillary canines (Figure 10). Her early interceptive treatment involved maxillary expansion with a bonded expander and fixed appliances to create space for the potentially impacting canines. Six months after the start of treatment, her expander was removed, and a CBCT scan was taken to monitor the eruption paths of the canines (Figure 11A). The CBCT imaging revealed that the canines were continuing upon their same, potentially destructive, eruption paths and consequently, she was referred to the oral surgeon for exposure and bonding of the canines for guided eruption. CBCT imaging is invaluable in cases like this one since it not only revealed the buccal position of the canines but also that the incisor roots were intact (Figures 11B and 11C). Note that even with maxillary expansion, it is evident that canine impaction was imminent. Successful surgical exposure of the canines is more reproducible with improved imaging. Bilateral exposure of the canines was accomplished 6 weeks after expander removal. Elastic cord was attached to the gold chains and the upper archwire. Nine months after surgery, 16 months after the start of treatment, the canines erupted. The patient was debanded 29 months after the initiation of treatment, and the result was maintained with upper and lower removable Hawley retainers (Figures 12 and 13). The possibility of damage to the adjacent lateral incisor roots and/or permanent tooth extraction would have likely occurred without early treatment. Note that not all early treatment cases with impacting or potentially impacting teeth require surgical intervention. See Case report 2 from the CE article â€œThe fundamental objectives of early interceptive treatmentâ€? in the 2015 January/February edition of Orthodontic Practice US.5 In that case report,
Figure 9: 8-year-old female with potentially impacting maxillary canines
Figure 10: Diagnostic 3D panoramic image demonstrating potentially impacting maxillary right and left canines
Figure 11A: Progress 3D panoramic image on the day of RME removal, 6 months after the start of treatment Volume 6 Number 5
Figures 11B-11C: Progress 3D arch sectional images on the day of RME removal of the right and left lateral incisor roots revealing no evidence of root resorption Orthodontic practice 47
CONTINUING EDUCATION early interceptive treatment prevented the impaction of both maxillary canines and significantly improved the eruption path without surgical exposure. Patients such as these can be extremely challenging, but the rewards for the patient and the orthodontist are immeasurable. Remember, we are treating patients who will be using their smiles for a lifetime. OP
Figure 12: Interim deband photos; treatment time of 29 months
Shah RM, Boyd MA, Vakil TF. Studies of permanent tooth anomalies in 7,886 Canadian individuals. I: impacted teeth. Dent J. 1978;44(6):262-264.
Dewel BF. The upper cuspid: its development and impaction. Angle Orthod. 1949;19(2):79-90.
Fuller JL, Denehy GE. Concise Dental Anatomy and Morphology. 2nd ed. Chicago, IL: Year Book Medical Publishers; 1984: 55, 81, 139.
Coulter J, Richardson A. Normal eruption of the maxillary canine quantified in three dimensions. Eur J Orthod. 1997;19(2):171-183
Edgren BN. The fundamental objectives of early interceptive treatment. Ortho Practice US. 2015;6(1):26-33.
Mah J. Straight talk: Instruction on CBCT in orthodontic graduate education. Orthotown. Sept 2010:47-48.
McConnell TL, Hoffman DL, Forbes DP, Janzen EK, Weintraub NH. Maxillary canine impaction in patients with transverse maxillary deficiency. ASDC J Dent Child. 1996;63(3):190â€“195.
Schindel RH, Duffy SL. Maxillary transverse discrepancies and potentially impacted maxillary canines in mixed-dentition patients. Angle Orthod. 2007;77(3):430-435.
Miner RM, Al Qabandi S, Rigali PH, Will LA. Conebeam computed tomography transverse analysis. Part 1: Normative data. Am J Orthod Dentofacial Orthop. 2012;142(3):300-307.
10. Bazargani F, Magnuson A, Lennartsson B. Effect of interceptive extraction of deciduous canine on palatally displaced maxillary canine: a prospective randomized controlled study. Angle Orthod. 2014;84(1):3â€“10.
Figure 13: Interim deband 3D image displaying intact maxillary lateral incisor roots and very acceptable root parallelism after early interceptive treatment 48 Orthodontic practice
Volume 6 Number 5
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REF: OP V6.5 CISNEROS REF: OP V6.5 EDGREN
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An orthodontic perspective on white spot lesions: part 2
Early interceptive treatment of impacted and potentially impacting permanent teeth
With the addition of fixed appliances, the risk of demineralization can only be compounded, as the presence of brackets, archwires, ligatures, and other orthodontic devices make maintaining proper oral hygiene even more difficult, leading to plaque accumulation and ultimately demineralization around brackets in as little as _______ time. a. 3 days b. 7 days c. 2 weeks d. 4 weeks
c. d. 6.
both a and b Viridans streptococci
While there are quite a few companies manufacturing fluoride varnish, they all contain _____ sodium fluoride. a. 2% b. 5% c. 15% d. 30%
Varnish _____________________________. a. provides yet another measure based on patient compliance b. provides protection despite patient noncompliance c. delivers fluoride in a sustained manner d. both b and c
Studies have estimated the prevalence of white spot lesions (WSLs) after orthodontic treatment to be as high as _______. a. 50% b. 65% c. 80% d. 97%
(In the study that included Duraflor) The fluoride varnish group had approximately ______ less demineralization than the control group. a. 20% b. 30% c. 50% d. 75%
In a study conducted by Kashani, et al., it was shown that when comparing enamel demineralization depths adjacent to bands cemented with zinc polycarboxylate, glass ionomer (GI) and RMGI, the use of RMGI cement seems to present _______________ enamel demineralization. a. significantly better prevention of b. no better prevention of c. an equal amount of prevention of d. slightly more
The Todd, et al., study demonstrated that _________ of fluoride varnish was beneficial for reducing WSLs. a. a single application b. two applications c. three applications d. four applications
The study (by Benham, et al.) found that the nonsealed teeth developed white spot lesions at a rate of _____ times greater than teeth with sealants. a. 3.8 b. 5.0 c. 6.3 d. 11.2
Children aged _______ years are considered to be at greatest risk of developing caries. a. 3-6 b. 7-10 c. 11-14 d. 15-18
Plaque is a natural reservoir for cariogenic microflora, namely, ____________. a. Streptococcus mutans b. Lactobacilli
Volume 6 Number 5
When discussing early interceptive treatment of potentially impacting teeth, typically the _______ are being addressed since they are most commonly impacted teeth, second only to third molars. a. maxillary canines b. maxillary first premolars c. mandibular first premolars d. none of the above It has been hypothesized that the permanent maxillary canine is more susceptible to _________ because of its development high up in the most concentrated portion of the alveolus and its relatively late age of eruption. a. ectopic eruption b. impaction c. caries d. both a and b A study by Coulter and Richardson, found that the maxillary canine travels nearly ____ from its position at age 5 years to its final position at age 15 years. a. 5 mm b. 10 mm c. 16 mm d. 22 mm _______ the eruption of the permanent teeth can result in a dental and/or skeletal discrepancy that is too severe to achieve an ideal or even an acceptable orthodontic result. a. Treating the jaw after b. Leaving a jaw condition untreated until after c. Interfering with d. Anticipating The keys to early intervention of patients with impacting and potentially impacting teeth include a clinical exam, ___________, consideration for maxillary skeletal expansion, diligent monitoring of all erupting teeth, and timely referral to an oral surgeon for tooth exposure as necessary. a. cone beam computed tomography (CBCT) imaging
b. c. d.
lateral and frontal cephalometric analyses dentofacial growth analysis all of the above
Traditional panoramic images do not provide the subtle details of ________ necessary to diagnose and treat impacting teeth. a. tooth position b. root form c. dentoalveolar width d. all of the above
Schindel and Duffy also stated that patients possessing a transverse discrepancy are ______ to have an impacted maxillary canine than those without the transverse deficiency. a. more likely b. less likely c. just as likely d. never likely
They (Schindel and Duffy) also stated that the early mixed dentition is _______ to assess a patient for potential canine impaction. a. the best time b. the worst time c. an injudicious time d. a dangerous time
Bazargani, et al., found _________ in maxillary arch length occurred at sites where deciduous canines were extracted with palatally displaced canines compared to controls. a. no change b. a significant increase c. a significant decrease d. a small increase
Note that not all early treatment cases with impacting or potentially impacting teeth require _______. a. orthodontic treatment b. surgical intervention c. radiographs d. guided eruption techniques
Orthodontic practice 49
ORTHODONTIC PRACTICE CE
Infection control — how equipment plays a role Adrian E. LaTrace offers advice on controlling pathogens in the practice
nyone who has read Jared Diamond’s book Guns, Germs, and Steel, understands how bacterial and viral outbreaks have altered the course of human civilization. The plagues of the early ages and Spanish influenza in 1918 serve to remind us about the unpredictability of these devastating pandemics. This century’s outbreaks of the Ebola virus in western Africa occurred at random times, affecting the citizens of the various nations as well as the healthcare workers providing care to those infected. Closer to home, last year the United States saw its worse measles outbreak in decades with 648 confirmed cases in 27 states with the trend continuing into 2015. In 2015, 24 states have reported cases of measles with California and Illinois reporting the highest numbers. In June 2015, the state of California passed legislation in response to the Disneyland-linked measles cases that requires parents to immunize their children against measles in order to attend the state public school system. California joins 32 other states that require children to be vaccinated to prevent further spread of the disease. This all comes after the United States nearly eradicated the disease in 2000. Adrian E. LaTrace is the CEO of Boyd Industries, Inc., located in Clearwater, Florida. Boyd has been the premier operatory equipment supplier to the orthodontic industry for over 55 years. The company is the proud recipient of the 2013 and 2014 Townie Choice Awards for its high-quality treatment chairs and doctor seating. Before acquiring Boyd in 2012, LaTrace’s manufacturing career included executive roles in the healthcare, aerospace, and renewable power industries. He is an Executive Partner at Salt Creek Capital and currently serves on the advisory boards to the University of Iowa College of Engineering and Florida Medical Manufacturers Consortium. Adrian earned his MBA from the Kellogg School of Management at Northwestern University and has a bachelor’s degree in Chemistry from The Citadel. www.boydindustries.com
50 Orthodontic practice
Methicillin-resistant staphylococcus aureus (MRSA) strains of bacteria have been the subject of studies and the media since the 1960s. Much is understood about the bacteria’s infection and transmission, but it remains a ubiquitous strain of bacteria affecting both medical and public facilities. MRSA garnered much media attention when it was discovered in the locker rooms of both high school and professional football teams. When three Tampa Bay Buccaneers football players reported MRSA infections in 2013, many in the general public became more aware of its existence, in addition to those of us in the healthcare industry. Seldom deadly in healthy individuals, most MSRA exposures result in treatable skin infections but it can manifest into a “flesh-eating bacteria” with devastating consequences. At times, it seems we are bombarded with reports of new outbreaks of pathogens ranging from those already mentioned to that of hepatitis B or C, tuberculosis, HIV, and other transmittable diseases. I am not a doomsayer living in a plastic bubble, but
rather one aware of the risks presented by the various microbes that surround us. Being armed with good infection-control protocols and products designed to minimize the exposure and transmission of these organisms will go a long way in preventing unforeseen exposure to patients. You must remain diligent in maintaining proper procedures, training your staff for their own safety, as well as your patients, and equipping your offices with products incorporating the latest infection control concepts and materials. Today’s science provides us research and tools to better understand the nature of the many microbial threats we face. Because of this understanding, organizations such as the Centers for Disease Control (CDC) and American Dental Association (ADA) publish evidence-based guidelines to aid practices in developing their infection control protocols. In addition, the FDA and OSHA weigh in on specifics related to methods for disinfecting patient-care items and protection of your staff from pathogens. Since the CDC and ADA are not regulatory bodies, they rely on Volume 6 Number 5
THE REASON TO SPEND MORE FOR BOYD QUALITY IS BECAUSE YOU’LL ACTUALLY SPEND LESS. With Boyd quality cabinetry, you really get what you pay for. And with a lower-priced local cabinetmaker, unfortunately the same is true.
So if you’re considering using a local source, then please consider this: Boyd custom cabinets might cost more, but over the years they will save you time, eﬀort and money. In our over three decades of specializing in Orthodontic cabinetry (not kitchen cabinets), we’ve gained vast expertise in dental practices’ speciﬁc needs.
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GOING VIRAL federal agencies like the FDA and OSHA to put the teeth into compliance. I believe all dentists would agree that all their critical and semi-critical instruments should be sterilized before use on a patient. This is common sense. Based on a study published in the October 2012 edition of The Journal of the American Dental Association, entitled Advancing infection control in dental care settings, most dentists (76.9%) had attended one or more CE courses on infection control with 73% of respondents having read the CDC’s 2003 Infection Control Guidelines. However, when these same practices were surveyed on the implementation of the study’s four recommendations to promote infection control measures within the practice, only 26% had implemented three or all four recommendations. Of course, the survey was skewed toward general practice (GP) offices consistent with the overall number of GP versus all other dental specialists in the United States. This is not to imply dentists are not following the overall guidelines, but rather there is variation in their compliance methods. The CDC guidelines promote the use of a defined process flow provided by a properly designed Sterilization Center for instrument sterilization. This should include sections for the following: 1. Clearly identified storage for contaminated (dirty) instruments 2. Ultrasonic cleaning to remove particulate matter 3. Surgical milk bath for instrument lubrication 4. Air-drying station using heated-air system 5. Wrapping area 6. Heat sterilization equipment 7. Clearly identified storage for sterile (clean) instruments These processes need to occur in the proper order and in a linear flow to prevent transgression that could result in crosscontaminated instruments. My company suggests the Sterilization Center be custom designed to include these steps and sized specifically to the dimensions of the space where the practice assigns the sterilization room. Ever wonder where the idiom that someone was “born with a silver spoon in their mouth” originated? Sure, it’s a centuriesold description of someone born into a wealthy family, but its origin alludes to our ancestors’ understanding of the antimicrobial properties of silver. Some sources believe the idiom has roots in the fact that silver spoons 52 Orthodontic practice
Choosing products that include antimicrobial materials and are designed properly will provide tangible benefits in your office for many years.
were gifts to babies born to wealthy families. Babies fed with a silver spoon tended to be healthier. Later discovered as the “oligodynamic effect” by Swiss scientist Karl Wilhelm von Nageli, many metallic ions such as silver, copper, zinc, and gold were proven to be toxic to many forms of bacteria, viruses, and fungi. The antimicrobial effects of these metals are in use today by many medical and dental product manufacturers to prevent the spread of harmful microbes and reduce infections. Recently, equipment manufacturers have begun to use paints and other surface materials impregnated with copper to help kill harmful microbes on surfaces before they have had a chance to spread. One type of these materials developed by EOS Surfaces, LLC, a solid surface manufacturer, is called EOScu®. The product is a synthetic solid surface material enhanced with copper, which will kill over 99.9% of gram positive and negative bacteria within 2 hours of exposure. This product is a durable, attractive, solid surface material available in several colors for cabinetry countertops and delivery system cart tops. Companies such as Boyd Industries offer this product as an option in their cabinetry and side cart product line. Advances in antimicrobial compounds can be found in upholstery materials and plastics, too. For example, OMNOVA Solutions, the upholstery material manufacturer, uses an antimicrobial protective finish in its Boltaflex® product line. This vinyl upholstery product using the company’s PreFixx® coating resists the growth of many microbes, making it ideal for dental chair and seating products. Advances in material science makes these types of coatings durable and easy to clean with a variety of common disinfectant solutions. Plastic technology advances include products such as Microban®, the antimicrobial plastics additive. Plastics infused with this product will resist microbial growth, and because it’s blended into the plastic formulation, will not wash off or wear away. Both the upholstery and plastic additive comply with
the appropriate regulatory requirements for use in healthcare facilities. The use of these types of materials when specifying your equipment in combination with diligent disinfecting procedures will greatly reduce the possibility of microbial growth on your patient chairs and staff work surfaces. Your equipment supplier can offer several tools to assist you in accomplishing the goals of your infection control program. Here are a few tips when discussing your needs with a supplier. • Insist on equipment made by companies whose products are listed with the FDA and have passed the regulatory testing of either Intertek or Underwriters Lab, when necessary. These products conform to standards set forth by the FDA to safeguard both the patient and clinician. • When selecting your supplier, be sure to select a company that will work with you and your staff to select or design the products and features best suited for your practice. Companies offering a onesize-fits-all solution most likely will not be able to meet the specific requirements of your infection control program. • Ask your supplier about the use of antimicrobial materials used to construct their products and other design features that promote the ease for disinfecting or sterilization. Products that incorporate these features will reduce the level of effort required by both you and your staff to maintain an office compliant with your infection control program. Before making your investment decision, you should conduct thorough due diligence about the infection control characteristics of the equipment, sterilization centers, or cabinetry you are considering for purchase. This is a factor frequently overlooked when evaluating dental equipment and should be weighed along with other factors such as durability, esthetics, and ergonomics. Choosing products that include antimicrobial materials and are designed properly will provide tangible benefits in your office for many years. All orthodontists with whom I speak certainly understand the necessity to maintain a healthy environment for their patients and staff. Of course, their practice’s infection control program and protocols are very much at the center of this imperative. As discussed, maintaining an effective infection control program will prevent the possibility of the spread of pathogens and their harmful effects. Through your talents you create wonderful smiles; your infection control program will keep them smiling. OP Volume 6 Number 5
The Jasper Vektor™ — the first edgewise Class II corrector
reating Class II malocclusions has historically found the practitioner choosing from a standard set of treatment options that have either been dependent on patient compliance or risked undesired extrusion in the course of correcting the overjet. Another challenge to correcting the Class II malocclusion is applying adequate force to create the necessary movement without producing extrusive tipping force on the maxilla and anterior teeth, which is always contraindicated for the over-erupted Class II patient. According to Dr. James Jasper, “The greatest problem in orthodontics has always been that we can never touch or place any of our forces on the center of rotation of the teeth or jaws. Physics provides us with only one answer — curved vectors.” While curved force vectors have been the standard for creating tooth movement for nearly 87 years, their use has not been applied to correction of Class II malocclusions. The Jasper Vektor™ has changed all that by harnessing energy from the muscles of the jaw to apply gentle and efficient force, correcting the overjet without causing extrusion and with greater comfort to the patient. “The Jasper Vektor device does not tip the maxilla; it applies just what is required for efficient Class II correction — about 3.5 ounces of force,” says Dr. Jasper, inventor of the appliance. “This is free energy we are pulling from the face muscles; essentially we are using the same edgewise vectors we have traditionally used to move teeth to move the mandible.”
James Jasper, DDS, is one of the world’s leading experts on Class II correction. He began his extensive 45-year career as an orthodontic instructor in Denmark, where he also learned from Arne Bjork and others how the face developed. His works have been published globally, and he has lectured in over 35 countries. Dr. Jasper has a private practice in Fairview, Oregon, and holds several patents on Class II correctors, which have been used around the world.
Volume 6 Number 5
The difference between the Jasper Vektor and other Class II correctors is its innovative, arched spring design that flexes in its distal 25%-45% of the overall appliance length. The Jasper Vektor allows treatment of overjet with a host of benefits: • Curved force vectors apply only the force needed to gently and efficiently move the mandible — about 3.5 ounces. • The curved shape keeps the appliance away from the food bolus during eating and makes oral hygiene significantly easier. • The coil spring is tightly wound to prevent soft tissue impingement. • The low-profile arched spring allows for natural lateral mandibular movement for patient comfort. • Class II malocclusions can be effectively treated in about 6 months with no dependency on patient compliance.
Class II correction without tipping the maxilla The Jasper Vektor bite-correcting appliance attaches directly to brackets and archwire and works by introducing gentle intrusive force vectors to the patient’s upper and lower teeth. This light continuous force is not applied along the appliance’s axis, but instead sweeps in an arch to lift up on the front of the upper molar, and down on the lower front teeth as the appliance tries to return to its pre-installed (passive) state. This is in direct contrast to Herbst® and Herbst-like appliances, as well as spring-activated straight force devices that deliver their force straight along the axis of the appliance. These devices all attach to the distal of the upper molars, often with what amounts to be a small lever arm that ultimately magnifies the tipping force. A comparison of the types of Class II correctors available and the force types produced is illustrated by a Newton analysis (Figure 1).
Figure 1: This Newton analysis of Class II correction devices illustrates the effectiveness of the Jasper Vektor in creating optimal results with none of the unwanted challenges inherent in current technologies Orthodontic practice 53
Gentle, effective, and efficient Class II correction that sets a new standard for treatment
TECHNOLOGY Durability and dependability during treatment The Jasper Vektor is constructed of nickel titanium, making the appliance breakresistant throughout the course of treatment.* Combined with its low-profile design and clearance from the food bolus, the Jasper Vektor may be the most durable and reliable Class II corrector available.
Five minutes to install. Six months to results Even in an extreme case (a 14-mm Class II overjet), the Jasper Vektor has produced remarkably efficient results (Figure 2). Following an approximately 5-minute installation, the appliance produces full resolution of the overjet (Figure 3) and noticeable change in patient profile in just 6 months (Figure 4). “The results we are seeing when patients are treated with the appliance, particularly in terms of treatment time and patient comfort, are unheard of in the orthodontic industry,” says Dr. Jasper.
Figure 2: Patient with 14 mm Class II overjet at start of treatment
FIgure 3: Treated with rectangular wires for 7 months prior to installation of Jasper Vektor. Jasper Vektor was active for 6 months. Total case treatment time was 25 months
Figure 4: Patient shows visible improved profile after 6 months treatment with Jasper Vektor, even after missing multiple appointments during course of treatment
Installation of Jasper Vektor 1. Note that molars must be banded and the use of an occlusal headgear tube is required. Patient must be in .017" x .025" (0.4318 mm x 0.635 mm) or .021" x .025" (0.5334 mm x 0.635 mm) rectangular archwires to fill the slot completely. (Second molars should be banded for improved anchorage.) 2. When placing the large upper wire, narrow it as much as possible in the posterior area. For patient comfort, it is recommended to wait 4 weeks to install the Jasper Vektor appliance, which typically can be done in a 15-minute appointment. 3. Remove lower archwire and lower bicuspid brackets. 4. Place wire in anterior brackets; mark distal to canines and place 1-mm bayonet bands at marking. Place the archwire lock, and tighten at bayonet bend. (First loosen assembly without taking it apart, so it can slide on the wire.)
5. Reinstall the archwire, bend the distal down, and cinch back to prevent mesial movement of the lower anchorage teeth. 6. Have the patient bite down in centric and measure from the mesial of the upper molar headgear tubes down to the distal of the sliding arch. (Measure both sides.) 7. To this number add 12 mm or 13 mm. For example, an 18-mm measurement would require a 30-mm appliance. A 20-mm measurement would require a 33-mm appliance. Select the correct right and left appliance.
For more information about the Jasper Vektor appliance call, TP Orthodontics at 800-348-8856. Visit www.tportho.com/ Vektor to view the video. OP 8. Slip the gap in the split ring onto the lower archwire just behind the arch lock, and squeeze the gap closed with a Howe plier. 9. Hold the upper extension of the Jasper Vektor appliance with a Howe or Weingart plier, and slide it in the headgear
54 Orthodontic practice
tube from the distal. Hold it in with a finger, grip the 5 mm sticking out the front of the tube, and bend it into a U shape. The front 5 mm of this wire has been annealed to facilitate bending (and unbending during removal). 10. At the end of the correction phase (6 months), use of Class II nighttime elastics is recommended for retention.
*The Jasper Vektor appliance has undergone more than 7 million cycles in laboratory testing. Jasper Vektor™ is a trademark of TP Orthodontics, Inc., and is manufactured under US Patent 8,529,253. Herbst® is a registered trademark of Dentaurum, Inc. This information was provided by TP Orthodontics, Inc.
Volume 6 Number 5
In a class of its own. Introducing the most innovative, comfortable and efficient solution for Class II correction.
Comfortable and worry-free for your patients. Dependable and efficient for you. • Produces gentle, curved force vectors since the appliance flexes in 25-45% of its overall length • Robust nickel titanium design • Easy installation • Free from the “food zone” • Allows natural lateral mandibular movement for patient comfort • Compliance independent
The Jasper Vektor™ Class II Correction Appliance is the ONLY appliance that produces gentle, intrusive force vectors that do not tip the maxilla – just what is required for efficient Class II correction. Other appliances produce extrusive tipping forces on the maxilla and anterior teeth, which is always contraindicated for the over erupted Class II patient. Since the vector control module (VCM) is made from nickel titanium, the appliance is break-resistant and force values of only 3.5 ounces are produced. Provide your patients the latest Class II correction alternative with the Jasper Vektor appliance. See why the Jasper Vektor appliance is in a class of its own. Call or visit us online:
800-348-8856 Jasper Vektor is a trademark of TP Orthodontics, Inc. and manufactured under US Patent 8,529,253. © 2015 TP Orthodontics, Inc. All rights reserved.
The value of orthodontic study models for diagnosis and treatment planning: a survey Drs. Nathan Yetter and Donald J. Rinchuse investigate whether orthodontic e-models and/or plaster models are useful Introduction: The purpose of this survey study was to investigate whether orthodontic e-models and/or plaster models are perceived to be useful for orthodontic diagnosis and treatment planning. Methods: An email invitation from the American Association of Orthodontists, AAO Partners in Education, was sent to a random selection of 2,300 members of the AAO in the United States requesting participation in a 13 question online survey (SurveyMonkey®). Results: Of the 2,300 orthodontists randomly surveyed, 260 completed the survey for a response rate of 11.30%. 67.69% reported always taking pretreatment study models while only 33.08% take posttreatment models. Better diagnostics was cited by 66.54% of respondents as the reason for taking pretreatment models. At the same time, 57.31% also reported legal reasons as a motivation for taking pretreatment models. 27.31% said they never look at the pretreatment models after treatment has begun. While 29.23% strongly agree that having pretreatment study models is important to making treatment decisions, 25.77% strongly disagreed. 71.54% of survey respondents reported practicing orthodontics for more than 10 years with the majority of those practicing for more than 20 years. Conclusions: This study demonstrated the wide range of opinions on taking pretreatment study models and the reasons for
Dr. Nathan Yetter is in orthodontic practice in Mesa, Arizona. At the time of the study, he was a senior orthodontic resident at Seton Hill University in Greensburg, Pennsylvania. Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Graduate Orthodontic Program Director, Seton Hill University, Greensburg, Pennsylvania. He graduated from the University of Pittsburgh School of Dental Medicine in 1974 with degrees in Dentistry (DMD) and Pharmacology/Physiology (MS). He received his certificate and MDS degree in orthodontics in 1976 and a PhD in Higher Education in 1985 from the University of Pittsburgh. He is a Diplomate of the American Board of Orthodontics. In addition, Dr. Rinchuse is on the editorial review board of many professional journals, including the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO). He has published over 100 articles, several book chapters, and a book, and has made many presentations. He can be reached at firstname.lastname@example.org.
56 Orthodontic practice
taking them. There seemed to be a trend among younger orthodontists toward not taking pretreatment study models as the quality of digital photography increases and more emphasis is placed on having quality photographic images.
Introduction The success of orthodontic treatment is highly correlated with a correct diagnosis and proper execution of a thorough treatment plan.1 An experienced clinician often knows what the diagnosis and treatment plan for most patients will be at the initial examination. In fact, Mr. Bud Schulman2 has been advocating case acceptance at the first visit for many years. He stated, “I believe in some cases, possibly 80% of the cases, they can tell immediately that orthodontics is called for and what the approach may be… I believe the tendency throughout the profession is to reduce the entry-visit procedure.” Historically, orthodontists have used a thorough medical history, photographs, plaster models, cephalometric radiographs, and panoramic radiographs in conjunction with a comprehensive clinical examination to make a diagnosis. There have been many studies that have confirmed the usefulness and validity of the records orthodontists traditionally use for diagnosis and treatment planning.5,6,7,8,9,14 Currently, the American Association of Orthodontics4 recommends that complete orthodontic records should include the following: pretreatment and posttreatment intraoral and extraoral photographs, models (either plaster or digital), panoramic radiographs, lateral cephalometric radiograph with a diagnostic tracing, as well as any other records deemed necessary for the individual patient. With the ever-evolving technological advancements, adaptations to the necessary records have and will continue to change. Orthodontists may be required in the near future to convert all their records to the digital form. In line with these changes, e-models have been accepted as an adequate substitute for plaster models and have subsequently
made it easier for orthodontic offices to become digital. Stevens, et al.,5 evaluated the validity, reliability, and reproducibility of plaster versus digital study models and found that digital models would not cause an orthodontist to make a different diagnosis compared with plaster models. As the quality of digital photography has become better and used in most (if not all) orthodontic offices, digital pretreatment photographs have evolved into a critical pretreatment record. Digital photos are available immediately at the initial patient visit and can be retaken when needed. When properly captured, they offer a complete view of the patient’s dental malocclusion, soft tissue esthetics, and some skeletal orientation. It can be argued that more clinical information can be derived from pretreatment photographs than from plaster or digital patient models. Also, digital models are typically not available for at least 5 to 7 days after the initial patient visit, and usually a diagnosis and treatment plan are already formulated. Plus, as already stated, many clinicians advocate a one-visit case acceptance approach, which would eliminate the use of plaster models for diagnosis and treatment planning. Arguably, the most important piece of information that contributes to a proper diagnosis is the initial clinical examination. This is the time when the evaluating doctor will usually formulate a diagnosis and treatment plan based on what he or she sees clinically. Panoramic and cephalometric radiographs can be available during this exam (plaster or digital) as well as digital photographs. The models are typically not available during the initial evaluation. This raises the question as to what contribution study models have in reference to diagnosis and treatment planning and if having pretreatment study models has any effect on the treatment outcome.
Materials and methods A random sample of 2,300 orthodontists who were active members of the AAO were sent an email invitation to participate in this 13-question survey. The email invitation to Volume 6 Number 5
Table: Summary of survey results Topic
Pretreatment study models — how often taken?
Always — 67.69% Never — 8.46% Sometimes — 14.62% Most of the time — 9.23%
2. Posttreatment study models — how often taken?
Always — 33.08% Never — 33.46% Sometimes — 25.77% Most of the time — 7.69%
Reason for taking pretreatment models?
Results The survey was sent to 2,300 orthodontists who were active members of the AAO. Of the 2,300 orthodontists, 260 completed the survey, for a response rate of 11.30%. The Table shows the demographic information of the survey respondents (Nos. 9-12) as well as a summary of the results (Nos. 1-8). It was reported that 67.69% of those who responded always took pretreatment study models. 66.54% said they take pretreatment study models (plaster or digital) for better diagnostics while 57.31% also reported taking them for legal reasons. In response to whether having study models was important to making treatment decisions, 25.77% strongly disagreed that having pretreatment study models is important to making treatment decisions while 29.23% strongly agreed. Overall, there were wide-ranging views on whether it is important to have pretreatment study models.
Discussion Pretreatment orthodontic study models have been used for many years in diagnosis and treatment planning for orthodontic patients. They have historically been used as a diagnostic tool and as a legal record of the patients’ condition before the start of treatment. Information can be gathered from dental models that include overbite, overjet, tooth sizes, arch lengths, and transverse distances.13 There has been discussion and debate over the diagnostic value of pretreatment study models for a long time. Many doctors are taking pretreatment study models only because they feel that they must in order to protect themselves legally. The results of this survey indicate that a majority of orthodontists (67.69%) are taking pretreatment study models. The results also demonstrate that many orthodontists (23.08%) are not taking them for the majority of cases. Many orthodontists (57.31%) also cited legal reasons as a motivating factor for taking pretreatment study models. Volume 6 Number 5
Better diagnostics — 66.54% Legal reasons — 57.31% Monitor treatment progress — 35%
4. Were pretreatment models viewed after beginning treatment?
Never — 27.31% Once or twice — 50% Many times during treatment — 13.46%
5. Were pretreatment models important to treatment decisions?
Strongly agree — 29.23% Stongly disagree — 25.77% Somewhat agree — 21.15% Somewhat disagree — 12.31%
Plaster or digital?
Plaster — 61.15% Digital — 29.62%
If plaster, why?
Like holding models — 44.40% How I was trained — 25.87% Habit — 23.55%
If digital, why?
Easier storage — 33.46% Diagnostic and treatment planning — 15.77%
Male — 80% Female — 20%
10. Responder’s age?
34 or less — 12.31% 35-44 — 29.23% 45-54 — 27.69% 55-64 — 25.77%
11. How many years in practice?
4 or less — 13.08% 5-9 — 15.38% 10-19 — 29.23% 20 or more — 42.31%
12. Geographic region of responder?
Northeast — 18.22% Southeast — 18.22% Midwest — 24.81% Northwest — 22.87% Southwest — 8.91% Canada — 6.98%
As orthodontics continues to evolve, an evidence-based practice is a primary focus that should be strived for. As stated in the textbook Evidence-Based Clinical Orthodontics, “The orthodontist’s focus for clinical decision making should be on treatment protocols and strategies that are proven to be both efficacious and safe.”14 The question that should be asked is, What scientific evidence exists that supports the value of pretreatment study models for making better diagnostic and treatment planning decisions? In this survey, 38.08% of those who responded either strongly or somewhat disagreed that
having study models is important to making treatment decisions. Callahan, et al.,13 studied the value of plaster models in orthodontic diagnosis and treatment planning. They presented pretreatment records that included intraoral and extraoral photos, panoramic, and traced lateral cephalometric radiographs to four orthodontists. The orthodontists were asked to review the records and formulate a comprehensive diagnosis and treatment plan. Once they had completed the diagnosis and treatment plan, the plaster models were introduced with all the other records. They were then asked to re-evaluate their diagnosis and Orthodontic practice 57
participate in the survey included a description of the survey topic and its relevance and importance to the field of orthodontics. It encouraged all to participate. The first email invitation was sent on August 27, 2013, in which 159 responses were collected. A secondary reminder was sent on September 11, 2013, which generated another 101 responses. The survey was closed on October 7, 2013. Data collection and analysis were obtained through SurveyMonkey, and descriptive statistics were used.
RESEARCH treatment plan to see if having the models would change any diagnostic or treatment criteria. They found that none of the treatment plans had changed after the study models had been introduced and concluded that the use of plaster models for adequate diagnosis and treatment planning may be questionable.13 Advances in technology have created other opportunities to avoid alginate impressions and plaster models. Many studies have evaluated the reliability and validity of digital models, intraoral scanning, and cone beam computed tomography scanning compared to traditional plaster models for diagnosis and treatment planning.5,6,7,8,9,10,13,14 The consensus of these studies supports the use of digital alternatives. The American Board of Orthodontics also accepts these digital versions in place of traditional plaster models for the pretreatment record of board certification. They still, however, require plaster models for the final record. Parenthetically, the AAO, in a recent publication of the The Bulletin, responded to the question “Can digital photos be taken instead of traditional models?” by stating “The AAO does not have an official position regarding this issue.” This statement seems to be contradictory to the position they take in their official guidelines for “Patient Records and Record Keeping.”4 Regardless, the evidence is still lacking in support of any form of pretreatment models to enhance diagnosis and treatment planning. In the present study, 57.31% of orthodontists that responded said that one of the main reasons they take pretreatment study
Decisive scientific evidence needs to be established for the recommendation that orthodontic pretreatment study models should be taken on all orthodontic patients. models is for legal reasons. Historically, this has been true. Dr. Laurance Jerrold15 stated, “Dental records are supposed to be an accurate reflection of your conversations with the patient, the treatment rendered, recommendations made, etc.” However, with the improvement of digital photography, pretreatment intraoral and extraoral photographs can adequately document the patients’ condition prior to treatment. It could be argued that more information about a patients’ pretreatment condition can be derived from quality photographs than digital or plaster models because they show archform, crowding, periodontal condition, any gross carious lesions, pre-existing white spot lesions, malocclusion, extraoral asymmetry, and profile. With the AAO making the statement — “Pretreatment unaltered diagnostic records for comprehensive orthodontic treatment should include the following to establish a baseline for documenting treatment and/ or growth changes: Dental casts (or digital
models) to assess the inter-arch and intraarch relationship of the teeth, to help determine arch length and width requirements, and to assess arch symmetry”3 — may make it legally difficult to justify not taking pretreatment study models. By saying that pretreatment dental casts or study models “should” be used is essentially discrediting some of AAO’s members who choose not to take pretreatment study models on all patients.
Conclusion The results of this survey demonstrate the wide-ranging views on utilizing study models as a pretreatment record. • It was reported that 67.69% of orthodontist are currently taking pretreatment study models (digital or plaster) on all patients. • 66.54% of orthodontists cited better diagnosis as a reason for taking study models, while 57.31% also said they take pretreatment study models for legal reasons. • 29.23% of responding orthodontists strongly agreed that having pretreatment study models was important to making treatment decisions, while 25.77% strongly disagreed that having pretreatment study models was important to making treatment decisions. • 71.54% of those who responded to this survey have been in practice for longer than 20 years. Decisive scientific evidence needs to be established for the recommendation that orthodontic pretreatment study models should be taken on all orthodontic patients. OP
REFERENCES 1. Lightheart KG, English JD, Kau CH, Akyalcin S, Bussa HI Jr, McGrory KR, McGrory KJ. Surface analysis of study models generated from OrthoCAD and cone-beam computed tomography imaging. Am J Orthod Dentofacial Orthop. 2012;141(6):686-693. 2. Schulman M. JCO interviews Martin L. ‘Bud’ Schulman on success through sharing. Interview by Eugene L. Gottlieb. J Clinical Orthod. 2002;36(10):569-578. 3. Gladwell M. Blink: The Power of Thinking Without Thinking. New York: Little, Brown and Company;2005. 4. Patient Records and Record Keeping, available at www.aaomembers.org. 5. Stevens DR, Flores-Mir C, Nebbe B, Raboud DW, Heo G, Major PW. Validity, reliability, and reproducibility of plaster vs digital study models: comparison of peer assessment rating and Bolton analysis and their constituent measurements. Am J Orthod Dentofacial Orthop. 2006;129(6): 794-803. 6. Wiranto MG, Engelbrecht WP, Tutein Nolthenius HE, van der Meer WJ, Ren 7. Y. Validity, reliability, and reproducibility of linear measurements on digital models obtained from intraoral and cone-beam computed tomography scans of alginate impressions. Am J Orthod Dentofacial Orthop. 2013;143(1):140-147. 8. Okunami TR, Kusnoto B, BeGole E, Evans CA, Sadowsky C, Fadavi S. Assessing the American Board of Orthodontics objective grading system: digital vs plaster dental casts. Am J Orthod Dentofacial Orthop. 2007;131(1):51-56. 9. Whetten JL, Williamson PC, Heo G, Varnhagen C, Major PW. Variations in orthodontic treatment planning decisions of Class II patients between virtual 3- dimensional models and traditional plaster study models. Am J Orthod Dentofacial Orthop. 2006;130(4):489-491. 10. Cuperus AM, Harms MC, Rangel FA, Bronkhorst EM, Schols JG, Breuning KH. Dental models made with an intraoral scanner: a validation study. Am J Orthod Dentofacial Orthop. 2012; 142(3):308-313. 11. Han UK, Vig KW, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop. 1991;100(3):212-219. 12. Jerrold L. Litigation, legislation, and ethics. Dental records as evidence. Am J Orthod Dentofacial Orthop. 2000;118(2):241-242. 13. Proffit WR, Fields HW, Sarver DM, eds. Contemporary Orthodontics. 4th edition. St. Louis, MO:Mosby; 2007:192. 14. Callahan C, Sadowsky PL, Ferriera A. Diagnostic Value of Plaster Models in Contemporary Orthodontics. Seminars in Orthodontics. 2005;11:94-97. 15. Rheude B., Sadowsky P.L., Ferriera A., Jacobson A., “An evaluation of the use of digital study models in orthodontic diagnosis and treatment planning” Angle Orthod. 2005;75(3):300-304. 16. Miles PG, Rinchuse DJ, Rinchuse DJ, eds. Evidence-Based Clinical Orthodontics. Chicago, IL: Quintessence Publishing Co. Inc.; 2012. 17. Jerrold L. Litigation, legislation, and ethics. Dental records as evidence. Am J Orthod Dentofacial Orthop. 2000;118(2):241-242.
58 Orthodontic practice
Volume 6 Number 5
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Herbst appliance update A review of the Herbst appliance and the design evolution of the last 30 years
he Herbst™ appliance was introduced in 1909 by Dr. Emil Herbst. Dr. Herbst was a German orthodontist who contributed greatly to the orthodontic profession. He also introduced the rapid palatal expansion device. The original Herbst appliance mechanism was a rod and tube device that is still used on some designs today. However, the original rod and tubes were made from either silver or gold. Dr. Herbst would anchor to the upper first permanent molars and lower first bicuspids with a lingual arch on both arches. The lower lingual arch would be contoured between the interproximal of the first and second molars. Original Herbst designs had limited lateral movement that restricted the patient’s speech and chewing movements. They were also very bulky, and the extension arms were longer. The oversized appliance was not aesthetic and caused irritation to the cheeks and lips where the mechanisms were secured. Over the years, Herbst appliances have seen several anchorage designs. Dr. Hans Pancherez utilized cast frameworks that were bonded to the teeth to maintain total anchorage. He also utilized bands as anchorage in 1979. Dr. Raymond Howe patented the Acrylic Splint Herbst design on the upper and lower arches in 1982. Initially these splints were bonded to the teeth. This technique is still utilized today, but the splints are generally removable. Dr. Alton Bishop and some other orthodontists utilized mesh pads that were bonded to the buccal and lingual of the upper and lower teeth in the posterior and the lingual of the anterior teeth. Dr. Langford introduced utilizing crowns for anchorage in 1980. Dr. Terry Dischinger reintroduced his bioprogressive technique
As Vice President and partner at Specialty Appliances, Arlen Hurt, CDT, has dedicated the past 30 years to orthodontic appliance innovation. Mr. Hurt is recognized as an awardwinning inventor, published author, and national orthodontic speaker. Arlen is best known as one of the most dependable resources for orthodontists everywhere.
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with crowns in 1987. Bands, crowns, and crowns with the occlusal removed (ROC crowns) are the main anchorage systems today. The most popular anchorage system at Specialty Appliances is the ROC crown. It combines the strength of a crown with bandlike removal. Dr. Dischinger has been very instrumental in promoting and teaching the Herbst appliance treatment to several orthodontists over the last 20-plus years. His bioprogressive approach utilized fixed treatment combined with the Herbst appliance, which is the industry standard today. I was fortunate enough to travel with Dr. Dischinger for 9 years, promoting the Herbst appliance and attending 33 of his hands-on courses.
The traditional rod and tube mechanism is still utilized by several clinicians today, but other designs have evolved in the Herbst market. The Flip-Lock™ mechanism was introduced in 1996 by Dr. Miller. In 2003, Dr. Steve Hanks introduced the HTH™ telescoping Herbst mechanism with a ball and socket design. Specialty Appliances introduced the MiniScope™ Herbst with the AppleCore® screws in 2004. In 2009, Dr. Dischinger introduced his Molar to Molar™ Herbst mechanism. The latest design on the market is the M4™ MiniScope® mechanism introduced by Specialty Appliances in 2011. This four-part telescope mechanism is already used by over 65% of Herbst customers at Specialty Appliances. Volume 6 Number 5
Not only does the M4 Herbst improve patient comfort, but it also has the least amount of breakage.
Specialty Appliances and the new M4 Herbst Telescope addresses many issues related to Herbst treatment. The M4 utilized along with ROC crowns and AppleCore速 screws are becoming an industry standard. The AppleCore screw, invented by Specialty Appliances in 2004, offers up to 40 degrees of lateral movement. This gives the patient more
62 Orthodontic practice
natural function and greatly reduces breakage due to the freedom in lateral excursions. The M4 design has unique features that solve many issues in Herbst treatment. One of those being the size of the mechanism, which is offered in 16 millimeter and 19 millimeter sizes. The shorter mechanism is placed in the temporal and masseter muscle area and away from the pterygoid and buccinator muscle areas. In addition, the M4 design is angled anteriorly on the upper eyelet to prevent tissue irritation. The telescope design opens 65 millimeters, offering the greatest vertical opening of any telescope on the market today. Why is this
feature so important? If patients are limited by the vertical opening, they will either break the appliance or pull the lower crowns off of the teeth. The M4 Herbst is placed parallel to the occlusal plane, allowing the greatest lateral movement and eliminating unwanted vertical forces that can intrude teeth. If intrusion is wanted in a high-angle patient, then the lower arch cantilever arm is placed subgingivally to create a vertical force. Not only does the M4 Herbst improve patient comfort, but it also has the least amount of breakage. These benefits have greatly improved the Herbst treatment experience for both doctor and patient. OP
Volume 6 Number 5
Dental 3D University, hosted by KaVo Kerr Group imaging brands Gendex™, NOMAD™, SOREDEX™, and Instrumentarium, is an exciting 2-day event that promises to provide dental professionals with an educational environment dedicated to cone beam 3D solutions that will enhance their practice and put them in full control of treatment outcomes. 3DU will be held October 1-2, 2015, at the Hilton Chicago. Up to 12 credits can be earned. Topics include: • Successfully incorporating 3D into your practice • Implant planning with 3D and surgical guides • Reading 3D scans • Insurance and billing for a smoother reimbursement process A user’s meeting on October 1 offers an opportunity for existing Gendex™, SOREDEX™, and Instrumentarium owners to take part in advanced training and peer-to-peer networking. To reserve a spot at 3DU, visit dental3DU.com
Dr. Sam Daher presented practical insight on how orthodontists can grow their practices by incorporating new technology, accelerated treatment Dr. Sam Daher, an international orthodontic lecturer based in Vancouver, British Columbia, presented a complimentary webinar on Friday, June 12. “Accelerate Your Practice: Leveraging Virtual Treatment Tools to Maximize Accelerated Orthodontic Treatment Outcomes” was hosted live via OrthoAccelLearning.com. The webinar was open to orthodontists, treatment coordinators, clinical assistants, and all practice staff interested in learning more about accelerated orthodontics and earning CE credit. One of the first Canadian orthodontists to offer AcceleDent®, the first and only FDA-cleared, Class II medical device that speeds up orthodontic treatment by as much as 50%, Dr. Daher explained how incorporating the innovative technology into his practice yields positive clinical and business outcomes. He also discussed how he uses advanced imaging techniques to employ virtual treatment planning and customized appliances for almost every type of malocclusion. Participants who complete the complimentary webinar online and the subsequent exam will receive one CE credit accredited by the American Dental Association Continuing Education Recognition Program. To register, visit OrthoAccelLearning.com.
Volume 6 Number 5
An Overview of Sleep Medicine DVD by Dr. Parker New from Great Lakes Orthodontics, An Overview of Sleep Medicine DVD is an animated and engaging video written and narrated by Dr. Jonathan A. Parker, international lecturer and one of the leading and most sought-after clinicians on sleepdisordered breathing. Viewers get a concise overview of sleep, including the importance of, challenges to, and the potential effects of insufficient or inadequate sleep. Dr. Parker clearly explains the effects of obstructive sleep apnea on health and quality of life. This exceptional video is fun, creative, and educational for professionals, patients, and staff. For more information about Dr. Parker’s DVD, contact Great Lakes product customer service at 800-828-7626, and ask to speak with a sleep specialist, or visit our Dental Sleep Center at www.greatlakessleep.com.
Ormco Corporation announces fall and winter continuing education events Ormco Corporation is hosting continuing education events throughout the country to help orthodontists of all levels elevate their skill sets via intensive seminars. Ormco’s full calendar of more than 14 courses allows orthodontists to engage with industry experts and learn more about passive self-ligation, Insignia Advanced Smile Design™, molar-to-molar therapy, and more. For orthodontists who have completed a PSL Fundamentals I course, or are actively using passive self-ligation, there are five upcoming PSL Fundamentals Level II courses focusing on advanced treatment mechanics and treatment planning with added considerations for periodontal issues, Class II and Class III cases, extraction cases, and more. For those looking to better understand the merits of digital smile design and customized appliances that can dramatically improve case management efficiency and treatment outcomes, there are two upcoming Insignia Essentials seminars. • September 25, 2015 — Insignia Essentials, Dr. Jeff Kozlowski, Dallas, Texas • October 8, 2015 — Insignia In-Office Course, Dr. Jeff Kozlowski, New London, Connecticut • October 9, 2015 — PSL Fundamentals Level II, Dr. Frank Bogdan, Las Vegas, Nevada • October 16, 2015 — Insignia Essentials, Dr. Jamie Reynolds, Indianapolis • October 16, 2015 — Future Visions Course, Dr. David Sarver, Birmingham, Alabama • October 16, 2015 — Dischinger In-Office Course, Drs. Terry and Bill Dischinger, Lake Oswego, Oregon • October 30, 2015 — PSL Fundamentals Level II, Dr. Stuart Frost, Philadelphia, Pennsylvania • November 5, 2015 — Insignia In-Office Course, Dr. Jamie Reynolds, Novi, Michigan • November 6, 2015 — PSL Fundamentals Level II, Dr. John Graham, Atlanta, Georgia • November 6, 2015—PSL Fundamentals Level II, Dr. Mike Mayhew, Chicago, Illinois For more information, visit http://ormco.com/education/.
Orthodontic practice 63
KaVo Kerr Group Imaging launches inaugural Dental 3D University
The all-new Carriere® Motion™ Class III Appliance A remarkable breakthrough in Class III correction Rethink Class III Introducing a whole new way to think about Class III treatment from Henry Schein® Orthodontics™. The Motion Class III Appliance provides a new, remarkably easy-touse, and patient-friendly solution for Class III treatment. This discreet, comfortable appliance is direct bonded in just minutes, and is used in conjunction with intraoral elastics, guiding the mandible to its optimal position — all prior to fitting braces, brackets, or aligners. Unlike other treatment options, the Motion Appliance is sleek, minimally invasive, and comfortable. And it works so effectively; it significantly reduces treatment time. Imagine an appliance that gives you and your Class III patients an option without surgery, extraction, or cumbersome extraoral devices. The Motion Appliance corrects Class III in less time and effort than you ever thought possible.
Think outside the past The Motion Class III Appliance is nothing less than a breakthrough in the treatment of Class III malocclusions. That’s because it’s not just an appliance: it’s a new treatment paradigm. You treat Class III with the Motion Appliance before beginning other treatments, so there are no competing forces in the mouth to delay or complicate achieving a proper A-P alignment. As a result, average Class III correction takes from 3 to 4 months.
And, because the Motion Class III Appliance delivers highly visible results early in the treatment, it improves patient compliance throughout your entire treatment plan. The result: Overall treatment time is cut by several months, chair time is reduced as well, and your margins per case are increased. So step into the future of Class III treatment, with the Motion Appliance.
Think inside the mouth The Motion Class III Appliance is a simple, elegant solution to a difficult problem: correcting Class III malocclusions. It works inside the mouth, direct-bonded to the mandibular arch and connected via intraoral elastics to brackets on U6 or U7 molars.
Building A Future Together
Time in Braces 23.5 Months in Braces
Traditional Braces + Motion
4.27 Mos. Motion
Motion + SLX™ Self-Ligating Brackets
4.27 Mos. Motion
17 Months in Braces
14-15 Months in Braces
10 15 20 25
Harradine N. 2001, Tagawa O. 2006, Carriere L. 2006, Sandifer C. 2014
The Motion Appliance corrects the Class III malocclusion without extraction in an average of 3 to 4 months, significantly shortening treatment time. Because it is used before brackets are placed, the Motion Appliance also reduces the “time in braces” as compared when using a traditional Class III treatment protocol. 64 Orthodontic practice
Unlike other treatment options, the Motion Class III Appliance installs in minutes and requires no bands, crowns, or lab services. Once installed, it works 24/7, unobtrusively and with minimal patient involvement. And, it requires almost no additional chair time, because there are no separator appointments, no complicated pieces to adjust; and the one-piece design minimizes accidental debonding or breakage. Since the Motion Appliance is used prior to fitting any braces, brackets, or aligners, it can do its job without the presence of any competing forces. So, it achieves a Class I platform quickly, predictably, and reliably. The Motion Class III Appliance is easier on your patients. Easier on your staff. And easier on you. So when you think about Class III treatments, make the easy choice: a Motion Appliance. For more information visit HenryScheinOrtho.com or call us at 888-851-0533.
Our future is you! We work hard to earn our customers’ business. While we are growing and gaining market share, we are not resting on our laurels. The orthodontic community is a small community where relationships matter, and every customer is important. Our employees pride themselves in trying hard to develop successful relationships. Our teams, in the field and in the office, are dedicated to the success of the clinician’s business by helping you provide your patients with a great smile, plus total health solutions. From clinician to staff member, know that you can “Rely on Us.” OP This information was provided by Henry Schein Orthodontics.
Volume 6 Number 5
A REMARKABLE BREAKTHROUGH IN CLASS III CORRECTION
INTRODUCING THE ALL-NEW CARRIERE® MOTION™ CLASS III APPLIANCE The Carriere Motion Class III Appliance provides a new, remarkably easy-
to-use and patient-friendly solution for Class III treatment. This discreet, comfortable appliance is direct bonded in just minutes, and is as easily tolerated as elastics alone! Imagine an appliance that gives you and your Class III patients an option without surgery or cumbersome, uncomfortable, and unsightly extra-oral devices. If you’ve ever struggled while tackling Class III cases, take a look at the all-new Motion Class III Appliance today!
Learn more about the Motion Class III Appliance at 888.851.0533 or HenryScheinOrtho.com.
© 2015 Ortho Organizers, Inc. All rights reser ved. PN M802 05/15 U.S. Patent 7,985,070 B2
American Orthodontics Tanzo™ Premium Heat Activated Arch Wire
ince 1968, American Orthodontics has been a global leader in the orthodontic industry, dedicated to continuously improving its products and processes in order to provide the best overall value to customers. In keeping with this mission of continuous improvement, American Orthodontics is proud to introduce Tanzo™ Premium Heat Activated Arch Wire, manufactured at its state-of-the-art facility in Sheboygan, Wisconsin. The manufacturing process for AO’s Tanzo Premium Heat Activated Arch Wire starts with the highest quality raw materials. American Orthodontics’ manufacturing benchmark for Tanzo focuses on maintaining consistent loading and unloading forces so the wire delivers the same predictable
Manufacturing Tanzo in AO’s state-of-the-art facility allows the process to be continually evaluated for quality, ensuring consistency of the finished product. performance every time. Each wire is set to shape in industry standard arch forms through a proprietary heat-treating process. Each wire cross section is then thoroughly
Tanzo’s polished finish provides a smoother surface to minimize friction during treatment and to reduce the opportunity for debris accumulation 66 Orthodontic practice
analyzed for quality and to ensure that consistent forces are produced between lots. Tanzo’s unique copper nickel-titanium material allows for the delivery of lower loading forces while maintaining consistent unloading forces for increased patient comfort. Tanzo’s copper nickel-titanium material also allows for increased resistance to permanent deformation, allowing the wires to work in the mouth for longer intervals, which may result in fewer wire changes and lower wire inventories. Each Tanzo wire then goes through a final, thorough polishing process that results in an extremely smooth finish. The process is completed with the wires being laser marked with the AO logo to help provide a clear view of the midline. The wire is then packaged in sterilizable packaging to enhance safety, eliminate cross contamination, and add to the clean clinical environment of the orthodontic office. Individual pouches or bulk packaging are available depending on customer needs. Tanzo Premium Heat Activated Arch Wire is available in both Mid and Low Force levels, and available arch forms include Form A medium and large*, Natural Arch Form I, III, and VLP** small, medium, and large arch forms. Learn more about Tanzo at www.american ortho.com/Tanzo OP * Compare Form A to Accu-Form®, a registered trademark of GAC **Compare VLP to the Damon® arch form, a registered trademark of Ormco This information was provided by American Orthodontics.
Volume 6 Number 5
ONE SYSTEM. MULTIPLE APPLICATIONS. ZERO COMPROMISE. Discover the Empower Dual Activation System – a system designed to enhance your treatment philosophy with the time-saving benefits and
ease of self ligation plus the best of both interactive and passive systems. • Interactive anterior brackets
• Passive posterior brackets • Extensive prescription and wire options • A system you can truly make your own
NOW AVAILABLE WITH EMPOWER CLEAR!
What’s your Dual Activation? Visit americanortho.com/DualActivation to get started. ©2015 AMERICAN ORTHODONTICS CORPORATION | +1 920 457 5051 | AMERICANORTHO.COM
AOA, customizing the MARA™ since 1994
OA released the first generation of the MARA™ back in 1994 and has since worked with many doctors, introducing multiple enhancements, all designed to make sure we’re delivering one of the best Class II appliances for doctors and patients. Today’s version, the MARA 3.0, offers a sleek, forged lower arm designed to withstand natural mastication forces and provide a smaller profile than that of previous designs. AOA currently produces over 10,000 MARAs annually! “As the orthodontist becomes comfortable in the performance of the appliance, the simplicity of design becomes more appreciated since there is little to master,” says Jerry Engelbart, AOA’s lead MARA technician since the MARA first made its debut. The basic MARA consists of: • Four crowns or bands • Upper and lower archwire tubes • Lower arms soldered to the crowns • Upper elbow tubes soldered to the crowns • Upper elbows shimmed to support the desired advancement. Ball end hooks for ligation • Lower lingual archwire soldered to lower crowns/bands The MARA can also easily be combined with a variety of different expansion screws to incorporate both transverse correction and mandibular advancement into one simple design. Another benefit of this appliance is the option for placement at various stages of patient treatment. It can be just as easily placed in a mixed dentition as it can in a permanent dentition due to its compact size and ease of delivery. Its ability to combine with upper and lower brackets, 5-5, can have an influence on reducing overall patient treatment time. To get started today or for more information, call our experienced Technical Support and Customer Care Team at 800-262-5221.
Evolution of the MARA
“As the orthodontist becomes comfortable in the performance of the appliance, the simplicity of design becomes more appreciated since there is little to master.” About AOA Since 1984, AOA has set the standard in providing the orthodontic profession with a full range of custom-crafted appliances. We have become a well-known industry leader founded on our creative technicians, family culture, and overall knowledge of the orthodontic market. With decades of industry experience, AOA continues to satisfy its customer base by striving to produce high-quality appliances while providing first-class customer service. From start to finish, AOA has an unlimited number of customized appliances. OP This information was provided by AOA.
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Volume 6 Number 5
A Simple & Aesthetic Alternative to Class II Correction “The MARA has been a simple, trustworthy, patient-friendly way to not only correct a Class II, but also frequently to improve the chin.” Dr. James Eckhart, Torrance, CA.
• Its compact design allows for bracketing upper and lower 5-5, potentially reducing treatment time. • It’s conveniently available as either a customized appliance or a 13 patient kit.
Submit your MARAs and all your cases to AOA using your scanner. Due to our commitment to quality and craftsmanship, our preferred method is Stereo Lithography (SLA), and is highly regarded as the premier method of rapid prototyping.
Send to us and experience the difference!
Learn more about the MARA at 800.262.5221 or visit us at aoalab.com. Orthodontic Laboratory
NEW PRODUCT ANNOUNCEMENT
3-Dimensional Intelligent Bonding
pecialty Appliances is proud to announce the exclusive North American agreement with Arcad Digital Solutions. Arcad is the developer of Arcad VSi (Virtual Setup Interface), an orthodontic computer-aided treatment software designed specifically for precision straight wire bracket placement. Arcad’s user-friendly interface allows orthodontists to approve or modify a digitally proposed end-of-treatment result in a matter of only minutes. Specialty Appliances combines this sophisticated case planning technology with their decades of indirect bonding leadership and expertise. This new revolution of indirect bonding is called 3DiB™ (3-Dimensional Intelligent Bonding), exclusively from Specialty Appliances. The goal of 3DiB is to optimize straight wire appliances with perfect bracket placement. Intelligent bonding technology delivers faster treatment while reducing inefficient wire bends and bracket repositioning.
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Ultimate CAD Precision First, Specialty uses the intelligent software to segment each tooth and carefully identify the long axis, key anatomical landmarks and the doctor’s prescribed bracket heights. Next, they use the prescribed treatment plan to guide the virtual ideal posttreatment finish. Bracket position is optimized by using the identified tooth landmarks and the prescribed fully engaged finishing archwire. The ideal finish and bracket positions are checked for quality and uploaded to the doctor’s cloud portal.
Absolute Control With 3DiB, orthodontists can maintain their desired level of control through an intuitive web-based approver software. In just a few short minutes, doctors can fine-tune teeth and/or the bracket positions while visualizing the real-time counter effects on both pre and posttreatment models. The simplified
approver approach gives orthodontists full control without consuming valuable time.
Reduced Chairtime Once approved by the orthodontist, Specialty Appliances prints the malocclusion model. Using a proprietary system, brackets are placed to capture the exact virtual position, and production of the indirect delivery tray is completed. The doctor’s chairside bonding time is greatly reduced if not eliminated. Clinical staff members can efficiently deliver their doctor’s high tech bracket placement. 3DiB minimizes doctor and patient chairtime, while maximizing quality and office production. OP This information was provided by Specialty Appliances.
Volume 6 Number 5
Planmeca Romexis® software Open architecture, endless possibilities
echnology in dentistry is evolving. With an ever-growing platform and so many options in the industry, it’s time for a software platform that features all-in-one capabilities and open architecture, allowing you to choose the best technology for your practice. Built on an open architecture software platform, Planmeca Romexis offers best-inclass integration, providing users with the freedom to use third-party products for a customizable workflow built to fit the needs of any office. TWAIN protocol and DICOM compliance, as well as full support for Windows and Mac OS operating systems, make Planmeca Romexis an ideal fit for any practice.
Your all-in-one software solution Planmeca Romexis is the first software in the world to combine 2D and 3D imaging with complete CAD/CAM workflow and even extended connectivity with Planmeca dental units. Planmeca Romexis software offers these capabilities and more — IO scanning and restorative design, ceph analysis and tracing, orthodontic tasks with Ortho Studio, and Planmeca ProFace true 3D facial photos for case presentations that are more detailed than ever.
plans. Easy mouse-driven navigation means no complicated keyboard combinations to remember: Your necessary functions are in front of you, clearly marked, and ready to use.
Secure image sharing from anywhere Share files from wherever you are with the innovative Planmeca Romexis Cloud, a secure transfer service for Planmeca Romexis users and their partners. The service is easy to use and seamlessly integrated into Planmeca Romexis, saving you even more time and cost by eliminating DVDs and other physical processes.
Efficient clinic management
With Planmeca Romexis, versatile applications are easy to use with intuitive features that make it simple to view, edit, and enhance images, as well as create detailed treatment
For larger practices with multiple operatories, Planmeca Romexis also offers its Clinic Management module for an innovative link between software and equipment,
Planmeca 3DMax 3 x 3D = CBCT + ProFace + impression scan Volume 6 Number 5
making it possible to remotely monitor your unit functions, access user-specific presets from any unit, proactively manage unit maintenance for decreased downtime, and more.
A future-proof investment Planmeca Romexis software offers a complete workflow engineered with the flexibility to adapt to you and your patients’ evolving needs. Planmeca Romexis leads the world in image capture and diagnostics for superior treatment planning with the ability to upgrade and make your investment future-proof. Open file architecture and true modularity means you can add technology as you need it, ensuring your practice won’t be left behind as dental technology continues to advance. OP This information was provided by Planmeca.
Planmeca 3Ds large view image Orthodontic practice 71
OWN THE FUTURE™
The ProMax® 3D Family Ultra-Low Dose protocol achieves an average of
77% reduction in radiation dose WITHOUT COMPROMISING IMAGE QUALITY*
For a free in-office consultation, please call
or visit us on the web at www.planmecausa.com
*When compared with standard imaging protocols, according to “Dosimetry of Orthodontic Diagnostic FOVs Using Low Dose CBCT Protocol” by JB Ludlow and J Koivisto. For a copy of this study, please contact Planmeca USA.
Create your virtual patient - with just one software
Planmeca ProMax 3D Optional ProFace®
OWN THE FUTURE™
Practice Planmeca Planmeca Romexis® software oﬀers a digital workﬂow with complete integration for modern dentistry. From intraoral scanning to 3D imaging, the most sophisticated tools are just a few mouse clicks away. · All scanned and designed data for prosthetic restorations is immediately available and can be mapped with the patient’s CBCT image ®
· Share data easily with partners through Planmeca Romexis Cloud image transfer service
For a free in-oﬃce consultation, please call 1-855-245-2908 or visit us on the web at www.planmecausa.com
PLANMECA USA INC. 100 North Gary Avenue, Suite A, Roselle, IL 60172, P.630.529.2300
NO impression material
NO focusing on the screen NO limitations
ALL YOU NEED TO ACQUIRE 3D DIGITAL MODELS, AND NOTHING YOU DON’T WELCOME TO THE NEW REALITY In the new reality, the CS 3500 intraoral scanner and CS Model software create highly accurate, true color 2D images and 3D digital models of teeth without conventional impressions. • • • • •
Obtain digital models in a fraction of the time of conventional models Virtually automatic bite registration Slim scanner head with two tip sizes for patient comfort Unique light guidance system for more patient-focused scanning Send digital files directly to lab for appliance fabrication
Enter the new reality at carestreamdental.com/cs3500ortho or call 800.944.6365 © Carestream Health, Inc. 2015. 12097 OR CS 3500 AD 0215