clinical articles • management advice • practice profiles • technology reviews
PROMOTING EXCELLENCE IN ORTHODONTICS Management of TMD during orthodontic treatment: disc displacements Dr. Harold F. Menchel
Clinical tips to increase consistency using a “StraightWire Appliance” Drs. Tom Pitts and Duncan Brown
Stop Following the Crowd and Start Following the Leaders
November/December 2015 – Vol 6 No 6
BioDigital Orthodontics part 18 Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans
Corporate profile Ormco™ Corporation
Practice profile Dr. Michael Bicknell
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Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi
EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon
PUBLISHER | Lisa Moler Email: email@example.com MANAGING EDITOR | Mali Schantz-Feld Email: firstname.lastname@example.org Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: email@example.com EDITORIAL ASSISTANT | Mandi Gross Email: firstname.lastname@example.org NATIONAL ACCOUNT MANAGER | Adrienne Good Email: email@example.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: firstname.lastname@example.org CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: email@example.com
When it relates to kids, the medium is the message
here’s been a lot of talk about the power of social media and the role it can play in building your practice. As a true believer in social media, I can tell you that this is 100% true. Without a doubt, the efforts my staff and I put into social media have been rewarded many times over in the building of our practice in the Greater Toronto Area. In fact, social media comprises a significant portion of our marketing. But most importantly, even if there was no financial reward for these efforts, they would still be one of the most essential tools at our disposal. Let me explain. Everyone who’s drawn to this profession has a passion for Dr. Ajeet Ghumman working with children. The experience is the reward. We’re not just helping children look better in their selfies and senior portraits. We’re changing the way they think of themselves and how they embrace the adult world, a task that’s hard enough without feeling insecure about your smile. The thing that’s so important, and so often overlooked about social media is that it’s not just a vehicle for communicating with today’s plugged-in preteens and teens. It’s the actual language they speak. Marshall McLuhan coined the phrase “the medium is the message” back in the 1960s. Four decades before the idea of social media was even invented, he understood that the actual form of the communication carried as much impact as the communication itself. He believed that “content” was nothing more than “a juicy piece of meat carried by the burglar to distract the watchdog of the mind.” The Dental Works 4 Kids practice has thousands of posts, tweets, and images out there. While it’s wonderful to recognize patients that get their braces off or celebrate the latest big win by our hometown Toronto Blue Jays, in a lot of ways, the medium is just as important. Every kid that reaches a certain age becomes a bit of a skeptic. And this is a good thing! It means they’re becoming independent, and they’re preparing for a world that doesn’t always have their best interests in mind. The flip side is that it can make it difficult for an adult to reach them, even when he/she has the teen’s best interest in mind. This is precisely why social media is so invaluable. When you’re on the social channels, you’re not just meeting kids on their own turf — you’re doing so in their own language. This has the wonderful effect of allowing you and your message to slip past their natural skepticism filter, allowing them to weigh the significance of what you’re saying without having to win them over. I’m sure you don’t need to be told the value of this. Social media is a great way to build a practice, but it’s an even better way to build a rapport, and that’s the real value. Dr. Ajeet Ghumman
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Volume 6 Number 6
Ajeet Ghumman, DDS, CERT. ORTHO., FRCD(C), completed his BSc in Biological Sciences at the University of Calgary, 4 years of dental school at Howard University in Washington, DC, and 1 year of General Practice Residency at Hartford Hospital in Connecticut. He then completed an additional 3 years of training at the University of Medicine and Dentistry of New Jersey where he earned his Specialty Certificate in Orthodontics. Dr. Ghumman is a Fellow of the Royal College of Dentists of Canada and is an active member of the Ontario Association of Orthodontics, Canadian Association of Orthodontists, American Association of Orthodontists, and American Academy of Dental Sleep Medicine. He is also certified by the Academy of Orofacial Myofunctional Therapy.
Orthodontic practice 1
November/December 2015 - Volume 6 Number 6
MESSAGE FROM THE PUBLISHER
When inspiration meets reality Dear Readers: With this issue of Orthodontic Practice US, I am delighted to introduce a new series of articles that have the potential to change the course of your life. I know this to be true because over the years, the author of these articles, Tony Robbins, has impacted me both professionally and personally. This story begins when I was in my 20s. At that time, life’s challenges were daunting, and the road ahead seemed not only to be winding, but filled with potholes and roadblocks. Also, I was searching for a career path that would also be my life’s passion. It was then I discovered peak performance strategist and bestselling author Tony Robbins. Listening to his motivational tapes in my car on the way to and from work was often the only positive voice that I would hear all day. “Human beings have the awesome ability to take any experience of their lives and create a meaning that disempowers them or one that can literally save their lives.” His insights catapulted me to achievement of my professional aspirations, as well as personal fulfillment. I remember wishing that I could attend one of Tony’s seminars in person. Fast-forward 25 years later. As a successful publisher and entrepreneur, I had the opportunity to attend CEREC® 30, an educational event sponsored by one of our long-term clients, Sirona Dental, Inc. I was beyond excited that Tony was going to be a featured speaker at this event! It was a surreal moment when I had the opportunity to stand up in front of upwards of 6,000 attendees and ask a question of my mentor, Tony Robbins, peak performance strategist and bestselling author, who wasn’t even aware of the impression he had made on me over the years. It was with Lisa Moler, publisher and CEO of MedMark, LLC, at CEREC 30 even more incredible when he was gracious enough to schedule a personal interview with MedMark for our magazines. This brings me to good news for our readers. I am so proud and honored that Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, will be authoring a Financial Focus column for our publications in 2016. This column will discuss what to look for in a 401k plan, show how fees can erode 401k savings, and will also discuss the fiduciary responsibility of plan sponsors and the serious ramifications of non-compliance with The Employee Retirement Income Security Act of 1974 (ERISA). This federal law sets minimum standards for most voluntarily established pension and health plans in private industry to — Tony Robbins provide protection for individuals in these plans. Sadly, many plan sponsors do not live up to their duties, and as a result, the savings of all the participants in their plan may be subjected to needless and excessive fees. Tony said, “The abuse is mind-boggling.” At MedMark, we pride ourselves on educating the dental community on new techniques, the latest products, and creative practice management methods. Now, Tony Robbins and Tom Zgainer will share their expertise to protect and help grow your retirement savings. At our interview, Tony Robbins and I discussed living in the moment and letting go of the ghosts of the past. He once said, “In life, you need either inspiration or desperation.” It was in times of desperation that I found inspiration in his powerful insights. Now, I am honored that it’s my turn to be a catalyst, through this new Financial Focus column, for our readers to have more control over their financial success in retirement. All the best,
“In life, you need either inspiration or desperation.”
Tom Zgainer, founder and CEO of America’s Best 401k, with Lisa Moler at CEREC 30 2 Orthodontic practice
Volume 6 Number 6
Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans MedMark is proud to launch a new column that will help dental professionals make important decisions about retirement plans
isa Moler, publisher and CEO of Robbins’ knowledge has been widely recognized. He was named to the Worth Power MedMark, LLC, recently experienced one of the pinnacle events of her career at 100 as No. 49 on the list of the world’s most the CEREC® 30 conference in Las Vegas. powerful players in global finance. Working with America’s Best 401k, She had the privilege of holding an in-person business owners can alleviate their fiduciary meeting with peak performance strategist responsibility while providing their employees and bestselling author, Tony Robbins and Tom with a plan that does not sacrifice perforZgainer, founder and CEO of America’s Best mance for lower fees. The company has 401k. These two visionaries discussed the worked with numerous dental practice changing landscape of employer-sponsored owners to help them drastically reduce the retirementYou plans andknow the information can’t where youthat are going business owners need to adhere to the investment fees associated with their plans, if you don’t know where you are. Department of Labor regulations. helping clients save an average of 57%. This topic was discussed at the event At the meeting with Robbins and Zgainer, is also highlighted in Tony Robbins’ Lisayour Moler discussed Stepand 1. Send us your fee disclosure (also called abest408b2) from existing provider. Ifthe you changing don’t where landto locate it, call us and we will direct you.the Keep in mind7that scape Department of 401k Labor space, regularlywhat requires plan pracselling book, MONEY: Master Game: of the dental sponsors to benchmark their plan so this will fulfill your fiduciary obligation. Simple Steps to Financial Freedom. After titioners across the country need to know 401k’s unique, lowin your order toon meet DOL member regulations, and the destination Best is a financially secure retirement, is 401k course? A of our team Stepseeing 2. If theAmerica’s will walk through your complimentary comparison so you can see the impact that costyou approach firsthand, Tony“side-by-side” Robbins feepair’s mission to save America’s retirement. higher fees will have on your account balance over time. became a partner in the business, and the “If you offer your employees a run-ofSteppair 3. Take the to switch America’s Best 401k. There is noplan, conversion fee a and our team the-mill 401k there’s good chance set action out onand a make mission helptoAmericans makes the conversion process painless. The quicker you make the change, the quicker your savings begin. across the country rescue their retirement. you are vulnerable to Department of Labor
YOUR NEXT STEPS
Volume 6 Number 6
oversight, which has become more aggressive in recent months,” Zgainer said. Robbins adds, “Small business owners often have no idea that they are the fiduciaries for their plan. That means that they have to benchmark that plan annually or they have to pay penalties, with average penalties that can reach $600,000. We can help these people meet their responsibilities in this area.” In as little as 60 seconds, dentists and other business owners can access the company’s free Fee Checker (americas best401k.com/medmark), which can help them meet their fiduciary obligation and ensure their retirement plans are for the sole benefit of their employees. When a dentist sponsors a retirement plan, he/she takes on new responsibilities in addition to being a doctor and a business owner. They also need to meet their fiduciary obligation and fulfill their trustee responsibility. Robbins and Zgainer’s advice can lead to employees keeping more of what they’ve saved, and enjoying a longer, more-secure retirement. America’s Best 401k has assembled a team of world-class retirement plan experts across design, administration, recordkeeping, and actuarial disciplines to offer an alternative to expensive, complex plans. Working with America’s Best, business owners can alleviate their fiduciary responsibility while providing their employees with a plan that doesn’t sacrifice performance for lower fees. For information, contact America’s Best 401k at 855-905-4015 or info@americas best401k.com. Readers of Orthodontic Practice US will be able to share more of this exciting and informative conversation with Robbins and Zgainer through a series of interview articles that will appear in upcoming issues. OP Orthodontic practice 3
TABLE OF CONTENTS
Financial focus Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans................................................3
Case study Integrating innovative technology to meet patient deadlines
Practice profile Michael Bicknell, DDS, MS
His social, scientific, and artistic life
Dr. Gary W. Chu said “I do” to speeding up a patient’s orthodontic treatment for her wedding day ....................................................... 20
Watching … wondering … observing Dr. Ron Roncone discusses using Roncone PDS to have fewer appointments and shorter treatment time.................................24
Orthodontic concepts BioDigital Orthodontics Management of skeletal deformities with orthognathic surgery (OraScan) (3): part 18 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi discuss the Type three approach for planning and managing surgical patients with suresmile® when only 3D intraoral scans are available..........................30
Corporate profile Ormco Corporation
Differentiate your practice, educate your patients … and grow!
ON THE COVER Cover photo courtesy of Drs. Tom Pitts and Duncan Brown. Article begins on page 44.
4 Orthodontic practice
Volume 6 Number 6
Stop Following the Crowd and Start Following the Leaders
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Friday, January 29, 2016
• Evening Poolside Welcome Reception
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This year’s list of world-class keynote speakers include John DiJulius, Mark Jeffries and Jim Abbott.
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TABLE OF CONTENTS
Propelling orthodontics The host in the machine Dr. Jonathan Nicozisis waxes philosophical on Propel Orthodontics’ Excellerator technology....................38
Continuing education Clinical tips to increase consistency using a “Straight-Wire Appliance”
Drs. Tom Pitts and Duncan Brown discuss an efficient, gentle approach to orthodontic treatment
Management of TMD during orthodontic treatment: disc displacements Dr. Harold F. Menchel discusses how to proceed when a patient develops TMD symptoms during treatment .......................................................40
Practice management Laboratory link 7 ways online patient communication tools can improve your practice efficiency
Scott Eklund discusses the importance of having the right tools and systems for patient communication............................... 50
Controlled molar distalization
James Bonham discusses a durable, comfortable, and predictable appliance........................................ 52
An unforgettable extravaganza of unsurpassed hands-on learning and first-class entertainment...................58
American Orthodontics Digital Marketing Resources
Soft tissue 10,600 nm CO2 laser orthodontic procedures
Martin Kaplan, DMD, and Peter Vitruk, PhD, explore soft tissue CO2 laser uses in orthodontics........................59
G&H Orthodontics celebrates milestone and rebranding .......................................................56
6 Orthodontic practice
Volume 6 Number 6
Control. Confidence. Damon Clear2. ™
I have always loved Damon
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Watch Dr. Stuart Frost’s new webinar and discover the benefits of Damon Clear2 and how to: Deliver amazing results using standard PSL mechanics. Treatment plan, reposition, finish, and debond with ease. Provide great aesthetics during treatment. . .beautiful results after. Exceed patient expectations and grow your practice.
Visit ormco.com/education to watch Dr. Frost’s Damon Clear2 webinar today!
© 2015 Ormco Corporation
FEBRUARY 10â€“13 | SOUTHERN CALIFORNIA
Join world-renowned experts, peers, and friends in stepping out of the office to experience an orthodontic conference like none before, The Face 2 Face Forum. This must-attend event features four incredible days of personalized education paths, one-on-one networking opportunities, and a spectrum of clinical and practice management sessions designed for your entire orthodontic team. The program includes distinct Doctor and Staff general sessions and over 40 engaging workshops to choose from. Discover new insights that will take your practice to the next level! C E L E B R A T I N G
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DISCOVER. GROW. CONNECT. Dr. Chris Chang Taiwan
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Dr. Stuart Frost USA
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Michael Bicknell, DDS, MS His social, scientific, and artistic life
t’s a rather simple formula for Dr. Mike Bicknell of Advanced Orthodontic Specialists in Elmhurst, Illinois — work hard, treat people with kindness and honesty, and you’ll build and maintain a successful orthodontic practice. Serving a tight-knit suburb of Chicago, Dr. Bicknell runs an esteemed practice founded on bringing the highest quality of care and service to his patients. In this issue, we’re getting to know Dr. Bicknell — from what makes his practice stand out to what profession he would pursue if he wasn’t an orthodontist.
What can you tell us about your background, and why you decided to become an orthodontist? I grew up in a small suburb of Chicago where my mom was a nurse and my dad was an accountant. My parents stressed the value of education to my siblings and me and, subsequently, the importance of hard work. I went to an all-boys Catholic high school, and for our senior year project, we were tasked with giving a presentation on what profession we’d like to pursue. I had a great relationship with my dentist growing up, so I did a little research Dr. Bicknell’s practice is located in a tight-knit suburb of Chicago and gave my presentation on becoming an oral surgeon. I guess you When I opened my practice, I was in tune quickly learned that could say this is where with the fact that my practice was essentially communication and my interest in the profesthe customer expea start-up business. As I evaluated what prodsion was born. ucts and technologies would best fit into my rience are critical to I then went on to being successful in practice, I knew self-ligating brackets would study biochemistry at this occupation. be huge. It was the way to go. I talked to a Michael Bicknell, DDS, MS the University of Illinois at Today in my pracfew manufacturers and decided to go with Chicago. I continued my education at the tice, I have exceptional relationships not only the Damon™ System by Ormco™. To this day, university, pursuing dentistry, and received with patients, but also with their families. I that’s the passive self-ligating bracket system I my Doctorate of Dental Surgery. At this enjoy hearing about and celebrating their use in my practice. I’m impressed not only with point, I was still interested in dentistry but personal and professional achievements. the results it delivers, but also with the focus decided not to pursue oral surgery. I knew and attention Ormco places on bringing innomy future was in orthodontics. I love how the How long have you been practicing, vative, forward-thinking products to the table. world of orthodontics is built upon personal and what appliances do you use? My practice is approximately 60% adolespatient relationships. This meshed well with I have been practicing orthodontics cents and 40% adults. The adult patients love my personality. Also, I worked a variety of for more than 10 years, and this year my Damon Clear™; it offers them an esthetic different service jobs throughout my underoption that doesn’t compromise patient practice actually celebrated its 10-year graduate studies and residency, where I anniversary. comfort, treatment time, or final results. 10 Orthodontic practice
Volume 6 Number 6
Big innovations that start with a smaller footprint The new iTero® Element™ intraoral scanner is engineered to deliver everything doctors look for in digital impression technology in a compact footprint design with even bigger capabilities. The iTero Element is designed with speed in mind. It’s portable, powerful, and intuitive, demonstrating our continued investment in clinical precision and patient satisfaction. Now is the perfect time to add intraoral scanning to your practice.
Visit iTero.com to schedule a demo or to learn more.
© 2015 Align Technology, Inc. All rights reserved.
PRACTICE PROFILE Who has inspired you? First and foremost, my parents have been incredible influences in my life. My core — what I believe, and how I treat people — was developed based on how they raised me. My inspiration also comes from my junior high school science teacher who also happened to be my wrestling coach. He had a lot of character and passion for what he did, and carried himself with confidence and wasn’t afraid to be his own person. Professionally, to this day, I look up to Dr. Kevin Kopp, a prosthodontist in my area, who centers his whole practice on patients, and I love that. He has a great practice model that is very admirable. As far as orthodontists, there are countless professionals who have inspired me. To name a few, Dr. David Sarver is extremely insightful, Dr. Dwight Damon operates with unmatched passion, and Dr. Stuart Frost creates exceptional smiles with signature smile arcs.
Dr. Bicknell notes that his office staff is like an “extension of his family”
What is the most satisfying aspect of your practice, and what makes it unique? The most satisfying thing about my practice and profession is that it is a reflection of every aspect of my personality, which makes my job so enjoyable — it’s social, scientific, and artistic. It’s also comforting and satisfying knowing that we are taking care of people and helping make their lives better. At my practice, we place a significant emphasis on engaging with the surrounding community and, more importantly, giving back to it. We’ve hosted a holiday season toy drive for the past several years, and have donated more than $150,000 in treatment to
Dr. Bicknell and his staff take pride in improving the lives of patients as they celebrate his 10-year practice anniversary 12 Orthodontic practice
Dr. Bicknell uses the Damon™ System by Ormco in his practice Volume 6 Number 6
Brackets. On Target
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5 things Dr. Bicknell can’t live without
For a successful practice, work hard, and treat people with kindness and honesty, states Dr. Bicknell
local schools. We also supply mouth guards for youth football programs in the area. It’s truly a win-win.
Professionally, what are you most proud of? This is by all means a joke, but I’m really proud of the fact that I give away T-shirts with our practice logo on them, and patients actually wear them! I like to think that we’ve officially “made it” now that we have a T-shirt with our name on it. My staff and I joke about this all the time because it’s such a trivial part of our practice, but I admittedly spent quite a bit of time designing the shirt. In all seriousness though, I’m proud of the fact that I consider my staff an extension of my family, and that we all share similar values: to be hardworking and kind. Being able to work in such a great, close community is also something I’m proud of and truly grateful for.
What is the future of orthodontics? The future of orthodontics is interesting because I think there are some negative perceptions lingering around the industry right now and where it is headed. That said, I feel the opposite. I’m positive about what the future holds for orthodontics. While it’s hard to predict what the future will look like for the industry, I do know that as technology 14 Orthodontic practice
1. My wife, Katherine, and my three kids — Morgan, Macy, and Max. 2. Salt — I love cooking with my wife, and this one ingredient makes everything better. 3. Water — I love living by Lake Michigan; I can go to the beach or go boating whenever. 4. Steak! 5. A project — I like to always be working on something and learning new things.
continues to evolve, so will orthodontic products and solutions. Think of it this way; 30 years ago, do you think anybody believed that one day orthodontic manufacturers would be selling digital intraoral scanners that create digital impressions in just minutes? Probably not. Regardless of what the future may or may not hold, I believe that if orthodontists continue to lead patient-centric practices, we will be successful. Techniques and technologies may change, but the fundamentals of how you treat patients and the quality of customer service you provide should remain constant at the highest level possible.
What advice would you give to budding orthodontists? More than anything, I like to encourage orthodontic residents and those interested in orthodontics to provide their customers with the highest quality of care possible. I believe that if you are kind, honest, and work really hard, you will be successful. What’s great about this sentiment is that it applies to just about any profession. Meet your challenges head-on too — don’t shy away from them. With hard work and dedication, you can be the best. Additionally, it’s imperative that you never stop learning — orthodontics is a
lifelong learning process. Even when you think you’ve perfected a specific technique or mastered your practice marketing, know that there is always something more to learn. Embrace this reality because at the end of the day, it will make you a much better practitioner.
What are your hobbies, and what do you do in your spare time? I’m very family oriented, so anything that I can do with my wife and three kids is ideal. My wife and I have been into skiing quite a bit lately and actually introduced it to our kids too. We are also big fans of taking family boat trips. We live right near Lake Michigan, so on the weekends, if the weather is right, we’ll take the kids out on the boat and explore different harboring towns.
What would you have been if you had not become an orthodontist? I like this question! I would probably be a fighter pilot or astronaut, but the kind of astronaut that actually gets to go to space. A blockbuster actor would be pretty cool too. I say all these things with a sense of humor because I truly would not want to be doing anything other than what I’m doing right now. I absolutely love my job and wouldn’t trade it for any other profession. OP Volume 6 Number 6
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Ormco™ Corporation Differentiate your practice, educate your patients … and grow!
“Ormco” is an acronym for Orthodontic Research and Manufacturing Company. In this photograph, an Ormco technician tack welds a lingual cleat to a band during the manufacturing process
rom its early beginnings to today, Ormco™ Corporation has been focused on arming orthodontists with the tools and education needed to build and maintain a thriving practice and exceed clinical and practice management goals. With increased interest in orthodontic treatment from prospective patients across the globe, Ormco stands firm in its commitment to support the orthodontic specialist. Whether your practice is focused on Damon™ System treatment, implementing a comprehensive digital workflow with Insignia™ Advanced Smile Design™, utilizing industry-standard twin bracket systems, or leveraging Ormco’s award-winning practice-building resources, Ormco has proven to be a global market leader within the orthodontic community.
Dedication to innovation There are very few orthodontic manufacturers that can tout more than 50 years of 16 Orthodontic practice
diverse product offerings and industry breakthroughs. Ormco has a rich history in product innovation and has been at the forefront of significant industry “firsts”— which include direct bonding, rhomboid and computeraided design (CAD) brackets, Copper Ni-Ti® and TMA™ archwires, the Titanium Orthos™ appliance system, and Damon™ Clear, the first 100% clear, passive self-ligating bracket. The company is intently focused on accelerating the industry’s access to advanced solutions via significant R&D investments. Under the leadership of Patrik Eriksson, Ormco president, the company continues to take great pride in collaborating with progressive doctors, engineers, materials scientists, and universities to develop products and services that exceed orthodontists’ expectations across a wide spectrum of practice needs — from traditional to cutting-edge. To date, the company manufacturers more than 21,000 different products including more than
20 appliances from twin to self-ligating and aesthetic offerings. It prides itself on offering a myriad of products to support the various treatment philosophies and mechanics of orthodontists around the world. Initially introduced by Dr. Dwight Damon and Ormco Corporation as Damon™ SL, the Damon System celebrates nearly 20 years of proven technology and design enhancements to meet doctor and patient needs. Ormco continues to invest in extensive research and development to fuel its innovation pipeline for the Damon System, with more than 50 patents and 25 pending patent applications. With 110 globally filed patents in digital orthodontics, Ormco has elevated its focus on digital treatment solutions to the next level in recent years. Developed with the orthodontist in mind, the company continues to invest in and pursue high-tech solutions that will make tomorrow’s dreams today’s reality for the practice. Volume 6 Number 6
Global education Ormco’s unprecedented devotion to education is a testament to its support of orthodontists and their patients. Each year more than 10,000 orthodontic professionals participate in Ormco’s courses throughout the Americas, Europe, the Middle East, China, South Africa, Australasia, and more. Offering regional seminars, interactive in-office courses, online webinars, and multiday global conferences with the world’s most prominent clinicians, Ormco’s CE program sets the standard for comprehensive orthodontic education. The Forum, a staple of Ormco’s continuing education lineup, will be hosted next year at the oceanfront Terranea Resort in Rancho Palos Verdes, California, February 10-13, 2016. Celebrating its 15th anniversary, The Forum 2016 will be built around Ormco’s ongoing commitment to delivering engaging “Face 2 Face” experiences where industry experts, peers, and friends can Doctors and staff members participating in Ormco CE Events around the world
Offering regional seminars, interactive in-office courses, online webinars and multi-day global conferences, Ormco’s CE program sets the standard for comprehensive orthodontic education.
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gather to create meaningful relationships while discovering new treatment modalities, progressive technologies, and practice differentiation strategies. Drs. Chris Chang (Taiwan), Ramon Perera (Spain), and Stuart Frost (United States) are among the notable speakers scheduled to present their philosophies and exemplary clinical cases on The Forum’s main stage. Throughout the 4-day conference, participants will have the
opportunity to attend a variety of lectures and workshops addressing beginner to advanced content on Damon passive selfligation mechanics, finishing, open bites, Class II and Class III treatment, digital smile design, and more. To learn more about Ormco’s broad range of continuing education courses, designed for orthodontists and staff members of all skill levels, visit www.ormco.com/education.
Orthodontic practice 17
Ormco’s broad range of products include Damon Q and Titanium Orthos brackets, AdvanSync™ Class II appliances, a collection of archwires, OrthoSolo and a variety of adhesives
Expansive product portfolio
Setting the standard for customized appliances for more than 35 years, Ormco’s flagship product line, the Ormco’s AOA Lab has become one of Damon System, continues to lead the the world’s largest full-service orthodontic passive self-ligation industry. Comprised laboratories with more than 2,500 years ™ of Damon Q and Damon Clear passive of combined technical orthodontic experiself-ligating brackets, high-tech archwires ence. With the deepest and most versaand minimally invasive treatment protocols, tile portfolio of available appliances in the the light-force system provides exceptional lab market, AOA fabricates customized benefits for both doctor and patient. More appliances, including Class II correctors, than 4.5 million patients have been treated aligners, splints, retainers, and more. For with the Damon System and thousands of the growing demand of digital lab solutions, orthodontists around the world rely on the the AOA team has invested in stereolithogsolution to deliver remarkable results. raphy (SLA) — a type of model printing Recognized for exceptional quality, highly regarded as the premier method for versatility, and value, the industry is also rapid prototyping. For improved practice rediscovering the dependability of Ormco’s efficiency, accuracy and high-end resolutwin brackets. With a dozen different twin tion, the print material helps produce the appliances to choose from, such as Tita® highest quality digital-dental models. ™ nium Orthos, Mini Diamond and Mini-Twin , Underscoring Ormco’s commitment to Ormco offers a comprehensive selection of practices, the Ormco Lifetime brackets. These traditional appliRewards (OLR) Program allows ances have served as the solid members to earn points on foundation of Ormco since the purchases that can be redeemed company’s inception. any time. Participating orthodonTaking note of orthodontists’ tists earn points on every dollar increased emphasis on digital spent on Ormco and AOA’s selecworkflow and smile customization of orthodontic appliances, and tion, Ormco’s product portfolio can then redeem accumulated features state-of-the-art digital points for Ormco’s valued auxiliary technologies and personalization products and services, including techniques. The award–winning instruments, Copper Ni-Ti and Insignia platform allows orthoTMA wires, Ortho Solo™, various dontists to combine their treatment Insignia™ Advanced Smile Design™ allows orthodontists to combine their treatment preferences with the precision of computer-aided smile design supplies, and CE course tuition. preferences with the precision of 18 Orthodontic practice
computer-aided smile design. Its advanced 3D technology helps better visualize and treatment plan for more ideal finishes. Offering unprecedented levels of interactive visualization, patient-specific brackets, and custom wires, Insignia helps make difficult cases more manageable and routine cases exceptional. Later this year, Ormco will introduce a variety of Insignia product improvements, such as new molar tube options and re-engineered 3D printed placement guides, to deliver increased clinical efficiency and personalization. Further enhancing the digital treatment workflow, Lythos™ — Ormco’s state-of-theart digital intraoral scanner — can seamlessly integrate into practices. Lythos removes the inherent challenges associated with traditional impressions and works with Insignia and AOA Lab to help increase efficiencies for greater practice profitability.
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Over the past several years, the orthodontic industry has witnessed a significant increase in the demand for aesthetic, yet effective, treatment choices. Extending beyond pre-teen and teen patient demographics, the numbers indicate that adults undergoing treatment account for 22% of all orthodontic cases — that’s more than one in every five patients. With vast potential to treat adults, doctors can increase their practice revenue by promoting aesthetic appliances that appeal to adult consumers. Ormco supports the orthodontists’ ability to cater to the aesthetically minded patient by offering a variety of discreet solutions. With a completely clear body and door that is resistant to staining, Damon Clear and Damon Clear2 provide orthodontists with the control and performance needed to treat a wide range of cases with exceptional results. The patented laser-etched pad and innovative SpinTek™ slide ensure optimal bond strength and quick and comfortable wire changes. Damon Clear is also available with Insignia, providing patients with a customized, efficient, and discrete treatment experience. An alternative to braces, Ormco’s Insignia™ Clearguide™ Express aligner option combines the technology of Ormco’s Insignia Advanced Smile Design software with AOA custom lab services. For orthodontists seeking an aesthetic twin appliance, Inspire ICE™ is the bracket of choice that has exceeded patient expectations. Unlike ceramic brackets that are opaque and colored to mimic a particular tooth shade, Inspire ICE brackets are crystal clear and virtually invisible regardless of the tooth color. With a low profile, yet ample tie-wing undercuts, Inspire ICE is easy to work with and provides a smooth surface and rounded facial contours to enhance patient comfort. To assist orthodontists in promoting their aesthetic offerings, Ormco’s online Doctor Locators are designed to drive consumers of all ages to doctors treating with Damon
There has been a 267% increase in Damon Doctor Locator searches, over a five year period Volume 6 Number 6
Doctors can grow their practices by promoting aesthetic appliances such as Damon Clear, Insignia Clearguide Express aligners and Inspire ICE
Clear, Insignia, and Inspire ICE. Ormco’s award-winning Damon Doctor Locator (damonbraces.com), Insignia Doctor Locator (insigniasmile.com), and Inspire ICE Doctor Locator (iceclearbraces.com) have proven to be invaluable services for increasing patient starts. It’s estimated that the Damon Doctor Locator drives one to two starts each month to participating clinicians. Over a 5-year period, there has been a 267% increase in Damon Doctor Locator searches — which currently translates to $82 million in potential practice revenue each month for Damon doctors in North America. To support doctors’ local patient education and practice marketing efforts, Ormco’s online resource center — marketing.ormco.com — offers a wide range of practice marketing assets and staff training tools. The platform is home to a large library of patient imagery, consultation tools, lobby and website videos, press release templates, webpage assets, and more for doctors offering the Damon System, Insignia, Lythos, and Inspire ICE. This year, Ormco introduced My Smile Consult™, taking the patient education process to the next level for doctors leveraging the Damon System. Designed to increase patient starts, My Smile Consult is the industry’s latest online consultation tool
that enables doctors and staff to efficiently present the benefits of orthodontic treatment and the Damon System — including Damon Clear — before, during, and after the consultation. My Smile Consult engages patients with over 25 patient testimonial videos and numerous before/after photos and may be customized with your practice branding and patient photographs. To date, the consultation tool has received critical industry acclaim, honored as a winner in the 2015 Digital Heath Awards and 2015 WebAwards.
Looking ahead With patient demand on the rise, orthodontists can rely on Ormco and its proven track record to support their clinical and practice management objectives. Offering a breadth of progressive products and solutions, Ormco is devoted to helping doctors build successful and thriving practices. Looking ahead, Ormco’s future remains bright with plans to introduce nextgeneration innovations for its appliance systems and technology. To learn more information about Ormco’s product line, call 1-800-854-1741, or visit Ormco online at www.ormco.com. OP This information was provided by Ormco™.
Insignia and Damon System practice marketing resources including My Smile Consult on www.marketing.ormco.com Orthodontic practice 19
Aesthetic offerings and practice growth support
Integrating innovative technology to meet patient deadlines Dr. Gary W. Chu said “I do” to speeding up a patient’s orthodontic treatment for her wedding day
ive years ago, if a bride-to-be had come to my orthodontic practice requesting to start and complete her treatment prior to her wedding that was less than a year away, it was highly unlikely that neither I nor any other orthodontist could safely and effectively make that request a reality. In fact, over the years, orthodontists have consistently been challenged to meet patients’ deadlines because the field simply didn’t have the technology and innovation to do so without the use of drugs or invasive surgery. Today, however, with the advancements that are happening as a result of the emergence of accelerated orthodontics, I am able to give patients healthy, beautiful smiles just in time for their weddings, graduations, or other special deadlines. At my practice, Chu Crew Orthodontics in Racine, Wisconsin, we offer patients
AcceleDent®, an FDA-cleared, Class II medical device that speeds up treatment by as much as 50% and relieves the discomfort associated with wire adjustments. Therefore, when a soon-to-be bride walked into my practice in the fall of 2013, I was confident that we could help her achieve the smile she wanted in time for her big day, which was just 9 months away. She was one of my first AcceleDent patients, and I was extremely pleased with the results and thought it would be beneficial to share this case with my peers. The 24-year-old patient presented in September 2013 with Class II, Division I malocclusion which specifically included 12 mm of significant crowding in the lower arch, a buccal crossbite between tooth No. 5 and tooth No. 28, and a complaint of protruding canines. Her overbite was 80%
and overjet was 2 mm. She had a deep curve of Spee, and her upper midline was 0.5 mm to the left. Adding to the complexities of her malocclusion, the bride was an adult patient which makes tooth movement more difficult due to the fact that bone remodeling in orthodontics is markedly reduced in the adult population. I remember clearly this patient telling me that she wanted to look the best she possibly could for her wedding pictures. That resonated with me from the very beginning, which is why I offered her AcceleDent. I was confident that with this innovative technology we could reduce her projected 18-month treatment time to 9 months.
Light forces and minimum friction I felt confident that I could help her meet her deadline primarily because of the
Gary W. Chu, DDS, MS, practices at Chu Crew Orthodontics in Racine, Wisconsin. A Diplomate of the American Board of Orthodontics, Dr. Chu graduated from the University of Texas at San Antonio Dental School where he received his doctorate in dental surgery. He then spent an additional 2 years completing his orthodontic residency at the University of Iowa College of Dentistry.
Initial pan 20 Orthodontic practice
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Initial facial photos
Initial intraoral photos
Initial occlusal photos
AcceleDent technology and also because my treatment plan included the Damon® Q™ fixed appliance bracket system. I knew that the Damon Q brackets in conjunction with AcceleDent would deliver the optimal movements and light forces that I’ve found effective with my patients. In my opinion, the Damon System is superior because it utilizes light forces and passively allows archwires to slide through the bracket slot. As a result, the brackets promote biocompatible movement, which leads to far more comfortable and efficient treatment. I’ve been intrigued by the technology behind AcceleDent since it was being Volume 6 Number 6
evaluated in clinical trials. Having attended dental school at the University of Texas at San Antonio, I knew how reputable and forward thinking the university’s research was at my alma mater. Prior to its recent publication in Seminars in Orthodontics,1 I reviewed Dr. Dubravko Pavlin’s randomized controlled trial that demonstrated how pulsatile forces significantly accelerate tooth movement. I flew down to Houston to meet with the OrthoAccel executives to ensure that I would be one of the first orthodontists in the country to offer this innovative technology in my practice. Dr. Pavlin’s research not only explained how SoftPulse
Technology® could accelerate my patients’ orthodontic treatment, but also convinced me that AcceleDent is safe and gentle.
50% reduction: 18-month treatment completed in 9 months In this particular case, the patient was on board, committed to my treatment plan, and bonded in October 2013. I typically change wires at 10-week intervals with Damon brackets, but with AcceleDent, I discovered that I was able to change her wires every 5 weeks. Treatment began with a .014 Nitinol wire to engage tooth movement; this wire Orthodontic practice 21
CASE STUDY is essentially a wake-up call for the tissues. I extended the .014 wire through the first molars because extending it further posteriorly could have created a situation where the wire might come out while the patient was eating. When I progressed to the .018 Nitinol wire, I extended that through the second molars. The third molars were not addressed during treatment at the patientâ€™s request. The .014 x .025 Nitinol was the first rectangular wire I used with this patient, and it began the development of the arches and initiated root alignment. Typically, it is critical to leave this wire in for 10 weeks, but again, I was happy with tooth movement after just 5 weeks with AcceleDent. The .018 x .025 Nitinol was the largest Nitinol wire we used, and it achieved the majority of the arch form and root alignment that I look for in all my
finished cases. The .018 x .025 Nitinol was again used for 5 weeks instead of the 10 weeks that is typical with standard treatment. The final wire was the .016 x .025 TMA, which allowed for any remaining corrections following the rectangular Nitinol wires. Perhaps one of the greatest benefits of the accelerated treatment with AcceleDent is arriving at final wires with ample time to apply artistic bends enhancing and perfecting a patientâ€™s smile. In standard treatment, patients are typically burned out and impatient by the time they get to the finishing wires. However, we now get to the final wire faster with AcceleDent, and I still have time to be selective and precise with detailing the finished result.
Prior to debonding, impressions and a panorex were taken to evaluate the alignment and also check for proper function, including incisal guidance and cuspid rise. Short Class II elastics began with the .014 x .025 Nitinol wires and continued until debonding. Retention consisted of a bonded lingual 3 x 3 and upper and lower vacuum molded removable retainers. This patient was debonded in July 2014. As you can tell from her wedding photos, she had a very confident smile on her big
Final facial photos 22 Orthodontic practice
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Final intraoral photos
Final occlusal photos
day. Additionally, she recalled experiencing little to no pain throughout treatment. I have to say she was the perfect patient and complied with everything that was asked of her, including using her AcceleDent for 20 minutes daily. She was obviously very motivated by her deadline, but it’s also important to note that she had a very demanding schedule as she was working full time, going to school to earn her master’s degree and, of course, planning her wedding. Accelerated treatment was especially important to her considering
that she committed to driving over half an hour to and from every visit.
Accelerated orthodontic treatment is standard of care My primary takeaway from this case is that a 9-month treatment of a Class II, Division I malocclusion case is possible because of the appliances and technology that are now available to orthodontists. AcceleDent works well with the Damon System because it enhances bone remodeling with such light forces that we are able to achieve excellent
expansion posteriorly, which means that the majority of my cases are now non-extraction. Since the Damon System allows us to keep the forces light and biologically compatible, we are not cutting off blood flow to the teeth; we are actually encouraging osteoblastic and osteoclastic activity while avoiding necrosis and microtrauma. Similarly, AcceleDent enhances that protocol because the micropulses of the device’s SoftPulse Technology® are intended to increase bone turnover in order to accelerate tooth movement. AcceleDent cycles at a frequency of 30 Hz, far less force than what is used to chew gum and 8 times less than what is emitted through a power toothbrush. Damon in conjunction with AcceleDent has become my practice’s standard of care. All of my new patients automatically receive AcceleDent, and the cost is included in the overall treatment fee. Our practice has a reputation for providing the highest quality of care to our patients, and our community has come to realize that accelerated orthodontic treatment is now a part of the care that people have come to associate with Chu Crew Orthodontics. OP REFERENCES
Patient’s wedding photos
1. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Semin Orthod. 2015;21(3):187-194.
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Orthodontic practice 23
Watching … wondering … observing Dr. Ron Roncone discusses using Roncone PDS to have fewer appointments and shorter treatment time
hat if an orthodontist were to observe the same phenomenon several thousand times? The Same Input = The Same Output Would this be clinically significant? If these observations could not be found in the literature, would they be invalid? Would we NOT be practicing evidencebased orthodontics? I would like to mention just seven of the many observations I have made in 44 years of orthodontic practice. The vast majority have occurred since 1981. Since that time, I have taken tomographs or CBCT on “almost” every patient. I have taken frontal cephs (or CBCT) on “almost” every patient. Except for a 1½-year period (1976-1978), I have articulated all starts and all finished cases. I have treated more than 35,000 patients since 1974.
Figure 1: Arrows show antegonial notching
Observation 1 Antegonial notching of the mandible is evidence that there has been a long-term (years) hypertonicity of the masseter and medial pterygoid muscles (Figure 1). This will impede timely orthodontic treatment at best or cause failure at worst. Easy cases turn into difficult ones. What to do? Initiate at least 6 weeks of full-time splint therapy along with the use of ultrasound and ethyl chloride spray before orthodontics begins. Turbos on maxillary central incisors must be used as part of the treatment plan to keep muscles relaxed and avoid posterior tooth contact.
Observation 2 Close approximation of cervical vertebrae on the dorsal surface almost always Ronald Roncone, BA, DDS, MS, received his degrees in physiology from Marquette University and his postdoctoral Certificate in Orthodontics from Forsythe Dental Center and Harvard School of Dental Medicine. Dr. Roncone maintains a large practice in Vista, California, with 55% adult patients. Dr. Roncone has lectured extensively, presenting more than 1,000 seminars around the world, and is President and CEO of Roncone Orthodontics International®, which offers practice management courses as well as in-office consulting and marketing services.
24 Orthodontic practice
Figure 2: Cervical vertebrae with no spacing
Figure 3: Maxillary asymmetry — left side lower
indicates that the mandible is in a forward position to achieve maximum occlusion. Since the average person swallows between 1,700 and 2,400 times a day, this maximum intercuspation is easier to achieve with the head in a forward position. The true occlusion is either more Class II then we see or more Class III (Figure 2).
What to do? If the mandible can easily be hinged to a first contact position, begin orthodontics with turbos or a banded Nance bite plate to unlock occlusion. If the mandible is not easily hinged to first contact — splint and physical therapy (PT) modalities for 6-8 weeks. This forward head position has NOTHING to do with lack of airway. With the advent of CBCT and good health history, you can be sure it is not an airway problem.
A significant majority of patients have a maxillary frontal asymmetry. This causes the mandible to grow asymmetrically as well. This causes joint problems, muscle problems, and esthetic problems. We have all seen and treated uncorrected maxillary asymmetries. We have all seen the uncomplimentary smiles where more gingival tissue is seen on one side of the arch than the opposite side — even though the teeth meet correctly (Figure 3). What to do? Place a fixed Hyrax appliance, and expand. Continue two forward turns, alternating with two backward turns for at least 6 weeks. These turns are alternated on consecutive days. The continuous swallowing (1,700 – 2,400 times daily) will assist in “leveling” the maxilla. I have observed this phenomenon for more than 35 years. Volume 6 Number 6
Just under 30% of children between the ages of 10 and 16 have some evidence of condylar degenerative joint disease (DJD). Most of this does not coincide with past trauma. This is why I have taken tomograms and now CBCT on almost every patient we see. Most of these young people are asymptomatic (Figure 4). The joints shown in Figure 4 are from a 15-year-old who came in for aligner treatment. What to do? Take CBCT on all patients. You never know.
Observation 5 I have placed two wires initially since 1971. Since 1987, my initial wires have been .014 NiTi fully engaged with steel ligatures and then active self-ligating brackets. We see the patient at 12 weeks for a check and then reschedule him/her for another 12 weeks. If turbos are routinely used, alignment and rotations are corrected (usually
8-10 weeks), archform is complete, Curve of Spee is corrected, and molars are derotated, correcting a large number of Class IIs, and any nonparallel roots are mostly parallel. The force of twin wires is minimal, if a tooth is significantly malaligned. Then only one of the wires is engaged initially. The other wire is engaged at the 12-week appointment. Teeth move rapidly, and discomfort is minimal (4 out of 10) when patients were asked pain levels. This was asked of each full-bonded patient over a more than 8-year period (Figure 5). Figure 6 shows the same patient after a little over 5 months, when a rectangular wire was placed in each arch. Appointments have been reduced significantly, and root resorption is virtually not seen. The friction or binding that we have been told to be worried about plays no part in rate of tooth movement. What to do? Routinely use two .014 NiTi superelastic wires initially.
Observation 6 Where it is applicable, use anterior turbos made of clear Triad® material. Why are they so important? There are a number of reasons: 1. The posterior teeth do not meet, so the Curve of Spee is corrected permanently in most cases. I keep turbos on for at least 10 months. This allows the lower posterior teeth to erupt quickly, but more importantly, bone fills in at the apices of these teeth. If the posterior teeth come together 2,000 times a day, there can be no bony fill, thus causing the Curve of Spee to eventually return. 2. Since the teeth do not meet in the posterior, premolar and molar brackets rarely fail. 3. Since only lower incisors contact the turbos, teeth move more quickly. 4. There is no wear of teeth as they transition from Class II to Class I. 5. Forces of occlusion are significantly diminished; therefore, muscles stay relaxed. 6. The condyles stay “hinged” in an ideal position.
Observation 7 Over the years, I have attempted many options to bring in impacted canines. Most have been successful, but they took too much time — lengthened treatment time in order to make space for the canine first and then to expose the tooth, perhaps have it passively erupt, then move the tooth in multiple directions in order to get it into the arch. Since 1991, I have used one and only one method to bring in all impacted canines. These conditions must be present: • The use of a molar tube with 20 degrees distal rotation and 20 degrees of torque — Roncone PDS anchorage molar Figure 4: Significant DJD right condyle
Figure 5: Initial twin .014 PDS SE wires Volume 6 Number 6
Figure 6: Upper and lower.020 x .020 PDS HANT wires Orthodontic practice 25
CASE STUDY • A single-strand .018 HANT wire • A gold chain attached to the impacted tooth In most cases, an open coil spring, etc., does not need to be used to open space. Bringing in canines in the manner I will demonstrate in Case 1 and Case 2 has worked thus far for every patient whether labially or palatially impacted but one. The one patient commuted from the Midwest and had three other orthodontists involved who kept changing the protocol. That patient lost two teeth and needed implants.
What to do? Case 1
Figure 7: Placement of brackets with 20/20 molar. No elastics, open coil springs, TADs, or co-ligation of teeth were ever used. Space was made by using a large NiTi wire (.018), causing rotation of maxillary right first molar and friction/binding. After 10 weeks, the impacted canine (labial) was ligated, and the wire placed through a link on the gold chain
Figure 8: Twenty weeks after initial bonding, the gold chain was cut and the same .018 HANT placed through a “higher” link. Notice how space has been made through using the correct prescription
Figure 9: Six weeks later, the tooth was erupted and was bonded
Figure 10: Day of removal — 15 months treatment time; 7 total appointments 26 Orthodontic practice
Volume 6 Number 6
“A Life Changing Potential...”
“Greatest Course EVER! Simply put, my involvement with Dr. Roncone has been career transforming. JSOP takes Dr. Roncone’s unique insight to achieve clinical efficiency and blends it with a comprehensive M.B.A. program. JSOP truly has a life changing potential.” Dr. David Caggiano - Parsippany, NJ 2013 JSOP XVIII Graduate
The PhysioDynamic System was developed by Dr. Ron Roncone with 6 key principles to drive practice efficiency, profitability and clinical excellence. By simply implementing these core principles you can reveal the precious gift of time. No more valuable gift exists. Learn how you can treat 90% of your patients with superb functional results in an average of 7 appointments in less than 15 months. Upcoming Courses: JSOP XXVII: Starts November 19-22, 2015 Advanced PDS Course: December 11-12, 2015 JSOP XXVIII: Starts January 28-31, 2016 JSOP Europe: March 17-19, 2016 Resident Course: February 4-6, 2016 For more information, visit us at: www.ronconeroi.com or call us: 1-800-758-5836 www.forestadentusa.com
CASE STUDY What to do? Case 2: Bilateral palatially impacted canines
Figure 12: Extraction of deciduous Cs and ligation of impacted 3s
Figure 11: The exact same technique was used — PDS prescription, 20/20 molar, .018 HANT, gold chain
Figure 13: Final result
“Discovery consists of seeing what everybody else has seen and thinking what nobody has thought.” — Albert Szent-Györgyi
There are many other observations that I believe are equally important, which this brief article does not allow. However, it might behoove orthodontists to add more weight to their observations rather than to blindly follow. The words of Nobel Prize Laureate Albert Szent-Györgyi may be appropriate: “Discovery consists of seeing what everybody else has seen and thinking what nobody has thought.” OP
Figures 14-15: Treatment time, 16 months; 6 appointments 28 Orthodontic practice
Volume 6 Number 6
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BioDigital Orthodontics Management of skeletal deformities with orthognathic surgery (OraScan) (3): part 18 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi discuss the Type three approach for planning and managing surgical patients with suresmile® when only 3D intraoral scans are available Introduction suresmile technology enables the orthodontist to plan surgical treatment in 3D and design staged pre-surgical and post-surgical prescriptive archwires based upon patient needs.1-17 Also, the interactive nature of the software allows both synchronous and asynchronous planning of care with members of an interprofessional team in situ or virtually. In previous articles,16,17 three approaches to planning care for orthognathic surgical patients were described (Sachdeva). In this paper, the Type three approach for planning and managing surgical patients with suresmile when only 3D intraoral scans are available is discussed. ®
Patient K.T. Patient K.T. presented to the clinic at the age of 19 with the chief complaint of “my front teeth don’t meet, and my jaw seems to be shifted.” Both the clinical and cephalometric findings suggested that the patient presented with Class III asymmetry accompanied with a dental open bite (Figure 1). No mandibular
shift was detected, all teeth were present, and the 8’s were unerupted. Patient K.T.’s oral hygiene was satisfactory. The treatment plan was initially designed in 2D using WinCeph® Ver 9.0 software from Rise Inc. (www.risecorp.co.jp) (Figure 2). The displacement coordinates of the mandibular movements obtained from the 2D plan were used as a guide to plan the A-P movements of the mandibular arch on the VDM. Both transverse and A-P mandibular skeletal movements were simulated in 3D. Dental movements were planned next. Note, in conjunction with surgery, dental expansion of the maxillary posterior teeth and eruption of the maxillary anteriors are needed to coordinate the arches and plan for appropriate overbite (Figures 3A-3F). The patient’s upper arch was bonded with Tomy OPA-K® (www.tomyinc.co.jp) brackets with 0.018” slot width. Initial alignment of the upper arch was started with .016" SE CuNiTi AF 35°C Ormco™ (www. ormco.com) (Figure 4). Four weeks later, an upper quad helix was inserted to expand the upper arch (Figure 5). At the next appointment (week 8), the lower arch was bonded
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 Institute 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.
30 Orthodontic practice
with GAC .018" brackets, and alignment in the lower arch was started with a .016" SE CuNiTi AF 35°C (Figure 6). Twelve weeks later, the previous wires were replaced with .016 x .022 CuNiTi AF 35°C (Figure 7). A Therapeutic scan for patient K.T. was taken 4 weeks later (Figure 8). Although the planned maxillary archwidth was achieved by expansion, the anterior open bite increased (Figure 9). The superimposition of the Virtual Diagnostic Model (VDM) versus the Virtual Therapeutic Model (VTM) shows this (Figure 9D). The open bite was created as a result of the reactive intrusive forces felt by the upper anterior segment in response to the extrusion of the upper canines. The leveling of the lower arch also contributed to the increased open bite. The definitive surgical treatment plan was designed using the VTM (Figure 10A). Note both the upper and lower anteriors were extruded dentally to reestablish the esthetic occlusal plane (Figures 10B-10D). For patient K.T., a hybrid active-passive surgical archwire (Sachdeva classificationType 4) described in an earlier article8 was designed (Figure 11). This means that the wire was designed passively for the posterior segments and actively to extrude the anterior segments. The reason for this was to take advantage of the Rapid Acceleratory Phenomenon (RAP)18 that would be triggered post-surgically to extrude the anteriors rapidly. Upper and lower .017" x .025" CuNiTi AF 35°C suresmile precision archwires were inserted 4 weeks later (Figure 12). The patient was operated on the next day immediately post-suresmile archwire insertion. This mitigated any tooth displacement that could impact the fit of the surgical splint. Immediately post surgically, vertical box elastics and Class III check elastics were Volume 6 Number 6
Figures 1A-1E: Patient K.T. 1A. Initial intraoral photographs. 1B. suresmile Virtual Diagnostic Model (VDM). 1C. Lateral ceph, PA, and panorex. 1D. Initial ceph tracing and analysis. 1E. Initial PA radiograph. Note left mandibular asymmetry
Figures 2A-2B: Patient K.T. 2D surgical treatment plan showing both soft tissue and hard tissue displacements Volume 6 Number 6
Orthodontic practice 31
ORTHODONTIC CONCEPTS VDS (surgical movement)
VDM vs. VDS (surgical & dental movement)
VDM vs. VDS (dental movement)
Figures 3A-3F: Patient K.T. 3A. Virtual Diagnostic Simulation of the surgical and dental plan. 3B. Virtual Diagnostic Simulation (VDS) vs. Virtual Diagnostic Model (VDM). 3C. Planned surgical displacements. 3D. Surgical and orthodontic tooth displacements. 3E. VDS vs. VDM showing the planned tooth movements. 3F. Planned orthodontic tooth displacements
Figure 4: Patient K.T. Upper arch bonded with Tomy OPA-K® brackets with 0.018" slot width and initial alignment of the upper arch was started with .016" SE CuNiTi AF 35°C
Figure 5: Patient K.T. Upper quad helix inserted 4 weeks later to expand the upper arch
Figure 6: Patient K.T. 8 weeks later. Lower arch bonded with Tomy OPA-K® brackets with 0.018" slot width, and initial alignment of the upper arch was started with .016" SE CuNiTi AF 35°C
Figure 7: Patient K.T. 12 weeks later. .016" x .022" CuNiTi AF 35°C upper and lower archwires were inserted
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Figures 8A-8B: Patient K.T. Therapeutic scan for patient K.T. was taken 4 weeks later. 8A. Intraoral photos. 8B. Ceph and pano at time of Therapeutic scan
Patient K.T. demonstrates the versatility in the use of suresmile technology, which allows the clinician to design a patientâ€™s care plan in 3D and offers her the ability to design plan specific archwires.
VDS (white) vs. VTM (green)
Figures 9A-9C: Patient K.T. Note although the planned maxillary archwidth was achieved by expansion, the anterior open bite increased. 9A. Initial right buccal view. 9B. Therapeutic right buccal view. 9C. Virtual Therapeutic Model (VTM). 9D. VTM superimposed over VDS shows the open bite increased in response to the reactive intrusive forces created on the upper incisors as the upper canines extruded during the alignment of the upper arch. Additionally, the leveling of the lower arch contributed to this response Volume 6 Number 6
Orthodontic practice 33
ORTHODONTIC CONCEPTS VTS
VTM (green) vs. VTS (white)
VTM (green) vs. VTS (white)
Figures 10A-10D: Patient K.T. 10A. Virtual Target Setup (VTS) with surgical and dental simulation. Note the “rat holes” between the upper and lower anteriors. 19B. VTM (green) vs. VTS (white). 10C. Surgical displacement values. 10D. VTM (green) compared to VTS (white) shows the lower anteriors were extruded dentally to reestablish the esthetic occlusal plane
Wire design on VTM
Figure 11: Patient K.T. Hybrid active-passive surgical archwire was superimposed over the Virtual Therapeutic Model (VTM)
Figure 12: Patient K.T. Four weeks’ post Therapeutic scan, upper and lower .017" x .025" CuNiTi AF 35°C suresmile precision archwires were inserted. The surgery was performed 1 day later
34 Orthodontic practice
initiated. The patient was seen 4 weeks later (Figure 13). At this point, the patient was asked to continue wearing anterior box elastics, double the Class II elastic wear on the left, and use single Class II light elastics on the right. The patient was seen 4 weeks later (Figure 14) and debonded the following week. The final intraoral photographs and X-rays are shown in Figures 15A and 15B. The cephalometric re-analysis is shown in Figures 15C and 15D. Note the superimposition of the Virtual Target Setup (VTS) against the Virtual Final Model (VFM) shows that most of the treatment objectives were met. The midline remained slightly off (Figure 16). Also, the Volume 6 Number 6
Figure 13: Patient K.T seen 4 weeks post-surgery. Patient was asked to continue wearing anterior box elastics and double Class II elastics on the left and single Class II elastics on the right
Figure 14: Patient K.T. 4 weeks later (week 28)
Figures 15A-15D: Patient K.T. Debonded at week 29. 15A. Final extraoral and intraoral photos. 15B. Final lateral ceph, PA, and panorex. 15C and 15D. Initial vs. Final ceph re-analysis
VFM (white) vs. VTS (green)
Figures 16A-16B. Patient K.T. 16A. 3D Virtual Final Model (VFM). 16B. Superimposition of the VFM to VTS (Virtual Target Setup) demonstrates that the treatment outcome closely matches the plan Volume 6 Number 6
Orthodontic practice 35
ORTHODONTIC CONCEPTS “rat holes” in the upper right canine region and the left lateral may be primarily attributed to the shape of the teeth. This was expected as can be seen the virtual target simulation (Figure 10 A). A summary of the clinical pathway developed by Sachdeva is shown in Table 1.
Table 1: Surgical clinical pathway with suresmile (Sachdeva) Phase
Patient’s chief complaint. Determining patient’s needs and wants
Diagnostic record coalition
2D photos, ceph, PA, and panorex 3D Virtual Diagnostic Model (VDM)
• • • • • •
Perform cephalometric analysis 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); CAT/CBCT if needed
2D cephalometric superimposition of initial versus final 3D superimposition of the VFM to VTS
Conclusions The total treatment time for patient K.T. was 7 months. Serial archwire changes could have been avoided by beginning with .016" x .022" AF 35°C CuNiTi archwires in both the upper and lower arches. Additionally, the lower arch could have been bonded at the first appointment with the upper arch and the upper quad helix appliance placed. These actions would probably have saved at least 8 weeks in treatment time. The iatrogenic side effect of intrusion of the upper anteriors could have been minimized by either asking the patient to wear box elastics anteriorly during first alignment or with the use of overlay mechanics. A passive upper archwire could have been designed with suresmile bypassing the canines to hold the posterior and anterior segment rigidly. Concurrently, a .016" SE NiTi archwire could have been overlaid on this wire and the canines engaged to extrude them. Patient K.T. demonstrates the versatility in the use of suresmile technology, which allows the clinician to design a patient’s care plan in 3D and offers her the ability to design plan specific archwires. In the case of patient K.T., it was an active-passive hybrid precision archwire. OP
Acknowledgments Our sincere thanks are extended to Dr. Matsumoto Yushi (Department of Maxillofacial unit, Oita Oka Hospital, Oita City, Japan), the surgeon in our care team for his outstanding care to patient K.T. We thank both Dr. Sharan Aranha and Arjun Sachdeva for their help in the preparation of this manuscript.
* 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-fusion model (part 1). Orthodontic Practice US. 2015;6(4):26-32. 17. Sachdeva RCL, Moravec S, Kubota T, Uechi J. BioDigital orthodontics. Management of skeletal deformities with orthognathic surgery — Direct (CBCT) (2): part 17. Orthodontic Practice US. 2015;6(5):28-35 18. Minichetti JC, D’Amore JC, Hong AY, Cleveland DB. Human histologic analysis of mineralized bone allograft (Puros) placement before implant surgery. J Oral Implantol. 2004;30(2):74-82.
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Volume 6 Number 6
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The host in the machine Dr. Jonathan Nicozisis waxes philosophical on Propel Orthodontics’ Excellerator technology
he machinery that is involved in orthodontic tooth movement is a complex milieu of cascading events and tissue reactions of the host periodontium. As the oldest specialized discipline in dentistry, we have researched and understood the periodontal response when forces are imparted on teeth better than anyone else. We fully understand the direct connection of the physical push and pull that elicits bone remodeling to satisfy the body’s mindful desire to return to homeostasis. The “ghost in the machine” is a concept describing philosopher René Descartes’ mind-body dualism to explain mental activity carrying on in parallel to physical action, but where their means of interaction are unknown. To translate, it is the notion that the mind is distinct from the body, and that mental
states are separable from physical states. Hence “the ghost in the machine” describes the fundamental distinction between mind and matter with the presumption that they act independently in parallel without a direct cause-and-effect relationship. As orthodontists, we certainly know this is not the case in what we do. We appreciate that there is a direct cause and effect of our mental planning of mechanics to accomplish physical tooth movements given our initial diagnosis and planned treatment. Our everyday routine actions, however, have created a mental complacency that has lulled us into repetitive activities, robbing us and our patients of novel processes to provide better outcomes in shortened treatment times. In a sense, unknowingly, a disconnect has developed between our
thoughts in planning and how our physical mechanics are received by the host tissues of the periodontium. This is our orthodontic ghost in the machine. Simply put, we have forgotten the details involved in the physiology of tooth movement and thus do not even think of the possibility of enhancing the process to our advantage; for doctors in private practice, the host in the machine that is the periodontium reacting to orthodontic tooth movement has been overlooked for too long, thus resulting in this disconnect. Prior to today’s technology, the connection between our mental thought processes to augment the physical reaction of the host tissues was to apply either a heavy or a light force. Heavy forces were reserved for
Case 1 crossbite: Adult female treated in 12 months with Invisalign® and four Propel treatments in all four quadrants with two perforations from mesial of the first molars to distal of the centrals. One refinement with aligners only and no crossbite elastics used
Jonathan Nicozisis, DMD, MS, has been in the specialty practice of orthodontics since 1999. He completed his dental education at the University of Pennsylvania before attending Temple University for his orthodontic residency. While at Temple University, Dr. Nicozisis received his specialty certificate in orthodontics and a master’s degree in oral biology. During his training, he also completed an externship at the Lancaster Cleft Palate Clinic in Lancaster, Pennsylvania, where he was involved with the care of patients with craniofacial syndromes. Dr. Nicozisis is a member of Invisalign® National Speaker’s Bureau and Clinical Research Network where he helps conduct research and development of new technologies and improvements to the Invisalign technique. Dr. Nicozisis is also the founding orthodontist and a scientific advisory board member of BAS Medical (now Corthera), a development stage company founded in 2003 with a mission to develop and market a novel technology to accelerate and improve the stability of orthodontic treatments. Dr. Nicozisis’ master’s research is the basis for BAS Medical innovative research. In February 2010, Corthera was acquired by Novartis. Dr. Nicozisis has been awarded membership to the Edward H. Angle Society of Orthodontists. He is a member of the American Association of Orthodontists, Middle Atlantic Society of Orthodontists, New Jersey Dental Association, Mercer County Dental Society, and the Greater Philadelphia Society of Orthodontists. Dr. Nicozisis is a paid lecturer, but not a consultant, for Propel Orthodontics.
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Volume 6 Number 6
Case 2 crowding: Adult male presented for orthodontic treatment prior to periodontal grafting therapy. Treatment time to completion is 7.5 months. There were two Propel treatments at the first visit and 3 month visit to get patient to refinement in 5 months. Propel was done from the mesial of the first bicuspid to the distal of the centrals in all four quadrants. No Propel was done in refinement
skeletal movements (think cervical or highpull headgear, protraction face masks, and palatal expanders), whereas light forces were applied for tooth movement to minimize tissue ischemia and promote frontal resorption as opposed to undermining resorption. The basic science behind Propel Orthodontics’ proprietary Excellerator technology is the answer to the ghost in our own machine that is orthodontic tooth movement. To that end, Propel allows us to connect the mental understanding of the physiology of tooth movement and physical actions to elicit the desired movement. More so, Propel now affords us the capability of enhancing this connection between our understanding and actual undertaking of tooth movement to our advantage and benefit to the patient. Modestly put, an increase in local inflammation via transmucosal osteoperforations causes an increase in osteoclast recruitment and differentiation. This causes the bone to remodel faster, and therefore, teeth move Volume 6 Number 6
faster through the bone. Doctors are in full control and can target where this facilitated phenomenon occurs without relying on patients for compliance. The parallel knowledge of and physical stimulation of the host machinery involved in orthodontic tooth movement is now truly linked. Decades of academic research is crossing over into private practice and practical application in a non-disruptive way regardless of the modality of treatment chosen for our patients’ benefit. Patients benefit from shortened treatment times, which means less time in orthodontic appliances or aligners. Furthermore, it means fewer visits to the office and taking less time away from work or school to complete treatment. Finally, there is no recovery from the procedure, and patients can go about their day without any downtime or discomfort. Doctors benefit from better outcomes in less time. This means less chair time overall to finish each case with an increase in profitability
Euclid had his postulates in Geometry. Nicozisis has his postulates of Propel: 1. Incorporation of Propel in a treatment plan and the corresponding decrease in number of visits to complete the case is congruent with an increase in profitability per visit. 2. If there is a space that exists between two teeth, then there exists one Propel procedure that will close the space faster than conversely without Propel. 3. A single office visit with a nominal increase in chair time of no more than 15 minutes for all four quadrants will substitute for a savings of two to three visits to produce the same movements. 4. The Fourth Order of Orthodontics is elicited with Propel allowing doctors to augment the host tissue response to their advantage preceding force application. 5. Doctor-controlled and targeting capabilities are characteristics inimitable to Excelleration with Propel. 6. If X is a variable, the one’s investment of $”X” thousand in Propel will translate in effecting 4.0-5.5 times “X” patients versus effecting 1 times “X” patients with other devices currently in the market place. per visit. Distinct marketing advantages of Propel accelerating orthodontic technology help attract new patients to the office as well as convert those who may have been reticent based on the length of time they were originally quoted. If the average case takes one to three devices, the modest increase in overhead, approximately $100-$300, is well worth the savings elsewhere. The concept of mind-body dualism need not be reserved for philosophers waxing poetic on explaining the possible parallel nature of human being’s mental and physical activity. It can now be applied to bridge the fine gap between the basic science research behind Propel Orthodontics’ Excellerator technology and actual clinical application to the mutual benefit of both patients and doctors. The complacency of our mundane day-to-day office routines can now be filed in the history chapters of our orthodontic literature! OP This information is sponsored and provided by Propel Orthodontics.
Orthodontic practice 39
Postulate: (or axiom) is a statement accepted as true without proof
Management of TMD during orthodontic treatment: disc displacements Dr. Harold F. Menchel discusses how to proceed when a patient develops TMD symptoms during treatment
very orthodontist dreads the emergency call from the parents of an adolescent in active treatment. “My daughter woke up this morning with jaw pain, and she can’t open her mouth!” Most TMD orthodontic emergencies involve young female adolescents with disc displacements. It has been my experience as a graduate instructor in dental programs that many orthodontists are not familiar with diagnosis or management of these patients. This article will give you the essentials to manage this common occurrence.
Introduction TMD disorders occur primarily in the female population (85%).1,2,3 Disc displacements occur most often in young postpubertal females.4,5,6 This makes them common in the orthodontic population. • Hormonal influence (estrogen metabolism) has been suggested as a possible etiologic factor, but the exact mechanism is unknown.7 • Hypermobile patients have a higher incidence of disc displacement.8 • There is weak evidence that Angle Class II patients are more prone to this pathology, especially Division II.9,10 • The majority of these patients exhibit parafunction (particularly clenching). • In most patients, this pathology is preceded by biochemical changes in the synovium and is not strictly a mechanical joint problem.12 • Disc displacements without reduction have a higher incidence of arthritic joints as the patient ages, but this does not always occur.13,14
Educational aims and objectives
This article aims to discuss how proceed when a patient develops TMD symptoms during treatment.
Orthodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some reasons for TMD disorders to occur. • Identify some common reasons for TMJ disc displacements. • Realize some possible prevention methods for TMD problems. • Recognize some differentiations between disc displacements and other TMD diagnoses. • Discuss management of patients who develop locking during treatment.
Disc displacements TMJ disc displacements occur when the disc is mobilized when the infratemporal fossa ligaments are stretched and the disc assumes a position anterior, lateral, medial, or posterior to its normal position. These can occur from macrotrauma or microtrauma over time. The most typical displacement is anterior-medial.
Subjective history The most common presentation of these patients is a history of increasing clicking and popping progressing to occasional locking, and then typically, the patient wakes with a limited opening or suddenly locks while eating chewy food. Many of these patients are habitual gum chewers and nail biters. There are several reasons for the jaws locking, including acute contraction of the masseter and temporalis muscles, the squeezing out of the joint the synovial fluid that provides lubrication for the joint, and a displaced disc.
Harold Menchel, DMD, is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep-disordered breathing. Dr. Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Ft. Lauderdale Florida. He is the director of orofacial pain at Larkin Teaching Hospital in Miami and lectures both nationally and internationally. He is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.
Figure 1: The posterior band of the disc 40 Orthodontic practice
Figure 2: Routine palpation of masseter muscles
Prevention The best prevention for TMD problems is a thorough TMD examination prior to starting orthodontic treatment in every patient. The following procedures should always be included for every new patient. • Palpation of joints and muscles for pain • Measure initial range of motion (normal opening 45 mm-55 mm) • Documentation of joint noises • Documentation of deviation on opening and protrusion • Measurement of excursive movements to see if they are normal and symmetrical • Patients with disc displacements will often deviate initially to the side of the Volume 6 Number 6
Diagnosis of disc displacement with reduction Disc displacements have to be differentiated from other TMD diagnoses: myospasm, arthritis, or post-injection trismus.15 • History of painful clicking and popping and occasional locking with increasing symptoms • Limited opening (usually 25 mm35 mm) with a “hard” end feel. (The patient has a consistent opening measurement with no “give”) • Deviation to the side of the disc displacement on opening and protrusion • Limitation of movement to the contralateral side • Disappearance of joint sounds with locking • Tenderness over the TMJ lateral pole • Decrease of pain with placement of separator on the side of the disc displacement; increase in pain with placement on the contralateral side (Mahan’s sign)16
Management of orthodontic patients with disc displacements Reducing displacements • Painless clicking and popping with no dysfunction (locking) can be treated normally, but with caution if the patient develops symptoms! • Patients who have painful clicking and locking should have conservative TMD therapy until there is no pain or dysfunction and then proceed with orthodontics with coordination of treatment as necessary with an orofacial pain dentist. • Asymptomatic clicking and popping during treatment should be noted, but treatment may continue. • Judicious use of anterior repositioning appliances during therapy should be considered. Non-reducing displacements Most patients with disc displacements do not develop significant occlusal changes.17 It is conjectured that the posterior occlusion should be heavy on the side of the displacement with an anterior open bite, but this is not consistently seen in practice. The reason for this is unknown. Patients with limited opening and pain prior should have no ortfhodontic treatment until pain is managed and the ROM is normal! • These patients can be treated “off the disc” after ROM is normal. Pain
is managed with conservative TMD therapy. • Some patients may require either arthroscopic lysis and lavage or discopexy (disc repositioning) prior to orthodontic treatment. In my practice, this is less than 10% of the patients with disc displacements without reduction .1 • If surgery is performed, it is recommended that orthodontic treatment be delayed 3-6 months for healing and for occlusal changes to stabilize.
Management of patients who develop locking during treatment Management of these patients is always easier the later in treatment the disc displacement occurs. The use of anterior repositioning appliances in these patients is questionable. In cases of non-reducing joints or in the later stages of internal derangement of the TMJ, it is not possible to achieve a normal disc-condyle relationship using protrusive splints.18 The main reason is that non-reducing disc displacement cannot occur without the loss of disc contour, which has the responsibility of providing the anatomic basis for normal disc position. However, this change is gradual. The acute stretching of the ligaments and comcomitant joint laxity as well as normal traction of the lateral pterygoid muscle now being pathologic are responsible for difficulty establishing a normal condyle disc relationship.
Figure 3: Measuring range of motion (ROM) with TMJ Trimeasure (Pankey Institute) Normal range 45 mm-55 mm
Figure 4: Deviation on opening to the right. This patient has a disc displacement in the right condyle. He is also limited in left lateral excursions Volume 6 Number 6
Figure 5: Disc displacements with and without reduction. On the top you can see the condyle closed (on the right with disc anterior to the condyle). This reduces or repositions into normal position on top of the condyle when the patient opens and the condyle translates. This is a “clicking “ joint. On the bottom, the disc is far anteriorly displaced so that it does not reduce to its normal positioning and blocks the opening Orthodontic practice 41
disc displacement, and then when it reduces (clicks), they will come back to center with an “S”-shaped opening • Panorex radiographs
CONTINUING EDUCATION • Mechanical tooth movement should be stopped until symptoms are reduced and opening is normal. • There are three ways to treat disc displacements without reduction during orthodontic treatment without removing the appliances: 1. Use bonded anterior bite stops or bite turbos to prevent any further posterior positioning of the condyle in the infratemporal fossa of the mandible and to act as a temporary splint. 2. Have the orofacial pain dentist place the splint over the appliances on one arch. He will request that you remove the arch wires and take alginates for him. When the patient is comfortable, turbos can be placed and the treatment finished.
3. “Flip splints.” This is the most time-consuming method but sometimes has to be done in severe cases. Move the teeth opposing the splint until you are finished, and then “flip” the splint to the other arch now finishing your orthodontic movement on the arch with previous splint.
Conclusions Disc displacements sometimes appear in the orthodontic population. The best way to manage them is with a TMD examination prior to treatment and then TMD treatment before any orthodontic movement. If the disc displacements occur during treatment management, techniques are discussed in many cases without removing the orthodontic appliances. OP
Retention of cases with disc displacements or general bruxism Splints are usually required for retention especially where bruxism is evident. The simplest configuration is an upper flat plane splint against a lower bonded retainer or lower labial bow retainer. Essix retainers are contraindicated because the occlusion cannot be adjusted. Invisalign® retainers present the same limitation.
REFERENCES 1. Nebbe B, Major PW. Prevalence of TMJ disc displacement in a pre-orthodontic adolescent sample. Angle Orthod. 2000;70(6):454-463. 2. Ribeiro, RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, Magalhaes AC, Tavano O. The prevalence of disc displacement in symptomatic and asymptomatic volunteers aged 6 to 25 years. J Orofac Pain. 1997;11(1):37–47. 3. Nilner M, Kopp S. Distribution by age and sex of functional disturbances and disease of the stomatognathic system in 7–18 year olds. Swed Dent J. 1983;7(5):191-198. 4. Tegelberg A, List T, Wahlund K, Wenneberg B. Temporomandibular disorders in children and adolescents: a survey of dentists’ attitudes, routine and experience. Swed Dent J. 2001;25(3):119–127. 5. Keeling SD, McGorray S, Wheeler TT, King GJ. Risk factors associated with temporomandibular joint sounds in children 6 to 12 years of age. Am J Orthod Dentofacial Orthop. 1994;105(3):279-287. 6. Isberg A , Hagglund M, Paesani D. The effect of age and gender on the onset of symptomatic temporomandibular joint disk displacement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.;1998;85(3):252-257.
Figure 6: Bonded bite turbos
7. Aufdemorte TB, Van Sickels JE, Dolwick MF, Sheridan PJ, Holt GR, Aragon SB, Gates GA. Estrogen receptors in the temporomandibular joint of the baboon (Papio cynocephalus): an autoradiographic study. Oral Surg Oral Med Oral Pathol. 1986; 61(4):307–314. 8. Hellsing G, Holmlund A. Development of anterior disk displacement in the temporomandibular joint: An autopsy study. J Prosthet Dent. 1985;53(3):397-401. 9. De Boever AL, Keeling SD, Hilsenbeck S, Van Sickels JE, Bays RA, Rugh JD. Signs of temporomandibular disorders in patients with horizontal mandibular deficiency. J Orofac Pain. 1996;10(1):21–27. 10. Roth RH. Temporomandibular pain-dysfunction and occlusal relationships. Angle Orthod. 1973;43(2):136–153. 11. Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S. Temporomandibular internal derangement: correlation of MRI findings with clinical symptoms of pain and joint sounds in patients with bruxing behavior. Dentomaxillofac Radiol. 2003;32(5):304-310. 12. Milam SB, Schmitz JP. Molecular biology of temporomandibular joint disorders: proposed mechanisms of disease. J Oral Maxillofac Surg. 53(12):1448-1454.
Figure 7: Splint made over existing orthodontic appliances
13. de Leeuw R, Boering G, Stegenga B, de Bont LG. Clinical signs of TMJ osteoarthrosis and internal derangement 30 years after nonsurgical treatment. J Orofac Pain. 1994;8(1):18-24. 14. Kropmans TJ, Dijkstra PU, Stegenga B, de Bont LG. Therapeutic outcome assessment in permanent temporomandibular joint disc displacement. J Oral Rehabil. 1999;26(5):357–363. 15. Okeson JP, de Leeuw R. Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dent Clin North Am. 2011;55(1):105-120. 16. Mahan P. Facial Pain. 3rd ed. Philadelphia, Pa: Fea & Febiger; 1991:4-143. 17. Murakami K, Hosaka H, Moriya Y, Segami N Iizuka T. Short-term treatment outcome study for the management of temporomandibular joint closed lock: A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;80(3):253-257. 18. Eberhard D, Bantleon HP, Steger W. The efficacy of anterior repositioning splint therapy studied by magnetic resonance imaging. Eur J Orthod. 2002;24(4):343-352.
Figure 8 42 Orthodontic practice
Volume 6 Number 6
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Management of TMD during orthodontic treatment: disc displacements
Clinical tips to increase consistency using a “Straight-Wire Appliance
TMD disorders occur ________. a. primarily in the female population (85%) b. primarily in the male population (85%) c. equally in the male and female population d. very infrequently across the gamut of patients TMJ disc displacements occur when the disc is mobilized when the infratemporal fossa ligaments are stretched and the disc assumes a position ____________, or posterior to its normal position. a. anterior b. lateral c. medial d. all of the above The most common presentation of these patients is a history of ____________ and popping progressing to occasional locking, and then typically, the patient wakes with a limited opening or suddenly locks while eating chewy food. a. loud grinding b. increasing clicking c. tongue thrusting d. rheumatoid arthritis The best prevention for TMD problems is a thorough TMD examination prior to starting orthodontic treatment ___________. a. in female patients only b. in male patients only c. only in patients who complain of pain d. in every patient (The following procedures should always be included.) Measure initial range of motion (normal opening ___________) a. 20 mm-26 mm b. 30 mm-40 mm
Volume 6 Number 6
c. 45 mm-55 mm d. 60 mm -65 mm 6.
Some patients may require ________ prior to orthodontic treatment. a. arthroscopic lysis and lavage b. discopexy (disc repositioning) c. estrogen metabolism testing d. both a and b If surgery is performed, it is recommended that orthodontic treatment be delayed ______ for healing and for occlusal changes to stabilize. a. 1 month b. 3-6 months c. 8-10 months d. 1 year Management of these patients is always easier __________ the disc displacement occurs. a. the earlier in treatment b. the later in treatment c. depending upon the contour in which d. depending upon the direction in which
In cases of non-reducing joints or in the later stages of internal derangement of the TMJ, it is ______ to achieve a normal disc-condyle relationship using protrusive splints. a. possible b. not possible c. a realistic expectation d. the perfect time
_________ is/are responsible for difficulty establishing a normal condyle disc relationship. a. the acute stretching of the ligaments b. comcomitant joint laxity c. normal traction of the lateral pterygoid muscle now being pathologic d. all of the above
Orthodontic clinical procedures and esthetic preferences are evolving toward _____ with a reduced tendency toward four-premolar extractions, with increased preference for non-extraction treatment. a. fuller lips b. greater enamel display c. wider smiles d. all of the above
The “tooth by tooth” method of varying torsion “built into” the appliance is _____ for us and frequently requires either repositioning of brackets, or complex wire bending to finish precisely. a. just as efficient b. not as efficient c. the method chosen most frequently d. most valuable
As NHP (natural head position) is reasonably stable in both the short- and long-term, the patient should be assessed __________. a. comfortably standing b. engaged in natural conversation c. generating unposed smiles d. all of the above
In contrast, ______ is far more predictable, requires fewer bracket repositions, and allows wire adjustments with uniformly “spun” wires. a. “flipping and flocking” b. varying torsion in groups c. using heavy elastics d. both a and b
As SAP (Smile Arc Protection) upper bracket positions to optimize esthetics are frequently more gingival than conventional positions, ____ can be a tremendous advantage when needed. a. soft tissue recontouring b. crown angulation c. torsion control d. direct bonding
______ is a complex process dependent upon magnitude of torsion, wire stiffness or resilience, bracket design, engagement angle, mode of ligation, wire dimension and corner radius of the wire, angulation of the bracket, deformation of the bracket or wire under torsion, manufacturing tolerances in the bracket and the wire, initial tooth inclination, bracket position, and the measurement technique used to evaluate torsion. a. Smile Arc Protection b. Torque expression c. Natural Head Position d. Early Active Appliances
As today’s treatment targets for incisor position in three planes of space are based on esthetics, the reliance on “treatment built” into an appliance for the anterior teeth relative to the occlusal plane is _____ to ensure esthetically superior results. a. a practical way b. not a practical way c. the best way d. the most cost-effective way
______ article, acknowledged as the catalyst for development of the first fully pre-adjusted appliance, advocates using the center of the clinical crown (FA), the long axis of the center of the clinical crown, and the thickness of the clinical crown from the long axis to FA, as guides for bracket positioning. a. Angle’s “Six Keys” b. Andrews’ “Six Keys” c. Scuzzo’s Light lingual d. Tweed-Merrifield’s
In clinical practice, incremental increases in archwire size _____ of controlling axial inclination when the slot isn’t filled. a. is the chosen method b. is the most effective means c. is not the most effective means d. allows for superior means
With the worldwide tendency to ______, the control of proclination of the maxillary anterior teeth has become a greater challenge. a. speed up treatment as quickly as possible b. discover less expensive treatment options c. treat more patients without extractions d. depend on clear aligner therapy
Orthodontic practice 43
ORTHODONTIC PRACTICE CE
Clinical tips to increase consistency using a “Straight-Wire Appliance” Drs. Tom Pitts and Duncan Brown discuss an efficient, gentle approach to orthodontic treatment
verything should be made as simple as possible, but not simpler.” — Einstein Orthodontic clinical procedures and esthetic preferences are evolving toward fuller lips, greater enamel display, and wider smiles with a reduced tendency toward fourpremolar extractions, with increased preference for non-extraction treatment.1 The clinical approaches that we rely on today are different from those earlier generations of orthodontists used frequently.1 Esthetic declines, once common with treatment,2 are no longer acceptable to the majority of patients, and “straight teeth,” once the predominant treatment goal, is now secondary to strategies directed toward esthetic improvement3 (Figures 1-2). Most orthodontists use a variation of the “Straight-Wire Appliance,” a concept that has dominated our profession since Dr. Larry Andrews’ breakthrough article4 led to its development in the 1970s. In the last 2 decades, appliance developments have revolved around relatively minor changes in
Educational aims and objectives
This article aims to discuss some clinical aspects to increasing consistency using a “Straight-Wire Appliance.”
Orthodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize certain clinical benefits to passive self-ligating mechanisms. • Identify Active Early” Case Management Protocols. • Realize the importance of diagnosing in natural head position. • Identify some aspects of torque expression. • See the value of optimizing micro-esthetics in finishing.
appliance prescription, direct bonding, the development of PSL (Passive Self-Ligating)/ ASL (Active Self-Ligating) ligating mechanisms, increased use of sliding mechanics, and incorporating reduced force levels.5 The recognition that certain torsion concepts of “straight-wire” theory are not congruent with some modern esthetic goals or with contemporary mechanics does not diminish the value of Dr. Andrews’ landmark concepts. Orthodontists must appreciate the
Figure 1: Macro-esthetic results achieved with contemporary case management practices. (Images courtesy of Dr. Duncan Brown, 2014)
biomechanical flexibility that is required to use the appliance for improving the quality of treatment results. There was a gain in popularity in ASL/ PSL systems during the 1990s when small wires in a larger “closed” slot provided effective movement due to reduced Resistance to Sliding (RTS). For many orthodontists, when larger rectangular wires were used during major tooth movement, results were disappointing5 with “sloppy slots” that lacked
Figure 2: Mini-esthetic and micro-esthetic results achieved with contemporary case management practices. (Images courtesy of Dr. Duncan Brown, 2014)
Tom Pitts, DDS, MSD, is a world-renowned lecturer and clinician, highly recognized for his continued teaching of orthodontic finishing and clinical excellence. Dr. Pitts is an associate clinical professor at the University of the Pacific and founder of the well-respected Pitts Progressive Study Club. Dr. Pitts has been published in multiple journals and clinical publications. He has been actively teaching the orthodontic community in a variety of settings both nationally and internationally since 1986. Duncan Brown, DDS, MS, is a highly regarded international speaker and educator in passive ligation bracket systems. Dr. Brown teaches regularly at the University of Alberta and University of Manitoba and is also a Kodak/Carestream Dental speaker and consultant.
44 Orthodontic practice
Volume 6 Number 6
Clinical Tips • Don’t get stuck in a biomechanics rut that doesn’t deliver exceptional esthetics: (Impressive Smile and Facial Esthetics has been my field of interest for the last many years.) Most orthodontists appreciate Andrews’ “Six Keys to Normal Occlusion” — (Key 1) the characteristics of molar relationship, (Key 2) crown angulation or tip, (Key 3) crown inclination, (Key 4) no rotations, (Key 5) absence of spaces, and (Key 6) occlusal plane — as being important features of a sound functional occlusion. The work of Dr. David Sarver clearly describes characteristics of great esthetics that supplement the criteria applied to normal occlusions8. The biomechanics and case management used by esthetically motivated orthodontists to achieve great occlusions are likely considerably different from those who are mainly occlusally motivated. Put simply, “Great Occlusions don’t always equal great esthetics,” so clinically, find ways to achieve both. • Try “Active Early” case management protocols: In “Active Early” protocols,7 the appliance is activated as early as
possible, using the Smile Arc Protection (SAP9) bracket position to adjust vertical position of the incisors, inverting groups of brackets when necessary to activate torsion in the appliance, selecting archwire progressions that control axial inclination early in treatment, wider arch forms that develop the posterior segments of the arches sooner, esthetic arch shape, ELSE (Early Light Short Elastics) to control forces and moments, and appropriate disarticulation to encourage early “wanted” tooth movements.6 This controls early vertical erupion and intrusion of teeth. Using these strategies improves patient management efficiency for us (Figure 3). • Diagnose in Natural Head Position (NHP): Diagnosis for esthetics is based on how the patient presents in day-today activity.8 As NHP is reasonably stable in both the short- and long-term,10 the patient should be assessed comfortably standing, engaged in natural conversation, and generating unposed smiles. The orthodontist then makes patient specific determinations of bracket height progressions to generate optimal enamel display8 and assesses the requirement for creation of torsion within the appliance to optimize axial inclination of the maxillary anterior teeth (Figure 4). Far too many finished orthodontic patients end up with proclined maxillary incisors, so we are purposeful in the assessment. • Optimize tooth shape, and improve gingival contour prior to bonding: The value of optimizing micro-esthetics in finishing is well appreciated.11 The less common strategy of creating a normalized contour of the teeth through positive and negative coronoplasty prior to bonding creates a number of opportunities. Ability to place brackets in vertical positions designed to enhance the smile
Figure 4: Effect on NHP on Smile Arc: Clinical assessment in NHP is one of the critical aspects of esthetic-based diagnosis. (Image courtesy of Dr. Rungsi Tavarungkul, 2012) Volume 6 Number 6
Active Early Model Tipping
Early Tipping Mechanics
Nonadjustable Mechanics Tipping
Straight-Wire Model Figure 3: In an “Active Early” case management model, forces directed to toward transverse arch development and control of axial inclination are lighter in magnitude, applied for longer durations, and applied earlier in the treatment cycle than in traditional “straight-wire” models. (Image courtesy of Dr. Tom Pitts)
arc, simplified correction of rotational control, and more predictable performance in third order movements are all benefits of normalizing tooth shape and contour prior to bonding. As SAP upper bracket positions to optimize esthetics are frequently more gingival than conventional positions, soft tissue recontouring can be a tremendous advantage when needed (Figure 5). • Increase torsion “built into” the appliance by “flipping” where needed: Torque expression is a complex process dependent upon12 magnitude of torsion, wire stiffness or resilience, bracket design, engagement angle, mode of ligation, wire dimension and corner radius of the wire, angulation of the bracket, deformation of the bracket or wire under torsion, manufacturing tolerances in the bracket and the wire, initial tooth inclination, bracket position, and the measurement technique used to evaluate torsion. Fortunately, to the clinician, it matters solely when/if torsion is developed within the slot during commonly used archwire progressions.
Figure 5: Achievement of SAP bracket position achieved after soft tissue revision (diode laser) and optimization of tooth shape. (positive coronoplasty) (Image courtesy of Dr. Nimet Guiga, 2015) Orthodontic practice 45
control of axial inclination and rotations. Passive ligation demands very accurate slots with special dimensions, particularly in the anterior region for obvious reasons. We favor the use of a PSL mechanism for many reasons: quick wire changes, consistent bracket engagement, lower forces and wire sliding with control, and improved hygiene, among others. We combine proven PSL case management strategies6 and “Active Early” approaches7 to control torsion and arch development, with the improved slot geometry and tighter tolerances of the H4™ appliance (Ortho Classic), along with more esthetic arch forms.
Figure 6: Case where “flipping and flocking” of brackets would be beneficial; proclined upper incisors, Class III occlusion, and retroclined lower incisors. Use of Class III biomechanics is anticipated. (Image courtesy of Dr. Duncan Brown, 2015)
With the worldwide tendency to treat more patients without extractions, the control of proclination of the maxillary anterior teeth has become a greater challenge. The correction of pre-existing crowding and proclination, proclination associated with relief of crowding during traditional round wire mechanics, or incisor proclination-associated Class III elastics is particularly problematic. The challenge for many non-extraction patients has been in getting enough lingual crown torsion without having to resort to complex wire bending to attain esthetic results. These are patients that benefit from “flipping (upper anteriors) and flocking (upper cupid)” the maxillary anterior/canine brackets.13 The “tooth by tooth” method of varying torsion “built into” the appliance is not as efficient for us and frequently requires either repositioning of brackets, or complex wire bending to finish precisely.14 In contrast, “flipping and flocking” and varying torsion in groups is far more predictable, requires fewer bracket repositions, and allows wire adjustments with uniformly “spun” wires (Figures 6-7). • Bond brackets to optimize esthetics not at the center of anatomic crown (FA): As today’s treatment targets for incisor position in three planes of space are based on esthetics,8,15 the reliance on “treatment built” into an appliance for the anterior teeth relative to the occlusal plane is not a practical way to ensure esthetically superior results. In the “Active 46 Orthodontic practice
Figure 7: “Flipped and flocked” upper anteriors, and “flipped lower incisors” appliance appropriate to counteract the anticipated effects of Class III mechanics. (Image courtesy of Dr. Duncan Brown, 2015)
Figure 8: SAP versus traditional bracket placement: For smile arc protection or enhancement, the wire plane should be parallel to the upper lip in a posed smile, and the incisal edges parallel to the lower lip. (Image courtesy of Dr. Tom Pitts, 2013)
Early” approach, individualized bracket positions based on esthetics7 (SAP) is combined with other initial planning considerations to gain control of maxillary incisor vertical position. For patients with “flat” occlusal planes or those that require increased enamel display, the divergence of the upper wire plane from molar to incisor created by bracket position must increase to develop the smile arc by extruding the upper incisors relative to the upper premolars. In patients with normal occlusal planes, a more modest progression in the upper wire plane is still advisable to protect the smile arc as we broaden the maxillary arch with treatment. A modest progression in still advised in deep bite cases to avoid excessive reduction in the smile arc as the overbite reduces. Compensating changes in the mandibular wire plane levels the mandibular arch and establishes an optimum overbite. It is not necessary to have a deeper bite to have a great smile arc.
Andrews’ “Six Keys” article, acknowledged as the catalyst for development of the first fully pre-adjusted appliance, advocates using the center of the clinical crown (FA), the long axis of the center of the clinical crown, and the thickness of the clinical crown from the long axis to FA,5 as guides for bracket positioning. This limits the usefulness of the appliance for patients whose teeth or faces deviate from “normal standards.” We do not subscribe to the core “straight-wire” principle that the wire plane must parallel the occlusal plane to attain excellent occlusions, and failure to adjust bracket height to adjust vertical positions of the maxillary incisors can result in esthetic deterioration. SAP bracket placement strategy allows adjustment of the vertical position of the maxillary incisors, which improves their display and the smile arc without increasing the overbite (Figure 8). • Appreciate the reality of undersize wires and oversized slots: Contemporary fixed orthodontic treatment is usually completed in wire sizes that are less than full dimension15 for the designed bracket Volume 6 Number 6
unpredictable. However, with the H4 bracket, the manufacturing tolerances are predictably accurate, with reduced slot depth leading to less wire adjustments. By varying bracket height with SAP bracket positioning and “flipping and flocking” maxillary anterior brackets when needed, lingual crown torsion is assured. By proper management of mandibular incisors, those teeth can be kept upright when required (Figure 10). • Use broader arch forms for better esthetics: Dr. Pitts has found that broader arch width, (not in the canine region) especially in the molars is more attractive, and smaller buccal corridors are preferred in both men and women. The alignment and broadening of maxillary and mandibular dental arches to reduce buccal corridors and producing “10” or “12” tooth smiles results in more space for the anteriors to have more lingual crown torque/inclination. Of course, proper inclination of the premolars and molars must be maintained upon broadening. Research has
confirmed that final arch width is a function of arch form, not of the bracket18 used during treatment, so an improved arch form is required for improved esthetics. One of the biggest impacts on transverse arch dimension in the molars, and arch form in general has been the adoption of “Pitts’ Broad” arch forms in both nonadjustable and adjustable wire profiles (Ortho Classic). This arch form improves the “flow” of mini-esthetics, making the attainment of a “12 tooth” smile much easier. By using a moderate progression SAP bracket placement, the orthodontist can broaden the arches and still maintain a beautiful smile arc (Figures 11-15). In short, the shape of the arch is just as important as the width. • Finish micro-esthetics details with optimal esthetics in mind: It was primarily the efforts of Dr. David Sarver who classified the concepts of macro-, mini-, and micro-esthetics19. While optimizing the “white and pink” tissues has been common practice in esthetic dentistry, it is less common in orthodontics20. By
Figure 9: Incremental increases in AW size is not an effective means of creating torsion within the appliance due to manufacturing discrepancies in slot dimension, AW dimension, and corner radius. (Image courtesy of Dr. Duncan Brown, 2015)
Figure 10: By understanding effects of bracket position and “wire play,” appropriate levels of lingual crown torsion can be attained by “flipping” anterior brackets. (Image courtesy of Dr. Duncan Brown, 2015)
Figure 11: Pitts’ Broad (green), Pitts’ Standard (yellow), Universal (blue) arch forms — broader arch forms produce broader arches and broader smiles. (Image courtesy of Dr. Tom Pitts, 2013)
Figure 12: Improved smile arc, broader smiles, and upright incisors as a result of SAP bracket position, “flipped and flocked” anterior brackets, Pitts’ Broad arch forms, and “Active Early” protocols. (Image courtesy of Dr. Duncan Brown, 2015) Volume 6 Number 6
Figure 13: Improved smile arc, broader smiles, and upright incisors as a result of SAP bracket position, “flipped and flocked” anterior brackets, Pitts’ Broad arch forms, and “Active Early” protocols. (Image courtesy of Dr. Duncan Brown, 2015) Orthodontic practice 47
slot dimensions. This seems gentler on the patient, and the consequences of this incompletely filled bracket lumen is torsional play that decreases engagement of the contact between the archwire and the bracket.16 While decreasing friction — a potential benefit during early leveling, aligning, and sliding mechanics — torsional play reduces control of axial inclination necessary for ideal esthetics. In clinical practice, incremental increases in archwire size is NOT the most effective means of controlling axial inclination when the slot isn’t filled7 (Figure 9). • Understand the appliance system you are using: Manufacturing tolerances also vary greatly so that the ability of the appliance to generate torsion with a specific wire progression and deliver stated appliance Rx17 is really what matters. Fortunately, to the clinician, it matters solely when/if torsion develops within the slot during commonly used archwire progressions. Unfortunately, many manufacturer’s tolerances often cause variable slot sizes, which makes torsion
Figure 14: Improved occlusion, arch form, and upright incisors as a result of SAP bracket position, “flipped and flocked” anterior brackets, Pitts’ Broad arch forms, and “Active Early” protocols. (Image courtesy of Dr. Duncan Brown, 2015)
mastering the techniques and disciplines applied in cosmetic dentistry, patients have the potential to finish with wonderful microesthetics that provide the final touch to patients who have well managed macroand mini-esthetic results (Figure 16). We take particular care in avoiding “black triangles” at the gingival papilla through management of contacts and connectors during the finishing process. It is an exciting time to be in orthodontics. Contemporary esthetic-based diagnosis, a modern understanding of how to optimize straight-wire appliances, use of advanced straight-wire appliances that control axial inclination and rotations, using esthetic broader arch forms, adopting the “Active Early” approach to case management, and finishing “white and pink” tissues for esthetics provide expanded opportunities for improving esthetics. In the “Active Early” approach, lighter forces, applied earlier, for longer duration are accomplishing many things more efficiently for the orthodontist and more gentleness for the patient than has ever been possible before. OP
REFERENCES 1. Janson G, Maria FR, Bombonatti R. Frequency evaluation of different extraction protocols in orthodontic treatment during 35 years. Prog Orthod. 2014;15(1):51. 2. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile. Clin Orthod Res. 1998;1(1):2-11. 3. Samsonyanová L, Broukal Z. A systematic review of individual motivational factors in orthodontic treatment: facial attractiveness as the main motivational factor in orthodontic treatment. Int J Dent. Epub 2014 May 20. doi: 10.1155/2014/938274. 4. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972; 62(3): 296-309. 5. MacLaughlin RP, Bennett JC. Evolution of treatment mechanics and contemporary appliance design in orthodontics: a 40-year perspective. Am J Orthod Dentofacial Orthop. 2015; 147(6):654-662. 6. Pitts T, Brown D. The 14 Keys to Pitts Case Management and Active Early Concepts. Pitts Protocol. 2015; 1:8-15. http://issuu.com/orthoclassic/docs/pitts_protocol_issue_1. Accessed October 12, 2015.
48 Orthodontic practice
Figure 15: Improved incisor inclination as a result of SAP bracket position, “flipped and flocked” anterior brackets, Pitts’ Broad arch forms, and “Active Early” protocols. No miniscrews or surgery used. (Image courtesy of Dr. Duncan Brown, 2015)
Figure 16: Post-orthodontic micro-esthetic adjustments to “white and pink” tissues resulting in a beautiful mini-esthetic result. (Image courtesy of Dr. Nimet Guiga, 2015)
7. Pitts T, Brown D. Active early Principles. Pitts Protocol. 2015;2: 8-14. http://issuu.com/orthoclassic/docs/pitts_ protocol_issue_2. Accessed October 12, 2015. 8. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001; 120(2): 98-111. 9. Pitts, T. Begin with the end in mind and finish with beauty. EJCO. 2014;2(2):39-46. 10. Peng L, Cooke MS. Fifteen year reproducibility of natural head posture: a longitudinal study. Am J Orthod Dentofacial Orthop. 1999;116 (1):82-85. 11. Brandão RC, Brandão LB. Finishing procedures in orthodontics: dental dimensions and proportions (microesthetics). Dental Press J Orthod. 2013;18(5):147-174. 12. Archambault A, Major TW, Carey JP, Heo G, Badawi H, Major PW. A comparison of torque expression between stainless steel, titanium molybdenum alloy, and copper nickel titanium wires in metallic self-ligating brackets. Angle Orthod. 2010;80(5): 884-889. 13. Pitts T, Brown D. Flipping and Flocking. Pitts Protocol. 2015;3: 6-18. 14. Johnson E. Selecting custom torque prescriptions for the
straight-wire appliance. Am J Orthod Dentofacial Orthop. 2013;143(4):S161-167. 15. Badawi HM, Toogood RW, Carey JP, Heo G, Major PW. Torque expression in self-ligating brackets. Am J Orthod Dentofacial Orthop. 2008; 133(5): 721-728. 16. Meling TR, Odegaard J, Meling EO. On mechanical properties of square and rectangular stainless steel wires tested in torsion. Am J Orthod Dentofacial Orthop. 1977;111(3):310-320. 17. Dalstra M, Eriksen H, Bergamini C, Melsen B. Actual versus theoretical torsion play in conventional and self-ligating bracket systems. J Orthod. 2015;42(2):103-113. 18. Fleming PS, Lee RT, Marinho V, Johal A. Comparison of maxillary arch dimensional changes with passive and active self-ligation and conventional brackets in the permanent dentition: a multicenter, randomized controlled trial. Am J Orthod Dentofacial Orthop. 2013; 144(2): 185 -193. 19. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120(2): 98-111. 20. Sarver DM. Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop. 2004;126(6):749 – 753.
Volume 6 Number 6
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Evolving Concepts in the Management of Class II and III Problems: Reflections Over 40 Years
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Orthodontics and 3D Technology: What You Need To Know
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Beyond Biomechanics: The Use of Injectables in Orthodontics
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Revelations of a Revitalized SLB Enthusiast - I Got My MOJO Back!
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7 ways online patient communication tools can improve your practice efficiency Scott Eklund discusses the importance of having the right tools and systems for patient communication
anaging a successful practice isn’t just about delivering quality results. To stay profitable, orthodontists and practice managers must reduce no shows, keep schedules full, collect treatment fees, and attract new patients. In order to achieve these goals, your practice has likely developed a comprehensive, and perhaps complicated, set of systems to manage your daily activities. Many times these existing systems are carried out manually instead of being automated, leading to inconsistent results, inefficient use of your staff’s time, and unhappy patients. By implementing a robust patient communication system, you can automate many of your processes, save time, and improve the patient experience. The following seven tips will help you take full advantage of your patient communication system and improve your practice efficiency.
1. Appointment reminders and confirmations How much time and effort is spent in your practice making routine appointment confirmation calls, manually sending emails, or mailing postcards? Not only are these methods time consuming, they are also inefficient and inconsistent. By automating the appointment confirmation process through online communications tools, you can significantly cut down on the administrative work required to complete this routine task and drastically reduce no-shows. The numbers on this are pretty clearcut; over 85% of orthodontists say automated reminders reduced no-shows and increased production.1 These automated reminders reduce stress, as your team knows confirmations will be executed in a timely, complete, and consistent manner. In fact, 87.6% of surveyed dental professionals agreed that automated patient reminders give them the peace of Scott Eklund is the Marketing Manager at Sesame Communications, the premier provider of online services for the dental industry. Sesame helps dental and orthodontic practices harness the power of the Internet to accelerate new patient acquisition and transform the patient experience
50 Orthodontic practice
mind to know that all patients are consistently contacted prior to their appointment.1
2. Collection calls Calling patients about past-due payments is both time consuming and awkward. As a practice that strives every day to build a strong, positive relationship with each patient, a call about a past-due payment can put stress on this relationship and may not always be effective in soliciting payment quickly. An email about a past due balance discretely nudges the patient and is much less confrontational or embarrassing than a personal phone call. Most importantly, this is less expensive and more effective in collecting payment. Research shows that within 24 hours of sending an automated past due balance email reminder, 32% of patients make an online payment. Within 48 hours, 50% will make an online payment.2
3. Payment processing Patients have come to expect online bill-pay with their utilities, credit card, and phone payments, so why is a payment for their orthodontist any different? The convenience of being able to pay online not only means a quicker turnaround for payments, but the ability to collect payment outside of office hours.
Sesame Members receive over 46% of their payments outside of normal business hours3 — meaning the money is in their account and waiting for them by the following morning.
4. Health history forms When new patients decide to start treatment, they are required to read and fill out an extensive amount of paperwork. This process takes a lot of time and effort by the patient, which slows down your patientintake process and ultimately makes your practice less efficient. By providing online health history forms, you allow your patients to complete the forms at their convenience and help make their initial visit more comfortable. It’s also more efficient — an online health history form keeps the data digital, where it can then be used by your practice management system and patient communication systems. It’s a high-tech timesaver that is fast becoming an expectation from patients.
5. Patient feedback Orthodontic practices can be a hectic environment, and many practices often fail to ask their most valued patients for feedback on how to better serve them. Feedback from patients is a crucial part of understanding where your practice excels, and where there is room for improvement. Timely feedback Volume 6 Number 6
6. Newsletters and greetings Patients want to know what’s new in your practice, and it’s your responsibility to keep them up-to-date. The average orthodontist has hundreds, even thousands of active patients. This magnitude of patients makes it difficult to have a personal connection with each one of them on a regular basis. By reaching them electronically through email newsletters, you can keep in touch with patients and facilitate their engagement in your practice on an ongoing basis.
In addition to formulating informative educational newsletters, a patient communication tool allows you to use email to automatically manage your holiday and birthday greetings. If you’re mailing postcards for these occasions, you can save both time and money by using an automated system. No need to worry about remembering a patient’s birthday; these reminders will go out automatically.
7. Daily schedule One of the most widely used tools of a successful practice is the daily schedule. This simple tool is the single most critical element determining production and profitability. In a fast-paced environment, it is imperative to have a functional schedule that provides you and your team with the necessary patient information so you can best serve them. A digital solution can help solve this by bringing your daily schedule and your practice management software together. Sophisticated patient management tools let you view your daily schedule at a glance from any computer, access all your patient data, control reminder settings, and more. Ensure the system you choose integrates with your
dental practice management software, so you’re always working off of the latest information for new and existing patients.
Take your practice to the next level Managing a successful practice takes a lot of work, but with the right tools and systems in place, you can improve staff efficiency, patient experience, and practice profitability. There are many patient communications systems in the market that have a lot of different features and price points. Make sure that the system you choose to work with has the preceding features at a minimum, and you will be on your way to practice success. OP
REFERENCES 1. Sesame Communications. 8 Ways to use online patient communication tools to improve practice efficiency and effectiveness: A Sesame Guide to Practice Success [white paper]. http://www.sesamecommunications.com/research/ patient-communication/?gated=true. Accessed October 6, 2015. 2. Friedman D. Sesame Communications database of dental and orthodontic members. 2014. 3. Friedman D, TransFirst®. Impact of online bill pay on accounts receivable and practice efficiency [case study]. 2014. http://www.sesamecommunications.com/ wp-content/docs/education-research/Case-Study_Transfirst.pdf. Accessed October 6, 2015.
MAKE THE INTERNET WORK FOR YOUR PRACTICE WITH SESAME Website Design
Drive More New Patients and Increase Production Call Sesame At
sesamecommunications.com Volume 6 Number 6
Orthodontic practice 51
allows you to keep tabs on your patients’ level of satisfaction and promptly take corrective action as needed. By automating the feedback process with post-appointment survey emails, you ensure a steady stream of constructive feedback from patients without spending time trying to administer the surveys yourself. You can then use this valuable information to continually improve the experience of patients in your practice and keep them returning. More importantly, you can leverage great reviews and feedback provided by your patients to enhance your online presence, social media channels, and SEO.
Controlled molar distalization James Bonham discusses a durable, comfortable, and predictable appliance
rthodontists today have multiple appliance options to achieve molar distalization. Some distalization appliances have a broader market exposure than others, usually created through podium speakers and company marketing campaigns. Recently, an appliance called the Rapid Molar Distalizer (RMD) has grown only by word of mouth to become the doctor- preferred distalization appliance at Specialty Appliances laboratory. After thousands of successfully treated cases, we wanted to share what makes this distalization appliance so exceptional. The Rapid Molar Distalizer (RMD) offers predictable molar distalization without molar tipping or anterior advancement. Using small expansion screws on the buccal of the arch, the RMD does not interfere with the patient’s speech or swallow pattern. Each screw is comfortably placed parallel to the buccal line angle or central groove, and capable of 12 mm of distalization. When seeking either unilateral or bilateral molar distalization, orthodontists have complete control through their prescribed screw activations. Each screw is generally activated twice per week (right Monday, left Wednesday, right Friday, and left Saturday) until desired distalization is achieved. With
RMD with added transverse expansion and lingual buttons to aid in second bicuspid retraction
James Bonham is a partner at Specialty Appliances and manages sales and marketing. He has spent the past 12 years in orthodontics with a strong focus on the integration of digital technology into orthodontic practices.
52 Orthodontic practice
only a ¼ millimeter activation per turn, there is no continuous pressure on the patient’s anterior tissue. This eliminates the Nance indent on anterior tissue and prevents tipping of anterior teeth that is seen in most distalization appliances. Appliance anchorage can be tailored to the patient. In the absence of fully erupted permanent second molars, the appliance is anchored to bands on the first bicuspids and first molars. The second bicuspid will generally follow the first molar down the alveolar process. If the patient has fully erupted second permanent molars, it is anchored to the second molar bands and the second bicuspids. In this case, the first molar will generally follow the second molar down the alveolar process. Lingual buttons are often added so power chain can close the diastema from the drifting teeth. Transverse corrections are often desired before distalization. The RMD can incorporate a palatal expansion screw in the second bicuspid area, soldered to the lingual support wire. The appliance has extension to the first or second molars as needed but is not soldered to the molar bands so distalization can occur. Digital scanning and computer-aided design technology delivers many positive workflow enhancements. The Rapid Molar Distalizer is the only distalizing appliance that allows for same day fabrication of both RMD and the holding Nance appliance. Because RMD distalization is measureable by the number of screw activation turns, simply inform the laboratory how much distalization is desired. Specialty Appliances will digitally replicate the prescribed distal movements and print a second model for Nance fabrication. With this new process, doctors eliminate a valuable appointment and deliver the Nance immediately after removing the RMD. Due to its solid reputation of durability, patient comfort and predictable results, the RMD has become the orthodontist’s distalizing appliance of choice at Specialty Appliances. For more information please visit our website at www.specialtyappliances.com or contact us at 1-800-522-4636. OP
Figures 1A-1C: A. Before RMD. B. RMD in progress. C. After RMD
“The RMD is the most stable distalization appliance I’ve ever used, giving me complete control without breakage.” – C. Lynn Davis, DDS
Volume 6 Number 6
American Orthodontics Digital Marketing Resources
merican Orthodontics is committed to helping you grow your practice. We do this by supporting your marketing efforts with a full library of digital resources. From customizable literature and other promotional marketing materials, to the ability to download a full library of assets to build your website, AO is committed to helping your practice succeed. Here’s a look at AO’s available digital resources.
American Orthodontics is committed to helping your practice succeed.
AO Custom Plus AO Custom Plus allows you to elevate your practice’s brand by customizing literature with your practice logo and information. The site features custom patient brochures that let you educate your patients about the products used in your office, while keeping your brand top of mind with the use of your practice logo and contact information. You can also add doctor biographies and other information. In addition to patient literature, AO Custom Plus features customizable direct mail postcards that can be directly shipped to potential patients, as well as other customizable promotional marketing materials. AO Custom Plus also helps you with the critical task of attracting new patients. The site lets you download materials with information on holding Adult Patient Seminars. This turnkey solution offers you all the materials you need to host these seminars that help get interested prospects in the door. The 60-minute in-office seminars are geared toward adults — often the parents of existing patients, and allow you to provide an overview of your practice, the orthodontic specialty, clinical benefits of straight teeth,
treatment options available, and the next steps in the treatment process. Customized flyers and direct mail postcards are available to market these events in your region. http://www.aocustomplus.com/
AO Asset Library Boosting the look and credibility of your website is critical in marketing your practice. The AO Asset Library helps with this by providing relevant product images, videos, and more for use on your website and marketing materials. This means you don’t have to use generic stock footage. AO logos are also available for use on your site. http://americanortho.organize.cgx.com/ PORTAL/STARTUP.php
AO YouTube Channel Engaging videos can help patients understand their treatment and make them
Customizable postcards promoting Adult Orthodontic Seminars are available on AO Custom Plus
AO patient literature can be customized with practice information
feel more comfortable and confident about what procedures and products you utilize in your practice. American Orthodontics’ YouTube Channel contains relevant patientfacing videos, including patient testimonials for several AO products such as Radiance Plus™ ceramic braces, Empower® Clear self-ligating brackets, and the Harmony digital lingual system. These videos can be directly viewed on YouTube, or linked directly to your site. https://www.youtube.com/user/ AmericanOrthodontics
AO Direct AO Direct is American Orthodontics’ robust online ordering system, built with the needs of the modern orthodontist in mind. It’s another way to help keep your practice running efficiently by allowing you to easily order products, check account status, build your own custom catalog, and more. With 24/7 access, AO Direct complements AO’s already world-class customer service team. http://www.aodirect.com
About American Orthodontics American Orthodontics is the largest privately held orthodontic manufacturer in the world, proudly based in Sheboygan, Wisconsin. Since 1968, American Orthodontics has been manufacturing quality orthodontic products and peripherals for customers in more than 100 countries. More than 90% of American Orthodontics’ products are manufactured at its state-of-the-art Sheboygan facility using highly automated production equipment and a skilled, dedicated workforce. With 11 wholly owned subsidiaries, a direct sales force in North America, and a global team of exclusive distributors, American Orthodontics is a true orthodontic industry leader, committed to providing customers quality products, personalized service, and dependable delivery. OP This information was provided by American Orthodontics.
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Volume 6 Number 6
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
G&H Orthodontics celebrates milestone and rebranding
his year marks our 40th anniversary as a leading diverse global provider of clinical solutions for the orthodontic community. In celebration of this milestone, we embarked on a comprehensive rebranding, which was unveiled at this year’s American Association of Orthodontists Annual Session in San Francisco. We have built a reputation as a precision manufacturer of high-quality orthodontic product lines — archwires, springs, and elastomerics. We introduced to the profession new levels of evidence-based testing for applied intraoral forces. The response from clinicians worldwide has made products like G4™ Nickel Titanium the standard of the industry for quality and consistency. In 2012, we acquired Orthodontic Design and Production, a manufacturer of high-quality brackets, bands, and tubes, further advancing the breadth of products manufactured by G&H. Our rebranding is a natural outcome of this successful merger. We have fully integrated our customer service, sales, marketing, manufacturing and distribution departments with such success that we were selected by GE Capital as “Performance Improvement Partner of the Year.” Our rebranding symbolizes that every team member is dedicated to deliver on our mission: To provide our customers with a great experience achieved through quality manufacturing and exceptional service. 56 Orthodontic practice
With the proven performance of our brackets, wires, elastomerics, and practice supplies, we boast a 99% practitioner satisfaction rating on our manufactured items. As the world’s best manufacturer of premium archwires, we are proud to introduce our new M5™ Thermal Copper Nickel Titanium Archwire. M5™ Thermal Copper NiTi offers gentler loading forces for easier engagement and a precise temperature transformation of 27°C for consistent, predictable tooth-moving forces. M5™ wire, as are all G&H wires, is processed with a proprietary polishing technique to facilitate reduced surface friction. Please contact us for a free sample in your preferred wire size and shape at firstname.lastname@example.org, or call 888-8913748. We offer a full line of orthodontic products made in the United States. In addition to our precision-manufactured products, our OrthoClub® adds another supply dimension, which makes us truly unique in the industry. The OrthoClub offers orthodontists a selection of more than 6,000 brand-name clinical supplies. OrthoClub specializes in the disposable
and consumable supplies used daily in every orthodontic office. Items such as gloves, masks, disinfectants, sterilants, and much more — all with the brand names you know and trust — are available through this program. OrthoClub also offers discounted pricing through its membership option. Members receive deep discounts on all clinical-supply items as well as every G&H manufactured product. By combining high-quality, cutting-edge technologies with an all-encompassing product line and personalized customer care, we offer global distributors and individual doctors a truly unique partner that is ready, willing, and able to help their businesses flourish. It’s an exciting time here at G&H, and it is our continued commitment to provide our customers a great experience achieved through quality manufacturing and exceptional service. To learn more about G&H Orthodontics’ products, visit GHOrthodontics.com. OP This information was provided by G&H Orthodontics.
Volume 6 Number 6
G&H® makes brackets in the U.S.A., and that makes the difference.
G&H® Brackets Most Preferred by Orthodontists
Low Profile Bracket System Metal Injection Molded Surgical-Grade Stainless Steel (MIM)
“miniPrevail brackets are high-quality twin brackets. The base and scribe lines make for easy bracket placement. The tie wings allow for easy tie-ins with multiple ligatures if needed, but are strong and comfortable for the patient.”
– Graham Jones, D.D.S., M.S.D.
Unique Features: – MIM Manufactured with all the features of a modern mini twin – Distinctive Compound Contoured esh Bonding Base Mesh for increased bonding strength and precise placement
Unique Features: – CIM Manufactured for strength and smooth contours – Revolutionary Bonding Base Adhesive flows through the portals for unprecedented, secure, mechanical bonding
The G&H® Difference – A full, synchronized G&H orthodontic system State-of-the-art engineering and the highest quality materials Excellent value when you buy from G&H, the US manufacturer Available in popular bracket prescriptions Temporary color-coded ID system with permanent identification indents for ease of use Full rotational control Low profile and rounded facial contours for patient comfort
Contact G&H® for trial offers, samples or to schedule a Free Bracket Consultation Online at: GHOrthodontics.com/consult or call: 888-891-3748
See and order our full line of products at
Ceramic Bracket System Ceramic Injection Molded Polycrystalline (CIM)
“The Vapor system provides all the characteristics one would look for in a high-quality ceramic bracket: esthetics, ease-of-bonding, smoothness and strength. Thanks to the unique portals in the base, mechanical bond strength is enhanced yet the bracket is easy to debond. It is made in the USA and is cost-effective. I can’t think of anything else one could possibly ask for.” – Howard Fine, D.M.D., M.M.S.c
MKT.004.B – OPRCT1015
miniPrevail and Vapor are trademarks of G&H Orthodontics
CEREC® 30 An unforgettable extravaganza of unsurpassed hands-on learning and first-class entertainment
irona Dental, Inc., celebrated its momentous CEREC 30th Anniversary Celebration (C30) with a 3-day educational extravaganza geared toward all dental and laboratory professionals. An impressive ensemble of key opinion leaders journeyed from around the world to delve into a multitude of CEREC-specific topics. Excitement for this event The event was hosted at The Venetian and the Palazzo Las Vegas from September 17-19, 2015. Highlights included an extensive exhibit hall showcasing top dental companies, an outstanding educational curriculum, and amazing entertainment. Original attendance projections of 5,000 attendees were exceeded. MedMark’s Publisher Lisa Moler and National Sales Manager Adrienne Good were invited to attend Sirona’s premier continuing education forum. They had the opportunity to see an exhibit floor jampacked with the best and newest Tony Robbins speaking at C30 Train performing on stage with audience members technology, to attend educational This event will be difficult to top, but Lisa and Adrienne both noted that in their and uplifting main and breakout sessions, Sirona promises to host more extrava11 years of attending dental publishing events, to sample top-notch delicious food, and to ganza events. You do not want to miss that this one was one of the most valuable that enjoy unbeatable entertainment. the next one! they had ever experienced. Grammy awardLisa interviewed life success and business Visit the website: www.cereconline.com/ winning band, Train, rocked the night for all leadership coach Tony Robbins (see pages siroworld-information to stay apprised of attendees, and the Nasdaq closing bell was 2-3). His speech the previous evening was future events. OP live onsite! What a great experience! powerful and informative.
Exhibit floor 58 Orthodontic practice
NASDAQ close Volume 6 Number 6
Martin Kaplan, DMD, and Peter Vitruk, PhD, explore soft tissue CO2 laser uses in orthodontics Introduction Soft tissue surgical lasers have many advantages over traditional scalpel surgery, cryosurgery, and electrosurgery. However, not all lasers are equally efficient at both cutting the soft tissue, coagulating, and hemostasis because light absorption in the soft tissue varies with wavelength.1-3 As illustrated in Figure 1, some dental laser wavelengths (around 1,000 nm, such as diodes and Nd:YAG) are efficient coagulators, but inefficient scalpels since they are poorly absorbed by the soft tissue. Other dental laser wavelengths (around 3,000 nm, such as Erbium lasers) are well absorbed by the water-rich soft tissue and are great at cutting, but are not as efficient at coagulating and hemostasis.
Why CO2 laser?
The 10,600 nm CO2 laser wavelength it is not as good as Erbium laser at cutting (but is a much better coagulator2) and not as good as diode/Nd:YAG laser wavelengths at coagulating (but is a much better scalpel2,3). As indicated in Figure 1, the 10,600 nm CO2 laser wavelength is a compromise for simultaneous cutting and coagulation/hemostasis; most importantly, the 10,600 nm CO2 laser’s coagulation depth closely matches blood capillary diameters2. The radiant energy of the CO2 laser is used directly to photothermally vaporize (cut, incise, ablate) and, at the same time, to photo-thermally coagulate the soft tissues. The CO2 laser is a “whatyou-see-is-what-you-get” surgical soft tissue
Figure 1: Optical absorption coefficient spectra2 at different histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2), and melanin. Logarithmic scales are in use
laser with minimal collateral thermal effects that are sufficient for sealing blood vessels, lymphatics, and nerve endings; the surface bacteria are efficiently destroyed4 on incision/ ablation margins. Laser handpieces and ergonomics The CO2 surgical lasers in the 1970s1980s utilized the articulated arm beam
Dr. Martin Kaplan, DMD, practices exclusively in Stoughton, Massachusetts. Dr. Kaplan completed his undergraduate degree at the University of Massachusetts and then attended Tufts University School of Dental Medicine. After earning his DMD degree, he completed a pediatric residency at Montefiore Hospital in New York. Dr. Kaplan is an Adjunct Clinical Instructor at Tufts University School of Dental Medicine in the Postgraduate Pediatric Dental and Orthodontic Departments. He is a member of the American Academy of Pediatric Dentistry, Massachusetts Academy of Pediatric Dentistry, American Dental Association, Academy of Laser Dentistry, Massachusetts Dental Society, Academy of Sports Dentistry, Massachusetts Breastfeeding Coalition, and Breastfeeding USA. Dr. Kaplan continues to take advanced training and recently gained masters’ proficiency in Laser Dentistry. He is one of only a handful of pediatric laser dentists. When not practicing dentistry, Dr. Kaplan enjoys karate and has attained the level of fourth-degree black belt. Peter Vitruk, PhD, MInstP, CPhys, is a founder of LightScalpel, LLC, in Woodinville, Washington. He is a member of The Institute of Physics, United Kingdom, and is the member of the Science and Research Committee, Academy of Laser Dentistry, United States. He is also on the faculty of Global Laser Oral Health, U.S. Dr. Vitruk can be reached at 1-866-589-2722 or email@example.com.
Volume 6 Number 6
delivery systems. The flexible, hollow fibers, introduced in the 1990s, significantly simplified CO2 laser surgery. Modern flexible fiber CO2 lasers use a scalpel-like ergonomic autoclavable handpiece (Figures 2 and 3) for 1) cutting, 2) ablation, and 3) photothermal coagulation and hemostasis. Tipless CO2 handpieces are designed to operate without disposables. The right-angle, pensized tipless handpiece permits easy and convenient access to the soft tissue within the oral cavity in patients of all ages, including infants.5 Photo-thermal ablation and coagulation The photo-thermal ablation of soft tissue is a process of vaporizing intra- and extracellular water near the surface, where the laser beam intensity is at its maximum. For a fixed laser beam diameter (or spot size), the volume of the tissue exposed to laser beam is proportional to the optical penetration depth (inverse of absorption coefficient Orthodontic practice 59
Soft tissue 10,600 nm CO2 laser orthodontic procedures
TECHNOLOGY from Figure 1). The 10,600 nm CO2 laser is energy efficient at ablating the soft tissue photo-thermally with low ablation threshold intensities due to very small volume of irradiated tissue (because of extremely short absorption depth around 15 µm).2 Immediately below the ablation zone, the coagulation zone is located where the denaturation of soft tissue proteins occurs in 60°C–100°C temperature range. This process leads to a significant reduction in bleeding and oozing of lymphatic liquids on the margins of ablated tissue. For the CO2 laser, its excellent coagulation efficiency is due to the close match between the sub-100 µm6 photo-thermal coagulation depth2 and the oral soft tissue blood capillary diameters of approximately 20-40 µm7. Laser pulsing and controlling thermal effects Laser pulsing is as important for laser surgery as the wavelength — short and powerful pulses are often superior to long and weak ones. The exact physics of pulsed laser surgery deals with the Thermal Relaxation Time,2,3 which depends both on tissue’s light absorption and thermal diffusivity, first described by Einstein.8 The rate at which the irradiated tissue diffuses the heat away is defined by Thermal Relaxation Time TR, which equals approximately 1.5 msec for 75% water-rich soft tissue irradiated by the 10,600 nm CO2 laser. Practical implications of the Thermal Relaxation Time concept are simple, yet crucial for the appropriate application of laser energy. The irradiated tissue heats most efficiently when the energy of a laser pulse is high, and the duration of a pulse is much shorter than TR. The tissue adjacent to the ablated zone cools down most efficiently when time duration between laser pulses significantly exceeds TR. Such laser pulsing is referred to as SuperPulse (see Figure 4). SuperPulse minimizes the depth of coagulation and is therefore a must-have feature of any state-of-the-art soft tissue surgical CO2 laser. The optimal combination of the CO2 laser wavelength and pulsing results in a char-free and bloodless surgery. This also allows for a scar-free, uncomplicated healing that is valued by surgeons across all specialties such as dentistry, OMFS, ENT, and plastic surgery. Laser beam spot size for cutting and coagulation Just like the sharpness of the steel blade defines the quality and ease of the incision, the size of the laser beam focal spot defines the quality of the laser cut. The smaller 60 Orthodontic practice
Figure 2: CO2 laser angled dental tipless handpiece. The handpiece is pen-sized, autoclavable, and uses no disposables
Figure 3: Laser-tissue incision with focused (0.25 mm spot size) laser beam. Defocused beam (approx. 0.8 mm spot size) with reduced fluence coagulates the tissue
Figure 4: SuperPulse explained: High-power, short laser pulse duration maximizes soft tissue removal rate and keeps adjacent tissue cool
Figure 5: Ablation depth in water-rich soft tissue with LightScalpel’s tipless dental handpiece at 2 watts SuperPulse
The many uses for a soft tissue CO2 laser in orthodontics, such as gingivectomies, frenectomies, exposure of impacted teeth, and others, feature minimal blood loss and reduced discomfort for the patients. (or sharper) the focal spot of the beam, the narrower and deeper the incision. For cutting, the LightScalpel laser handpiece is maintained 1 mm–3 mm away from the tissue and is moved at a hand speed of a few millimeters per second as illustrated in Figure 3. Just like a dull blade cannot produce a quality incision, an oversized laser beam spot cannot produce a precise and narrow cut. For a rapid switch from cutting to photo-coagulation alone, the laser beam can be de-focused either by selecting a larger spot size, or by simply moving the handpiece away from the tissue by approximately 10 mm (for LightScalpel tipless laser handpieces), and “painting” the “bleeder” for enhanced hemostasis. Laser power density and depth of ablation For a laser scalpel, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade. In other words, greater
laser fluence3 (i.e., higher power density and slower hand speed) results in greater depth and rate of soft tissue removal. During each SuperPulse pulse, the ablation depth δ is given by the formula δ = A (E – Eth) / Eth for the steady state ablation conditions3 where A is the absorption depth from Figure 1 and Eth is the ablation threshold fluence,3 and E is the fluence during the SuperPulse pulse. At the 10.6 µm wavelength of the CO2 laser, the ablation threshold for a water-rich soft tissue with an assumed water content of 75% equals approximately Eth = 3 J/cm2. For repetitive pulses that are scanned across the soft tissue, the fluence is defined by the pulse frequency and the hand speed: i.e., the depth of incision depends on laser power settings, spot size, and the surgeon’s hand speed (Figure 5). Two important built-in safety features are 1) sub-millimeter superficial depth of ablation and 2) approximately 0.2 mm ablation depth variation as distance to tissue changes in Volume 6 Number 6
TECHNOLOGY Figures 6A-6C: A. Pre-op view. Gingival hyperplasia due to poor oral hygiene. B. Intra-op view with laser markings prior to incision. C. Two weeks’ post-op view shows good tissue healing
1 mm–5 mm range, which makes the CO2 laser a gentler and more forgiving tissue vaporization instrument in comparison with a scalpel, electrosurge, or diode surgery. Also significant is the switch from ablation to coagulation mode by defocusing the beam, with laser beam fluence dropping below the ablation threshold of 3 Joules/cm2.2
CO2 laser use in the presence of orthodontia hardware Gingival hypertrophy (caused by orthodontic positioning and poor oral hygiene) as well as overlying operculum are common problems during orthodontic therapy.9-11 Drug-induced hyperplasia presents another challenge for some orthodontic patients.13 Additionally, orthodontic devices attract bacteria and thus exacerbate the inflammation; periodontal disease often worsens in adolescents with fixed orthodontic hardware.9-13 Figure 6 demonstrates completely bloodless CO2 laser gingivectomy around the mandibular incisors in the orthodontic patient. CO2 laser gingivectomies, such as the ones presented in Figures 6-8, help improve the esthetics and oral health; they also allow for more ideal bracket placement and quicker treatment with fewer appointments. Gaining access to an impacted tooth or teeth is often necessary in order to place orthodontic braces. With conventional scalpel surgery, many problems occur when placing brackets, such as sutures breaking before brackets are bonded. Brackets will not bond properly if enamel is wet due to bleeding. Clean, bloodless enamel is necessary for enamel acid etching and bonding of the composite resin. Using the CO2 laser to expose an impacted tooth produces a dry surgical field thus creating conditions required for immediate bracket bonding. The CO2 laser-assisted cuspid exposure procedure is shown in Figure 9. This quick CO2 Volume 6 Number 6
Figures 7A-7C: A. Pre-op view of thick hyperplastic gingiva. B. Immediate post-op view. Note excellent hemostasis. C. Two weeks’ post-op view
Figures 8A-8C: A. Pre-op view of the mandible with gingival hyperplasia. B. Immediate post-op. C. Two weeks’ post-op view. Note rapid healing
Figures 9A-9C: A. Laser-marked outline of impacted tooth. B. Intra-op view of CO2 laser excision. C. Immediate post-op view of impacted tooth exposed to assist with eruption
Figures 10A-10C: A. Pre-op view of excessive gingiva causing a “gummy” smile. Low frenal insertion obstructing access for maintaining oral hygiene can also be seen. B. Immediate post-op view of CO2 laser-assisted gingivectomy and frenectomy. C. Four weeks’ post-op healing of improved crown length after recontouring of excessive gingiva (no encroachment of biological width) Orthodontic practice 61
Figures 11A-11C: A. Diastema and rotation of tooth No. 9. Pre-op view. B. Immediate post-op. Note excellent hemostasis and clean margins. C. Post-op view final. Diastema closure and self-corrected rotation of tooth No. 9
Figures 12A-12C: A. Pre-op view showing thick maxillary labial frenum and diastema. B. Immediate post-op view with good hemostasis. No sutures were placed. C. 4 weeks post-op with healed tissue
Figures 13A-13C: A. Pre-op view of a wide tight maxillary labial frenum in an infant. B. Immediate post-op. C. 2 months post-op. (Mother did not follow home-care instructions. However, very wide and dense tissue often requires two treatments)
Figures 14A-14C: A. Pre-op view. Lingual frenum restricts range of motion. B. Intra-op view. During frenum ablation, a sublingual vein was exposed. It was quickly coagulated and sealed with the defocused laser beam. C. Immediate post-op tongue-tie release. Anterior view with noticeably improved tongue lift
laser treatment allows access for bracket placement, saving the patient months of waiting for the tooth to erupt on its own. The CO2 laser provides a clean, non-bleeding border. The CO2 laser straight and angled handpieces, illustrated in Figures 2 and 3, permit a convenient reach into areas that may be obstructed by braces. Once an impacted tooth is exposed by laser ablation, the bloodless surgical field is ready for the next step. The orthodontic traction hook can be bonded to the exposed enamel immediately after ablation during the same visit,10,11 saving time for both the patient and clinician. Many patients require banding of molars, but an overlying operculum gets in the way of placing appliances on these teeth. The CO2 laser is an excellent tool to remove this excess tissue. Hemostasis allows for banding to happen immediately following CO2 treatment. Local anesthetic may be required in some cases. Figure 15 presents the LightScalpel LS-1005 CO2 laser operculectomy (3 watts SuperPulse Repeat Mode F1-7) prior to band placement. Bands were seated shortly after operculectomy was performed, in the same visit. An important safety consideration is the heating rate of the orthodontia that could be accidentally exposed to a direct laser beam. Due to the differences in the light reflectance of stainless steel at different wavelengths,14 the wavelengths of approximately 800 nmâ€“3,000 nm (diode, Nd:YAG and Erbium lasers) are absorbed 50%-250% stronger than CO2 laser wavelengths around 10,000 nm. Such high reflectivity by stainless steel makes the CO2 laser the safest wavelength around stainless steel orthodontia. When compared to lasers, electrosurgical units present a different safety challenge of conducting electrical currents by orthodontic hardware during accidental contacts with electrosurgical electrodes.
Figures 15A-15C: A.Pre-op view of operculum visible on mandibular first molar. The bands cannot be seated due to tissue interference. B. Immediately post-op view. Laser ablated the thick interfering tissue. Note lack of bleeding. C. Bands were seated properly and without discomfort during the same visit the operculectomy was performed 62 Orthodontic practice
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TECHNOLOGY Minimized bleeding for enhanced visibility and precision The enhanced hemostatic ability and precision of the CO2 laser is especially valuable in visible (esthetic) zones. The CO2 laser surgical removal of the tissue presented in Figures 6-15 illustrates excellent coagulation and hemostasis due to a close match between the oral soft tissue blood capillaries’ diameters of 20-40 µm7 and the coagulation depth during soft tissue ablation.2 Incisions with minimal bleeding, or entirely bloodless incisions, provide great visibility of the cut site, and thus higher precision for a minimized tissue trauma and better esthetic outcome.9-13,15-17 For example, Figure 10 shows the use of LightScalpel LS-1005 CO2 laser (2 watts SuperPulse Repeat Mode with F1-6 through F1-8 settings) for soft tissue crown lengthening of the maxillary incisors and for labial frenum revision. Both procedures were performed during the same visit while the patient was under anesthesia. No sutures were placed. Figure 11 presents the selfcorrection of a rotated tooth No. 9 after frenum revision. Laser frenectomies in Figures 12 and 13 resulted in spontaneous closure of midline diastemas. In comparison with traditional scalpel surgery, the precision of CO2 laser ablation allows for sub-millimeter control over tissue vaporization depth (Figure 5). The CO2 laser accuracy is especially important for highly vascularized areas. For example, the 14-year-old patient in Figure 14 had a CO2 laser lingual frenectomy performed during which a sublingual vein was exposed and coagulated (sealed) with a defocused laser beam. As a result, no sutures were needed, and the surgical wound was left to heal by secondary intention. Tissue healing With CO2 laser-assisted oral surgery, sutures are often not necessary, unlike with scalpel procedures. Laser wounds are often left to heal by secondary intention, as presented in Figures 6-14. Studies have shown that there is a diminished risk of scarring and wound contraction associated with CO2 laser surgery.18-22 Laserinduced wounds heal with greater fibroblast proliferation, with young fibroblasts actively producing collagen. Laser wounds also have been reported to contain smaller amounts of myofibroblasts (cells responsible for wound contraction), compared to scalpel wounds.22-24 Secondary intention healing and lack of scarring are especially important 64 Orthodontic practice
for treating lesions located in esthetic/visible zones. Reduced postoperative pain and discomfort It is important to avoid charring or causing excessive thermal damage to soft tissue. The experienced CO2 laser surgeon using the proper laser settings and hand speed will have small (sub 50 microns thick) zones of thermal necrosis.5 Patients report less postoperative pain and discomfort with laser surgery.25 The healing process associated with CO2 laser surgery is enhanced and less painful than with cryosurgery or electrosurgery.20-21
Summary The many uses for a soft tissue CO2 laser in orthodontics, such as gingivectomies, frenectomies, exposure of impacted teeth, and others, feature minimal blood loss and reduced discomfort for the patients. In comparison with other dental laser wavelengths (circa 1,000 nm for diode and
Nd:YAG lasers and circa 3,000 nm for Erbium lasers), the CO2 laser wavelength exhibits the least absorption rate by the stainless steel orthodontia hardware, and the optimum coagulation depth closely matching gingival blood vessel diameters. The CO2 laser ablation depth is controlled to a few tenths of a millimeter, which characterizes this wavelength as a safe and gentle soft tissue removal tool, while the sub-100 micrometer coagulation depth (better than diodes and electrosurgery) allows for enhanced, scar-free healing of highly vascular oral tissues (often by secondary intention). The accuracy and precision of CO2 laser surgery are increased by the visibility of the surgical field not being obscured by bleeding. OP
Acknowledgments Authors greatly appreciate the help and contribution from Anna (Anya) Glazkova, PhD, and Olga Vitruk, BSc, in preparing this material for publication.
REFERENCES 1. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-61. 2. Vitruk P. Oral Soft Tissue Laser Ablative & Coagulative Efficiencies Spectra. Implant Practice US. 2014;7(6):22-27. 3. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644. 4. Cobb C, Vitruk P. Effectiveness of a Super Pulsed CO2 Laser for Removal of Biofilm from Three Different Types of Implant Surfaces: An In Vitro Study. Implant Practice US. 2015;8(3):20-28. 5. Kaplan M, Hazelbaker A, Vitruk P. Infant Frenectomy with 10,600 nm Dental CO2 Laser. Washington Academy of General Dentistry newsletter. 2015;April(34):10-12. 6. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. Incision properties and thermal effects of three CO2 lasers in soft tissue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):685-691. 7. Yoshida S, Noguchi K, Imura K, Miwa Y, Sunohara M, Sato I. A morphological study of the blood vessels associated with periodontal probing depth in human gingival tissue. Okajimas Folia Anat Jpn. 2011;88(3):103-109. 8. Einstein A. Über die von der molekularkinetischen theorie der wärme geforderte bewegung von in ruhenden flüssigkeiten suspendierten teilchen. Ann Phys. 1905;322(8):549-560. 9. Gama SK, de Araujo TM, Pinheiro AL. Benefits of the use of the CO2 laser in orthodontics. Lasers Med Sci. 2008;23(4):459-465. 10. Convissar RA, Diamond LB, Fazekas CD. Laser treatment of orthodontically induced gingival hyperplasia. Gen Dent. 1996;44(1):47-51. 11. Chmura LG. Soft tissue lasers in orthodontics. In: Convissar RA. Principles and Practice of Laser Dentistry. St. Louis, MO: Mosby; 2011:225-242. 12. Monteiro LS, Mouzinho J, Azevedo A, Infante da Camara M, Martins MA, Fuente-Lanos J. Treatment of epulis fissuratum with carbon dioxide laser. Rev Port Estomatol Med Dent Cir Maxilofac. 2011;52(3):165-169. 13. Convissar RA. The top ten myths about CO2 lasers in dentistry. Dent Today. 2009;28(4):68, 70, 72-76. 14. Bergman TL, Dewitt DP, Incropera FP, Lavine AS. Radiation: Processes and Properties. Fundamentals of Heat and Mass Transfer. 7th ed. Hoboken, NJ: John Wiley & Sons; 2011:768-860. 15. Deppe H, Horch HH. Current status of laser applications in oral and cranio-maxillofacial surgery. Med Laser Appl. 2007;22(1):39-42. 16. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004;48(4):861-888. 17. Namour S. Atlas of Current Oral Laser Surgery. Boca Raton, FL:Universal Publishers. 2011;121-135. 18. Zaffe D, Vitale MC, Martignone A, Scarpelli F, Botticelli AR. Morphological histochemical and immunocytochemical study of CO2 and Er:YAG laser effect on oral soft tissues. Photomed Laser Surg. 2004;22(3):185-189. 19. Zeinoun T, Nammour S, Dourov N, Aftimos G, Luomanen M. Myofibroblasts in healing laser excision wounds. Lasers Surg Med. 2001;28(1):74-79. 20. Mason C, Hopper C. The use of CO2 laser in the treatment of gingival fibromatosis: a case report. Int J Paediatr Dent. 1994;4(2):105-109. 21. Wang X, Ishizaki NT, Matsumoto K. Healing process of skin after CO2 laser ablation at low radiance: a comparison of continuouswave and pulsed mode. Photomed Laser Surg. 2005;23(1):20-26. 22. Grbavac RA, Veeck EB, Bernard JP, Ramalho LM, Pinheiro AL. Effects of laser therapy in CO2 laser wounds in rats. Photomed Laser Surg. 2006;24(3):389-396. 23. de Freitas AC, Pinheiro AL, de Oliveira MG, Ramalho LM. Assessment of the behavior of myofibroblasts on scalpel and CO2 laser wounds: an immunohistochemical study in rats. J Clin Laser Med Surg. 2002;20(4):221-225. 24. Fisher SE, Frame JW, Browne RM, Tranter RM. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch Oral Biol. 1983;28(4):287-291. 25. Tuncer I, Ozçakir-Tomruk C, Sencift K, Cöloğlu S. Comparison of conventional surgery and CO2 laser on intraoral soft tissue pathologies and evaluation of the collateral thermal damage. Photomed Laser Surg. 2010;28(1):75-79.
Volume 6 Number 6
OWN THE FUTURE™
The ProMax® 3D Family Ultra-Low Dose protocol achieves an average of
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