Opus v8n1 issuu

clinical articles • management advice • practice profiles • technology reviews January/February 2017 – Vol 8 No 1

Educator profile Dr. Frank Spear

Drs. Jeffrey H. Lee, Daniel Rinchuse, Thomas Zullo, and Lauren Sigler Busch

Reframing orthodontics: part 4 Dr. Rohit C.L. Sachdeva

Practice profile Dr. Gerry Ahrens

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION

CREDITS PER YEAR!

24

February 23-25, 2017 | Arizona Biltmore

Dr. Maurizio Cannata

Esthetic preferences regarding the anteroposterior position of the mandible

HSO SYMPOSIUM

The use of Kilroy Springs in the disimpaction of upper canines

Orthodontic Excellence & Technology

PROMOTING EXCELLENCE IN ORTHODONTICS

I

N O

Iere T Ans h V O pe

p N a Nh

Discover theValue of Aesthetics For more than 50 years, Ormco has led fixed appliance innovations supporting multiple treatment methods. Ormco offers an array of new and legacy aesthetic brackets that meet growing patient demand and offer uncompromising performance, efficiency and patient comfort.

1. Fracture Strength of Ceramic Bracket Tie Wings Subjected to Tension Gerald Johnson, DDS; Mary P. Walker, DDS, PhDb; Katherine Kula, DDS, MSc Angle Orthodontist, Vol 75, No 1, 2005 2. G. Scuzzo, MD, DDS, K. Takemoto, DDS, PHD, Y. Takemoto, DDS, G. Scuzzo, DDS, L. Lombardo, DDS. “A New Self-Ligating Lingual Bracket with Square Slots”, Journal of Clinical Orthodontics, Volume XLV, No. 12 (2011): 682 - 683.

3. John. H. Hickham, D. M. (1993). Predictable Indirect Bonding. Journal of Clinical Orthodontics, 215-218.

© 2016 Ormco Corporation

without Compromise NEW!

Variable Torques With a completely clear body and door that is resistant to staining, Damon Clear2 brackets provide the control and performance needed to treat a wide range of cases.

Eliminating the need for elastomerics, the self-ligating bracket design with innovative SpinTek™ slide ensures efficiency and quick and comfortable wire changes.

Inspire ICE clear twin is a patient favorite with its small, completely clear appearance and tie wings that are 2X stronger than other ceramic brackets1 offering the clinician maximum treatment options and efficiency.

NEW!

Alias is the world’s first passive self-ligating, lingual straightwire appliance with a unique square slot that provides greater torque and rotational control.2 The small bracket design allows for greater interbracket distances for more effective movement, and custom indirect bonding offers accuracy and efficiency.3

To learn more, visit ormco.com, call 800-854-1741, or speak with your Ormco representative.

INTRODUCTION

Make patients a priority in 2017!

January/February 2017 - Volume 8 Number 1 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

H

appy New Year! The beginning of the year is always an exciting time to make future plans and reflect upon the previous year. Take this time to reevaluate how you handle new patients, current patients, referral sources, and renewing office policies for educating patients.

This new year, place a greater emphasis on making patients happy and welcomed. Despite all the various external marketing techniques, internal marketing often yields the better results. Your greatest internal referral sources are your happy patients and parents. Greeting patients and parents by name with a warm smile Dr. Bradford Edgren and a hello by staff as they walk in the door immediately places a positive light on their upcoming appointment. The office atmosphere immediately becomes warmer, more inviting, and patients feel valued. Patients who feel valued are more likely to refer their friends and family to your practice. Establish good rapport by learning the name of the patient’s dog, his/her hobbies, and/or favorite sports teams. Make notes of the patients’ interests in their chart. It’s very easy to glance down the treatment notes to help remember.

Developing a relationship with your patients demonstrates that you take a personal interest in them, ultimately making them feel special.

Create a positive office atmosphere so that patients look forward to their appointments.

For example, give patients a small gift of chocolates as they leave from their appointments when scheduled on their birthday. Celebrate special food days by serving hot dogs on National Hot Dog Day or baking cookies on National Chocolate Chip Cookie Day. Many times it’s the small things that ultimately make patients feel special and builds their confidence in the practice. As patient confidence grows, valued loyalty grows as well.

This new year, also make it a point to fully educate your patients and parents about the importance of their role in treatment. Well-educated patients are better participants in their care — ultimately resulting in better outcomes. Ask open-ended questions of your patients to learn about how much they comprehend about their treatment. Have patients repeat back and/or demonstrate that they fully understand the instructions they have just been given. Develop goals to achieve by each appointment. A better understanding by patients of the goals of treatment will minimize questions and improve cooperation, thereby reducing treatment times.

Finally, treat your own patients at their every appointment; don’t leave the treatment to auxiliaries. I recall a story where an orthodontist once asked a child in his neighborhood who was doing her braces. The young girl replied, “Why you are doctor.” Seeing patients at every appointment makes them feel special and valued when they know the orthodontist treats them.

Make 2017 the year when the patient comes first; ultimately, it will enrich your life as well as theirs.

Dr. Bradford Edgren

Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS 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-inchief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

Bradford Edgren, DDS, MS, FACD, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a director of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

2 Orthodontic practice

© FMC 2017. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Volume 8 Number 1

OPTIMAL AESTHETICS. PROVEN PERFORMANCE. The Inspire ICE monocrystalline bracket features crystal-clear sapphire finishing for optimal aesthetics and unparalleled strength1 that provides clinical performance during treatment while also offering safe, easier, single piece removal.2

To learn more, visit ormco.com, call 800-854-1741, or speak with your Ormco representative.

1. Fracture Strength of Ceramic Bracket Tie Wings Subjected to Tension Gerald Johnson, DDS; Mary P. Walker, DDS, PhDb; Katherine Kula, DDS, MSc Angle Orthodontist, Vol 75, No 1, 2005 2. Angle Orthodontist, Vol 85, No 4: 651-656, 2015

Š 2017 Ormco Corporation

TABLE OF CONTENTS

Financial focus Five things your 401(k) provider does not want you to know Tom Zgainer delves into possible pitfalls of 401(k) plans...................... 12

Research “Mouth frown arcs” — dental and skeletal characteristics

Practice profile Gerry Ahrens, DMD

8

Drs. Mark E. DeMaria, Donald Rinchuse, Daniel Rinchuse, and Thomas Zullo investigate particular dentofacial characteristics of patients with frown arcs................................20

Living the legacy

Educator profile Frank Spear, DDS, MSD Coaching dentists to believe in their capabilities......................................28

Orthodontic concepts

Clinical case study

16

Manual osteoperforation and high-frequency vibration Dr. Bruce McFarlane illustrates technologies that facilitate treatment goals

4 Orthodontic practice

Reframing orthodontics: designing accelerated orthodontics by managing error — the BioDigital way, part 4 Dr. Rohit C.L. Sachdeva continues his steps to a patient-centered, ultra-safe practice environment.......................32

Volume 8 Number 1

Remastering a Masterpiece Introducing the New OmniArch PLUS • • • • • •

Re-imagined and reengineered Small enough for the most discerning patient Large enough to preserve workability Metal injection molded for predictability Fine-tuned offset for enhanced control Manufactured in our new state-of-the-art facility in Sarasota, Florida

(800) 645-5530 DENTSPLYGAC.com

TABLE OF CONTENTS

Continuing education

38

Esthetic preferences regarding the anteroposterior position of the mandible

Drs. Jeffrey H. Lee, Daniel Rinchuse, Thomas Zullo, and Lauren Sigler Busch investigate how the advancement of the mandible changes facial esthetics from a frontal and three-quarter view

Continuing education The use of Kilroy Springs in the disimpaction of upper canines Dr. Maurizio Cannata explores the use of the Kilroy Spring to facilitate management of a challenging dentition .......................................................46

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118

Laboratory link Digital technology improves the contemporary splint James Bonham and Dr. Mark Coreil discuss material and fabrication options for full occlusal splints ....................................................... 52

Materials & Practice development equipment Important Facebook® developments

.......................................................55

Ian McNickle, MBA, discusses how to stay face-to-face with patients using Facebook........................................51

Industry news .......................................................56

MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com MANAGER – CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

6 Orthodontic practice

$149 $399

Volume 8 Number 1

This year, be prepared. ✓ In-office options ✓ At-home options ✓ Exceed patient expectations

propelortho.com | (855) 377-6735

PRACTICE PROFILE

Gerry Ahrens, DMD Living the legacy

What can you tell us about your background?

I grew up in Louisville, Kentucky, with my two siblings in an ortho family. Sports were a huge part of my life. I was lucky enough to be nominated as an All-American Quarterback by USA Today after our team won the state tournament during my senior year in high school. I then played a few years for University of Louisville before multiple shoulder surgeries ended my sports career.

This was really blessing in disguise because it got me focused on a career in dentistry. I attended the University of Kentucky School of Dentistry and New York University for my Orthodontic Residency.

shadow my father and see exactly what he did from 8 to 5. I was quickly hooked on all of the interpersonal interactions but mostly the fun my dad and his staff members were having with the patients.

How long have you been practicing, and what systems do you use?

I have been practicing for 6 years and am more motivated than ever to find better ways for us to care for our patients.

Our practice software is CS Ortho Trac (Carestream). I use Forestadent® USA selfligating brackets and some Micro MiniTwin™ brackets. I am currently lecturing for Forestadent with an emphasis on selfligating brackets and treatment.

Why did you decide to focus on orthodontics?

What training have you undertaken?

I began working around my father’s practices as the yard boy and sporadically helping as an assistant. When I got older, I spent more time assisting in his office.

This assisting allowed me an opportunity to

In residency, I took Dr. Jack C. Fisher’s TAD course, Dr. “Wick” Alexander’s Principles course, some wire-bending courses, and numerous other courses. Post-residency, I have taken Dr. Ron Roncone’s extensive

8 Orthodontic practice

Drs. Douglas and Gerry Ahrens at their office in Louisville, Kentucky Volume 8 Number 1

PRACTICE PROFILE

lecture series and too many CE courses to mention. The Damon® Series and lectures from Dr. David Sarver are on my list to attend in the future.

Who has inspired you?

My professors and the faculty members were absolutely amazing and extremely knowledgeable while I was in school, but I’d have to say my father has taught me more than you could imagine. It really has been a blessing to learn from him and to lean on him during difficult situations both professionally and personally.

What is the most satisfying aspect of your practice?

I am truly grateful to be an orthodontist because we have the opportunity to interact with people and help improve their selfimage. If I had to pinpoint the most satisfying aspect of my job, it would be the faces and tears of the patients who have had some form of orthognathic surgery. The reactions from those patients and their families are the most moving!

Dr. Gerry with a patient during a routine appointment

The entire team at Ahrens Orthodontics Volume 8 Number 1

Orthodontic practice 9

PRACTICE PROFILE Professionally, what are you most proud of?

I am most proud of the personal relationships we have with our patients, their families, and the community in general. This practice is now seeing three different generations of families coming to Ahrens Orthodontics.

What do you think is unique about your practice?

We have three different office locations, and in each one we treat patients from three completely different socioeconomic regions. So I’d like to think we are very flexible and can accommodate a wide array of different patients.

What has been your biggest challenge?

Hands down, the biggest challenge has been being a business owner and managing a staff! As students, we were not properly trained in that aspect of the profession.

Luckily, I didn’t have to reinvent the wheel because I had my father to mentor me.

Julie assisting a patient during her records appointment

What would you have become if you had not become a dentist?

I really liked the idea of working with athletes, so I’d say a physical therapist.

Maybe I might have had a career in coaching football.

What is the future of orthodontics and dentistry?

I really feel that the advances being made in technology are drastically changing the way we practice. With the improvements to wires, brackets, practice software systems, and different X-ray machines, we are treating cases more efficiently than ever before. The future is very bright for our profession, and I am excited!

What are your top tips for maintaining a successful practice?

Set goals for yourself, your staff, and your practice. Try to avoid knee-jerk reactions, and think through all decisions before acting. In residencies, we are not trained about managing businesses or business concepts. We are not taught how to manage a large staff. We are not taught how to effectively communicate with the other professionals, such as the other dentists, pediatric dentists, or surgeons. All of these aspects are crucial to our success.

Attending professional meetings, reading orthodontic magazines, and joining study groups are great ways to educate yourself and to become a more proficient practicing orthodontist.

What advice would you give to budding orthodontists?

Top 10 favorites 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Our amazing staff Working with family Flexible hours 3Shape TRIOS® scanner Interacting/lecturing to orthodontic residencies I love paying taxes!

Our Planmeca digital X-ray machines Spending time with colleagues, friends, and vendors at CE events Signing my father’s paycheck Making a positive difference in so many people’s lives

10 Orthodontic practice

The more urban populations are very saturated with orthodontists, and a lot of the older practicing orthodontists are not retiring. Set up a practice in more rural populations. Live in the city of your choice, and work in surrounding counties/cities that are underserved.

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

I enjoy traveling, working out, spending time with loved ones, and following the Louisville Cardinals. OP Volume 8 Number 1

CS 3600

ANY COMPANY CAN MAKE A SCANNER MAKING IT FAST, ACCURATE, EASY AND OPEN IS WHAT WE DO

INTR AOR AL SCANNING

MADE EASY FOR YOU MADE EASY FOR YOU

© Carestream Health, Inc. 2017. 14954 OR CS 3600 AD 0117

Carestream Dental makes it easy for you to elevate your practice above the rest with the CS 3600 intraoral scanner. High-speed continuous scanning captures dual arches quickly and easily, while full HD 3D scans simplify communication with patients, referrals and labs. With open system files and no hidden click fees, Carestream Dental has designed the CS 3600 to rise to the challenge of making digital impressions fast, accurate, easy and open.

Visit us at carestreamdental.com

FINANCIAL FOCUS

Five things your 401(k) provider does not want you to know Tom Zgainer delves into possible pitfalls of 401(k) plans

I

magine giving up 50% or more of your future nest egg to excessive fees. This is precisely what is happening when you utilize a traditional 401(k) plan (which represents 95% of the plans in existence). Seemingly, small percentages have a massive impact when you look at how they impact your account growth over time. Just 1% in excessive annual fees can add up to hundreds of thousands, even millions, of lost retirement dollars.

1. Fees matter, and their impact can be devastating.

Have you ever been told your plan is “free?” Many 401(k) providers will market their plans as essentially “free” because there are no explicit checks being cut for recordkeeping, administrative fees, etc. But we all know there is no “free lunch” in this world.

If you encounter a “free” plan, ironically, you could be in an extremely expensive plan.

The fees are simply being subtracted from your retirement savings, which can act like a hole in your boat! Make no mistake. Just

Tom Zgainer is CEO and founder of America’s Best 401(k) and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

12 Orthodontic practice

because you may not be cutting a check for your plan, you still may be cutting into your future nest egg.

Figure 1 is a real-life example of two identical plans with the same growth rate, same ongoing contributions, but with different fee structures (0.65% versus 1.68% annually). All things being equal, the additional fees erode more than a million dollars in potential retirement savings.

2. Layers upon layers of fees are hidden in plain sight.

The traditional providers have been pushing the same old 401(k) plan for 30 years, but in 2012, the law finally required fees to be fully disclosed. The good news

is that the curtain was pulled back. The bad news is their layer cake of fees is hidden in 30-50 page fee disclosures that the average person has no chance of deciphering. This is evident by the fact that 71% of Americans think they pay NO 401(k) fees. Nothing could be further from the truth.

Not only do providers make money by kickbacks from mutual funds, they are also happy to layer on additional, seemingly arbitrary fees that can double or even triple the cost of your plan. If that weren’t enough, many will also hit you with a onetime sales charge (aka commission) on every single dollar that goes into the plan. It’s an expensive and entirely unnecessary toll for the “privilege” of saving money.

Figure 1: Assumes both plans have a starting balance of $1 million, a 7% annual growth rate, and $100,000 in annual contributions Volume 8 Number 1

Designed by Orthodontists, for Orthodontists Priced lower than most competitors’ sale pricing Extreme Versatility. Exceptional Control.

The EasyClip+® Systems can be used as fully passive, fully interactive, or a combination of both. This hybrid approach enables you to use both passive and interactive brackets, offering a variety of treatment options.

THOUGHTFUL DESIGN • • •

Familiar twin design / spacious tie-wing undercuts if ligation is needed Ultra low profile, rounded corners, provide maximum patient comfort Torque in base for level slot line up and improved finishing

Passive (Flat Tab)

TOTAL CONTROL Mesial-to-distal coverage offers total rotational control

PROVEN RELIABILITY

EASY POSITIONING

Thermal NiTi Clip will not deform or degrade for the life of the treatment

V channel for easy positioning and visual reference - unlike competitor brackets that do not have a reference on the vestibular base.

SUPERIOR BONDING

Interactive (Curved Tab)

Mushroom-shaped pylons provide up to a 40% stronger bond

MANY OPTIONS & CHOICES

Lever action opening of the clip offsets forces for patient comfort - no special instruments required.

To close, use a utility plier, tweezer, or fingertip. Audible ‘Click’ when closing the clip. Opens easily using an explorer.

Passive Interactive Interactive & Passive MBT

• • • •

Roth Damon Low Damon Standard Damon High

Great Lakes’ version of the Damon, Roth, and MBT prescriptions. Does not imply endorsement by the doctor. Damon is a registered trademark of Ormco Corporation.

SMPP586Rev062116

EASY TO OPEN & CLOSE. STAYS SHUT

• • • •

FINANCIAL FOCUS Here are the charges that should raise red flags.

• Contract asset charge/Asset management charge — a layer of fees charged on the entire balance of your plan. This is over and above the cost of the investments.

• Required revenue — an almost comical line item, this is a fee charged to smaller plans where the providers insist they aren’t making enough.

• Sales charge — a one-time commission that subtracts 3% to 6% from every dollar you deposit.

• Surrender charge — many insurance company providers have figured out a way to have your 401(k) held within a “group annuity.” This means they can penalize you with hefty surrender charges if you decide to switch plans to another provider.

3. The mutual funds in your plan menu are often chosen for all the wrong reasons.

The vast majority of 401(k) providers make huge sums of money from kickbacks from the mutual funds in the plans they sell.

This payment for “shelf space” is a legal but opaque process called revenue sharing. The net result is what we call “menu stuffing” — stuffing your plan’s fund menu with the funds that are most profitable for the provider.

Worse yet are the providers that stuff the menu with their own more profitable namebrand funds.

Odds are that your 401(k) plan is packed full of expensive “actively managed” mutual funds that are hoping to beat the market by being the best stock pickers. The problem is that although they may have a hot streak, the studies overwhelmingly show that in due time, they will often lag the market. So you are usually overpaying for underperformance.

What’s the alternative?

A great number of Nobel laureates and investment legends such as Jack Bogle and Warren Buffet would recommend that most investors use low-cost index funds.

Index funds simply track a basket of leading stocks like the S&P 500, for example. David Swensen, the Chief Investment Officer responsible for growing Yale’s endowment from $1 billion to $24 billion, warns us, “When you look at the results on an after-fee, after-tax basis, over reasonably long periods of time, there’s almost no chance that you end up beating the index fund.”

Most plans do not offer access to lowcost index funds because they can’t receive kickbacks (aka revenue sharing) from these 14 Orthodontic practice

ultra-low-cost funds. Many small or midsize plans will be told they don’t qualify for index funds because their 401(k) is not large enough. (Translation: “We wouldn’t make enough money off of you if we granted you access.”) Or worse, if they do offer them, they charge an outrageous markup. One plan we reviewed offered index funds with a 3,000% markup from its normal retail price. That’s like buying a $30,000 car for $900,000. All clients of America’s Best 401k have access to same low-cost index funds regardless of the size of the plan. No commissions, no kickbacks, and no markups.

4. Many of the biggest providers have been named in lawsuits for excessive fees and self-dealing.

There has been a flurry of recent lawsuits against 401(k) providers. The primary reason is for excessive fees and the use of proprietary products. Interestingly, it’s not just the customers who are suing, but many providers have been sued by their OWN employees for their own in-house plan. Providers were caught with their hand in the cookie jar by peddling their own, more expensive namebrand mutual funds and, thus, profiting from their employees’ retirement savings.

Business owners beware!

You have a legal obligation to make sure the fees in your plan are both fair and reasonable. As the plan sponsor, the Department of Labor states that the fiduciary obligation falls on you to make sure the plan is set up for the sole benefit of your employees. Nothing external can influence the decisions you make for your plan, including a relationship with the existing broker. More importantly, it’s your legal duty to periodically benchmark your plan, so a side-by-side comparison is a task that is in your best interest to perform.

America’s Best 401k will provide a complimentary benchmark at your request.

5. The traditional model is being disrupted and rapidly becoming a dinosaur.

The 401(k) industry is ripe for disruption. Much like Uber has the transportation industry on its heels, our company is seeking to transform a decades-old industry that is riddled with conflicts of interest and often puts profits ahead of people. They have seemingly forgotten that it’s YOUR money, NOT theirs. America’s Best 401k is a next generation solution that eliminates brokers, levels the playing field with transparency, and provides a combination of high-tech and high-touch interaction for our clients.

Your next step: Get a complimentary side-by-side plan comparison Most of our prospective clients are astonished when they see the results of their sideby-side plan comparison. In many cases, the immediate savings is more than $10,000 in the first year alone. But the real impact is what happens over 10, 20, or even 30 years. Below is a chart showing a 401(k) with $1 million in total assets. Here we show our average plan cost versus two other common providers. Note that although fees vary from plan to plan, we often see fees that are even higher from these two providers as well as other major insurance companies and national payroll companies. Assuming the plan is growing at 7% and has modest contributions of $60,000 per year, there are millions in potential savings being left on the table if a switch is not made immediately.

These savings will go right back into the pockets of you and your employees and make sure your money will last as long as possible into retirement. By sending us your fee disclosure form (to info@americasbest401k.com), which we can help you locate, and by taking 15 minutes to review the results, we hope to show irrefutable evidence why a switch is in your best interest. OP

Table 1: 401(k) with $1 million in total assets America’s Best 401k Fees

Transamerica*

John Hancock*

0.65%

1.50%

2.25%

Year 1 (start)

$1,000,000

$1,000,000

$1,000,000

Year 5

$1,722,690

$1,660,243

$1,606,716

Year 10

$2,705,886

$2,523,154

$2,371,881

Year 20

$5,863,251

$5,124,922

$4,553,892

Year 30

$11,707,110

$9,569,117

$8,024,433

*These examples above are actual examples of specific plans where the fee disclosure was provided for both Transamerica and John Hancock. We have analyzed hundreds of plans from Transamerica and John Hancock where the fees are both higher and lower than the amounts listed above. Fees in plans vary drastically even from the same provider

Take control, start here: http://americasbest401k.com/fee-checker-medmark.

Volume 8 Number 1

SMPP587Rev062116

CLINICAL CASE STUDY

Manual osteoperforation and high-frequency vibration Dr. R. Bruce McFarlane illustrates technologies that facilitate treatment goals

O

ver the years, as I explore beneficial technologies to add to my practices, I have found that I am an “eternal student.” I search for products and equipment with the potential to enhance patient care. For many years, I focused on discovering better wires, superior brackets, less friction, and more efficient plastic for moving teeth. Currently, the profession has tweaked those options close to the highest level. In my experience two technologies, manual osteoperforations (MOPs) and high-frequency vibration, can help achieve our treatment goals.

Patience is not one of my patients’ best attributes. They want to know how long treatment will take, and they want to finish their treatment more quickly. Patients seeking accelerated treatment can fall into several categories including: • Impatient patients Patients who are not good at waiting to achieve their goals.

• Patients on the move Patients who plan to leave the area and want to complete treatment within a certain time period.

• Major life events Brides, graduates, and others who want to look their best during photo opportunities and need to have treatment completed in a specific period of time.

R. Bruce McFarlane, DMD, graduated with a Bachelor of Science degree and his Doctorate of Dental Medicine in 1984 from the University of Manitoba. He then practiced as a general dentist for 6 years in Brandon, Manitoba, before returning to the University of Western Ontario in 1992 to graduate as a Specialist in Orthodontics.

Dr. McFarlane has become a Fellow of the Royal College of Dentists of Canada, a Diplomate of the American Board of Orthodontics, an inductee into the Omicron Kappa Upsilon Honorary Dental Fraternity, Mensa, and a member of the Pierre Fauchard Honorary Dental Academy. He has acted as the Chairman of the Manitoba Dental Association’s Specialist’s Committee, was an Assistant Professor of Graduate Orthodontics at the University of Manitoba (2000-2006), and is a part of the Invisalign® “Alpha” Group. Dr. McFarlane is a frequent presenter for Align Technology, Henry Schein® Orthodontics, and Propel Orthodontics. He is an active member of the Winnipeg chapter of the Seattle Study Group. Dr. McFarlane is a Board member of the American Academy of Clear Aligner Orthodontics.

16 Orthodontic practice

• Insurance benefits Patients who are changing or losing their jobs or switching insurance companies and want to complete treatment while still insured.

I use MOPs with Propel Orthodontics Excellerator™ Series drivers since 2014 both proactively and reactively. Proactively, we preplan and factor the MOPs process into the original orthodontic treatment plan.

MOPs are tiny perforations created through the mucosa and into the bone near the roots of teeth. These osteoperforations cause a local area of inflammation that encourages a cytokine cascade and ultimately osteoclast activation, which have been observed in some studies to accelerate the rate of tooth movement.1,2 I anesthetize the patient before performing MOPs. I use injection anesthetic, usually a simple local infiltration with carbocaine and epinephrine. Some practitioners prefer topical, but I like to make sure patients feel nothing at all, and I like the vasoconstrictor. The technique is minimally invasive and causes very little if any discomfort — perhaps tenderness around the treatment site for 24-48 hours. One of the strengths of the MOPs system is that the patient does not have to participate to make it effective. All they have to do is rinse and keep it clean.

When I want to use MOPs proactively, I listen carefully to the patients for the cues before proposing acceleration. In this scenario, I added MOPs into the cost of the initial treatment plan. In many states and provinces, most insurance plans cover MOPs although it may be listed under a surgical code rather than orthodontic.

Reactive situations require a different approach and are often prompted by a clinical instance that may throw the treatment off track. When the teeth do not move quickly enough or profoundly enough, I suggest adding MOPs to facilitate the needed changes. I do not charge the patient when reactively adding MOPs because moving treatment in a positive direction benefits both me and the patient. Before MOPs,

when orthodontists were faced with slow or difficult movements, the patient would either have to wait until the teeth moved on their own, or undergo procedures such as corticotomy or luxation. Isha, et al., noted, “Corticotomy-assisted orthodontic treatment is quite invasive as it requires extensive flap elevation and bone surgery.”3 On the other hand, using MOPs saves the patient a painful surgical procedure and, as noted previously, there is some evidence that it decreases treatment time.

I also use a high-frequency device called VPro5™ (Propel) to aid aligner seating, which keeps aligner therapy on track. Patients wear the high-frequency device for just 5 minutes each day, and in my experience, 5 minutes amounts to a reasonable amount of time to ask for compliance. This device is also relatively inexpensive ($399 USD suggested retail) as an addition to the treatment cost.

As Dr. Amit Lala noted, “Improperly seated aligners can slow treatment, forcing patients to back track to previous trays, and create unintended collateral tooth movements, with a consequence being time-consuming and costly refinements.”7 Before vibration was available for aligner seating, I recommended Chewies™ aligner tray seaters: soft plastic rolls that patients would bite on, affecting isolated areas of the dentition at any given time. I recommended these for patients when there was “daylight” between the aligner and the teeth, or if the teeth were not tracking well inside the aligner.

I think of high-frequency vibration as the ultimate Chewie, without all the chewing. The vibration also allows the aligners to track better around attachments that I use for more difficult movements such as rotations and extrusions. That is where this technology truly shines.

After all the tooth movement is completed, retention offers yet another important feature of orthodontic therapy. For this, we use clear retainers almost exclusively. When I first give patients their retainers, I advise them to continue using the VPro5 for 5 minutes each day to help seat the retainers.

Volume 8 Number 1

CLINICAL CASE STUDY

Figure 1: MOPs and aligner seating vibration to help a patient achieve the desired results. Patient 1: Braces. Initial MOPs and vibration

Case presentations Patient 1: A 25-year-old female wanted to speed up her treatment since she was moving away in a year. She had a severely rotated upper-right second premolar and severely crowded lower incisors. We used MOPs for maximum velocity with vibration for aligner seating Patient 2: A 37-year-old female was undergoing treatment for space closure. I used Invisalign and the G6 premolar extraction protocol. I used MOPs on the edentulous area and vibration for aligner seating.

Patient 3: The 23-year-old male was 1 year into treatment. The UR3 would not move and lifted the adjacent teeth as well.

After one session of MOP around the canine, it and the other teeth erupted and aligned in 4 weeks.

Figure 2: MOPs and aligner seating vibration to help a patient achieve the desired results. Patient 2: Aligners. Initial MOPs and vibration

Figures 3A-3B: Patient 3: Here is a patient using MOPs to help achieve the desired results. 3A. Braces: initial MOPS. 3B. Braces: 4 weeks after MOPs Volume 8 Number 1

Orthodontic practice 17

CLINICAL CASE STUDY

Figures 4A-4B: Patient 4: This patient needed MOPs to help achieve the desired results. 4A. Braces: Initial MOPS. 4B. Braces: 4 weeks after MOPs

Patient 4: A 39-year-old male patient had a LR3 that was surgically exposed after having been impacted for many years. It came in rotated and ectopic; MOP hastened its movement.

Patient 5: This female patient in clear aligners wanted her spaces closed. After 5 months, and with one MOP session, the spaces closed.

These treatments provide a minimally invasive, patient-friendly manner of ensuring the best results.

Conclusion MOPs provides a minimally invasive and patient-friendly manner of accelerating treatments, and VPro5 keeps aligner therapy on track, resulting in a win-win situation for both the clinician and the patient. OP

Figures 5A-5B: Patient 5: Here is a case study using MOPs to help a patient achieve the desired results. 5A. Aligners.

5B. Aligners: 5 months after MOPs

REFERENCES 1. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648.

2. Camacho AD, Velásquez Cujar SA. Dental movement acceleration: Literature review by an alternative scientific evidence method. World J Methodol. 2014;Sep 26;4(3):151–162. Published online Sep 26, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202454/. Accessed December 23, 2016.

3. Isha A, Madhurima N, Manu W, Vishesh D. Surgical Methods to Enhance Orthodontic Tooth Movement: A Review. Int Res J Clin Med. Apr2016;1(4):17-22. http://cdn.irjcm.com//Upload/04_ IRJCM_1(4)_RA01_20160607.pdf. Accessed December 23, 2016.

4. Butezloff MM, Zamarioli A, Leoni GB, Sousa-Neto MD, Volpon JB. Whole-body vibration improves fracture healing and bone quality in rats with ovariectomy-induced osteoporosis. Acta Cir Bras.

2015;30(11):727-735. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-86502015001100727. Accessed December 23, 2016.

5. Stuermer EK, Komrakova M, Werner C, Wicke M, Kolios L, Sehmisch S, Tezval M, Utesch C, Mangal O, Zimmer S, Dullin C, Stuermer KM. Musculoskeletal response to whole-body vibration during fracture healing in intact and ovariectomized rats. Calcif Tissue Int. Aug 2010; 87(2): 168–180.

6. Lala A. Vibration therapy in orthodontics: realizing the benefits. Ortho. 2016;1:24-27.

18 Orthodontic practice

Volume 8 Number 1

It’s Time to Demand More From Your Supply With MidAtlantic Ortho’s new E-Commerce marketplace, we provide a 24/7 on demand resource for all of your practice supply needs. More than online ordering, MAO now provides a user friendly way to place, track, and store your purchase and ordering history with just a click of a button. With MidAtlanticOrtho.com, you are free to start and treat more patients instead of waiting on your sales representative, buying more than you need, figuring out a complicated group program, or stressing over your supply. Over 100 years of orthodontic marketplace expertise, bringing leading manufacturers to your fingertips – 24/7.

Supply that supports your Bottom Line.

CONVENIENCE THROUGH

M I D A T L A N T I C O R T H O. CO M

800-255-3525

RESEARCH

“Mouth frown arcs” — dental and skeletal characteristics Drs. Mark E. DeMaria, Donald Rinchuse, Daniel Rinchuse, and Thomas Zullo investigate particular dentofacial characteristics of patients with frown arcs Abstract Introduction The purpose of this study was to investigate whether subjects with “mouth frown arcs” (lips at repose are turned down at the commissures) have any particular dentofacial characteristics as compared with subjects who do not possess “mouth frown arcs” (non-frown arc group, also called the control group).

Method From a population of approximately 3,200, 94 subjects were selected based upon having mouth frown arcs versus not having mouth frown arcs (control group).

Seventy-four subjects possessed frown arcs, and 20 subjects had non-frown arcs.

Subjects in the mouth frown arc group were then classified as being mild, moderate, or severe. Various dental and skeletal measurements were performed to determine how many subjects in the frown and non-frown arc groups possessed various dento-skeletal characteristics. Subjects’ Angle’s classifications were evaluated through pretreatment intraoral photos, while the vertical and maxilla-mandible skeletal relationships were determined from cephalometrics (Sassoui and Steiner Analyses).

Using SPSS software, Pearson Chi Square Analyses were performed to test whether there was a statistical relationship between the dentofacial characteristics previously described and a mouth frown arc.

Results There was no statistically significant (P = <0.05) relationship between mouth frown arc and various dentofacial characteristics. However, subjects with mouth frown arcs (of any magnitude) tended (P = 0.087) to have proportionally more skeletal Class IIIs and less skeletal Class IIs then subjects with non-frown arcs.

A frown is a unique facial expression that involves the action of many muscles.1-9 The famous naturalist and biologist Charles Darwin previously had described the act of frowning as “the furrowing of the brow which leads to a rise in the upper lip and down turning of the corners of the mouth.”10 It is hypothesized that humans share an “adaptive quality to frowning which allows for social communication or a negative emotional state.”10 This adaption crosses cultural lines and is one of many nonverbal actions that can express how a person is feeling at that particular moment.

The opening sentence in an article posted on Psychology Today reads, “If you frown all the time, it is likely you feel a certain amount

of pain, or at least discomfort.”11 A study in 2012, published in the Journal of Psychiatric Research,12 concluded that botox may be a viable treatment for depression by inhibiting the muscles necessary to frown from contracting, again illustrating the universal connection of frowning with sadness.

Another study investigating the effect of brow lowering, as seen in a frown, on the perception of laugher in a static photograph versus a dynamic video resulted in participants rating the laughter of those in static photographs as being more malicious, less intense, and less benevolent than in dynamic videos.11 Studies have illustrated that minimal exposure to a frown can influence what one thinks of the frowning individual, even if the exposure is brief. “When shown a 30-second video clip (without audio) of a frowning college professor, students tended to rate the professor poorly on evaluations.”10-12 All of these studies had focused on the frown in the more broad sense of a facial expression, involving more than just the downturning of the mouth. In North America, however, the frown is typically thought of as a purposeful expression dealing solely with the mouth; however, it is recognized that the true definition includes not only features of the mouth, but also the eyebrows and forehead.10 In addition to those who can purposefully create a mouth frown with voluntary contraction of 11 facial muscles (Figure 1), it can be seen as part of the natural aging process with soft tissue sag

Figure 1: Deliberate frown arc through muscle contraction

Figure 2: Frown due to loss of vertical dimension and agerelated sagging

Conclusions There was a tendency (not statistically significant at P = >0.05) for subjects with mouth frown arcs to have proportionately more skeletal Class IIIs and less Class IIs than subjects with non-frown arcs.

Introduction

Mark DeMaria is a Resident at Seton Hill University Center for Orthodontics in Greensburg, Pennsylvania.

Donald Rinchuse, DMD, MS, MDS, PhD, is in Private Practice in Greensburg Pennsylvania.

Daniel Rinchuse, DDS, MS, MDS, PhD, is Professor and Program Director, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

Thomas Zullo, PhD, is an Adjunct Professor of Biostatistics, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

20 Orthodontic practice

Volume 8 Number 1

Method From a population of approximately 3,200 subjects at Seton Hill University Center for Orthodontics in Greensburg, Pennsylvania, 94 subjects were selected based on having mouth frown arcs versus not having mouth frown arcs (non-frown arc/control group). A subject was determined to have a frown arc if it appeared that the commissures of the lip were below the midpoint of the junction of the philtrum in repose (Figure 4). Seventyfour subjects possessed frown arcs, and 20 subjects had non-frown arcs. The frown arc group was divided into categories of mild (22), moderate (28), and severe (24). To help Volume 8 Number 1

RESEARCH

and the development of marionette lines (Figure 2).10-13,16 “The frown lines make my whole mouth look like a big frown. People say I look unhappy when I just feel normal. I look like a miserably unhappy person, which really puts people off. It’s far from attractive and completely belies what I’m feeling on the inside!”11 That is the plea of a 57-yearold dealing with a mouth frown developed from the natural aging process. Parenthetically, Sarver13 has observed that typically the philtrum position is ideally located 2 mm to 3 mm shorter than the commissure height, but it is highly variable with age. Usually, however, over the patient’s lifetime, the vertical position of the philtrum lengthens at a faster rate than the commissures do, which contributes to flattening of the upper lip.13 Further still, some people do not specifically have to activate the 11 muscles responsible for producing the frown or be elderly, but nonetheless, have a similar expression on their faces even while in natural repose.10-19 The “mouth frown arc” is the curve of the lips forming a down-open curve (Figure 3).5-9 In pop culture, the expression of the mouth frown arc can be seen with digital text as a colon followed by a convex parenthesis, or L.10 It may be due to the natural dental and facial skeletal characteristics that underlie the soft tissue of those with reposed mouth frowns; i.e., “mouth frown arcs.”

This investigation aims to explore whether there are particular dental and facial skeletal characteristics of those with a non-aged (young subjects), “natural/reposed” mouth frown arc (not those purposely frowning or who appear to be frowning due to soft tissue old age changes) (Figure 2), as compared to those in a control group who do not possess this arc. The null hypothesis was that there are no statistically significant differences in the dental and facial skeletal characteristics of subjects with mouth frown arcs and those who do not possess mouth frown arcs.

Figures 3-4: Soft tissue “mouth frown arc.” Frown arc severity calculation. Horizontal line segment distance/vertical line segment distance) width/height = severity ratio

Figure 5: Sassouni Class I Skeletal. Note: ANS and pogonion are on the anterior arc

control certain extrinsic factors, only subjects 25 years and younger were included in this study. Subjects with a loss of the vertical dimension due to attrition, extracted teeth, congenitally missing teeth, pathology, or trauma, were excluded, as well as subjects who had undergone surgical intervention or previous orthodontic treatment.

Subjects were initially screened for frown and non-frown arcs by visual inspection.

Final determination was made by mathematical measures. That is, a frown arc ratio was calculated for subjects by measurement of the width of the lips by a horizontal straight line from right commissure to left commissure; depth was determined by a vertical straight line from the philtrum of the lips to a tangent to the width line (Figure 4). The frown arc group was divided into categories of mild, moderate, and severe by inspection of the ratios and looking for natural division separation “breaks” in the data.

Various dental and skeletal measurements were performed to determine how many subjects in the frown (and for each of the three frown arc categories) and nonfrown arc groups possessed the various

dento-skeletal characteristics. The dental and skeletal classes (categories) were: Dental • Angle’s Classification ДД Class I ДД Class II ДД Class III Skeletal • Anterior-posterior ДД Class I ДД Class II ДД Class III • Vertical ДД Normal ДД Deep ДД Open • Maxilla-Mandible relationship ДД Maxilla - Normal - Deficient - Excess ДД Mandible - Normal - Deficient - Excess The skeletal categories were determined by the Sassouni Analysis, which is based Orthodontic practice 21

RESEARCH upon individual patient proportions and not on average group norms or comparisons to an ideal through the use of facial planes and arcs (Figure 5).14-15 It analyzes true skeletal proportions rather than dentoalveolar (i.e., Points A and B) by using ANS and pogonion, which are skeletal landmarks, whereas other analyses focus on ANB which is a dentoalveolar measure (e.g., SNA-SNB ).

The reader can get a better understanding of the Sassouni Analysis by reading the article by Araujo in the 2015 AJODO as well as the book by Athanasiou.14-15 Using this cephalometric analysis, it was possible to determine subjects anterior-posterior, maxilla-mandible relationship, and examples are presented throughout Figures 5-8. The vertical skeletal component of the study was gleaned from the Steiner analysis, specifically SN-MP (Figure 9). SN-MP is the angle formed by a line connecting sella to nasion and its intersection with a line drawn along the mandibular plane.14 Dental categories were determined by visual inspection of pretreatment intraoral photos. All subjects who were selected had a definitive Angle’s classification. No subject, for instance, had missing or unerupted permanent teeth, which may make Angle’s classification ambiguous.

Figure 6: Class II, mandibular retrognathic based on the Sassouni Analysis: Pogonion is behind the anterior arc compared with ANS

Statistical analysis Using SPSS software, Chi-Square Analyses (Pearson Chi-Squares) were performed to test whether there was a statistical relationship (P = /<0.05) between Angle’s dental classifications, anterior-posterior and vertical skeletal classifications, and maxilla and mandible anterior-posterior relation as compared with the various categories of frown arcs in mild, moderate, and severe (based on frown arc ratio), as compared with non-frown arcs (controls). For this study, significance (p value or alpha) was 0.694, and the value for observed power is 0.144.

Also, multivariate and univariate ANOVA tests were performed to elucidate relationships between frown arc groups (mild, moderate, severe, control) and the measures of frown arc height, width, and ratio. Pairwise comparisons for the measure “frown arc ratio” were also performed.

Figure 7: Class III, maxillary deficient based on the Sassouni Analysis. ANS is behind the anterior arc, while pogonion is on it

Results The results of this study are reported in Tables 1-6. Frown arc ratios were developed and then separated into four categories; one as non-frown arc (control) and three with different severities. The categories, as mentioned in the Methods, were mild, 22 Orthodontic practice

Figure 8: Steiner analysis, “Sella-Nasio - Mandibular Plane Angle” helps glean the patient’s vertical. (33O for this particular patient) Volume 8 Number 1

Volume 8 Number 1

Table 1: Frown arc — pairwise comparison Dependent variable

(I) Frown Arc Groups

Mild

Moderate Frown Arc Height Severe

Control

(J) Frown Arc Groups

Moderate Frown Arc Width Severe

Mild

Moderate Frown Arc Ratio Severe

Control

95% Confidence Interval for Differenceb Lower Bound

Upper Bound

-1.198*

.249

000

-1.869

-.528

Severe

-3.485*

.258

000

-4.179

-2.790

Control

2.391*

.270

000

1.663

3.118

Moderate

1.198*

.249

000

.528

1.869

Severe

-2.286*

.243

000

-2.941

-1.631

Control

3.589*

.256

000

2.900

4.279

Moderate

3.485*

.258

000

2.790

4.179

Severe

2.286*

.243

000

1.631

2.941

Control

5.875*

.264

000

5.163

6.588

Moderate

-2.391*

.270

000

-3.118

-1.663

Severe

-3.589*

.256

000

-4.279

-2.900

Control

-5.875*

.264

000

-6.588

-5.163

2.919

1.691

.526

-1.643

7.482

Severe

.620

1.752

1.000

-4.107

5.347

Control

-3.419

1.834

.393

-8.367

1.529

Moderate

-2.919

1.691

.526

-7.482

1.643

Severe

-2.299

1.651

1.000

-6.754

2.155

Control

-6.339*

1.738

.003

-11.027

-1.650

Moderate

-.620

1.752

1.000

-5.347

4.107

Severe

2.299

1.651

1.000

-2.155

6.754

Control

-4.039

1.797

.162

-8.888

.809

3.419

1.834

.393

-1.529

8.367

Severe

6.339*

1.738

.003

1.650

11.027

Control

4.039

1.797

.162

-.809

8.888

Moderate

-3.022*

.325

.000

-3.898

-2.147

Severe

-7.869*

.336

.000

-8.776

-6.961

Control

2.297*

.352

.000

1.347

3.247

Moderate

3.022*

.325

.000

2.147

3.898

Severe

-4.846*

.317

.000

-5.702

-3.991

Control

5.320*

.334

.000

4.420

6.220

Moderate

7.869*

.336

.000

6.961

8.776

Severe

4.846*

.317

.000

3.991

5.702

Control

10.166*

.345

.000

9.235

11.097

Moderate

-2.297*

.352

.000

-3.247

-1.347

Severe

-5.320*

.334

.000

-6.220

-4.420

Control

-10.166*

.345

.000

-11.097

-9.235

Moderate Control

Sigb

Moderate

Moderate Mild

Mean Std. Differences Error (I-J)

Orthodontic practice 23

RESEARCH

moderate, and severe for mouth frown arcs; a control group of non-frown arc was also established. Data were listed in a frequency distribution. The basis of group formation was close to equal thirds and based upon “natural breaks.” The frown arc ratios ranged from 0.816-13.86, and the control ratios ranged from -0.82 to -13.44. A natural break occurred between the mouth frown arc ratio values 3.8776 and 4.0169, and 29.7% of the cases were = <3.8776 (M=mild). The next natural break to capture approximately a third of the cases was for mouth frown arc ratios between 7.9412 and 8.5873. 32.4% of the cases had frown arc ratios => 8.5873 (severe), while the remaining 37.8% had mouth frown arc ratios between 4.0169 and 7.9412 (moderate). Multivariate (F = 61.428) and univariate Tests (Height F = 172.749; Width F = 4.477; Ratio) F= 332.849) (P = 0.001) reflected that there were differences among the four frown arc groups (severe, moderate, mild, control) and the three frown arch measures (height, width, ratio). The tests for pairwise comparisons showed that for the measure “frown arc ratio,” all possible comparisons were significantly different from one another (Table 1). That is, severe was greater than mild, moderate, and control. Moderate was greater than mild and control. And mild was greater than control. The results for frown arc height were exactly the same. For frown arc width, the only significant difference was between the moderate and control groups. One might conclude that the major contribution of the frown arc ratio is from frown arc height.

The Pearson Chi-Square tests showed no statistically significant relationship between frown-arc and non-frown arc for the dental and skeletal classifications studied. Likewise, there was no significant difference among the frown arc group categories (mild, moderate, severe) for any of the dental and skeletal variables (Tables 2-6).

When looking at the value of the Pearson Chi-Square for each of the five chi-square tests, it is evident that none of them achieve a value that is statistically significant. Essentially, there was no significant relationship between mouth frown arc classification and any, or all, of the five measures used in this study.

There was, however, proportionally more skeletal Class IIIs and less skeletal Class IIs in the mouth frown arc group. This was a trend (P=0.087) and not statistically significant at P=> 0.05 (Table 3B). That is, for the frown arc categories mild, moderate, and severe, there were 10, 18, and 14 subjects, respectively,

RESEARCH with skeletal class IIIs, compared with 4 subjects in the non-frown arc (control) group.

For the skeletal Class IIs, there were 5, 5, and 5 with mild, moderate, and severe frown arcs, compared with 9 with non-frown arcs (Table 3A).

Discussion The null hypothesis of no difference (P = <0.05) in the dental and skeletal characteristics between subjects with mouth frown arcs and those without was supported by the finding of this research. However, as

noted in the Results, the study found a trend (P = 0.087) for subjects with frown arcs to have proportionately more skeletal Class IIIs and less skeletal Class IIs then subjects with non-frown arcs. Although there is much published on many aspects of lip and smile characteristics, especially related to esthetics, this is the first time (to these authors’ knowledge) that the dentofacial characteristics of mouth frown arc was studied (i.e., described and measured), so there is no literature to compare with.

Table 2A: Angle dental classification distribution Frown Arc Groups Mild Count

Angle Dental Classification

5

18

% within Angle Dental

22.2%

27.8%

22.2%

27.8%

100.0%

% within Frown Arc Groups

18.2%

17.9%

16.7%

25.0%

19.1%

8

8

4

10

30

% within Angle Dental

26.7%

26.7%

13.3%

33.3%

100.0%

% within Frown Arc Groups

36.4%

28.6%

16.7%

50.0%

31.9%

2

2

3

4

11

18.2%

18.2%

27.3%

36.4%

100.0%

9.1%

7.1%

12.5%

20.0%

11.7%

8

13

13

1

35

% within Angle Dental

22.9%

37.1%

37.1%

2.9%

100%

% within Frown Arc Groups

26.4%

46.4%

54.2%

5.0%

37.2%

22

28

24

20

94

% within Angle Dental

23.4%

29.8%

25.5%

21.3%

100%

% within Frown Arc Groups

100%

100%

100%

100%

100%

% within Angle Dental

Count

Count Total

Total

4

% within Frown Arc Groups

Class III

Control

5

Count Class II Div II

Severe

4

Count Class II

Moderate

Although a statistically significant relationship between a frown arc and the underlying dentofacial characteristics was not shown, future research is needed on this topic. If future research shows that there is in fact a relationship between mouth frown arc and various dento-skeletal characteristics, then orthodontists may be able to offer mitigating treatments for mouth frown arc through conventional orthodontic treatment/orthognathic surgery.17-19 It is generally known that the mouth frown arc will typically develop/get worse with age due to natural aging processes (“sagging” of the soft tissues).13,16,17-22 So the question is, does someone who starts with a mouth frown arc have an increased chance for a negative soft tissue response with aging

Table 2B: Angle dental classification Chi-Square Tests Value

df

Asymptotic Significance (2-sided)

Pearson Chi-Square

14.387a

9

.109

Likelihood Ratio

17.330

9

.044

Linear-by-Linear Association

1.570

1

.210

N of Valid Cases

94

a. 7 cells (43.8%) have expected count less than 5. The minimum expected count is 2.34

Table 3A: Skeletal classification distribution Frown Arc Groups Mild Count

Class II

7

24

% within Skeletal

29.2%

20.8%

20.8%

29.2%

100.0%

% within Frown Arc Groups

31.8%

17.9%

20.8%

35.0%

25.5%

5

5

5

9

24

% within Skeletal

20.8%

20.8%

20.8%

37.5%

100.0%

% within Frown Arc Groups

22.7%

17.9%

20.8%

45.0%

25.5%

10

18

14

4

46

% within Skeletal

21.7%

39.1%

30.4%

8.7%

100.0%

% within Frown Arc Groups

45.5%

64.3%

58.3%

20.0%

48.9%

22

28

24

20

94

23.4%

29.8%

25.5%

21.3%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

% within Skeletal % within Frown Arc Groups

24 Orthodontic practice

Total

5

Count Total

Control

5

Count Class III

Severe

7

Count Skeletal Classification

Moderate

Table 3B: Skeletal classification Chi-Square Tests Value

df

Asymptotic Significance (2-sided)

Pearson Chi-Square

11.044a

6

.087

Likelihood Ratio

11.423

6

.076

Linear-by-Linear Association

1.292

1

.256

N of Valid Cases

94

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 5.11

Volume 8 Number 1

being angry or unapproachable, due to no fault of their own, likely to assume that role just because people typically expect that of them â&#x20AC;&#x201D; a self-fulfilling prophecy?1-9 Childhood studies of those with a mouth frown arc could look at whether those children are likely to grow up to be bullied, or possibly even the ones who become the bullies.24-26 Those judged and reacted to by society on the way they look and in the way they are reacted upon, those with disfigurements and other dentofacial anomalies, become who they are conditioned to be.22-26 Future studies could also be done with the same

Table 4A: Skeletal vertical distribution Frown Arc Groups Mild

Moderate

Count

Normal

7

4

29

% within Skeletal Vertical Dimension

20.7%

41.4%

24.1%

13.8%

100.0%

% within Frown Arc Groups

27.3%

42.9%

29.2%

20.0%

30.9%

13

11

12

11

47

% within Skeletal Vertical Dimension

27.7%

23.4%

25.5%

23.4%

100.0%

% within Frown Arc Groups

59.1%

39.3%

50.0%

55.0%

50.0%

3

5

5

5

Table 4B: Skeletal vertical Chi-Square Tests Value

6

.669

18

Likelihood Ratio

4.064

6

.668

1.189

1

.276

94

16.7%

27.8%

27.8%

27.8%

100.0%

% within Frown Arc Groups

13.6%

17.9%

20.8%

25.0%

19.1%

N of Valid Cases

22

28

24

20

94

23.4%

29.8%

25.5%

21.3%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

% within Frown Arc Groups

Asymptotic Significance (2-sided)

4.058a

Linear-by-Linear Association

% within Skeletal Vertical Dimension

df

Pearson Chi-Square

% within Skeletal Vertical Dimension

Count Total

Total

12

Count Open

Control

6

Count Skeletal Vertical Dimension

Severe

methodology, but look at a larger, better categorized sample.

Limitations of this study include it being a descriptive study which does not address the cause-effect or the consequences of having a frown arc. Another possible limitation of this study could be that the dental and the skeletal classes are not equally distributed in nature.

For example, Angle found that most individuals possess Class I dental malocclusion, so the finding for the mouth frown arc should account for the fact that certain dental and skeletal characteristics are more probable than others, irrespective of any other variable or action.

For instance, Proffit, et al.,17 estimates that approximately 40% of the population is Class I malocclusion, 15% Class II, and only 3% Class III, with the remainder being a combination.

a. 3 cells (25.0%) have expected count less than 5. The minimum expected count is 3.83.

Table 5A: Maxilla presentation distribution Frown Arc Groups Mild Count Normal

Deficient

17

67

% within Maxillary

19.4%

29.9%

25.4%

25.4%

100.0%

% within Frown Arc Groups

59.1%

71.4%

70.8%

85.0%

71.3%

9

6

6

1

22

% within Maxillary

40.9%

27.3%

27.3%

4.5%

100.0%

% within Frown Arc Groups

40.9%

21.4%

25.0%

5.0%

23.4%

0

2

1

2

5

% within Maxillary

0.0%

40.0%

20.0%

40.0%

100.0%

% within Frown Arc Groups

0.0%

7.1%

4.2%

10.0%

5.3%

22

28

24

20

94

23.4%

29.8%

25.5%

21.3%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

% within Maxillary % within Frown Arc Groups

Volume 8 Number 1

Table 5B: Maxilla presentation Chi-Square Tests

Total

17

Count Total

Control

20

Count Excess

Severe

13

Count Maxillary

Moderate

Value

df

Asymptotic Significance (2-sided)

Pearson Chi-Square

9.064a

6

.170

Likelihood Ratio

10.899

6

.092

Linear-by-Linear Association

.783

1

.376

N of Valid Cases

94

a. 5 cells (41.7%) have expected count less than 5. The minimum expected count is 1.06.

Orthodontic practice 25

RESEARCH

than an individual who does not have a mouth frown arc?1-9, 21-26 In addition to more research that might uncover treatment options for this dentofacial morphology, psychological studies can be undertaken in order to find out what, if any, lasting effects may develop if an individual with a frown arc has to constantly assure others that they are not sad, mad, or angry when they are simply enjoying a moment of silence.

Can the impression one displays, through no conscious effort of his/her own, mold them into whom they become as an adult?

Are people who are thought of as always

RESEARCH Table 6A: Mandible presentation distribution Frown Arc Groups Mild Count Normal

Deficient

Table 6B: Mandible presentation Chi-Square Tests

Total

6

8

32

% within Mandible

28.1%

28.1%

18.8%

25.0%

100.0%

% within Frown Arc Groups

40.9%

32.1%

25.0%

40.0%

34.0%

6

5

5

9

25

% within Mandible

24.0%

20.0%

20.0%

36.0%

100.0%

% within Frown Arc Groups

27.3%

17.9%

20.8%

45.0%

26.6%

7

14

13

3

% within Mandible

18.9%

37.8%

35.1%

% within Frown Arc Groups

31.8%

50.0%

22

Count Total

Control

9

Count Excess

Severe

9

Count Mandible

Moderate

% within Mandible % within Frown Arc Groups

In addition, it would have been beneficial if Class III patients with anterior crossbites would have been identified. Furthermore, the results of chi-square analyses must be interpreted with caution when no more than 20% of the cells have expected frequencies less than 5, and this occurred for all analyses, except for that of the mandible. Future studies should have larger samples, especially when so many subcategories are needed.

Value

df

Asymptotic Significance (2-sided)

Pearson Chi-Square

10.249a

6

.115

Likelihood Ratio

10.724

6

.097

37

Linear-by-Linear Association

.132

1

.716

8.1%

100.0%

N of Valid Cases

94

54.2%

15.0%

39.4%

28

24

20

94

23.4%

29.8%

25.5%

21.3%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

Conclusions • This investigation reported for the first time a description of the “mouth frown arc” and a method for its measurement based on height/width ratios.

• There was no statistically significant (P = < 0.05) dental and skeletal characteristics of subjects with mouth frown arcs.

REFERENCES 1.

Darwin CR. The Expression of Emotion in Man and Animals. London: John Murray, 1872.

2.

Strack F, Martin LL, Stepper S. Inhibiting and facilitating conditions of the human smile: a nonobstructive test of the facial feedback hypothesis. J Pers Soc Psychol. 1988;54(5):768-777.

3.

mith CA. Dimensions of appraisal and physiological response in emotion. J Pers Soc Psychol.

S 1989;56(3):339-353.

4.

mbady N, Rosenthal R. Half a minute: Predicting teacher evaluations from thin slices of A nonverbal behavior and physical attractiveness. J Pers Soc Psychol. 1993;64(3):431-441.

5.

I zard CE. Innate and universal facial expressions: evidence from developmental and crosscultural research. Psychol Bull. 1994;115(2):288-299.

6.

ussell JA. Is there universal recognition of emotion from facial expression? A review of R cross-cultural studies. Psychol Bull. 1994;115(1):102-141.

7.

imberg U, Thunberg M, Elmehed K. Unconscious facial reactions to emotional facial expresD sions. Psychol Sci. 2000;11(1):86-89.

8.

ess U, Adams RB Jr, Kleck RE. Who may frown and who should smile? Dominance, affiliH ation, and the display of happiness and anger. Cogn Emotion. 2005;19(4):515-536.

9.

alter BM, Cray JJ, Burrows AM. Selection for universal facial emotion. Emotion.

W 2008;8(3):435-439.

10. F rown. Wikipedia. https://en.wikipedia.org/wiki/Frown. Published October 1, 2015. Updated February 13, 2016. Accessed June 3, 2016. origini M. Botox and depression: the frownless face of happiness. https://www.psycholo11. B gytoday.com/blog/overcoming-pain/201404/botox-and-depression-the-frownless-facehappiness. Published April 10, 2014. Accessed June 3, 2016.

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 5.32.

• There was also no relationship among the various degrees of mouth frown arcs (i.e., mild, moderate, severe) and dental and skeletal characteristics.

• There was, however, a trend (P = 0.087) for subjects with mouth frown arcs to have proportionally more skeletal Class IIIs and less skeletal Class IIs than subjects with nonfrown arcs. OP

14. Bosch, C., Athanasiou, A.E. Landmarks, variables and norms of various numerical cephalometric analyses: cephalometric, morphologic, and growth data references. In: A.E. Athanasiou (Ed.) Orthodontic Cephalometry. London: Mosby-Wolfe, 1995. raújo E. Viken Sassouni: scientist, teacher, and mentor. Am J Ortho Dentofacial Orthop.

15. A 2015;148(4):540-542.

16. M oss M. The functional matrix hypothesis revisited. 1. The role of mechanotransduction. Am J Orthod Dentofacial Orthop. 1997;112(1):8-11. roffit WR, Fields JH Jr, Sarver DM. Orthodontic treatment planning: from problems list to 17. P specific plan. In: Contemporary Orthodontics, 4th ed., Mosby 2007.

18. S chabel B. Franchi L. Baccetti T. McNamara JA Jr. Subjective vs objective evaluations of smile esthetics. Am J Orthod Dentofacial Orthop. 2009;135(4)(suppl):72-79. cNamara L., McNamara JA Jr, Ackerman MB. Baccetti T. Hard- and soft-tissue contributions 19. M to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop. 2008;133(4):491-499.

20. P epicelli A, Woods M, Briggs C. The mandibular muscles and their importance in orthodontics: a contemporary review. Am J Orthod Dentofacial Orthop. 2005;128(6):774-780. harma PK, Sharma P. Dental smile esthetics: the assessment and creation of the ideal smile.

21. S Semin Orthod. 2012;18(3):193-201.

22. C ollins M. The eye of the beholder: face recognition and perception. Semin Orthod. 2012;18(3): 229-234.

23. Reyneke JP. Ferretti C. Clinical Assessment of the Face. Semin Orthod. 2012; 18(3):172-186.

24. D onega R. Bullying and cyberbullying: history, statistics, law, prevention and snalysis. The Elon Journal of Undergraduate Research in Communications. 2012;3(1):33-41.

12. W ollmer, MA, de Boer C, Kalak N, Beck J Götz T, et al. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Research. 2012;46(5):574-581.

25. P ithon MM, Nascimento CC, Barbosa GC, Coqueiro Rda S. Do dental esthetics have any influence on finding a job? Am J Orthod Dentofacial Orthop. 2014;146(4):423-429.

13. Sarver DM. Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning. Am J Orthod Dentofacial Orthop.

2015;148(3):380-386.

26. A l-Bitar ZB. Al-Omari IK. Sonbol HN. Al-Ahmad HT. Cunningham SJ. Bullying among Jordanian schoolchildren, its effects on school performance, and the contribution of general physical and dentofacial features. Am J Orthod Dentofacial Orthop. 2013;144(6):872-878.

26 Orthodontic practice

Volume 8 Number 1

PLAN YOUR NEXT YEAR OF EDUCATION WITH SPEAR SEMINARS In two days, Spear seminars lead you to a more productive practice with targeted learning youâ&#x20AC;&#x2122;ll use right away.

2-DAY SEMINARS 14 CE CREDITS LOCATION: THE SPEAR CAMPUS, SCOTTSDALE, ARIZ.

Implants - The Surgical/ Restorative Connection

Interdisciplinary Management of Esthetic Dilemmas

March 10-11, 2017

Oct. 12-13, 2017 (LIMITED SEATS)

The essentials of treatment planning, placement

Confidently diagnose, treatment plan and present

and restoration of dental implants in both simple

esthetic dentistry to your patients, enhancing the

and complex implant reconstructions.

quality and quantity of the care you provide.

The Art of Treatment Planning and Case Presentation

Demystifying Occlusion Aug. 10-11, 2017 (SEATTLE)

March 30-31, 2017

Treat occlusion patients more predictably â&#x20AC;&#x201C; from a

Gain confidence and skill in knowing treatment

single second molar crown, to full arch restorations,

options available for a number of common but

or even patients with symptoms of facial pain.

complex dental problems.

Treating the Worn Dentition April 6-7, 2017 (DALLAS)

Treating the Terminal Dentition and the Fully Endentulous Patient

Acquire a solid foundation in what to look for, how to

Aug. 25-26, 2017

plan and predictably treat worn dentitions.

Explore the essentials of treatment planning and implant restorative design for the patient with

Treating Comprehensive and Esthetic Cases With a Digital Workflow

terminal dentition and/or a fully edentulous condition.

April 29-30, 2017 Explore the digital workflow in treating esthetic and larger, more comprehensive cases.

Learn more at speareducation.com/seminars or speak to an education advisor at 866.781.0072 or info@speareducation.com.

EDUCATOR PROFILE

Frank Spear, DDS, MSD Coaching dentists to believe in their capabilities

What can you tell us about your background?

Fife, Washington, population 1,500, where I was born and raised, is a small rural farming community where my parents were also raised 30 years earlier. Fife is an hour south of Seattle, Washington. My mother was a second-grade schoolteacher, and my father was a mechanic who owned a gas station and garage. My interests when younger were the same as most small town boys — sports, fishing, hunting, and eventually, girls and cars. When I left for college, I went to Pacific Lutheran University (PLU), the same small college my parents went to about 30 minutes from where I grew up. I really didn’t have any idea what I wanted to be, just that I wanted to play football in college and have a good time. And I did have fun, finishing my first year of college with a 2.3 GPA and a D in a religion class.

My second year in college, it was required to choose a major, so I chose physical education, with a goal of becoming a football coach. One of the hardest classes for that major was anatomy; I decided to sign up for it first semester of my second year. I loved the professor, a woman named Ruth Sorenson, and the class and topic. At the end of the semester, she asked if she could meet with me after finals. She looked at me across the desk and asked me what I was going to do with my life, to which I replied become a football coach. She said that was what she thought and, she then asked me what else I had considered; I had no answers.

Next, she asked if I had ever considered becoming a physician, a dentist, or perhaps a veterinarian. I replied no to all three. In my small town, both of my parents were raised very poor, and we viewed the physician, dentist, and veterinarian in the town as being at a different level than we were; there was no way I ever would have considered becoming any of the three. Ruth Sorenson then looked me straight in the eye and said, “I think you should consider one of the three, because I see a lot more capability in you than you do.”

She then informed me that she had arranged a meeting for her and me down the hall. We walked down to a room that I 28 Orthodontic practice

Dr. Frank Spear lectures at Spear Study Club Summit 2016 in Scottsdale, Arizona

had never been in before — it was Harald Leraas, the Pre-Med Pre-Dent advisor’s office. We sat down across from Harald, and it turned out he was a dentist. Fifteen minutes after sitting at that desk, I decided to become a dentist; to this day I can’t tell you how that happened. I went on to finish my undergrad with one B in a lab class, and all the rest A’s — how motivating clarity and direction can be. I did still finish playing football for all 4 years — just gave up on the physical education part as well as becoming a coach.

From there I went to the University of Washington School of Dentistry for my DDS and then onto an MSD in Perio-Pros.

What originally attracted you to dental education? What aspects of your training inspired you to add “educator” to your list of accomplishments?

As I said, my mother was a secondgrade schoolteacher, and both my mother and father believed very strongly in education being the most important thing you can give anybody. In addition, mom was very gifted at

what she did. She passed away at age 92 in 2014, and many of her former students attended her memorial service, some she had taught over 50 years earlier. They all remarked how much they remembered the experience of being in Mrs. Spear’s secondgrade class.

In addition, while I was in my senior year of dental school, I was chosen as a faculty member to help teach second-year dental students in their first clinical denture course.

Part of that experience involved the students giving the prosthetics department written feedback about each member of the faculty.

Thankfully, my feedback was very positive, and I realized how much I enjoyed helping others learn.

Along with those experiences, in my Perio-Pros residency, you had to learn how to give presentations. We had an entire year course on every aspect of a presentation — graphics, title slides, organizing content, timing, etc. I loved it, and our final exam was a 1-hour presentation in front of the faculty of the periodontics, prosthetics, and restorative departments. I had taken some public speaking courses in my undergrad days, and Volume 8 Number 1

Who has inspired you as a clinician and an educator?

The list of people I have been inspired by would be fairly long, but some names definitely stand out. I have already mentioned the one who had the most impact on me as an educator, Ruth Sorenson, my undergrad anatomy professor. Without her and that meeting after finals with Harald Leraas, I wouldn’t be writing this for you right now. In fact, one of my major prayers is that I can be Ruth Sorenson for people in my audiences.

In other words, I can help them see that they are more capable than they believe they are.

In dentistry, the one who most formed the direction I went was the director of my PerioPros program, Dr. Ralph Yuodelis. He was gifted as a clinician, but he was one of the least dogmatic educators I have ever seen in dentistry. While everyone else would be telling you there was a right way and a wrong way to do things, and their way was the right way, Ralph would be telling us to try all the different ways and learn for ourselves what works for us as individuals. Not to mention the work he would show was so inspiring, I knew that was what I wanted to do.

Another name that readily came to mind would be Dr. Lloyd Miller from Tufts — one of the true gentleman of dentistry — massively talented esthetically and so nurturing of young dentists. He wanted only the best for everyone he taught. Dr. Richard V. Tucker

is another in that same vein as Lloyd, so humble, but his work was simply spectacular.

And finally I would add Dr. Pete Dawson, someone I have considered a friend for 30 years. I have learned so much from Pete, and I also had the good fortune of teaching with him a week a year for 9 years starting in the mid-’90s at The Pankey Institute. We would stay in the same condo for the week, and after the day was done, some of my most enjoyable memories were he and I drinking a Scotch and talking about life and his history in dentistry.

What are your proudest moments in the clinical and teaching aspects of your life?

As a clinician, I have always loved the experience of watching a patient’s selfconfidence transform following treatment that took a debilitated dentition and turned it into something beautiful. In addition, anytime a patient gives you a hug because of what you have done to help him/her, that is hard to beat.

As an educator, the greatest rewards for me have always been watching students who didn’t think they could see something, do it, or understand it, and then those students suddenly gets it. Seeing that aha flash across their faces is wonderful. The other thing I love about education is getting feedback about how what you have taught someone has impacted their life, either in practice or personally. I have been fortunate to have been doing what I do for close to

35 years, and I have gotten lots of cards, letters, notes, etc., from students over those years, and I have kept all of them in “attaboy boxes.”

You are probably wondering what an attaboy box is. I mentioned that I played college football, and my coach was one of the most amazing men I have ever met. His name was Frosty Westering; he coached football, but in reality, Frosty coached young men about life. In his 32 years at PLU, he won six Division II national championships and was in the finals game another 6 times, so he was very successful as a coach. He would tell us life lessons he had learned, and one was about his attaboy box — a box where he kept all the things people sent him that were positive so that when he was down or life seemed hard, he could go to the box and remind himself who he really was. It is amazing how well it works.

What do you think is unique about the topics that you teach?

I would like to think I am like Frosty. I teach dentistry, but in reality, I would like to think that I am also a coach about the life of a dentist, so it is not a procedure or technique necessarily, but also how to integrate what you learned into your practice, your case presentation, and your fees. One thing I learned a long time ago about dentistry is that if you teach dentists a technique, but not how to integrate it into their practices, they will learn the technique but never get to do it.

That philosophy fits perfectly with our goals at SPEAR Education for our students.

We have four very simple-to-understand goals for the dentists we work with: 1. Help you have more fun in practice on a daily basis, basically help you enjoy dentistry more.

2. Help you become more profitable.

3. Help you have more free time.

4. Help you grow as a clinician to whatever level of clinical excellence you aspire.

We accomplish those goals by not teaching just techniques, but on focusing on all aspects of the practice, including TEAM training.

As an educator, what have you learned from your clinicianstudents?

From “The Art of Treatment Planning and Case Presentation” to “Treating the Worn Dentition,” Dr. Frank Spear teaches at several seminars each year, both on Spear Education’s campus and select locations around the U.S. Volume 8 Number 1

The greatest learning I have gotten from students comes from the evaluations that I want to see the least, ones with negative feedback. At first there is a tendency to rationalize the feedback, blame it on whoever Orthodontic practice 29

EDUCATOR PROFILE

I was very comfortable with it, so extending that to dentistry was enjoyable for me.

EDUCATOR PROFILE wrote it as being incompetent, etc., but almost universally, if you allow yourself to read it and ask the question, “How could I have presented this differently so this person would have understood it?” you will become a better teacher. To this day, all of us who teach at SPEAR Education read every one of our evaluations, and to this day, I learn how to improve after every course I teach.

One of the things I am most proud of about my teaching is getting feedback that I take complicated topics and make them easily understandable, but part of why that has occurred is because of the feedback I have gotten over the years about what students didn’t understand.

What has been your biggest challenge in sharing information and educating clinicians?

The answer to this is interesting because it goes back to me at PLU and sitting across from Ruth Sorenson. I had never considered being a dentist because I didn’t believe it was possible. My students are dentists, they have already gotten there, but the biggest issue I have is helping them get a clear vision of what is possible for them in practice — most don’t clearly see the possibilities.

I hear things such as “I just don’t see those patients in my practice,” “My patients only want what the insurance will cover,” etc. In other words, they don’t believe that any patients in their practice want more than basic single-tooth dentistry. Yet I promise in almost any town in America there are patients who want more and the dentists who are providing it. But if you don’t believe that is possible, it is a self-fulfilling prophecy because you won’t present anything more because you believe it will be turned down.

To clarify, our goal for our students is not for them to have complex restorative practices or boutique cosmetic practices, but instead a robust patient base with a good hygiene-recall program, while at the same time hopefully treating one or two patients a month who do want more. My experience is that if a general practitioner can do one or two more involved cases a month, it moves them significantly in the direction of our four goals: fun, profitability, free time, and clinical growth.

What would you have become if you had not become a dentist?

The first thing that comes to mind would have been a football coach, but you heard

Top 10 favorites Unlike perhaps some people in education, I tend to be somewhat material agnostic, meaning that I believe there are several different bonding agents that can work well, several different composites that are excellent, and I tend to tell students to find what works for them, and stick with it until there are some obvious reasons to change. I can certainly tell students what we use in the office, but that doesn’t mean there aren’t other products just as good. If I was to tell you the things I think are indispensable in practice, the list would look like this: 1. A digital SLR clinical camera, Nikon® or Canon®, both work well. Learn how to use it, or have someone on your TEAM learn how to use it. Take photos on every adult patient in your practice at the new patient appointment and at any recall where you re-do radiographs. Show the patient the photos, and he/she will ask for more dentistry than you ever would have presented.

2. Brasseler USA®/NSK electric handpiece. I switched from air to electric in 1995 and would never go back.

3. Straumann® implants have been my primary implant system since 1994. I have never had an implant or component failure with the system, not even a loose abutment screw.

4. 3M Rely-X™ Luting Cement, a predictable, simple-to-use, resin-reinforced glass ionomer cement.

5. 3M Scotchbond™ Universal bond dentin adhesive can be used as a total etch, selective etch, or self etch product, will also bond to zirconia, and can be used as a light-cure or dualcure product. We use it for our direct composites in a light-cure mode, as well as all of our indirect-bonded restorations.

6. 3M Rely-X™ Veneer Cement, a light-cure-only cement for translucent veneers or all ceramic restorations. I has excellent color stability, easy cleanup, and great shade choices.

7. 3M Rely-X™ Ultimate Adhesive Resin Cement, a dual-cure resin cement for all ceramic inlays, onlays, and crowns, contains the catalyst for the Universal adhesive, making their use together seamless.

8. Magnification, at least 4x power. I have and use both Designs for Vision, Inc., and Orascoptic™.

9. 3M Protemp™ 4 Temporization Material is incredibly durable, especially if cured in a light- and heat-curing oven for 2-3 minutes and also easy to work with and esthetic.

10. Ivoclar Vivadent® IPS e-max® Lithium Disilicate is just a great product, and almost the only material I use for indirect restorations.

30 Orthodontic practice

that story. My most likely other choice besides dentistry would have been plastic surgery, but I am happy I chose dentistry.

What are your top tips for maintaining a successful practice?

My top tips are not very complicated — solid clinical quality and a great patient experience. I view dentistry the way I see any customer service business — you have to identify who you want to be as a practice, clearly communicate that to your potential client base so they have the correct expectations about who you are, and then deliver what they were expecting. One of the biggest problems I see for many dentists is they don’t know who they are, and they don’t know what they would like their practice to be like; instead they just take whatever comes their way.

Also learning how to treatment plan and to communicate that plan to patients is imperative. Learn to present the results of your examination as a report of findings instead of a treatment plan. Most dentists examine the patient, look at radiographs, and then sit down and formulate a treatment plan, agonizing over how much or how little they should present. That plan then gets put on paper, and now the anxiety level goes up higher as the paper is handed to the patient who immediately looks at the bottom line.

Now the dentist tries to justify why they put what they did on the paper; it is a completely illogical order to the process.

Instead, do the exam, get radiographs and photographs, and sit down with patients with three goals in mind: 1) to make them aware of all the problems you found, 2) to tell them what you think the consequences will be if no treatment is done, and 3) finally, to inform them of how treatment will benefit the prognosis. Ask patients if they would be interested to hear what the actual treatment options and costs would be for the problem; and if they say no, move on to the next problem. If they say yes, write down the problem, and list potential treatment choices. The fees will be listed later after all the problems have been covered. This allows you, as Dr. Bob Barkley used to say, to “co-diagnose” the patient’s mouth and co-treatment plan, having the patient identify what is a concern for him/her.

At the end you may need to phase the treatment over time due to finances and insurance, but the patients now actually know the condition of their mouths, and what the most urgent concerns are, instead of the dentist not sharing the reality of what Volume 8 Number 1

EDUCATOR PROFILE

(Above) Dr. Frank Spear and his wife, Charlene Spear, dressed to impress at the 1920s-themed party during the Spear Faculty Club Summit 2014. (Right) At the 2015 Spear Faculty Club Summit party, Frank and Charlene wore their best Kentucky Derby-themed outfits

is going on out of the FEAR of scaring the patients away.

I would also say I cannot emphasize enough the importance of a cohesive wellaligned and trained TEAM to both growing and maintaining a successful practice. At SPEAR Education we have surveyed thousands of dentists about what they see as their biggest obstacles in practice, their TEAM always comes out as the number one or two issue they want help with, which is why we have added an entire TEAM training curriculum for all the different TEAM members.

What advice would you give to clinicians who are starting their practices?

My daughter got out of dental school in 2008, so I have recent experience with this issue. There can be many different ways of addressing the issue, all of which can be right for different dentists. Whether going into a residency of some type, corporate dentistry, working as an associate, purchasing an existing practice, or opening your own office from scratch, all can work but have different challenges and risks. And one driver today that has to be realized is the amount of debt the new graduate is carrying and what the rate of payback will be.

My wife, who retired after 28 years in practice, and I told our daughter we really wanted her to get experience before having her own practice, and we wanted her to get a lot of different experiences. Over 4 years, she worked as an associate in several different Volume 8 Number 1

offices — some in urban settings, some in rural settings, some fee-for-service-only practices, some all PPO practices — all of them were great learning opportunities for her, but not all were enjoyable learning opportunities, which was part of our intention for her.

Dentistry can be very enjoyable, but it can also be very stressful, and the nature of the practice, the patients you are seeing, people you are working with, and procedures you are doing, all impact the ratio of enjoyment to stress, but most dentists never consciously consider that. They just assume if they are busy with patients, all should be fine.

After the 4 years, our daughter had a clear picture of the practices she liked, the procedures she enjoyed, and also those she didn’t, which prepared her to move forward looking for a practice suited to her.

Her choice was to purchase an existing practice in a suburban setting that was 16 years old. It wasn’t large or fancy, and was roughly 60%-70% PPO patients, but had a fairly large, mostly blue-collar demographic she could draw from, had four operatories equipped with decent equipment, and could be enhanced esthetically fairly inexpensively with some paint and furniture. It also was very reasonably priced, as the previous dentist wasn’t overly productive, meaning there was a lot of dentistry left to do.

My point in telling our daughter’s story relates to one other piece of advice I would give young dentists; when it comes time to have your own practice, if you can, try to avoid getting underneath too much overhead too soon. The enjoyment and stress level

of practice are highly correlated to financial burden. Our daughter’s approach allowed her to see patients and get to know them without feeling she had to run them through and produce something every minute of every day.

My last piece of advice to young dentists is to continue your education as soon as possible. Dentists are interesting in that they tend to only talk to patients about things they feel competent doing. The reality is there is a lot that a new graduate doesn’t feel competent at, and there is a lot they simply don’t see in a patient’s mouth. An example may be how to diagnose and treatment plan a patient with significant tooth wear. The reality is that we can only treat what we see, and we only see what we have been taught to see.

Continuing education expands your vision and competence, and those two things lead to an increased confidence, which leads to an entirely new set of patient conversations.

Suddenly, you have patients choosing to do dentistry that you never would have even presented.

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

Photography, music (particularly listening to vinyl LPs), golf with my wife, our two mini-Australian labradoodles (Barney and Bailey), fly-fishing for trout or steelhead, cars, food and wine, and most enjoyably, spending time with family and friends, either on trips to Europe, or just hanging around the house. OP Orthodontic practice 31

ORTHODONTIC CONCEPTS

Reframing orthodontics: designing accelerated orthodontics by managing error — the BioDigital way, part 4 Dr. Rohit C.L. Sachdeva continues his steps to a patient-centered, ultra-safe practice environment Introduction In a previous article, (“Reframing orthodontics, part 3,”in the November/December 2016 issue of Orthodontic Practice US) I discussed the influence of misdiagnosis, misplanning, mismanagement, and miscommunication on both the effectiveness and efficiency of orthodontic care. In addition, I described the strategic care management practices that I have developed under the auspices of BioDigital Orthodontics to mitigate such error events with the aid of digital technologies such as suresmile®. In the current article, I discuss the therapeutic practices I have developed to manage error.

E) Error-proofing against therapeutic Mismanagement, Misprescription, and Misadministration By nature, conventional orthodontic care is error-prone and reactive. A number of factors contribute to this mode of practice.

Firstly, the diagnosis and plan (if there is one) and choice of therapeutics are often disintermediated. Secondly, the use of normative prescriptions built into the appliances (brackets) fail to account for individual variation.1 The manufacturing tolerances tend to be poor, adding to inexactitude in the prescription. Thirdly, the clinician often ignores sound principles of mechanics in favor of “convenience and simplicity” when designing, selecting, and managing orthodontic appliances. This often results in spurious tooth movement remedied only by reactive therapeutic measures. Additionally, the skills of the doctor are challenged in reliably bonding brackets2 or precisely bending archwires in 3D because of a lack of reproducible and reliable anatomical references to bond teeth or bend archwires. This issue is further compounded by limitations in human perception, manual skills, and the fidelity of orthodontic tools used.3 These intertwined

factors cause therapeutic dissonance, resulting in error that manifests in unplanned or unwanted tooth movement.

There are four major approaches that I use to prevent or contain errors related to the therapeutic management of a patient. These include the following.

Diagnopeutics and personalized targeted therapeutic planning driven by Simpeutics Diagnostic findings are integrated with therapeutic strategies (Diagnopeutics) to design a personalized 3D virtual target setup; I term this technique Simpeutics (Figure 1).

This setup is based upon consideration of patient needs, esthetics, anatomical constraints (root position, bone morphology, and growth potential), physiological limits, and a realistic appraisal of the corrective potential of the appliance used. I use both the auto and interactive design abilities of suresmile software to design the precision

Figure 1: An example of the principles of Diagnopeutics and the use of Simpeutics to manage care for this patient. There is a possibility of root collision occurring between the upper right canine with and first premolar during its mesial root correction if conventional mechanics were used. The Diagnopeutics-defined strategy for this patient was to initially extrude the upper first bicuspid to minimize the risk of root collision during root correction of the canine. Simpeutics was used to design the plan along with the series of staged archwires. The first one was to extrude the bicuspid while all other teeth were stabilized. The second was to root-correct the canine while stabilizing the rest of the arch with a passively designed archwire (active only for the canine). The last archwire was designed passive across the whole arch except for being active to intrude back the first bicuspid 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 improveortho@gmail.com to access information.

32 Orthodontic practice

Volume 8 Number 1

LESS TIME

*

30.7

29.6

26.3 23.0 15.8 CRE

MOS.

suresmile

20.8 20.0 18.5

14.7

OGS

MOS.

24.1

21.6

22.4

23.4 17.0

18.1

CRE

MOS.

13.4 CRE

MOS.

conventional

CRE- Case Report Examination

Jeff Johnson, DDS, MS, Dallas, TX

PROVEN RESULTS, FASTER. Studies show that the suresmile Treatment Management System achieves better or equal quality finishes in 30% less time while effectively accomplishing desired tooth movements.*

OGS- Objective Grading System

*Details available upon request from suresmile.

For more information, call suresmile at 877.787.7645 or visit suresmile.com

suresmile.com

to be sure.

© 2016 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix.

30%

“When people are given the proper tools and motivation, what can be accomplished is often nothing short of amazing.”

ORTHODONTIC CONCEPTS personalized indirect bonding trays and archwires. The interactive design tools allow me to design unique, customized appliances based upon my planned therapeutic strategies to minimize spurious tooth movement (Figures 2-3).

Figure 2: Interactive software tools are used to design single tooth IDB jigs or trays. An extensive electronic bracket library allows the clinician to choose the bracket system of his/her preference. STL files of the jigs/trays are produced and can be used for printing the output

A

B

C Figures 3A-3C: Personalized precision archwires are designed using a virtual target setup. 3A. Initial malocclusion. 3B. Virtual target setup. Some of the design considerations for the setup include esthetics (smile line), root position, anatomical limitations (bone), bracket prescription archwire cross section and material. 3C. Evaluation of both target tooth position against initial and archwire design

Robotic and 3D-printing-assisted precision appliance fabrication Robotically assisted precision archwire bending and precision 3D-printing technology are used to bend personalized archwires and fabricate indirect bonding jigs or trays and aligners, respectively. Both these technologies offer the ability to manufacture orthodontic archwires and IDB trays with great reproducibility, precision, and accuracy.4 These precision-manufacturing technologies overcome some of the limitations of human capabilities discussed earlier (Figure 4). However, it is important to note that I do not use robotically bent archwires, 3D-printed aligners, or IDB bonding trays on all my patients. I use them when I believe they will provide value in the care management of my patient.

Anticipatory orthodontics with free-body diagrams and Simtheranostics One of the best ways to manage error is to anticipate it and institute corrective measures in advance. Using free-body diagrams, I try to predict the impact of both active and reactive forces on tooth displacement. I then design the appropriate therapeutic strategies to counter unwanted tooth displacements (Figure 5).

I use simulations to forecast the influence of additive or subtractive bends placed in an orthodontic archwire (e.g., a curve of Spee) and bracket slot prescription to understand their potential to cause undesirable tooth movement. I term this technique Simtheranostics (Figure 6).

Statically determinate and consistent force system-based appliance design Designing and using appliances that generate statically determinate systems, such as cantilevers, allow me to apply both predictable and controlled force systems and achieve reliable and planned orthodontic tooth movement5 (Figure 7).

F) Error-proofing with root cause analysis (RCA) failure Figure 4: Robotically assisted orthodontics is used to fabricate the archwire. The input for the robots is driven by a spline that describes the final bracket slot position on the virtual target setup. These robots are located at suresmile facilities both in Richardson, Texas, and Berlin, Germany. 3D printers are used to print models and also IDB jigs/trays. suresmile currently requests its clients to outsource the printing to selected vendors and is also exploring the feasibility of manufacturing these products in-house in the future 34 Orthodontic practice

Every error incident in the practice should be reported and a root cause analysis6 performed. Root cause analysis is a preventative method of problem solving that attempts to seek the root cause(s) of the problems.

Volume 8 Number 1

Designing patient-centered highreliability (patient safety) practices The success in error-proofing a practice resides in establishing a culture of a highreliability organization and implementing operational practices that position the patient at the hub of the wheel of care. At the macro level, seven spokes around the wheel must

be aligned to achieve the tenets of quality care; I call these spokes the 7Pâ&#x20AC;&#x2122;s: People (the care team should have appropriate skills and work in an integrated and coordinated manner); Plan (the patient and care team should understand and agree upon a care plan and the path to accomplish it); Products (selection of the appropriate technology and

Figures 5A-5C: Anticipatory orthodontics 5A. Patient in whom an open bite developed with the use of a continuous archwire engaged into the high canines. 5B.This could have been predicted with the use of free-body diagram 5C. Diagnopeutics-driven appliance design. Risk of an open bite was averted by using a passive bypass archwire (reactive appliance) and using a piggyback archwire (active appliance) to extrude the canines

Figure 7: Statically determinate force systems are generated when a single force system is used. Note in this patient the line of action of the force system is located through the center of resistance of the canine and molar. As a result, no tipping is seen during the retraction of the first bicuspid Volume 8 Number 1

Figures 6A-6E: 6A.Simtheranostics used to predict the expression of standard slot prescription built into the lower left canine bracket.

Note clinically the torque on the canine appears fine. 6B. The canine slot has not fully expressed. 6C. Simulation shows full expression of the canine bracket prescription. Note the excessive amount of lingual root torque. 6D. Shows the canine into bony housing. 6E. Shows the potential risk of creating dehiscence/perforation in time on the lingual side of the canine assuming a full-sized archwire is used Orthodontic practice 35

ORTHODONTIC CONCEPTS

Once a root cause is identified correctly and removed from the problem fault sequence, recurrence of the undesirable event is eliminated. Removing causal factor(s), as is commonly done in practice, helps treat the symptoms, but unlike root cause(s), does not prevent its recurrence. RCA is tool of continuous improvement.

ORTHODONTIC CONCEPTS materials); Processes and Procedures (the correct sequence and way in which things are done); Place (the appropriate work space designed around transparency and a culture of reporting); and Performance (measures to gauge effectiveness that drive a system of double-loop learning to achieve continuous improvement in patient care) (Figure 8).

Discussion and conclusions Omnia mutantur, nos et mutamur in illis. (All things change, and we change with them.)

The tenets of BioDigital Orthodontics reside in the practice of Aeger primo (patient first) and Primum non nocere (First, do no harm). Its constitution mandates that the patient is treated with empathy, dignity, and as a “patient of one” within a caring and learning environment that practices patient safety (high reliability/error-free) and continuous improvement enabled by reflective thinking.7-8 Such practices, when acculturated by the doctor in his/her practice, are transformational in their character and shift the quality curve to the right.

I must also emphasize that the solutions I offer comprise a blend of conventional and digital technologies (The term I use to describe such practices is Blended Orthodontics.) These solutions, when incorporated in a systems-driven practice, minimize errors in care. They are designed to be patientspecific. These practices, when embraced by the clinician and his/her team, result in accelerated care, predictable treatment outcomes, and cost-effective care.

Safe practices require that the doctor relies upon a strong foundation in the principles of diagnosis and biomechanics, with a robust understanding of the nature of orthodontic tooth movement to design and plan appropriate patient care.

Furthermore, the larger concentric of coordinating care team activities and the sociocultural aspects of patient care cannot be blind sighted when developing an error management strategy.

Doctors must be fearless in terms of reporting errors, providing fertile grounds for the practice of patient safety. Furthermore, reflective, lifelong learning on the part of the doctor fortifies the path to better patient care.

Unfortunately, our practices have accepted a culture of normalization of deviance, which is a term coined by Vaughan9, She defines it as, “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated, without catastrophic 36 Orthodontic practice

Figure 8: The wheel of care. Alignment of all the 7P’s encourages safe practices

results, it becomes the social norm for the organization.” Such deviant practices should no longer be accepted as modus operandi by our profession.

The new reality on the ground is that the doctor and his/her team need to extend their skills sets and repertoire from managing patients in vivo to doing so in silico via simulation-driven orthodontics. This will require challenging the clinician’s mental models of care and ensuring they are congruent with reality. It is important to realize that dissonance between these models leads to incorrect design inputs for the virtual care plan — in fact, creating pathological virtual simulations/setups that, in turn, lead to the manufacture of incorrect appliances — a consequence of which is spurious tooth movement.

“Push-button” digital orthodontics is fool’s gold. Inappropriate management of a patient in the virtual world adds another layer

of complexity in error containment. Despite all of the technologies and processes that we have in our armamentarium to manage errors, the clinician must recognize that successful error management pivots around the human attributes of mindfulness, judgment, reason, sense making, and active listening. Most importantly, the doctor can never abdicate his/her primary responsibility to his/her patients; with a healthy dose of empathy, the doctor must care for patients in the physical world.

My intention in writing these series of articles on reframing orthodontics10-12 was to highlight some of the approaches that I have developed based upon the principles and practice of BioDigital Orthodontics to serve my patients with quality care. I very much realize that creating a patientcentered, ultra-safe practice environment — described under the auspices of the BioDigital Orthodontics manifesto — is a long and arduous journey. However, as Lao Tzu said: “I have taken the first step in a thousand mile journey.”

In closing, to quote Cicero, the meaningful question that should arise in our minds is “Cui bono?” (Who benefits?) From the practices discussed in this series of articles, it’s the patient! And shouldn’t this be all that really matters for us as doctors who have taken the ὅρκος horkos (Hippocratic oath)? OP

Acknowledgments This article is republished with permission from the European Journal of Clinical Orthodontics — Sachdeva RCL. Novus Ordo Seclorum. A manifesto for practicing quality care — part 1. EJCO. 2014;2:71-76. I sincerely thank the publishers and editors of the European Journal of Clinical Orthodontics, Dr. Raffaele Schiavoni and Ms. Lorella La Leggia for giving me permission to publish the above article in Orthodontic Practice US.

REFERENCES 1. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets — are standards as expected?

Angle Orthod. 2004; 74(4):450-453.

2. Balut N, Klapper L, Sandrik J, Bowman D. Variations in bracket placement in the preadjusted orthodontic appliance. Am J Orthod Dentofacial Orthop. 1992;102(1):62-67.

3. Eerkens JW. Practice makes within 5% of perfect: visual perception, motor skills, and memory in artifact variation. Current Anthropology. 2000;41(4):663-668.

4. Sachdeva R. Integrating digital and robotic technologies: diagnosis, treatment planning, and therapeutics, In: Graber ML, Vanarsdall RL, Vig KWL, eds. Orthodontics: Current Principles and Techniques. 5th ed. Philadelphia, PA:Elsevier/Mosby; 2012.

5. Sachdeva R, Bantleon H. Cantilever based orthodontic— biomechanical and clinical considerations. In: Sachdeva RCL, ed.

Orthodontics for the Next Millennium. Glendora, CA: Ormco Publishing; 1997.

6. Fontenelle A. Challenging the boundaries of orthodontic tooth movement. In: Sachdeva RCL, ed. 14. Root Cause Analysis. Patient Safety World Health Organization. doc:1.10.A http://www.who.int/patientsafety/education/curriculum/course5a_handout.pdf 7. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care - part 1. EJCO. 2014;2(3):71-76.

8. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care - part 2. EJCO. 2015;3(1):2-14.

9. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. London: The University of Chicago Press; 1996.

10. Sachdeva RCL. Reframing orthodontics: Ortho 3.0. Orthodontic Practice US. 2016;7(4):22-26.

11. Sachdeva RCL. Reframing orthodontics: a new manifesto driven by BioDigital orthodontics, part 2. Orthodontic Practice US. 2016;7(5):38-43.

12. Sachdeva RCL. Reframing orthodontics: Designing accelerated orthodontics by managing error — the BioDigital way: part 3.

Orthodontic Practice US. 2016;7(6):30-37.

Volume 8 Number 1

CONTINUING EDUCATION

Esthetic preferences regarding the anteroposterior position of the mandible Drs. Jeffrey H. Lee, Daniel Rinchuse, Thomas Zullo, and Lauren Sigler Busch investigate how the advancement of the mandible changes facial esthetics from a frontal and three-quarter view Abstract Introduction The purpose of this study was to investigate orthodontists’ esthetic preferences compared to laypersons when manipulating the anteroposterior position of the mandible from a retruded mandibular position (maximum intercuspation) to a protruded position (with a maximum 6 mm advancement of the mandible) in a frontal and threequarter profile view.

Method One male and one female target persons were selected based on the inclusion criteria for the study. These target persons were evaluated by a small group of laypersons and rated for average attractiveness to participate in the study. Each target person had a wax bite taken for each mandibular advancement positions (0 mm, 2 mm, and 6 mm advancements from maximum intercuspation) and had his/her photograph taken from these positions from a frontal view and a threequarter profile view. A total of 12 photos were manipulated for evaluation, with two duplicate photos taken for reliability. The raters were comprised of 10 orthodontists and 152 laypersons who rated each of the photos for its attractiveness level. Using SPSS software, a 2x2x3x2 ANOVA was performed to test whether there were statistically significant differences between the “main effects” (gender, view, mandibular position, and judge group) and the “interaction effects” with each of the main effects (i.e., gender x mandibular position, gender x view, etc.).

Jeffrey H. Lee, DDS, MS, is a former resident at Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. and is currently practicing in the San Francisco Bay area.

Daniel Rinchuse, DMD, MS, MDS, PhD, is a Professor and Program Director, Seton Hill University Center for Orthodontics.

Thomas Zullo, PhD, is an Adjunct Professor of Biostatistics, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

Lauren Sigler Busch, DDS, MS, is in private practice in Colorado Springs, Colorado, and is also an adjunct professor at Seton Hill University Center for Orthodontics.

38 Orthodontic practice

Educational aims and objectives

This article aims to discuss orthodontists’ and laypersons’ esthetic preferences in different occlusions.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify traditional ideal treatment goals for occlusion and jaw relationships.

• Realize the differences between how orthodontists and laypersons view facial esthetics.

• Recognize various ways to assess soft tissue facial profile.

• Identify how to determine if a large mandibular advancement or a small mandibular advancement changes esthetics ratings from a frontal view and three-quarter view perspective.

• Recognize differences in the resultant esthetics of the male subjects versus female subjects.

Results There were statistically significant (P < 0.05) differences for the gender and view categories. In addition, there were statistically significant (P < 0.05) differences among the interaction effects for both (gender x view) and (gender x mandibular position), but both interaction effects were slightly underpowered (0.555 and 0.606).

Conclusions There was more esthetic preference for the female target person and for the frontal view photos. Intrajudge reliability showed that orthodontists were inconsistent with their ratings versus laypersons. Interjudge reliability for the orthodontists was good (0.736).

Background In traditional orthodontics, ideal treatment goals were to obtain Angle’s Class I dental occlusion and jaw relationships.1,2,3 This focus shifted in contemporary orthodontics to a soft tissue paradigm and smile esthetics.4,5,6 Since esthetics plays a key role in orthodontic treatment, numerous studies have been performed to evaluate facial attractiveness utilizing silhouettes of profiles,2,4 digital imaging alterations to simulate esthetic alterations,5,6,7,8 as well as bite blocks or functional appliances to alter the position of the mandible.7,8,9,10,11 Other studies have examined the improvement of soft tissue profile changes after

orthognathic surgery with mandibular advancement.4,12 Orthodontists have used cephalometrics for decades to assess the soft tissue facial profile as part of their diagnosis.6,13 The information that cephalometric X-rays provide is only part of the records collection, since proper diagnosis also requires a panoramic film, model casts, and soft tissue analyses.14 In addition, orthodontists lack a comprehensive rubric for soft tissue analysis when compared to Angle’s classes of dental malocclusions or cephalometrics for skeletal measurements. Soft tissue analysis is perhaps the most complicated part of orthodontic diagnosis as it is rather subjective.12,13 Soft tissue preferences are more affected by the patient’s perception of beauty than a patient’s dental occlusion or skeletal relationship preference. Each patient’s perception of beauty can vary greatly by ethnicity, socioeconomic status, and the person’s personal preference.12,13,14,15 Previous studies have been done to show improvement in the facial profile via functional appliances,11 but there still remains a lot of controversy over this topic in effectively obtaining ideal jaw relationships. Recently, Barroso, et al.,16 conducted a novel study analyzing the ability of orthodontists and laypeople to discriminate between mandibular stepwise advancements from a profile view. They concluded from their study that laypeople might not be able to discriminate Volume 8 Number 1

Volume 8 Number 1

Allowing patients to view their pretreatment facial photographs may reduce the discrepancy between patients’ perceived levels of facial attractiveness, thus making orthodontists’ and patients’ visual emphasis on dentofacial esthetics more similar to one another. plan.35,36 Interestingly, most laypeople cannot differentiate their own profile.33 This lack of attention to detail of the soft tissue profile highlights a distinction between how orthodontists and the general public rate facial profile esthetics.5,37,38,39,40,41,42,43 Orsini, et al., found in their study that laypeople evaluated prognathic profiles more negatively than retrognathic profiles whereas orthodontists preferred prognathic profiles to retrognathic profiles.44 However, Bonetti, et al.,45 demonstrated that laypersons seldom view a person’s facial profile unless it is viewed via diagnostic photographs. In other words, people tend to converse with each other and view one another’s facial attractiveness from a frontal and oblique perspective rather than side profile position. Although this study was well designed, it utilized a computer-imaging software to alter the patient’s profile instead of the patients’ actual natural profiles. Other studies have also reinforced using the oblique view of the face since people are generally observed by others at a slight angle in daily interaction,46,47 and this oblique view provides the best impression of an individual's facial appearance.48 The three-quarter facial photographs have been reported to be reliable and valid in the assessment of facial attractiveness.49 Allowing patients to view their pretreatment facial photographs may reduce the discrepancy between patients' perceived levels of facial attractiveness, thus making orthodontists’ and patients’ visual emphasis on dentofacial esthetics more similar to one another. In conclusion, self-perception is strongly based upon how individuals view themselves in the mirror, and it has been reported that frontal views of the face and smile seem to be their chief concern.50,51 The aim of this study was to determine if a large mandibular advancement (6 mm) or a small mandibular advancement (2 mm) changes esthetics ratings from a frontal view and three-quarter view perspective.

Further, this study will characterize if there is any difference in the resultant esthetics of the male subjects’ versus female subjects’ mandibular advancement. This study will also compare the esthetic rating of orthodontists

versus laypersons. This study will aid the practicing clinician in determining to what extent the advancement of the mandible changes facial esthetics from a frontal and three-quarter view.

Materials and methods Frontal view and three-quarter view photographs of 12 Caucasian subjects: Six male and six female subjects, ages 10 to 16, prior to orthodontic treatment were collected and evaluated for participation in the study. All materials were collected after approval from the Seton Hill IRB committee.

The subjects’ records were obtained from pretreatment records from orthodontic residents at a postgraduate orthodontic specialty program and at private practice clinics in the Pittsburgh, Pennsylvania-area. The subjects had the following inclusion criteria: A. At least ≥ 6 mm of overjet to facilitate mandibular stepwise advancements of 5 mm-6 mm from maximum intercuspation (MIP) B. General facial symmetry, with slight deviation of the chin being acceptable (≤ 2 mm of chin deviation acceptable with no mentalis strain and no chin clefts) C. Angle’s Class II Division 1 malocclusion dentally and skeletally with a retrognathic mandible D. No occlusal cant E. SN-MP ranging from 25° to 30° Six laypersons rated each male or female subject recruited for average attractiveness on a 7-point Likert scale until one male and one female subject were rated as having the most average attractiveness (a rating of 3-4). The screening of patients ended once one male and one female patient of average attractiveness were identified and had met the inclusion criteria. The goal was to obtain one male subject and one female subject (two subjects total) who underwent stepwise mandibular advancements from centric relation to achieve a natural-looking face.

All analyses and photo uploads were done by Dolphin Imaging software (Dolphin Imaging & Management Orthodontic practice 39

CONTINUING EDUCATION

2 mm of mandibular advancement in evaluating facial-profile attractiveness as well as orthodontists.

Orthognathic surgery has helped significantly improve the soft tissue profile of many orthodontic patients.12,13,19,20,21 Dunlevy, et al.,17 reported that patients with smaller changes in mandibular position after mandibular advancement surgery were judged by laypersons to be less improved than those with larger changes from the profile view.

Thus, if a large anteroposterior discrepancy is present, a surgical option may be a better treatment protocol to address profile esthetics than with just orthodontic treatment alone. Montini, et al.,18 suggested that when significant differences were present, significantly less improvement in the visual analog scale (VAS) score was perceived by laypersons than by their professional counterparts, indicating that the laypersons could not perceive the changes occurring or that they did not view an improvement in facial convexity as being important. This further reinforces why clinicians should take the patient’s preferences into account in their treatment planning, which could improve their understanding of the patient’s esthetic objectives.19,20,21 Previously, orthodontists exhibited a paternalistic view on the treatment planning process, making all the decisions for the patient that they believed to be in the best interest of the patient.22,23 In the new paradigm of evidence-based clinical practice (EBCP) a greater emphasis is now shifting toward patient autonomy, in which treatment “success” is possibly defined by patient satisfaction with the treatment outcome rather than time-honored, cliniciancentered goals.24,25,26,27,28,29,30,31 Orthodontists and oral surgeons study profiles comprehensively and are trained to fixate on the areas of profile that are relevant to their respective profession: the lips, chin, nose, and dentoalveolar regions. In contrast, laypersons tend to be fixated on other aspects of the face, such as complexion, size and shape of the nose, chin shape, and hairstyle — all of which contribute to the perception of facial attractiveness.32,33 One study illustrated that even after profiles were “photographically warped” (a term that was used by the authors) to produce the same profile outline shape, there was still variability in attractiveness, denoting that other factors might impact facial esthetics other than the profile outline shape.6,34 Orthodontists pay specific attention to the esthetics of the face in profile when formulating a comprehensive orthodontic diagnosis and treatment

CONTINUING EDUCATION

Figure 1: Photos of female mandibular advancements (frontal and three-quarter view)

Solutions, Chatsworth, California). The resident or orthodontist who was overseeing the patient’s treatment traced and digitized the lateral cephalometric radiographs onto the Dolphin Imaging software (Dolphin Imaging & Management Solutions, Chatsworth, California). The overseeing resident or orthodontist also confirmed that the patient was skeletal Class II via the Sassouni cephalometric analysis. Upon selection of suitable candidates for the study, each subject was contacted by phone or email and informed of the purposes of the study. Informed consents were obtained from the subject for the study.

Photographs were obtained using an 18 megapixel digital camera and ring flash (Canon® EOS Rebel T3i DSLR camera and MR-14EX Macro Ring Lite, Canon, Tokyo, Japan) with adjustable 18 mm-55 mm lens.

The settings for the camera were set for manual mode, ISO 100, aperture setting at f/8.0, and shutter speed at 1/160. The images were uploaded, scanned, and adjusted with regard to different brightness and contrast using specific imaging software (Dolphin Imaging & Management Solutions). J.L took the photos of the frontal facial profiles with the lens of the camera positioned perpendicular to the face in natural head position,52 while the three-quarter profiles were taken with the lens of the camera positioned approximately 45 degrees to the right of the facial midline. Patients focused on a specific target “X” marked on the wall with tape and had their heads adjusted until natural head position was achieved. These photos were taken at a distance of 1 foot away from the 40 Orthodontic practice

Figure 2: Photos of male mandibular advancements (frontal and three-quarter view)

subject, with a lines marked on the floor for both the subject and experimenter to stand for consistency. The resident or orthodontist overseeing the patient’s case evaluated the position where the photos are taken for consistency. A white light box was used as background to improve the quality of the images. Photographs were printed on 8.5" x 11" photographic paper, identified by printing the subject’s initials on the reverse side, and placed in a specific sequence generated by a random number generator (Figures 1 and 2).

A VAS has been widely utilized in different areas of dental research.53 In orthodontics, the VAS has been used as a measuring tool in studies about dentofacial esthetic assessment.54 This measurement tool has been used in assessing the facial esthetics perceptions by various groups of raters, including orthodontists and laypersons.5 It is a measurement instrument for subjective characteristics or attitudes between two endpoints on 50 mm or 100 mm continuums.55 Although the specifics of what makes one attractive or unattractive cannot be exactly determined, the rating of attractiveness is very reliable, and subjects were able to make a realistic appraisal of attractiveness.56,57 VAS was utilized in the study to help determine facial attractiveness scores of the female and male target persons.

Selection of target persons Potential patients were presented to the orthodontic clinics and underwent a routine initial exam by an orthodontic resident or orthodontist. In addition to the routine

exam forms for the initial exam, as well as full records, the resident or orthodontist conducting the exam checked off a form clearly stating the inclusion criteria for the study and, if the patient met the criteria, gave the form to the principal investigator (J.L). A list of patients that met the inclusion criteria was provided to the principal investigator. At the initial records appointment, J.L confirmed that the patient truly had a Class II Division 1 malocclusion with a retrognathic mandible via their lateral cephalogram by using the Sassouni analysis.58,59 To ensure patients were not posturing forward, J.L. had them touch their tongue to the roof of their mouth and slowly close their jaw to get them as close to centric relation as possible. Potential patients were also screened at private practice clinics located in the Pittsburgh, Pennsylvania area.

Manipulation of target persons

Before obtaining the photo images, bilateral vertical marks were painted intraorally with indelible pencil on the buccal cusp tips of the upper first premolars with reference (A) mark on the occlusion in MIP. Using the reference (A) mark as a guide, four other marks were painted on the lower arch. The first one (reference mark No. 1), was coincident to reference mark (A) and two others marks: 2 mm (No. 2), and 6 mm (No. 3) distal to mark No.1. Using these marks, the subject was able to be positioned to be photographed in three different mandibular “positions” or mandibular stepwise advancements from MIP: The first was in MIP (marks [A] coincident with No. 1), and the others were Volume 8 Number 1

Selection of raters

Two panels consisting of orthodontists and laypersons were assembled by the following criteria: a) The orthodontist group consisted of orthodontic faculty or practicing orthodontists who had at least 2 to 3 years of clinical practice experience and were drawn from only faculty at Seton Hill University Center for Orthodontics; and b) the layperson group were drawn from undergraduate

students at Seton Hill University between the ages of 15 and 21.61 Informed consents were collected from raters participating in the study. The panelists were instructed to rate the six photographs for each male and female subject on a 100 mm VAS with “esthetically unpleasing” (0 mm) and “esthetically pleasing” (100 mm) as the two extremes for both the male and female subject groups, rating a total of 12 photos. One duplicate photo was added for each male and female subject set for a total of 14 photos to determine reliability. The photos were randomized with a random number generator. No time limit was imposed during the sessions.

Laypersons and orthodontists rated the photographs in separate sessions with no principal investigators present.31 Panelists were not aware of the aims of the study to minimize bias or a Hawthorne effect. Written and visual instruction was given to the raters.

Each rater scored each of the photos within the binder one time through.

Statistical analysis Statistical analysis consisted of a 2x2x3x2 analysis of variance (ANOVA) followed by Bonferroni post hoc tests whenever significant differences were found. It consisted of four factors: 1) view (Frontal or three-quarter), 2) mandibular position (0 mm, 2 mm, or 6 mm), 3) gender (male and female target person photos), and 4) judges (orthodontists

or laypeople). For this study, there were 10 orthodontic raters and 152 layperson raters.

The number of laypersons was substantially greater than the number of orthodontist raters.62,63,64 The analysis compared gender among laypersons to evaluate differences in facial attractiveness from a frontal or threequarter view. All data with a P < 0.05 were considered statistically significant. The statistical analysis was performed with SPSS software (version 24.0; IBM, Armonk, New York).

Results The results for the study are reported through Tables 1-3. Ten orthodontists and 152 laypersons were recruited to participate in the study. Gender was categorized as male or female, the views were categorized as frontal or three-quarter view, the position of the photo was categorized into 0 mm, 2 mm, and 6 mm advancements, and the judge groups were categorized into orthodontists and laypersons.

The study examined main effects and interaction effects: The main effects studied were gender, view, position of the photo and judge group, while the interaction effects explored how each of the main effects related to one another. Gender was highly statistically significant (F = 22.935) (P < 0.0001), with the female photo (mean = 48.360) receiving higher attractiveness scores to the male photo (mean = 40.092) among

Table 1: Comparison between means, standard errors, and 95% Confidence Intervals (CI) for the main effects Judge Group

Mean

Standard Error

Lower Bound

Upper Bound

Orthodontists

48.483

4.390

39.813

57.154

Laypersons

39.968

1.126

37.744

42.192

Gender

Figure 3: Intraoral markings for mandibular stepwise advancements

Male

40.092

2.557

35.042

45.141

Female

48.360

2.286

43.846

52.874

View Frontal

48.334

2.660

43.080

53.588

Three-quarter

40.118

2.250

35.675

44.561

0 mm

44.683

2.417

39.910

49.455

2 mm

47.063

2.552

42.023

52.103

6 mm

40.931

2.248

36.491

45.372

Position

Male x View Frontal

42.717

2.952

36.888

48.547

Three-quarter

37.466

2.604

32.323

42.609

Frontal

53.950

2.908

48.208

59.693

Three-quarter

42.769

2.299

38.229

47.309

Female x View

Figure 4: Example of patient wax bites Volume 8 Number 1

Orthodontic practice 41

CONTINUING EDUCATION

stepwise mandible advancements of 2 mm (marks [A] coincident to No. 2), and 6 mm (marks [A] coincident to No. 3) (Figure 3). The initial mandibular position and other positions were guided using a 2.5 mm bite registration sheet wax (Part No. 42600, Almore International Inc., Beaverton, Oregon). The plate of wax was gently intercuspated while pictures were taken (Figure 4). To ensure accuracy, another resident or private practice orthodontists checked the mandibular position just before taking both pictures while the principal investigator (J.L.) took the pictures.

Once all the photos were obtained for the subject, an alcohol swab was used to remove the marks from the patient’s dentition. The photographs had the target persons’ eyes blocked out prior to submission for publication to protect their identity and further minimize any possible psychological risk.60

CONTINUING EDUCATION both orthodontists and laypersons (Table 1).

When both target persons were recruited into the study, the female target person scored slightly higher average attractiveness scores (mean = 3.67) compared to the male target person (mean = 3.33), indicating that the female subject was slightly more attractive than the male before the study began.

The main effects for view were highly significant (F = 18.078) (P < 0.0001), showing that both orthodontists and laypersons gave higher attractiveness ratings for the frontal view (mean = 48.334) when compared to the three-quarter view (mean = 40.118). There was no statistical significance regarding view and judge group rating the photos (Table 1).

The main effects for position were also found to be statistically significant (F = 9.55, p < 0.0004). Pair-wise comparison tests revealed that the 6 mm position was preferred less than either the 0 mm or 2 mm positions. There was no difference in preference between the 0 mm and 2 mm positions.

There were no significant differences between the two judge groups. Even though orthodontists gave higher ratings to the photos than the laypersons, the difference was not statistically significant (F = 3.53, p = 0.062) (Table 2).

In regards to comparing interaction between the main effects, only two of the interaction effects (gender x view) and (gender x position), were statistically significant (P < 0.05). But these interaction effects were slightly underpowered (0.555 and 0.606) (F = 4.451 and F = 3.174). When tests for simple main effects were conducted for gender x view, no interaction effects could be detected. Tests for simple main effects for gender x position revealed no significant difference between 0 mm, 2 mm, and 6 mm advancement for the female photo, but for the male photo, 2 mm advancement was preferred to 0 mm, while 0 mm and 2 mm were preferred to 6 mm advancement (Table 3). All other comparisons of the other main effects were not statistically significant and had a low power value.

When evaluating intra-rater and inter-rater reliability, the reliability coefficient showed poor reliability with the original photos and the duplicate photos for both the male and female subject. The laypersons were more reliable than the orthodontists (0.775 vs. 0.493) for the male photo and (0.663 vs. 0484) for the female photo. Interjudge reliability among the 10 orthodontists was (0.736).

Discussion In regards to views, the frontal view was 42 Orthodontic practice

Table 2: Judge Group * Gender * View * Position â&#x20AC;&#x201D; Measure: Esthetics Judge Group

Mean

Std. Error

95% Confidence Interval

Gender

View

Position

Male

Frontal

0 mm

47.800

6.291

35.376

60.224

2 mm

50.600

7.006

36.763

64.437

Lower Bound

Threequarter

Orthodontists

Female

Frontal

Threequarter

Male

Frontal

Threequarter

Laypersons

Female

Frontal

Threequarter

Upper Bound

6 mm

42.200

6.141

30.072

54.328

0 mm

43.300

5.929

31.590

55.010

2 mm

48.900

5.833

37.380

60.420

6 mm

33.400

5.645

22.251

44.549

0 mm

60.600

5.776

49.192

72.008

2 mm

58.300

6.448

45.565

71.035

6 mm

53.000

6.050

41.051

64.949

0 mm

48.800

5.490

37.957

59.643

2 mm

48.200

5.204

37.922

58.478

6 mm

46.700

5.250

36.331

57.069

0 mm

37.211

1.614

34.024

40.397

2 mm

41.553

1.797

38.004

45.102

6 mm

36.941

1.575

33.830

40.052

0 mm

33.592

1.521

30.589

36.596

2 mm

36.875

1.496

33.920

39.830

6 mm

28.730

1.448

25.871

31.590

0 mm

49.803

1.482

46.877

52.729

2 mm

51.724

1.654

48.457

54.990

6 mm

50.276

1.552

47.212

53.341

0 mm

36.355

1.408

33.574

39.136

2 mm

40.355

1.335

37.719

42.991

6 mm

36.204

1.347

33.544

38.863

Table 3: Gender * Position Estimates â&#x20AC;&#x201D; Measure: Esthetics Gender

Position

Mean

Std. Error

95% Confidence Interval Lower Bound

Male

Female

Upper Bound

0 mm

40.476

2.692

35.159

45.793

2 mm

44.482

3.020

38.518

50.445

6 mm

35.318

2.647

30.090

40.546

0 mm

48.889

2.536

43.881

53.898

2 mm

49.645

2.607

44.495

54.794

6 mm

46.545

2.363

41.878

51.212

preferred to the three-quarter view. It could be interpreted that all people, both orthodontists and laypersons, generally prefer facial attractiveness from the frontal view since people view each other mainly from the frontal perspective.45,65 Even though both subjects met the inclusion criteria and the soft tissue changes were more exaggerated for the male than the female, there may be other factors contributing to the facial attractiveness scores of the female, such as hairline, eyes, ear, nose, and other

facial features.5,8 Although a small layperson group evaluated both patients for average facial attractiveness, it could be interpreted that for the main effects of gender, female subjects are generally viewed more attractive than male subjects. The female photo was preferred to the male for both the frontal and three-quarter view, and the frontal view was preferred to the three-quarter view for both the male and female photo. This finding contradicts previous studies, which shows that gender was not considered a factor Volume 8 Number 1

Volume 8 Number 1

Each patient’s perception of beauty can vary greatly by ethnicity, socioeconomic status, and the person’s personal preference.

from a frontal view. Orthodontists demonstrated that they were inconsistent with their ratings since their overall scores were lower for the duplicate photos than the laypersons.

When determining interjudge reliability, an intraclass correlation coefficient (ICC) was utilized for the study.74 It was calculated using the scores of the 10 orthodontic judges for the 12 photos evaluated as the data set and was considered good because the ICC value was between 0.60 and 0.74.

Interjudge reliability was not possible for the layperson group because there were far more laypersons than orthodontists for this to be determined.

From a clinical standpoint, the information gleaned from this pilot study can serve as preliminary data to establish esthetic preferences for both orthodontists and laypersons in both frontal and three-quarter views. Traditionally, orthodontists believed that treating to Angle’s Class I occlusion would yield the best treatment outcome,1,2,3 but this has shifted in recent years with more emphasis also given to soft tissue and smile esthetics.4,5,6 It is also imperative that patients are given autonomy for their treatment, as long as it causes no harm, and that their chief concerns are addressed as well in order to achieve the best possible treatment outcome.25,26,27,33,34,35 Since patients from various cultural backgrounds prefer different esthetic profiles, 69,70,73,74 it is also important to evaluate facial attractiveness from all the different aspects especially in the frontal and three-quarter view because laypersons tend to converse with each other from these perspectives.49,50,51,52 It may be interpreted that treating patients to an orthognathic profile may be an outdated treatment objective,48 and that treating to an orthognathic profile might not be a realistic and esthetic treatment outcome when assessing facial attractiveness from the frontal and three-quarter view. Given that the frontal view was preferred over the three-quarter view in the study, it may suggest that we should shift our attention to diagnosis and treatment planning for the frontal view more thoroughly in conjunction with the profile view because certain aspects of the profile are missing in the frontal view. Although this is an initial pilot

study, there are some ways to improve the study design. When recruiting potential target persons for the study, the subjects should initially have a full-cusp Class II dental pattern in maximum intercuspation. From this position, the mandible could be advanced to a Class I canine position to evaluate the soft tissue profile of the subjects. This may ensure that both the male and female subjects would have consistent changes as the mandible is advanced into the various positions.

One limitation of the study was the male target person chosen for the study. It can be interpreted that the male subject was too prognathic at 6 mm and did not exhibit as much of a Class II relationship compared to the female subject. Another potential limitation to the study was that there was not equal number of orthodontists to laypersons.

However, it is not realistic to get an equal number of orthodontists since there are fewer orthodontists in the general population.71 Another possible limitation was that all orthodontist raters were Caucasian raters.

Although a majority of the layperson raters were Caucasian, the other ethnic raters (Asian, African-American, and Hispanic) could have skewed the results slightly. Therefore, stricter exclusion criteria may be of value. Finally, another possible limitation was the use of an 18 mm–55 mm lens instead of a 18 mm–105 mm lens because the potential for facial distortion exists, since the 18 mm–55 mm lens is not able to capture as sharp an image as the 18 mm–105 mm lens.

Conclusions

• There was a statistically significant difference for the following main effects: gender and view.

• The female photo was preferred to the male for both the frontal and three-quarter view • The frontal view was preferred to the three-quarter view for both the male and female photo.

• There were two statistically significant differences among the interaction effects for both (gender x view) and (gender x position), but both were slightly underpowered. OP Orthodontic practice 43

CONTINUING EDUCATION

influencing facial attractiveness.66,67 However, this finding could be attributed to the fact that the female target person was rated as more attractive than the male target person to begin with.

The low power observed in the study may be attributed to the fact that there were generally more laypersons available to participate in the study than orthodontists. Ideally, the power would be much higher if there were equal numbers of raters for both the orthodontists and laypersons group, but this is unrealistic because in the general population there are far fewer dentists than laypersons, with even fewer orthodontic specialists.68 The mandibular position of the photo did show a statistically significant difference among the three different positions at 6 mm.

The facial attractiveness ratings at the 6 mm position were ranked the lowest among the three positions, indicating that a significantly protrusive position is least preferred by both judge groups. This finding differs from other studies where Caucasian cultures prefer slightly convex profiles,69,70 Korean cultures prefer slightly concave profiles,69 and Turkish cultures prefer orthognathic profiles.70 The present investigation shows that orthodontists tended to give higher ratings of attractiveness scores than laypersons when rating the photos. This may indicate that laypersons may be more critical of facial attractiveness than the orthodontists.71 This is in contrast to other studies, which found orthodontists were more critical than laypersons when rating facial attractiveness. This could be attributed to the fact that orthodontists are constantly evaluating the facial and smile esthetics, making them stricter in their evaluations.24,67,72,73 It also further suggests that beauty is very subjective and that each person’s view on facial attractiveness may vary greatly among each other.12,13,18,19 One interesting finding was shown when evaluating the interaction effects of the main effects. The facial attractiveness ratings for the female were almost rated the same for all the different positions in the frontal view than with the male group by the layperson judge group. It could be interpreted possibly that anteroposterior discrepancy for the female subject was not significant enough to show a discernible change.21 In regards to intrajudge reliability, both judge groups rated two photos twice during the experiment for the following photos: 1) the male photo at 2 mm from a three-quarter profile view and 2) the female photo at 0 mm

CONTINUING EDUCATION REFERENCES 1. Proffit WR, Fields HW Jr, Sarver DM. Contemporary Orthodontics. 5th ed., St. Louis, MO: Mosby; 2013.

2. De Smit A, Dermaut L. Soft-tissue profile preferences. Am J Orthod. 1984;86(1):67-73.

3. Ackerman JL, Proffit WR, Sarver DM. The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning. Clin Orthod Res. 1999;2(2):49-52.

4. Tsang ST, McFadden LR, Wiltshire WA, Pershad N, Baker AB. Profile changes in orthodontic patients treated with mandibular advancement surgery. Am J Orthod Dentofacial Orthop. 2009; 135(1):66-72.

5. Maple JR, Vig KW, Beck FM, Larsen PE, Shanker S. A comparison of providers’ and consumers’ perceptions of facial-profile attractiveness. Am J Orthod Dentofacial Orthop. 2005;128(6):690-696.

6. Spyropoulos MN, Halazonetis DJ. Significance of the soft tissue profile on facial esthetics. Am J Orthod Dentofacial Orthop. 2001;119(5):464-471.

7. Dongieux J, Sassouni V. The contribution of mandibular positioned variation to facial esthetics. Angle Orthod.

1980;50(4):334-339.

8. Hodge TM, Boyd PT, Munyombwe T, Littlewood SJ. Orthodontists’ perceptions of the need for orthognathic surgery in patients with Class II Division 1 malocclusion based on extraoral examinations. Am J Orthod Dentofacial Orthop.

2012;142(1):52-59.

9. Wey MC, Bendeus M, Peng L, Hagg U, Rabie AB, Robinson W. Stepwise advancement versus maximum jumping with headgear activator. Eur J Orthod. 2007;29(3):283-293.

10. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr. Mandibular changes produced by functional appliances in Class II maloclussion: a systematic review. Am J Orthod Dentofacial Orthop. 2006;129(5):599.e1-e12.

11. Baccetti T, Franchi L, Stahl F. Comparison of 2 comprehensive Class II treatment protocols including the bonded Herbst and headgear appliances: a double-blind study of consecutively treated patients at puberty. Am J Orthod Dentofacial Orthop. 2009;135(6):698.e1-10.

12. McCollum T. TOMAC: an orthognathic treatment planning system. Part I soft tissue analysis. J Clin Orthod.

2001;35(6):356-364.

13. Jacobson A, Jacobson RL. Radiographic Cephalometry: From Basics to 3-D Imaging. 2nd ed. Carol Stream, IL: Quintessence Publishing Co; 2007.

14. Câmara CA. Esthetics in Orthodontics: six horizontal smile lines. Dental Press J Orthod. 2010;15(1):118-131.

15. McLeod C, Fields HW, Hechter F, Wiltshire W, Rody W Jr, Christensen J. Esthetics and smile characteristics evaluated by laypersons. Angle Orthod. 2011;81(2):198-205.

16. Barroso MC, Silva NC, Quintão CC, Normando D. The ability of orthodontists and laypeople to discriminate mandibular stepwise advancements in a Class II retrognathic mandible. Prog Orthod. 2012; 13(2):141-147.

25. Ackerman M. Evidence-based orthodontics in the 21st century. J Am Dent Assoc. 2004;135(2): 162-167.

26. Turpin DL. Consensus builds for evidence-based methods.

Am J Orthod Dentofacial Orthop. 2004;125:1-2.

27. Keim RC. The editor’s corner: the power of the pyramid. J Clin Orthod. 2007;41(10):587-588.

28. American Dental Association Council on Ethics, Bylaws, and Judicial Affairs. 2010. Available at: http://www.ada. org/~/media/ADA/Publications/Files/ADA_Code_of_ Ethics_2016.pdf?la=en. (accessed October 29, 2016).

29. Ackerman MB. Enhancement Orthodontics: Theory and Practice. 1st ed. New York, NY: Wiley-Blackwell; 2007.

30. Phillips C. Patient-centered outcomes in surgical and orthodontic treatment. Semin Orthod. 1999;5(4):223-230.

31. Vig KW, Weyant R, O’Brien K, Bennett E. Developing outcome measures in orthodontics that reflect patient and provider values. Semin Orthod. 1999;5(2):85-95.

32. Hockley A, Weinstein M, Borislow AJ, Braitman LE. Photos vs silhouettes for evaluation of African American profile esthetics. Am J Orthod Dentofacial Orthop.

2012;141(2):161-168.

33. Cochrane SM, Cunningham SJ, Hunt NP. Perceptions of facial appearance by orthodontists and the general public.

J Clin Orthod. 1997; 31: 164-8.

34. Mantzikos T. Esthetic soft tissue profile preferences among Japanese population. Am J Orthod Dentofacial Orthop.

1998;114(1):1-7.

35. Soh J, Chew MT, Wong HB. A comparative assessment of the perception of Chinese facial profile esthetics. Am J Orthod Dentofacial Orthop. 2005;127(6):692-699.

36. Siquiera DF, Sousa MV, Carvalho PE, do Valle-Corotti KM. The importance of the facial profile in orthodontic diagnosis and treatment planning: a patient report. World J Orthod.

2009;10(4):361-370.

37. Soh J, Chew MT, Chan YH. Perceptions of dental esthetics of Asian orthodontists and laypersons. Am J Orthod Dentofacial Orthop. 2006;130(2):170-176.

38. Foster EJ. Profile preferences among diversified groups.

Angle Orthod. 1973;43:34-40.

39. Isiksal E, Hazar S, Akyalcin S. Smile esthetics: perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop. 2006;129(1):8-16.

40. McKoy-White J, Evans CA, Viana G, Anderson NK, Giddon DB. Facial profile preferences of black women before and after orthodontic treatment. Am J Orthod Dentofacial Orthop. 2006;129(1):17-23.

41. Gracco A, Cozzani M, D’Elia L, Manfrini M, Peverada C, Siciliani G. The smile buccal corridors: aesthetic value for dentists and laypersons. Prog Orthod. 2006;7(1):56-65.

42. McCoy-White, Evans CA, Viana G, Anderson NK, Giddon DB. Facial profile preferences of black women before and after orthodontic treatment. Am J Orthod Dentofacial Orthop. 2006;129(1): 17-23.

17. Dunlevy HA, White RP, Turvey TA. Professional and lay judgment of facial esthetic changes following orthognathic surgery. Int J Adult Orthod Orthognath Surg.

1987;2(3):151-158.

43. Coleman GG, Lindauer SJ, Tüfekçi E, Shroff B, Best AM. Influence of chin prominence on esthetic lip profile preferences. Am J Orthod Dentofacial Orthop. 2007;132(1):36-42.

18. Montini RW, McGorray SP, Wheeler TT, Dolce C. Perceptions of orthognathic surgery patient’s change in profile: a fiveyear follow-up. Angle Orthod. 2007;77(1):5-11.

44. Orsini MG, Huang GJ, Kiyak HA, Ramsay DS, Bollen AM, Anderson NK, Giddon DB. Methods to evaluate profile preferences for the anteroposterior position of the mandible.

Am J Orthod Dentofacial Orthop. 2006;130(3):283-291.

19. Krishnan V, Daniel ST, Lazar D, Asok A. Characterization of posed smile by using visual analog scale, smile arc, buccal corridor measures, and modified smile index. Am J Orthod Dentofacial Orthop. 2008;133(4):515-523.

20. Machado AW, McComb RW, Moon W, Gandini LG Jr. Influence of the vertical position of maxillary central incisors on the perception of smile esthetics among orthodontists and laypersons. J Esthet Restor Dent. 2013;25(6):392-401.

21. McKeta N, Rinchuse DJ, Close JM. Practitioner and patient perceptions of orthodontic treatment: Is the patient always right? J Esthet Restor Dent. 2012;24(1):40-50.

22. Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed consent issues. Angle Orthod. 1995;65(4):253-262.

23. Sarver DM. Commentary: Practitioner and patient perceptions of orthodontic treatment: Is the patient always right? J Esthet Restor Dent. 2012;24(1):51–52. doi:10.11 11/j.1708-8240.2011.00456.

24. Ismail AI, Bader JD; ADA Council on Scientific Affairs and Division of Science; Journal of the American Dental Association. Evidence-based dentistry in clinical practice. J Am Dent Assoc. 2004;135(1):78-83.

44 Orthodontic practice

45. Bonetti GA, Alberti A, Sartini C, Parenti SI. Patients’ self-perception of dentofacial attractiveness before and after exposure to facial photographs. Angle Orthod.

2011;81(3):517-524.

46. Peerlings RH, Kuijpers-Jagtman AM, Hoeksma JB. A photographic scale to measure facial aesthetics. Eur J Orthod. 1995;17(2):101-109.

47. Sarver DM. The face as the determinant of the treatment choice. In: McNamara JA, Kely KA, Ferrara eds. Frontiers of dental and facial esthetics. Ann Arbor: Center for Human Growth and Development; University of Michigan; 2001.

48. Van der Linden FPGM, Boersma H. Diagnostic aids. In: Van der Linder FPGM, Boersma H, editors. Diagnosis and treatment planning in dentofacial orthopedics. London: Quintessence; 1987.

49. Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use.

Am J Orthod. 1985;88(5):402-408.

50. Tüfekçi E, Jahangiri A, Lindauer SJ. Perception of profile among laypeople, dental students and orthodontic patients. Angle Orthod. 2008;78(6):983-987.

51. Shafiee R, Korn EL, Pearson H, Boyd RL, Baumrind S. Evaluation of facial attractiveness from end-of-treatment facial photographs. Am J Orthod Dentofacial Orthop.

2008;133(4):500-508.

52. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod. 2002;36(4):221-236.

53. Aitken RC. Measurement of feelings using visual analogue scales. Proc R Soc Med. 1969;62(10): 17-21.

54. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53(4):262-284.

55. Reips U-D, Funke F. Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator.

Behav Res Methods. 2008;40(3):699-704.

56. Berscheid E. An overview of the psychological effects of physical attractiveness. In: Lucker GW, Ribbens KA, McNamara JA, eds. Psychological aspects of facial form.

Ann Arbor: Center for Human Growth and Development; University of Michigan; 1980.

57. Graber L. Psychological Considerations of Orthodontic Treatment. In: Lucker GW, Ribbens KA, McNamara JA, eds.

Psychological aspects of facial form. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1980.

58. Sassouni V. A classification of skeletal facial types. Am J Orthod. 1969;55(2):109-123.

59. Sassouni V. A roentgenographic cephalometric analysis of cephalofacial-dental relationships. Am J Orthod.

1995;41:735-764.

60. Maurya R, Gupta A, Garg J, Shukla C. Evaluate the influence of panel composition on facial attractiveness. J Orthod Res. 2015;3(1):25-29.

61. Kerr WJS, O’Donnell JM. Panel perception of facial attractiveness. Br J Orthod. 1990;17(4):299-304.

62. Williams RP, Rinchuse DJ, Zullo TG. Perceptions of midline deviations among different facial types. Am J Orthod Dentofacial Orthop. 2014;145(2):249-255.

63. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics: asymmetric and symmetric situations. Am J Orthod Dentofacial Orthop. 2006;130(2):141-51.

64. Yin L, Jiang M, Chen W, Smales RJ, Wang Q, Tang L. Differences in facial profile and dental esthetic perceptions between young adults and orthodontists. Am J Orthod Dentofacial Orthop. 2014;145(6):750-756.

65. Proffit WR, Phillips C, Douvartzidis N. A comparison of outcomes of orthodontic and surgical orthodontic treatment of Class II malocclusion in adults. Am J Orthod Dentofacial Orthop. 1992; 101:556-565.

66. Mejia-Maidl M, Evans CA, Viana G, Anderson NK, Giddon DB. Preferences for facial profiles between Mexican Americans and Caucasians. Angle Orthod. 2005;75:953-958.

67. Chong HT, Thea KW, Descallar J, Chen Y, Dalci O, Wong R, Darendeliler MA. Comparison of White and Chinese perception of esthetic Chinese lip position. Angle Orthod.

2014; 84: 246-253.

68. American Dental Education Association: Dentists and Demographics. 2008. Available at: www.adea.org/deansbriefing/documents/finalreviseddeans/dentistsdemographics.pdf (accessed October 29, 2016).

69. Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences in the soft tissue profile of Korean and European-American adults with normal occlusions and well-balanced faces.

Angle Orthod. 2002;72(1):72-80.

70. Türkkahraman H, Gökalp H. Facial profile preferences among various layers of Turkish population. Angle Orthod.

2004;74(5):640-647.

71. Zange SE, Ramos AL, Cuoghi OA, de Mendonça MR, Suguino R. Perceptions of laypersons and orthodontists regarding the buccal corridor in long- and short-face individuals. Angle Orthod. 2011; 81(1): 86-90.

72. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-324.

73. Machado RM, Assad Duarte ME, Jardim da Motta AF, Mucha JN, Motta AT. Variations between maxillary central and lateral incisal edges and smile attractiveness. Am J Orthod Dentofacial Orthop. 2016;150(3):425-435.

74. Cicchetti, DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess. 1994;6(4):284–290. doi:10.1037/1040-3590.6.4.284.

Volume 8 Number 1

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2016 to 11/30/2018 Provider ID# 325231

REF: OP V8.1 LEE, ET AL.

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

EMAIL

TELEPHONE/FAX

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

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

Esthetic preferences regarding the anteroposterior position of the mandible LEE, ET AL.

1. In traditional orthodontics, ideal treatment goals were to obtain ________. a. Angle’s Class I dental occlusion and jaw relationships b. soft tissue paradigm c. smile esthetics d. perfect profiles 2. This focus (ideal treatment goals) shifted in contemporary orthodontics to ________. a. Angle’s Class II occlusion b. a soft tissue paradigm c. smile esthetics d. both b and c 3. Orthodontists have used ________ for decades to assess the soft tissue facial profile as part of their diagnosis. a. model casts b. cephalometrics c. transillumination d. digital photography 4. In addition, orthodontists ________ for soft tissue analysis when compared to Angle’s classes of dental malocclusions or cephalometrics for skeletal measurements. a. do not need a rubric

Volume 8 Number 1

b. have a comprehensive rubric c. lack a comprehensive rubric d. have devised an overly complicated method 5. Each patient’s perception of beauty can vary greatly by ________. a. ethnicity b. socioeconomic status c. the person’s personal preference d. all of the above 6. Barroso, et al., concluded from their study that laypeople might not be able to discriminate ____ of mandibular advancement in evaluating facialprofile attractiveness as well as orthodontists. a. 2 mm b. 4 mm c. 5 mm d. 6 mm 7. In regards to views, the frontal view was preferred to _______ view. a. a non-smiling b. a smiling c. the facial profile d. the three-quarter 8. Even though both subjects met the inclusion

criteria, and the soft tissue changes were ______, there may be other factors contributing to the facial attractiveness scores of the female, such as the hairline, eyes, ear, nose, and other facial features. a. equal for the female and the male b. more exaggerated for the male than the female c. more exaggerated for the female than the male d. more subtle for the male than the female 9. The facial attractiveness ratings at the 6 mm position were ranked the lowest among the three positions, indicating that a ____ is least preferred by both judge groups. a. significantly protrusive position b. concave profile c. convex profile d. orthognathic profile 10. Since the patients from various cultural backgrounds prefer different esthetic profiles, it is also important to evaluate facial attractiveness from all the different aspects especially in the _____ view because laypersons tend to converse with each other from these perspectives. a. full profile b. frontal c. three-quarter d. both b and c

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

The use of Kilroy Springs in the disimpaction of upper canines Dr. Maurizio Cannata explores the use of the Kilroy Spring to facilitate management of a challenging dentition Abstract Upper canine disimpaction is always a difficult task for general dentists or orthodontists. Here, by analyzing a clinical case, we aim to describe an approach that could facilitate its management by using a particular device: the Kilroy Spring.

Introduction Upper canine disimpaction represents a difficult task and a challenge in everyday practice. The principal task with affected young patients is to formulate an early diagnosis. This is done in two ways: First, by the evaluation of the angulation of maxillary canines since tilted canines can predict a difficult or impossible eruption, particularly if associated with a lack of space. Second, a family history of canine inclusion can also be an indication. If parents or family members have had canine impactions, a prediction of canine impaction is likely. So, when we’re confronted with a young patient with such features, we should try our best to allow a possible spontaneous eruption of maxillary canines. The first thing to do then is to confirm a palatal or buccal position of the canines. (A CBCT scan is now the gold standard.) The second is to make space for eruption. This can be done by expanding the palate in cases of transversal contraction.

Soon after this phase, or if there is an eruptive problem, the clinician should apply an orthodontic fixed appliance and create space for the maxillary canine, and remove the primary maxillary canines. Sometimes, fortunately, the permanent canines will spontaneously

Maurizio Cannata, DDS, received his degree in 1990 at the Sapienza University of Rome. He is a private practitioner in his own dental office in Rende, Italy. He is a member of the National Italian Association of Dentists (ANDI) and of the Italian Society of Osseointegration (SIO). He is one among the main animators of Italian Implant Dentistry forum Osteocom. He studied periodontology and implant dentistry with Drs. Stefano Parma Benfenati and Carlo Tinti, Fixed Prosthesis with Drs. Fabio Bertagnolli and Domenico Massironi, and orthodontics with Dr. Davide Mirabella. Dr. Cannata is a lecturer in periodontology, implant dentistry, and orthodontics. Dr. Cannata can be emailed at mauricannata@gmail.com.

46 Orthodontic practice

Educational aims and objectives

This article aims to describe an approach to upper canine disimpaction using the Kilroy Spring.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 50 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify how to make an early diagnosis of impacted maxillary canines.

• Realize how to facilitate a spontaneous eruption of borderline canines.

• Recognize how to create space for impacted canines.

• Identify how to correctly use Kilroy Springs.

• Realize how to finish treatment after Kilroy Springs achieve their purpose.

Figure 1

Figure 2

erupt. If they don’t, a surgical exposure will enable the traction and correct positioning.

To summarize the four steps of therapy: 1. Localization of the tooth 2. Space creation for eruption and correct positioning 3. Surgical exposition and hooking 4. Traction Several traction methods are available and should have the following features: 1. Ease-of-use 2. Effectiveness 3. The least invasive possible 4. Limiting the anchorage stress 5. As inexpensive as possible This article will consider the Kilroy Spring (American Orthodontics), an auxiliary stainless steel round-wire spring created by Drs. S. Jay Bowman and Aldo Carano. Some consider it to be an evolution of the Ballista Spring. It needs to work with a final rectangular archwire in order to express a maximum possible force to avoid undesirable side effects on anchorage and adjacent teeth.

In Figure 1, we can see a Kilroy spring positioned on a .019 x .025 stainless steel

archwire ready for activation. Activation is achieved by rotating the spring toward the palate and connecting it to the button or bracket previously cemented to the canine exposed by means of a stainless steel ligature wire (Figure 2). Do not use elastics during this phase.

Case presentation A 12-year-old male patient with a mixed dentition came to our office complaining of a bad occlusion and esthetics. We discovered a family history of bilateral maxillary canine retention. In Figures 3-5, we can note a transversal discrepancy between maxilla and mandible, a maxillary arch discrepancy, and a tendency for a II Class II dental relationship. To solve the transverse discrepancy and gain space for canine eruption while reducing the maxillary arch discrepancy, a 9-month treatment with a rapid palatal expander was done (Figure 6). After expansion (Figure 7), the dental crowding had improved slightly, while the transverse discrepancy was completely solved Volume 8 Number 1

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

(Figure 8). After removing the palatal expander, we began with fixed orthodontic therapy using the MBT technique. This therapy aligned the teeth, solved the arch length discrepancies, allowed correction of the II Class II malocclusion, and made space for the impacted canines (minimum 9 mm).

The canine eruption occurred using closed nickel-titanium springs on a stainless steel rectangular arch (Figures 9-11). The OPT made at the beginning of the therapy (Figure 12) after the removal of the palatal expander (Figure 13) and at the beginning of the fixed orthodontic therapy (Figure 14) showed that, Volume 8 Number 1

CONTINUING EDUCATION

Figure 3

Figure 13

Figure 14 Orthodontic practice 47

CONTINUING EDUCATION while a spontaneous partial eruption of the maxillary left canine occurred, the maxillary right canine had inclined more. This development led us to extract the primary left maxillary canine to eliminate every obstacle to the eruption of the maxillary left canine.

We left the right maxillary primary second molar to allow a tunnel through which the permanent canine could move after its surgical exposure.

After 26 months of therapy, we were ready for canine exposure. Figure 15 shows the condition at that time — a small spontaneous eruption of the maxillary left canine and the retention of the maxillary right canine.

A full thickness flap and a bone breach exposed the canine. Note that the flap is scalloped in order to respect the papillae of the incisors. Optimal hemostasis allows a perfect bonding on the impacted tooth. The

use of 4% articaine with 1:100.000 epinephrine and then hemostatic pastes like Traxodent® (Premier Dental) or Astringent (3M™ ESPE™) guarantees hemostasis, and then bonding proceeds with the usual steps — i.e., etching of enamel with 37% orthophosphoric acid and a light-cured composite, in this case Transbond™ XT 3M, which bonds a lingual button to the canine. Two custommade chains of stainless steel ligature wire were connected to this button: One of these

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

Figure 20

Figure 21 48 Orthodontic practice

directly tied up to the Kilroy Spring, and another passed under the flap into the socket obtained from the extraction of the maxillary left primary canine and linked with an elastic module to the vestibular archwire (Figure 16). This applies two different forces to the tooth: one directed downward to erupt the tooth and another directed outward to move the canine into the right position. The Kilroy Spring erupted the maxillary left canine. We replaced the buttons with brackets when

We believe the described approach offers the advantage of completing much of the orthodontic therapy before the disimpaction.

Figure 22 Volume 8 Number 1

Conclusions Impacted canines require long-term therapy and have several clinical conditions that can affect the effectiveness of therapy and its length. Many approaches are possible, and many devices can be used.

We believe the described approach offers the advantage of completing much of the orthodontic therapy before the disimpaction.

Only brackets, wires, and one auxiliary spring are needed. No further surgeries are needed for temporary anchorage devices to remove orthodontic implants. Our opinion is that the Kilroy Spring works efficiently and requires little investment. OP

Figure 23

Acknowledgment Thanks to Dr. Davide Mirabella for his priceless teachings.

REFERENCES 1. Wagenberg B, Froum SJ. Piani di trattamento e terapia dei canini inclusi. Rivista Amici di Brugg. http://www.amicidibrugg.it/rivista/201003/art6.asp. Accessed December 7, 2016.

2. Jacoby H. The â&#x20AC;&#x153;ballista springâ&#x20AC;? system for impacted teeth.

Am J Orthod. 1979;75(2):143-151.

3. Bowman SJ, Carano A. The Kilroy Spring for impacted teeth. J Clin Orthod. 2003 Dec; 37 (12):683-688.

4. Becker A, Chaushu S. Etiology of maxillary canine impaction: a review. Am. J. Orthod. Dentofacial Orthop.

2015;148(4):557-567.

Figure 24

Figure 25

5. Yadav S, Chen J, Upadhyay M, Roberts E, Nanda R. Threedimensional quantification of the force system involved in a palatally impacted canine using a cantilever spring design.

Orthodontics (Chic.). 2012;13(1):22-33.

6. Yadav S, Chen J, Upadhyay M, Jiang F, Roberts WE: Comparison of the force systems of 3 appliances on palatally impacted canines. Am J Orthod Dentofacial Orthop.

2011;139(2):206-13.

7. Crescini A, Nieri M, Rotundo R, Baccetti T, Cortellini P, Prato GP. Combined surgical and orthodontic approach to reproduce the physiologic eruption pattern in impacted canines: report of 25 patients.

Int J Periodontics Restorative Dent. 2007;27(6):529-537.

8. Crescini A, Baccetti T, Rotundo R, Mancini EA, Prato GP. Tunnel technique for the treatment of impacted mandibular canines. Int J Periodontics Restorative Dent. 2009 Apr;29(2):213-218.

9. Nieri M, Crescini A, Rotundo R, Baccetti T, Cortellini P, Pini Prato GP. Factors affecting the clinical approach to impacted maxillary canines: A Bayesian network analysis.

Am J Orthod Dentofacial Orthop. 2010;137(6):755-762.

Figure 26 Volume 8 Number 1

10. Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Pre-treatment radiographic features for the periodontal prognosis of treated impacted canines. J Clin Periodontol.

2007;34(7):581-587.

Orthodontic practice 49

CONTINUING EDUCATION

the canines erupted enough, and rotations were removed with elastic modules (Figures 17-18). Further alignment was effected with .014 nickel-titanium superelastic archwire (Figure 19). Twelve months after surgical exposure, the two canines have aligned correctly, and only a small diastema between the maxillary right lateral and canine remained (Figure 20). Treatment concluded 15 months after canine surgical exposure. A composite restoration reconstructed the fractured maxillary right central incisor (Figures 21-26).

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2016 to 11/30/2018 Provider ID# 325231

REF: OP V8.1 CANNATA

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

EMAIL

TELEPHONE/FAX

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

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

The use of Kilroy Springs in the disimpaction of upper canines CANNATA

1. The first thing to do (to evaluate the angulation of maxillary canines) then is to confirm a palatal or buccal position of the canines. (A _______ is now the gold standard.) a. CBCT scan b. OPT c. palpation d. 2D digital X-ray 2. The second is to make space for eruption. This can be done by __________ in cases of transversal contraction. a. placing a Ballista spring b. expanding the palate c. using a space maintainer d. using headgear 3. Sometimes, fortunately, the permanent canines will spontaneously erupt. If they don’t, a surgical exposure will enable the ________. a. most anchorage stress possible b. traction c. correct positioning d. both b and c 4. This article will consider the Kilroy Spring, an auxiliary _________ round-wire spring created

by Drs. S. Jay Bowman and Aldo Carano. a. brass

50 Orthodontic practice

b. nickel-titanium c. stainless steel d. copper 5. It (the Kilroy Spring) needs to work with a final _______ in order to express a maximum possible force to avoid undesirable side effects on anchorage and adjacent teeth. a. rectangular archwire b. round archwire c. orthodontic implant d. elastic module 6. Activation is achieved by rotating the spring toward the palate and connecting it to the button or bracket previously cemented to the canine exposed by means of ________. a. elastic modules b. dental floss c. a stainless steel ligature wire d. brass ligature wire 7. This therapy aligned the teeth, solved the arch length discrepancies, allowed correction of the II Class II malocclusion, and made space for the impacted canines (minimum ______). a. 5 mm b. 7 mm c. 9 mm

d. 15 mm 8. (For this patient) ________ exposed the canine. a. a full thickness flap b. a bone breach c. a split thickness flap d. both a and b 9. The use of 4% articaine with 1:100.000 epinephrine and then hemostatic pastes like Traxodent® or Astringent guarantees hemostasis, and then bonding proceeds with the usual steps — i.e., etching of enamel with 37% _______ and a light-cured composite, in this case Transbond™ XT 3M, which bonds a lingual button to the canine. a. orthophosphoric acid b. hydrofluoric acid c. alcohol d. citric acid 10. We believe the described approach offers the advantage of completing much of the orthodontic therapy before the disimpaction. Only ______ is/ are needed. a. brackets b. wires c. one auxiliary spring d. all of the above

Volume 8 Number 1

CE CREDITS

ORTHODONTIC PRACTICE CE

PRACTICE DEVELOPMENT

Important Facebook® developments

Ian McNickle, MBA, discusses how to stay face-to-face with patients using Facebook

I

t should be no surprise that the largest social media site on the planet continues to change and innovate at a rapid pace. It has been very interesting to monitor recent developments and understand their impact for dental practice marketing.

Facebook® newsfeed algorithm — how to get seen Last year, Facebook announced they would be making a change to the newsfeed algorithm so that they could better deliver relevant content to their users. They started to track what users were engaging with (likes and comments) and then gave higher relevance to similar stories being in someone’s newsfeed. This means if someone has liked or commented on a post from your practice, he/she would be more likely to see your posts again in the future. Facebook is essentially trying to understand your interests and match those topics with what would be Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Award for Dental Marketing and Dental Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, visit www.weodental.com.

Volume 8 Number 1

shown to you in the future. This is similar to Internet radio stations like Pandora® that learn what you like and attempt to give you more of what you like over time.

Earlier this year, Facebook announced another change to take this concept a step further. Now they are going to track how long you interact with an article or piece of content after leaving Facebook. Monitoring engagement time gives them additional insight into what a particular user likes to read and see in their newsfeed.

What does this mean for your practice?

Relevant and engaging content is more important than ever! If a Facebook user clicks on your content and immediately bounces right back to Facebook without taking much time to read it, then this could negatively impact your visibility in the future. On the other hand, if a user goes to your page and takes the time to read the entire article, then you’re likely to rank higher in the newsfeed.

The interesting thing to note is that although this information is valuable to track user engagement and relevant content, it’s also part of Facebook’s push to get

publishers using their new tool “Instant Articles,” which means more content is being published behind Facebook’s wall and less on other sites. Essentially, they are trying to keep people within the walls of Facebook and not link to external websites, thereby leaving Facebook during that browsing session.

For now, it’s important for your practice to take note of the changes and be sure that your blogs and other social media posts are engaging and targeted specifically to your audience.

In addition to creating engaging posts and content, there are other strategies to generate new patient leads from Facebook.

These strategies primarily fall into two categories: 1) boosted posts, and 2) paid ads. In our next marketing column, we will continue with our Facebook theme and dig deeper into these new patient-generating strategies.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. OP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Orthodontic practice 51

LABORATORY LINK

Digital technology improves the contemporary splint James Bonham and Dr. Mark Coreil discuss material and fabrication options for full occlusal splints

F

ull coverage occlusal splints are widely used throughout dentistry for the treatment of TMD and parafunctional jaw activity. The effectiveness of this simple device is well documented in the literature.1-3 Splints come in a variety of designs and can be made of hard plastic, soft plastic, or a combination of both. The upper hard splint is the most popular choice, and this device is constructed using a number of materials and methods. This article will highlight available materials and fabrication options among the major laboratories.

Digital technology has changed the practice of orthodontics and is also providing improvements in the construction of the contemporary splint. These improvements have the potential to decrease clinical time associated with delivery and adjustments, resulting in increased profitability for the practice. Finally, splints can now be looked upon as a profit center within the orthodontic practice!

Optimal traditional splint construction involves submission of accurate upper and lower impressions along with a bite registration. The bite registration should be taken at the exact vertical dimension of the splint construction. The rule of thumb is a 1.5 mm vertical separation between the terminal molars or most prominent tooth vertically. We have found that 2 mm of clearance is preferred for the CR splint to allow for adjustments as the condyles seat vertically. A facebow mounting of the upper model will provide for the most accurate splint construction. The most common submission to the lab involves upper and lower models without bite or facebow. In this

This technique will allow for adequate splint thickness and provide for future adjustment, and improved longevity. instance, the lab mounts the models on an adjustable articulator and opens the vertical to the desired setting. This technique leads to more clinical time during splint delivery when compared to submission using a physical or digital bite.

Intraoral scanning allows the doctor to now submit digital models of the teeth with an accuracy not previously seen in dentistry.

There is universal agreement that appliances made from digital models of the teeth are exceptionally accurate and require minimal adjustment. Currently, one can capture intraoral scans of both arches along with a bite registration in less than 5 minutes, and this is followed by a total submission time to the lab of under 5 minutes. The total time for accurate digital submission is 10 minutes compared to 30 minutes for the traditional physical submission. The 20-minute timesavings is worth $2504 to the practice.

Hard splints are made of a variety of materials that offer a variety of advantages at differing price points. Hard splint options include: 1. BiostarÂŽ base/acrylic overlay The 2.0 mm Biostar base is vacuumformed over the occlusal model followed by a covering of cold-cure acrylic to make the occluding portion of the splint. The acrylic is placed in a pressure pot for the curing process.

This virtually eliminates porosity in the splint and makes for a durable longlasting appliance ($100).

2. Injection molded acrylic The splint design is created directly on the upper model, and all aspects of the occlusion are defined within the design-matrix material. Once finalized, this design is flasked, and acrylic is injected under heat and pressure. Manufacturers claim longevity of 3 times longer than traditional splints in addition to decreased surface wear and breakage due to increased hardness. The maker also claims no porosity in the finished product allowing for improved stain and odor resistance ($160).

3. Computer-aided milling The splint design is aided by a software-driven process through which either the outer surface or, in some cases, all surfaces of the splint are designed virtually then processed using computer-aided milling. This is the same technology used to mill ceramic crowns in dental offices and labs around the world. Our evaluation process found these splints to have excellent occlusal contacts ($187).

4. 3D-printed splint Specialty Appliancesâ&#x20AC;&#x2122; lab is developing what we

Figure 1: 3D-printed splint using FDA-approved E-Guard material from EnvisionTEC

Figure 2: 3D-printed splints save time due to improved fit and occlusion

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.

Mark Coreil, DDS, is a board-certified orthodontist and Assistant Professor of Clinical Orthodontics at the Louisiana State University (LSU) School of Dentistry. He graduated from LSU School of Dentistry in 1986 and completed his orthodontic specialty training at LSU in 1988.

52 Orthodontic practice

Volume 8 Number 1

LABORATORY LINK believe is the future of splint fabrication. The FDA recently approved a printable splint material called E-Guard from EnvisionTEC (Figure 1). This revolutionary technology will change the playing field for splint fabrication in both the dental and orthodontic industry. The splint is designed virtually from the digital model using computer-aided design software and then is printed with extreme accuracy. This clear biocompatible material provides precise fit and maximum visibility. The process is more efficient and should reduce the cost of splint fabrication.

Digital splints provide additional timesavings for the doctor at the time of delivery due to improvements in fit and occlusion (Figure 2). Typical timesavings during delivery exceed 20 minutes, thus improving the bottom line for the practice an additional $250.4 The printed splint provides improvements in fit, occlusion, and profitability. Using a digital splint workflow within the office and a digital lab like Specialty Appliances will make

54 Orthodontic practice

occlusal splints a profit center within the orthodontic office. Contact Specialty Appliances to learn more about this exciting advancement in splint fabrication.

Digital bite registration technique DeLar bite registration wax is a simple and accurate method of capturing the perfect splint construction bite. Patients presenting with normal or deep overbite will require two layers of wax, and patients with an open-bite tendency may need up to four layers of wax.

The heated wax is placed between the upper

and lower incisors. Position the mandible into the desired AP position, in this case CR; then have the patient close down slowly as the wax cools until there is a minimum of 2 mm vertical opening between the closest contact point, in this case the second molars.

Remove the wax, and cool in ice water. After capturing the upper and lower arches with your intraoral scanner, re-insert the chilled wax bite for the final digital bite capture. Most scanners can register the bite as long as the upper and lower teeth are no more than 3 mm to 4 mm from contact. This technique will allow for adequate splint thickness and provide for future adjustment, and improved longevity. OP REFERENCES 1. Wassell RW, Adams, N, Kelly PF. The treatment of temporomandibular disorders with stabilizing splints in general dental practice. One-year follow-up. J Am Dent Assoc.

2006;Aug137(8):1089-1098.

2. Okeson JP. Management of Temporomandibular Disorders and Occlusion. Ed. 6. St. Louis, MO: Elsevier Mosby; 2008:334-340 3. Dawson PE. Functional Occlusion from TMJ to Smile Design. St. Louis, MO: Elsevier Mosby; 2007:380-392.

Figure 3: Use wax in the anterior to position the bite; then scan the posterior bite registration

4. Keim RG, Gottlieb EL, Vogels DS 3rd, Vogels PB. 2015 JCO Orthodontic Practice Study, Part 1 Trends. J. Clin Orthod. 2015;49(10):625-639.

Volume 8 Number 1

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT

OrthoEssentials has added to its Imperial Series Instruments OrthoEssentials has added four new pliers to its Imperial Series Instruments — four Thermal Forming Pliers designed to work on Aligners and used to make dimples and create spaces for auxiliaries.

For additional information, call 866-517-3257, or email info@ orthoessentials.net to receive an introductory offer.

3Shape TRIOS® Orthodontics and EasyRx announce integration 3Shape announced the integration of TRIOS® Orthodontics and EasyRx universal orthodontic lab prescription software to create, manage, and submit orthodontic prescriptions. The integration now enables EasyRx users to access TRIOS intraoral scans and related patient meta-data on the EasyRx platform. Using EasyRx’s universal lab prescription workspace, orthodontic professionals can then design and create orthodontic lab prescriptions based on TRIOS digital impressions. The integration also enables labs to match the EasyRx prescription seamlessly to the patient’s corresponding TRIOS scan. To send TRIOS digital color impressions to the EasyRx platform, TRIOS users can simply choose the solution from the many global solution providers TRIOS already connects with. Likewise, EasyRx prescription lab users can now work totally digitally with orthodontists using TRIOS intraoral scanners.

For more information, visit www.3shape.com.

AccepTx Pro releases new visual design OrthoBanc® has reported updates to its AccepTx Pro Treatment and Fee Presentation tool.

• New visual design The version 3.0 release included the new visual design, which is being widely praised by practices and responsible parties.

• More customization The firm has added additional customization opportunities in AccepTx Pro, which include a practice logo and marketing text on the initial treatment presentation that is shared for responsible-party viewing at home. The fee presentation portion also contains greater options for customization.

• Electronic signature of custom forms A practice can now upload any practice forms that need to be signed at the time of accepting treatment. The responsible party can view these forms from home and electronically sign the necessary documents.

Please contact marketing@orthobanc.com for a demonstration.

Target.com expands its oral care category with Dr. Sharp Natural Oral Care Planmeca announces new “connected” dental consoles Dental equipment manufacturer Planmeca Oy offers a solution to help clinicians work more efficiently in the footprint of their existing office. Connected technology and efficient environments combined with clever organization are the answer. The new line of Evolution™ Consoles, including the Evolution™ 12 O’Clock, Evolution™ Central Island Console, and Evolution™ Side Console — all feature quick and easy integration of modern technology. Offering Ethernet and 3.0 USB connections, PlanScan® (digital scanner) integration, CPU storage, LED lighting, and medical-grade duplex GFCI outlets, these digital and up-to-the-minute enhancements aid the clinician’s workflow and information processing. Flexibility, expandability, and antiseptic measures were all incorporated to the Evolution line of console design. With clinician-requested features, including LED lighting, durable Corian® work surfaces, powder-coated steel bases, writing shelf, pass-thru X-Ray apron, X-Ray safety door lock, and soft-close drawers/doors, Evolution consoles are feature-loaded to meet the needs of contemporary operatory environments.

Visit www.planmeca.com/na/Dental-Cabinetry/evolution-line/.

Volume 8 Number 1

Consumers now have quick access to the high-quality, allnatural premium product line by Dr. Sharp® Dentistry, called Dr. Sharp Natural Oral Care right on Target.com. The premium natural oral care line focuses on being healthier, vegan, fluoridefree, and also free of parabens, gluten, alcohol, sodium lauryl sulfate, and heavy metals. Dr. Sharp Natural Oral Care non-GMO products contain xylitol, green tea, and other natural extracts with soothing properties. The line includes the essentials for a natural, healthy oral hygiene routine, including fresh mint green tea toothpaste for adults, wild berry kids’ toothpaste, fresh mint alcoholfree mouthwash, and green tea mint dental tape. The carefully formulated, fluoride-free line of products safely meets the everyday needs of the entire family.

For more information, visit www.drsharpcare.com.

Orthodontic practice 55

INDUSTRY NEWS Journal of Clinical Orthodontics publishes case study highlighting accelerated tooth movement when AcceleDent® is integrated into orthodonticorthognathic surgery cases OrthoAccel® Technologies, Inc., announced that the Journal of Clinical Orthodontics (JCO) published results from “Accelerated Orthodontics Using Pulsatile Forces in Orthognathic Surgical Patients,” a case series demonstrating accelerated treatment when incorporating AcceleDent® into combined orthodontic and orthognathic surgery cases. In these cases, orthodontists are using techniques to both straighten the teeth (orthodontic) and correct structural conditions of the jaw or face (orthognathic). AcceleDent employs patented SoftPulse Technology® that enhances physiological bone turnover enabling orthodontists to achieve predictable clinical outcomes. Primary author Dr. Sharon Orton-Gibbs, who began prescribing AcceleDent to patients in 2009, found that the mean actual treatment time for the 15 orthodontic-orthognathic surgery patients who used AcceleDent in conjunction with their fixed appliance braces was 33% shorter than the predicted treatment time (14.9 months vs. 22.2 months). To accommodate for an estimated 30%-50% reduction in treatment time with AcceleDent, Orton-Gibbs reduces the intervals between archwire changes by 25%-33% during leveling and aligning for her surgery cases and was able to see patients every 5 days for the 5 weeks after surgery, rather than the standard weekly appointments for 6 weeks.

Orthodontic community collaborates and connects with industry-leading experts at premier educational event Ormco Corporation has announced that Drs. Dwight Damon (Washington), Chris Chang (Hsinchu, Taiwan), and Stuart Frost (Arizona) are among the 30-plus world-renowned speakers scheduled to present at The Forum 2017, the largest privately sponsored orthodontic event in North America. Ormco’s annual conference, taking place February 22-25 at the JW Marriott in Orlando, Florida, will feature 4 full days of personalized education paths, one-on-one networking opportunities, and comprehensive clinical and practice management sessions.

For more information, visit Ormco at www.ormco.com or call 800-854-1741.

The cosmetic dentistry market is growing quickly The demand for cosmetic dentistry worldwide, including treatments such as teeth whitening, Invisalign®, and porcelain veneer application, represents a growing sector in dentistry. As this trend evolves, more dental practices seek to upgrade or replace their existing dental equipment. However, the high cost to purchase some of these systems is preventing some practices from keeping up with current trends. Additionally, many cosmetic procedures are not currently reimbursed by insurance, which could limit the market’s growth if some providers choose not to take advantage of this growing consumer base.

Adrian LaTrace, CEO of Boyd Industries points out, “It’s true that some of these cosmetic equipment systems require a substantial upfront investment. But to keep up with the demands of your patients and set yourself apart from your competition — you have to be willing to update your old dental equipment and position your practice to be able to provide cosmetic dentistry services.”

For information, visit http://www.boydindustries.com/home.

In addition, the company also announced the launch of shop. acceledent.com, an e-commerce site that enables orthodontic and dentistry professionals to conveniently order AcceleDent® units and marketing materials online. Orthodontists and their team members can purchase AcceleDent patient kits and accessories, including AcceleDent units, mouthpieces and replacement USB cables, adapters, and covers as well as demo units and display stands to help them communicate the benefits of AcceleDent to prospective and current patients.

To access the full JCO article, visit https://www.jco-online.com/ archive/article-view.aspx?year=2016&month=10&articlenum=592.

For more information, e-mail shop@orthoaccel.com, or call 1-866-866-4919.

56 Orthodontic practice

Volume 8 Number 1

Breakthrough in Class II Treatment

New!

Carriere® Motion CLEAR ™ Class ll Appliance Unlike any other Class II appliance on the market, the Motion CLEAR Appliance is ideal for even the most aesthetically demanding patients. Whether it’s the simplicity of use, the sleek patient-friendly design, or the remarkable speed and predictability of how it works, the Motion CLEAR Appliance is truly your clear choice for Class II correction.

Initial

12 Weeks Class l Occlusion achieved

31 Weeks Braces will be removed at 35 weeks

Total treatment time: Carriere Motion CLEAR Appliance (3 months) + Carriere SLX Brackets (5 months)

888.851.0533 or HenryScheinOrtho.com © 2017 Ortho Organizers, Inc. All rights reserved. M1035-OP 01/17.

U.S. Patent No. 7,621,743, 7,238,022 B2, 7,618,257 B2, 6,976,839 B2, and foreign patent numbers.

2017 TECHNOLOGY & EFFICIENCY SEMINAR MARCH 9 HONOLULU, HI MAY 8 PHOENIX, AZ JUNE 2-3 WASHINGTON, D.C. JULY 14-15 VAIL, CO OCTOBER 6-7 LAS VEGAS, NV DECEMBER 1-2 WEST PALM, FL REGISTER TODAY 1.800.525.6375

RMO® IS THE EXCLUSIVE DISTRIBUTOR OF DM™ 650 West Colfax Avenue, Denver, Colorado 80204 P 303.592.8200 F 303.592.8209 E sales@rmortho.com 800.525.6375 | www.rmortho.com

MESSAGE FROM YOUR ORTHODONTIST

Hi Julia, Your treatment is progressing well, keep wearing your Energy Pak Elastics!

Hope the vacation is going well, no appointment is needed until next month!

Dr. Anderson