Orthodontic Practice US, Vol. 8, No. 4

clinical articles • management advice • practice profiles • technology reviews July/August 2017 – Vol 8 No 4

Congenitally missing mandibular premolars — treatment options for space closure Dr. Mark W. McDonough

Keeping the “special” in the orthodontic specialty: part 2 Dr. John Wise

An analysis of the impact of intraoral scanners on the orthodontic practice

A new perspective on Aligner Design.

PROMOTING EXCELLENCE IN ORTHODONTICS

Dr. Robert Waugh

See page 9 PAYING SUBSCRIBERS EARN CONTINUING EDUCATION

CREDITS PER YEAR!

24

THE CLEAR APPLIANCE FOR ALL YOUR PATIENTS Efficiently treat all your patients to a beautiful result with the improved Damon Clear2 bracket that provides the control needed for you to treat a wide variety of cases with outstanding results.

Adult Open Bite Case

Adult Impacted Cuspid Case

Featured Damon patients treated by Drs. Todd Bovenizer and Stuart Frost.

Visit ormco.com/damon to learn more.

EDITORIAL ADVISORS

Hybrid thinking and the customfit approach to appliance therapy

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

© FMC 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 4

L

abial. Lingual. Aligners. If clinically appropriate, these remain most patients’ — and doctors’ — choices, with traditional labial appliance therapy still the most common option, though losing ground to aligners. However you feel about aligner therapy, it is a reality and will continue to cut into the fixed-appliance portion of the orthodontic market. In our practice, we have found a way to give our patients what they want (aligners) and still achieve the standard of care we owe the patient. Digital treatment planning, in particular, gives us the ability to custom-fit appliance therapy to suit each patient’s unique malocclusion as well as his/her J. Peter Kierl, DDS, MS treatment preferences.

Here is a case in point. A prospective patient is getting married in 8 months (or, perhaps more commonly, in 3 or 4) and wants to “fix her smile.” Upon the initial exam, you determine that aligners alone won’t do the trick in the allotted time. In this case, the patient has an overbite of 60% and several teeth that have significant rotations in the maxillary and mandibular anterior segment. There is contact on the lingual of the maxillary incisors. In cases like this, digital case planning can save the day, not to mention the marriage. We treated this patient with labial appliances for 6 months to correct the anterior rotations and open the bite, and then continued treatment with aligners up until a week before her wedding. To the untrained eye, her smile was perfect; to the professional eye, it was vastly improved and required only some modest modifications to complete the case to our standards.

Marriage saved! Well, at least for now — schedule a recall in a few years, and hope that their happiness is operating at the same level as her retention.

Digital technology gives us a more sophisticated approach to case planning, an especially valuable benefit as patients’ increasing awareness of aligner therapy often shapes unrealistic expectations of treatment times and quality of results. Fixed appliances allow us to correct rotations quickly and level the arches to reduce our needs in the aligner phase of treatment to smaller, first-order movements. Vertical movements in the anterior occlusal plane are controlled by the fixed-appliance therapy. No need to do that with aligners. It also initiates the biological cellular activity needed to move teeth and, thus, makes it possible to plan larger first-order movements in our aligners. This reduces the number of aligners the patient must wear. In our practice, at least 30% of our cases now involve some combination of fixed appliances and aligners. I’m able to plan the initial movements in 4-8 months and finish regularly in 10-14 months with aligner therapy, the significant difference being that our job shifts from wire adjustments to tracking the movements of teeth with aligners. We are still driving the treatment to the desired finish, but we are using a different appliance to do so. The teeth do not care what force system is being used; however, the patient does.

Taking a hybrid approach requires more planning on our part, a process supported by suresmile®, our digital treatment system of choice, and supervision of patient compliance supervision in later phases of treatment. Nevertheless, using new technology allows us not only to meet our patients’ demands, but also to achieve consistently superior results that satisfy our professional requirements in an efficient manner. It’s a win-win approach for the doctor and the patient.

J. Peter Kierl, DDS, MS

J. Peter Kierl, DDS, MS, graduated from the University of Oklahoma College of Dentistry, completed his orthodontic residency at the University of Iowa, and received his master’s degree in Orthodontic Sciences. He has been in private practice for more than 33 years in Edmond, Oklahoma. He has been a clinical professor in the Graduate Clinic in the Department of Orthodontics at the University of Oklahoma College of Dentistry since 1982. He achieved his certification with the American Board of Orthodontics in 1993. Dr. Kierl has been a 100% suresmile® practice since July 2006. He has completed more than 3,000 suresmile cases and more than 250 lingual cases using the suresmile system.

Orthodontic practice 1

INTRODUCTION

July/August 2017 - Volume 8 Number 4

TABLE OF CONTENTS

Orthodontic insights Keeping the “special” in the orthodontic specialty: part 2

8

Dr. John Wise discusses technologies to create aligners “in your office” (IYO)

Continuing education An analysis of the impact of intraoral scanners on the orthodontic practice Dr. Robert Waugh discusses the many ways that intraoral scanners increase efficiency ........................................18

Event update Henry Schein Orthodontics celebrates 3rd annual Orthodontic Excellence & Technology™ Symposium ®

™

This event showcased the latest innovations and clinical solutions to help orthodontists

16 Continuing education Congenitally missing mandibular premolars — treatment options for space closure Dr. Mark W. McDonough discusses recognition and treatment planning for congenitally missing second premolars ....................................................... 23

2 Orthodontic practice

Volume 8 Number 4

We are excited to announce that this year’s Orthodontic World Congress will be held in conjunction with Dentsply Sirona World!

Register today for the OWC! mygcare.com/owc2017 or call 1.800.645.5530

OWC EDUCATIONAL SPEAKERS

DS WORLD KEYNOTE SPEAKER Simon Sinek Sinek is leading a movement to inspire people to do things that inspire them.

Hear what Simon has to say! Only at Dentsply Sirona World in conjunction with the OWC in Las Vegas.

Dr. Antonino Secchi Simplify Your Mechanics Improving Your Results!

Dr. Ryan Tamburrino The New Paradigm on Maxillary Expansion

Dr. Shalin Shah Digital Scanner in the Orthodontic Workflow

Dr. Martin Palomo 3d Airway and Sleep Disorders

WORLD CLASS ENTERTAINMENT

Jeff Dunham

Imagine Dragons

Performing Live!

Thursday, Sept. 14th

Performing Live!

Friday, Sept. 15th

More keynote speakers & entertainment to be announced!

© Copyright 2017 Dentsply Sirona. All rights reserved. 0280-MM-0075 Issued 6/17 Dentsply GAC International • One CA Plaza, Suite 100 • Islandia, NY 11749

Take a Good Look at Great

Enclosed Clip Channel Enclosed clip mitigates calculus build-up

Opening Mechanism Easy opening with no dedicated instrument

Low-Profile Reduced overall profile

Reduced Curvature Improves clip strength and increased wire retention forces

Presenting In-Ovation From GAC Crafted in collaboration with the orthodontic community, the new In-Ovation X bracket gives you the precision you want, the control you need and the confidence you deserve.

For better, safer and faster outcomes, take a good look at great with GAC’s In-Ovation X from Dentsply Sirona Orthodontics.

Put the future of self-ligation at your fingertips with the new In-Ovation X. (800) 645-5530 www.inovationx.com

TABLE OF CONTENTS

Step-by-step Bye-bye cold air — say hello to comfort

Product profile

30

Dr. David A. Chenin discusses the advantages of an air-free handpiece

AcceleDent® Optima — what’s new in accelerated orthodontics .......................................................32

Event news......................33

Book review Aligner Orthodontics: Diagnosis, Biomechanics, Planning and Treatment Werner Schupp, Julia Haubrich with contributions from Wolfgang Boisserée, John Morton, and Kenji Ojima...............................................36

Practice development How social media can help your SEO performance Ian McNickle, MBA, discusses the impact of search engine optimization .......................................................34

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com

Small talk

CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com

Leading through change

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com

Dr. Joel C. Small discusses methods for orderly and peaceful change.......38

Industry news...............40

WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Terri Burud Email: terri@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 4

Which do you prefer?

20 min

propelortho.site/stayontrack

Visit us to learn how you can stay on the track to success with our in-office and at-home options.

5 min

STAY ON TRACK TO SUCCESS

ORTHODONTIC INSIGHTS

Keeping the “special” in the orthodontic specialty: part 2 Dr. John Wise discusses technologies to create aligners “in your office” (IYO)

C

lear aligner treatment has become a staple of our orthodontic armamentarium. It’s common for our patients to ask for “Invisalign®” by name — masterful job at brand awareness. As the “Kleenex®” (facial tissue) of clear aligners, when our clients ask for “Invisalign,” they usually are really asking us about “clear aligners.” In addition, a new trend toward self-treatment with clear aligners has the potential to challenge our specialty. What is the orthodontic practice of tomorrow going to do to survive in a world where do it yourself (DIY) tooth alignment is common place? Will orthodontic practices be changed forever?

Orthodontic care may one day be offered at a mall kiosk outfitted with a DIY intraoral scanner and CBCT machine. Already, the impression, arguably the most difficult procedure to perform with consistency, has been simplified to the point that virtually anyone can make a digital 3D model of his/her teeth.

And the companies that want to leapfrog over the orthodontist are investing heavily in these devices. They own the gizmos that may someday put us all out of business. You protest and say, “What about quality photos of the malocclusion to assist in aligning teeth?” Can you say “selfie”?

These obstacles are fading fast. Soon our sacred orthodontic records that allow us to diagnose, treatment plan, and then treat a case will all be within reach of the DIY crowd.

Every orthodontist reading this article needs to become proficient at creating aligners “in your office” (IYO) to move teeth in a manner befitting our specialty and taking into consideration the new needs of the patients.

IYO lab costs Your cost to perform IYO clear aligner care is dramatically less expensive than the

Figure 1: Access to 3D-printed models is the key to IYO clear aligner success. Multiple aligners can be made from the same models, and the orthodontic specialist can adjust those same models as needed for patient specific situations

various third-party companies. And there is a wide array of cases out there begging for treatment — from the 1-2 aligners when the college kid is home on break to the 20-plus aligner cases for those folks who want things clear and clear only. All of the things you do today for a third-party clear aligner case related to chair time, digital intraoral scans, and records is the same as it is for the IYO model. The design, production, and sequencing of the aligners themselves are dramatically different. Doing clear aligners IYO is within reach, and in my opinion, we can do it better, faster, and less expensively than any third-party provider out there. Here is a typical cost breakdown for IYO clear aligner cases:

10 aligners upper and lower (equivalent in my office to 15-20 aligners using a third party) Software usage (suresmile) $45 TechC time (2.5 hours) $50 Model printing ($15/model) $300 Aligner fabrication time $40 $25 Aligner material TOTAL $460

5 aligners upper and lower (8-10 using a third party) Software usage (suresmile®) $45 Technology Coordinator time (2 hours) $40 Model printing ($15/model) $150 Aligner fabrication time $25 $15 Aligner material TOTAL $275

Outsourcing has come full circle

John Wise, DDS, is a specialty-trained orthodontist with two locations in growing suburbs near Dallas. Frisco and McKinney, Texas, are two of the most overserved towns in the United States with primary care dentists, corporate offices, and specialty care orthodontists on virtually every street corner. Dr. Wise practiced general dentistry for 3 years prior to completing his orthodontic residency program at the University of Texas Health Science Center in Houston, Texas, in 1992. He practices orthodontics exclusively with his partner, Dr. Jessica Lee and his team. Dr. Wise entered the world of virtual orthodontics in 2008 when he began utilizing CBCT scanning and suresmile®. He hasn’t looked back. Ms. Tammy Long became his TechC in 2009, possibly the first such designation in the orthodontic community.

8 Orthodontic practice

20 aligners upper and lower (30-40 using a third party) Software usage (suresmile) $45 TechC time (3 hours) $60 Model printing ($15/model) $600 Aligner fabrication time $60 Aligner material $50 TOTAL $815

Thomas Friedman’s book The World is Flat delves in great detail into the benefits of outsourcing. That was in 2005. And in the days when computer hardware, software, 3D printing, and digital storage was out of reach financially and technically, outsourcing of digital orthodontic cases made perfect sense. But today we have the capability — all on a laptop computer that can be purchased at Best Buy and 3D printer than can be purchased from Amazon and data storage that can go on a thumb drive — to design and create our own clear aligners for far less money, more control of the process, and, most importantly, with greater precision and improved outcomes. Results are just better Volume 8 Number 4

My practice often uses aligner therapy at the beginning and finish of treatment. Not only does suresmile Aligner Design put me in complete control, suresmile’s pricing program has already saved us thousands of dollars.

PETER

KIERL dds, ms EDMUND, OK

Choose suresmile | elemetrix Aligner Design for cases requiring moderate tooth movement, including: • Aligner-only treatment.

• Aligner treatment in conjunction with braces, either to start or finish cases.

• Clear retainers at the end of treatment with braces— the scan can be performed before removal of braces, eliminating an office visit and becoming the start of a practice retention program.

• Outstanding value.

To learn more, call 877.787.7645 or visit suresmile.com

suresmile | elemetrix Aligner Design Better Value. Precisely.

suresmile.com

© 2017 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix. elemetrix is a trademark of OraMetrix.

Aligner Design... your way.

You have a choice in aligners.

ORTHODONTIC INSIGHTS when you run the show. The orthodontic delivery system is dramatically improved when you, the orthodontist, have the tools and the know-how to use them. Outsourcing has been turned on its ear. These issues are now better handled in your office (IYO), not in a Central American country, India, or China.

Those troublesome attachments Why do we need attachments to move a tooth with clear aligners? Attachments, in my opinion, have limited usefulness in a clear aligner case. While extremely helpful to improve the retention of an aligner, the limitations imposed by the periodontal ligament (PDL) make attachments to torque, tip, or bodily move a tooth useless in most cases. We need and want attachments, but be frugal with your attachments. Remove them when the aligners aren’t tracking. You’ll like not having them around. As any trained orthodontist knows, complex movements are best handled with brackets and wires. A compliant patient is your most valuable tool for success with clear aligners.

Do not rely on an attachment to change the fundamental laws of the universe described by Sir Isaac Newton in the 17th century. “An object in motion will stay in motion unless it is acted upon by another object,” or “For every action, there is an equal and opposite reaction.” The PDL, bone, gums, and occlusal forces are all fighting against us, and a little blob of composite can’t change that.

has the option to create an entire sequence of STL files, which dramatically saves time (but comes with a cost). You and your TechC should be making clinical notes along the way to assist you clinically once the aligners are delivered. Anyone who can save and name a photo to his/her computer can save and name an STL file to a laptop.

When you have all of your STL files saved to a folder, you can access the 3D printer in your lab, or down the street at an imaging center, or across the country or the world at a printing lab. There are many resources for printing your models. Make sure you order models of an appropriate strength for multiple aligner fabrications since that’s one of the major reasons to do IYO aligners. A model costs anywhere from $10-$20 per arch to be printed. This is currently the most expensive part of this process. Don’t worry.

The price is coming down!

When your models arrive, make sure you catalog them extremely well, so they can be easily accessed for aligner fabrication. You already have someone working for you who is expert at doing this. Any modifications to be made to the models are done now. If you have a tooth that needs some special torque or rotational help, some simple model carving will do the trick. A shallow trough (approximately 0.5 mm deep) placed where you

need it works great. We make our aligners in batches of four or eight depending on the case. No need to make them all at once unless you just like storing stuff. Find some super cool packaging — preferably with your branding on it — and set the aligners aside to make them ready for delivery to the patient.

How long to wear each aligner?

No one knows exactly how long a person should wear an aligner to achieve maximum results. Is it 1 week, 2 weeks, or 10 days?

The point is not to choose the exact perfect amount of time; instead, you should choose the time that works best in your system. Eliminate confusion in your clinic and with your patients by sticking with the same amount for each aligner. We have chosen 2 weeks per aligner for our routine. Some offices will make two aligners from each 3D printed model. In this way, the patient has a “fresh” aligner to wear for each sequence. As we all know, any plastic material will deform over time, and having a fresh aligner will eliminate this issue.

So a case with ten 3D printed models will have 20 aligners. You may choose to shorten the wear time in this scenario to 1 week per aligner.

The decision for the amount of time to wear the aligners can be affected by how much movement you are trying to achieve

You and your team can do this!

Once you like your aligner sequence and attachment design, it’s time to build your STL files. You do this on the software with a few pushes of the buttons. They’ve made it so easy. Whatever you can display on the screen can be printed out. You or your technician will design each and every STL file for the case. It doesn’t take long to do.

As you design it, save it for printing. Some types of software do this for you. suresmile

Figure 3: The new patient start kit has everything your patient needs to achieve success. Build it yourself, and make it fit your style of care delivery

Figure 2: Package the aligners in an organized fashion using inexpensive products that are readily available 10 Orthodontic practice

Volume 8 Number 4

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

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Elevate your practice above the rest with the CS 3600 intraoral scanner. High-speed continuous scanning captures dual arches faster than ever, while high-definition 3D scans makes communication with patients, referrals and labs easy.

Plus, the open system means there’s no additional hidden fees. Another innovation that stands above the rest.

© Carestream Health, Inc. 2017. 15545 DE CS 3600 AD 0717

For more information, call 800.944.6365 or visit carestreamdental.com

ORTHODONTIC INSIGHTS with each one. So, your virtual movements and STL file/model creation should coincide with your time interval. In the IYO aligner world, being economical with the number of aligners will help your bottom line. The more models/aligners you make, the more costs for you.

At the first delivery appointment, you’ll need to set aside enough time to affix any attachments you designed along with instructions to the patient. We find it helpful to have printed instructions for the patients to look over while they are there waiting for the doctor to arrive. All of the clinical time up to your arrival has been with your staff. Doctor time at the first aligner delivery appointment is generally less than 5 minutes. An important part of your role is to direct your laboratory technician on how to prepare the next set of aligners.

You should have a simple form available at the chair for this purpose, just like any other lab appliance you make. Your lab tech needs your instructions to be clear and concise. How many aligners? Any special trimming? Model modifications? Delivery date?

The second and all subsequent aligner delivery appointments are even simpler than the first. Your clinical assistant will seat the patient and get a brief update on how the last few weeks have gone. A few probing questions will do the trick. Choose a good listener for this job. How are the aligners fitting? What sort of routine have you established to wear your aligners? What aligner are you on right now? Any special issues we need to address with your aligners? There should be floss, aligner trimming scissors, mouth mirror, scaler/explorer, the new set of aligners, and a carryout bag right there at the chair. Teach your clinical team to look at the current aligner in the mouth to discover

areas that are not tracking, impingement on gingiva, and any other issues related to a properly fitting aligner. Your assistant should take the current aligner to have it cleaned, and then floss the teeth — not to clean them but to ascertain which contacts are tight, light, or open. He/she should document the contacts for you.

At this point, if all lights are green, your clinical assistant can open up the next aligner set and deliver them to the patient. If not, no worries; staying in the current aligner for a few more days is not a big deal. The assistant should call you to the chair in either scenario at this point to: • Congratulate the patient on a successful aligner sequence experience, or give specific directions to complete the current aligner sequence before moving on to the next.

• Perform any necessary IPR (which was determined at the last visit and even before that with your clinical notes made during your software work).

• Direct your lab tech for the next aligner sequence construction.

Midcourse corrections/refinements As the master of your own fate with clear aligner design and fabrication, you have total control over any adjustments you want to make mid-treatment or toward the end of the aligner sequence. For longer cases, you can choose to print only a portion of the 3D models, monitor the case for tracking, and then adjust on the fly. Print a few more models and continue. At the end of the aligner sequence, if you need more movement, you can use the original scan to accomplish some changes. Other times,

Figure 4: Different aligner materials can be used as you see fit. Like your choice of wires, your choice of plastic can determine success and efficiency 12 Orthodontic practice

you’ll need an updated digital scan to reboot the case. But no worries; the lab cost to you is still very reasonable, and as I said before, you have control over the case. If you know you have a complex case upfront, plan for it and charge accordingly.

The finish line As any specialist knows, starting an orthodontic case is easy; the finishing is difficult. With aligners, just like with braces, those small, fine movements we need to really put the finishing touches on the case are tricky.

Make sure that you and your patients are realistic about what an aligner can accomplish.

Make sure your patients’ goals align with your goals. At the final delivery of aligners, make an assessment as to the need for refinement aligners. You’ll also want to decide if you will need another intraoral scan. In my practice, we do this about 10% of the time. The other 90% of aligner cases finish up the way we planned them from the beginning.

We ask our patients to wear their final aligner for some additional time. That’s the one with all of the last detailing. If that one fits well, you’ve succeeded. Ask them to wear it full time an additional 4, 6, or even 8 weeks.

Then when patients come in for their final check, have a new aligner/retainer ready for them. This appliance will have been made from the same exact 3D-printed model that you made their final aligner from. The only difference is the material. This last aligner/ retainer is made from a stiffer material that will last for many years.

In our practice, we use the Essix ACE® material for the aligners and the Essix® Plus™ material for the retainer. At this point, you can continue to ask the patient to wear the Essix Plus aligner for 24 hours, or you can start to

Figure 5: Modern vacuum/pressure machines use bar codes fed into the device to achieve consistency as you build your own aligners Volume 8 Number 4

EMMA HARRIS

Hi Emma, Your treatment is progressing well. Keep wearing your elastics!

Hi Emma, Your treatment is progressing well.

Keep wearing your elastics. Hope the vacation is going well! No appointment is needed until next month. – Dr. Anderson

LEARN. CONNECT. INNOVATE. 2017 TECHNOLOGY & EFFICIENCY SEMINAR %

100

Em m a, ke r t r e Ela p ea sti we tm cs a en ! rin t i Ho g sp no pe yo ro t ur g a h ne p e En res xt po va er sin m in c gy g on tm at Dr Pa we .A th en ion ! t is k l, nd is g er ne o so i n ed g n ed w un el , til

Hi

ME

OM

E FR

G SSA

YOU

R

CTO

O RD

Yo u

8:0

8 AM

OCTOBER 6-7 LAS VEGAS, NV

REGISTER AT RMO-SEMINARS.COM 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

Connected orthodontics

ORTHODONTIC INSIGHTS cut back the time. Since many of our patients in the clear aligner care cycle are adults, we entrust them to make decisions about wear.

They can titrate their wear time all the way down to sleeping hours only. In every case, our patients find the right amount of time to wear their retainer to hold their teeth straight.

They love these “slip cover” retainers — no wires showing and no bulky palatal plastic.

The Essix Plus material is very durable and will last for many years in most cases.

The chair time bonus One of the really cool things about clear aligner care is the fact that these patients are really tuned into wearing the aligners, so retainer wear is super easy for them. We find there is virtually no benefit to calling them back in for “retainer check” appointments for 2-plus years, which is our standard for teenagers and standard braces cases. Instead of four or five retainer checks, we have one or two. You can add one more item to the list of why IYO clear aligner treatment is a must for the modern specialist practice.

Technology has arrived The technological advances of just the past few years have dramatically changed our world. In the orthodontic world we all live in, that means that 3D treatment planning, robotic wire bending, aligner manufacture, and 3D printing and imaging are all easily within our reach. Just like with braces, the more control you have as the orthodontic specialist, the better. Let’s leave the third-party aligner companies for our general dentist friends who need the oversite and guidance for success. As specialists, we can be the experts in clear aligner design, manufacture, and treatment. And as we move forward with the rapidly changing technology, orthodontic specialists will be competing very effectively with the myriad third-party companies who are trying to win the “race to the bottom” on lab support.

Our patients’ smiles are important; they have every reason in the world to choose a specialist for their care. Let’s help them make the right choice by providing clear aligner treatment IYO, not DIY! OP

Figure 6: Your packaging should spread your name, not some third party’s. Dress it up, and make it special

Watch for It

14 Orthodontic practice

Volume 8 Number 4

THE WORLD’S MOST COMPLETE SELF LIGATING BRACKET SYSTEM JUST GOT EVEN BETTER. Micro etched Maximum Retention™ bonding pads Increases bond strength 15-30%* Modified clip shape Helps seat wire during clip closure Thicker and stronger clip Increases wire seating force and reduces clip deformation Chamfered slot entrance Reduces friction from wire binding

Experience Empower 2 for yourself.

Contact your American Orthodontics representative to learn more. * Not yet verified by published, peer-reviewed research

FOLLOW US ON

WWW.AMERICANORTHO.COM/EMPOWER ©2016 AMERICAN ORTHODONTICS CORPORATION +1 920 457 5051 | AMERICANORTHO.COM

EVENT UPDATE

Henry Schein® Orthodontics™ celebrates 3rd annual Orthodontic Excellence & Technology™ Symposium This event showcased the latest innovations and clinical solutions to help orthodontists

I

n February, Henry Schein® Orthodontics™ (HSO) held another sold-out Orthodontic Excellence & Technology™ Symposium in Scottsdale, Arizona, which brought together leading orthodontic speakers and forward-thinking attendees in a powerful learning environment. The event showcased a broad spectrum of the latest innovations and clinical solutions to deliver dental, facial, and total health results. Attendees had an opportunity to experience cutting-edge technology and evidencebased protocols that can help enable HSO customers to achieve new levels of patient care and practice enrichment.

Keynote speaker, Dr. Luis Carrière, was impressed to see and interact with so many orthodontists from around the world. “We all share the same interests of simplifying orthodontic procedures, enhancing quality of patient care, and exploring new orthodontic treatments.”

Industry experts lead panel discussion

2018 Speaker Lineup

Global Symposium in session

More than one dozen breakout sessions were held throughout the Symposium to help orthodontists achieve their goals of improving quality treatment, efficiency, and practice growth. Session topics included “The Future of Orthodontics: Designing Your Progressive Practice,” “The Ultimate Success Formula: Unique Efficiencies in Class II and III Correction,” and “Orthodontics and 3D Technology: Mapping Your Practice Future.”

Planning for the 2018 Symposium is already underway. Henry Schein® Orthodontics™ is working diligently to make it even better — more than 20 renowned speakers, more exciting events, and of course, the very 16 Orthodontic practice

Top: Motion CLEAR™ Class II Appliance. Above: Dr. David Paquette presenting “The Future of Orthodontics”

latest in progressive business management, clinical techniques, and technologies. Save the dates now for February 22-24, 2018, to be held once again in beautiful Scottsdale, Arizona. The host hotel is The Westin Kierland Resort & Spa, 6902 East Greenway Parkway, Scottsdale, Arizona 85254. OP

• Dr. Luis Carrière, Keynote Speaker • Dr. David Paquette, Program Chairman • Dr. Sean Carlson • Dr. Lou Chmura • Dr. Christy Fortney • Dr. Scott Frey • Dr. John Kaku • Dr. Jason Kaplan • Dr. Bruce McFarlane • Dr. Jim McNamara • Victoria Mucci • Dr. Jep Paschal • Dr. Patti Panucci • Dr. Juan-Carlos Quintero • Dr. Becky Schreiner • Dr. Thomas Shipley • Amanda Vasconcellos And more industry-leading speakers to come!

This information was provided by Henry Schein® Orthodontics™.

Volume 8 Number 4

A complimentary copy of Tony Robbins best selling new book,

UNSHAKEABLE & a free review of your 401(k) plan

#1 Best Seller

#1 Best Seller

#1 Best Seller

HOW IT WORKS 1. Visit FreeCopyPlease.com and give us the details of your 401(k) plan.

We will uncover all layers of hidden and unnecessary fees.

855.905.4015

2. After a brief call to review the results, we will send you a complimentary copy of UNSHAKEABLE.

CONTINUING EDUCATION

An analysis of the impact of intraoral scanners on the orthodontic practice Dr. Robert Waugh discusses the many ways that intraoral scanners increase efficiency Introduction Computer-aided design/computer-aided manufacturing (CAD/CAM) was first used in dentistry in the late 1970s/early 1980s in Europe. However, the sheer size of the equipment confined the technology to only the most advanced laboratories. In the early 2000s, developments in miniaturization made handheld scanners a reality for dental practices.

As CAD/CAM technology was refined over the decade, new software algorithms were introduced to meet the unique needs of the orthodontic profession. According to an informal survey conducted the by the Journal of Clinical Orthodontics, 62% of respondents indicated they now use an intraoral scanner.1 Considering the rapid pace of technological advances in the digital space, it is worthwhile to consider the effects intraoral scanners have had and will continue to have on orthodontics. Not only that, considering the market position practices are in to attract patients, intraoral scanners are also unique in the role they play in patient satisfaction and retention.

Intraoral scanners’ effects on practice workflow Studies show digital impressions are beneficial in creating a more efficient workflow.2 Although it varies based on examination needs, capturing a digital scan (versus

Robert Waugh, DMD, MS, has practiced orthodontics full time in Athens, Georgia, since 1989 and is also an Assistant Professor at Georgia Regents (USA) College of Dental Medicine’s Orthodontic Residency Program.

Dr. Waugh’s interests include using new technologies that help deliver better care for his patients. In 2008, he merged three offices into one facility of 24 chairs that allows him to deliver care using a wide variety of modalities in hygiene, patient scheduling, treatment delivery, and more. Dr. Waugh graduated from GRU College of Medicine in 1987 with both a DMD and a master’s in Oral Biology and was elected to Omicron Kappa Upsilon (OKU).

He earned his orthodontic certification and a second master’s degree at Baylor University in 1989. In 2000, he was boardcertified by the American Board of Orthodontics. Dr. Waugh has served as President of the Georgia Association of Orthodontists and is a member of the International Colleges of Dentists.

18 Orthodontic practice

Educational aims and objectives

The purpose of this article is to review the impact intraoral scanning has had on the orthodontic profession, the evolution of the technology, and how its use affects clinicians, staff, and patients.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 22 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize intraoral scanners’ effects on practice workflow.

• Realize intraoral scanners’ role in practice/lab relationships.

• Recognize intraoral scanners’ impact on fit of final appliances.

• Acknowledge intraoral scanners’ impact on patient comfort.

• Compare the true cost of traditional impressions versus digital impressions.

• Identify intraoral scanners’ impact on hygiene and patient safety

taking a traditional impression) generates timesavings due to the speed that scanners allow. As Figure 1 illustrates, however, actual timesavings come from eliminating the additional steps associated with preparing for, working with, and shipping traditional impressions/models to the lab. It’s also important to note that the more steps there are in any process, the more opportunities exist for the introduction of errors.

Recent advancements in software have tailored scanners to further fit orthodontists’ needs. For example, algorithms are optimized for fast dual-arch acquisition, facilitating an uninterrupted user experience in the orthodontic office. Integration with other imaging equipment and/or practice management software enables clinicians to quickly access the information they need with

minimal clicks, further improving the treatment workflow.

An improved workflow results in a process that is seamless from the moment the initial intraoral scan is taken. In most cases, it significantly decreases the total time required from impression to appliance delivery, saving chair time for clinicians and reducing disruptions to daily routines for patients.

Intraoral scanners’ role in practice/ lab relationships From the lab’s perspective, the impression-taking skills of clients can present a significant challenge. As many as 25% of the traditional impressions arriving at the lab are inadequate, due to a failure to follow guidelines and a lack of evaluating impressions

Figure 1: A comparison of traditional versus digital impression taking workflows. Modified from Patzelt SB, et al. J Am Dent Assoc. 2014;145(6):542-551 Volume 8 Number 4

Figure 2: Lower occlusal captured with Carestream Dental CS 3600 intraoral scanner. Software acquisition algorithms designed for orthodontics makes capturing arches and reflective objects such as brackets easier

Figure 3: Upper arch with retention wire displayed in HD 3D color for accurate detail of dentition and soft tissue

Intraoral scanners’ impact on fit of final appliances Digital scanners are generally acknowledged to be more accurate than traditional impressions,4 as they provide a level of detail of the dentition and soft tissue not previously available to oral health professionals. Additionally, orthodontists are at an advantage, as scans needed to fabricate appliances do not require nearly as much data as a scan meant to fabricate a crown or bridge (marked margin lines, interproximal and sub-gingival scans, etc.). Digital impressions lead to distortion-free models that some doctors feel result in appliances that fit more predictably than those fabricated using conventional methods. Better fitting appliances also result in higher quality treatment outcomes.

Figure 4: Model printed from digital impression using CS 3600 demonstrates accurate fit of appliance

Intraoral scanners’ learning curve Users take time to grow comfortable with any new technology, and the learning curve with digital scanners can vary from user to user. For experienced scanner operators, the need to rescan is minimal. However, sometimes scanners feature an auto-locate function that detects and corrects defects in the data set, which allows users to rescan an area to fill in missing information without starting over while the patient is still in the chair. This can help new scanner users gain confidence and hone their skill.

Volume 8 Number 4

Figure 5: Scanning with the CS 3600 Orthodontic practice 19

CONTINUING EDUCATION

before sending them to the lab.3 With intraoral scanners, it is possible to immediately send the digital impression to the lab for review.

If there is an issue with the impression, the practice can rescan the patient while he/ she is still in the chair. Once the lab receives the digital files from the intraoral scan, it can immediately communicate unmet needs to the office. If there is a question about the prescription or appliance, there is no lag time from shipping, which ultimately creates delays in fabrication.

The ability to communicate easily with third parties such as labs also facilitates the treatment-planning process. The file format accepted (either .STL or .PLY) varies from lab to lab. As a result, a scanner’s output should be in an open file format so that clinicians are not limited to only labs that accept a certain type of file. Within minutes of scanning, the lab receives these files and can open them in the design software of its choice. A phone call or remote viewing call from the lab to the orthodontist enables both parties to work together, even before the patient has left the appointment.

CONTINUING EDUCATION Beyond becoming familiar with the best technique for scanning for creating digital impressions, users must also change their mindset when analyzing models. Without a stone model to turn in their hands, physically probe, or bring close to the eye for examination, the switch to digital may be jarring. Adapting to software and manipulating models on a screen also takes adjustment. There are many benefits to introducing a digital scanner into an orthodontic workflow, but it’s recommended that practices allow extra time for the first three to five cases involving a scanner so that both the practice and lab can become familiar with the new workflow.

Intraoral scanners’ impact on patient comfort Intraoral scanning eliminates the risk of patients gagging, an advantage for all parties involved. When the clinician

performs a scan, if transient brushes with sensitive tissues occur, the clinician can simply move on and return in a more careful manner, recapturing that area after the patient has felt the accomplishment of the now nearly complete scan. The experience is more pleasant for both the patient and the clinician than with traditional impression methods.

Also, intraoral scanner tips typically come in two sizes to accommodate mouths of all sizes. These tips are ideal for anterior and occlusal surface scanning or for pediatric and adult scanning. If the scanner features a side-oriented tip, the clinician gains flexible choices in satisfying different clinical needs and user preferences. The side-oriented tip is designed to make it easier to obtain buccal surface scans, and the tip height is generally shorter than the standard tips. Side-oriented tips also enable greater access to the molars.

Intraoral scanners’ impact on practice ROI When comparing the true cost of traditional impressions versus digital impressions, there are several factors to consider.

First, intraoral scanners eliminate the cost of ordering consumables such as trays, alginate, etc., which, depending on practice size, can cost $1,500-$2,000 a month. Beyond the obvious cost-savings on materials, consider the cost of treatment if the practice needs to remake an impression or appliance. Assuming the lab doesn’t charge for a remake — which involves additional fees — if an assistant remakes a PVS impression, the cost in time and expense is actually threefold.

First, the impression is unusable, resulting in the loss of both time and money. Second, the remake adds time and expense, in addition to wasting materials. Third, an assistant is not available for a new patient and/or procedure while attending to the remake.

Intraoral scanning eliminates the risk of patients gagging, an advantage for all parties involved.

Figure 6: Example of missed back molars from traditional impression, leading to remake

Figure 7: Digital stone model and HD 3D view of dentition as alternative to physical stone models that require storage 20 Orthodontic practice

Volume 8 Number 4

From fewer appointments to quicker turnaround times at the lab to improved outcomes and happier patients, intraoral scanning and digital models are setting the stage for greater efficiencies across the board.

Intraoral scanners’ impact on hygiene and patient safety Asepsis is a critical concern for orthodontists, and maintaining an aseptic field of treatment is always a top-of-mind issue. The Centers for Disease Control (CDC) recommend that heat-tolerant semi-critical items in dentistry (items that come into contact with mucous membranes) be sterilized using heat.

If heat sensitive, dental healthcare practitioners should replace semi-critical items with a heat-tolerant or disposable alternative.5 This recommendation underscores the need for the disinfecting practices of the intraoral scanner to include heat sterilization. Scanner tips should be autoclavable to promote optimal sterilization for infection control.

Intraoral scanners’ impact on patient education and case acceptance During pre-exam office tours, seeing an intraoral scanner in action can convey technological competence on behalf of the practice to the patient. When parents observe the image acquisition process and the resulting images — as well as how calm and cooperative their children are — they may become advocates for the state-of-the-art technology and the practice that uses it.

Also, images produced by the intraoral scanner also help patients and parents quickly comprehend the treatment plan.

A digital model is presentation-ready as soon as scanning is complete. Thanks to the educational aspect of the model and a better understanding of their clinical situation, patients may feel more confident about the clinician’s approach. In addition, the same digital scan used for case presentation Volume 8 Number 4

Figure 8: Impressing patients with digital technology

can be used to create an appliance if one is needed. With the traditional method, typically the patient is sent home so that the office can create the stone models, and a follow-up appointment is scheduled to review the model at a later date. These extra steps are eliminated with digital impressions as a model can be reviewed immediately after it is captured with the digital intraoral scanner.

Conclusion Intraoral scanners are having a tremendous impact on the practice of orthodontics.

From fewer appointments to quicker turnaround times at the lab to improved outcomes and happier patients, intraoral scanning and digital models are setting the stage for greater efficiencies across the board. The simplicity of the scan-to-lab process — with a faster fabrication process, no remakes or substandard pour-ups, no need to package models in boxes, and no potential damage or loss in transit — is transformational to the field of orthodontics. Clinicians who adopt this technology are likely to discontinue the use of traditional impression material in their practices altogether. OP

REFERENCES 1. Sinclair, PM. The Readers’ Corner. J Clin Orthod. 2016;L(10):635-636.

2. Patzelt SB, Lamprinos C, Stampf S, Att W. The time efficiency of intraoral scanners: an in vitro comparative study. J Am Dent Assoc. 2014;145(6):542-551.

3. Marsico M. Some things never change: inadequate impressions still labs’ biggest client headache. LMT Communications Inc. http://lmtmag.com/topics/digital_impressions?view=articles. Accessed Mar 26, 2015.

4. Hack GD, Patzelt SB. Evaluation of the accuracy of six intraoral scanning devices: an in-vitro. ADA Professional Product Review.

2015;10(4):1-5.

5. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Dept of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health; 2016.

Orthodontic practice 21

CONTINUING EDUCATION

Traditional stone models also put orthodontic practices in a unique position. While impressions may be safely destroyed, practices are obligated to store the stone models they create for a certain number of years past the patient’s age of majority. To calculate the actual cost of storing stone models, clinicians should consider cataloging time and space requirements. The effort required to categorize models, box them up, and move them to the designated storage area is typically not an efficient use of staff time. If the office is in a high-rent district where space is priced at a premium, storage can be very cost prohibitive. Instead, intraoral scanners can be used to digitize existing stone models.

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 V8.4 WAUGH REF: OP V8.4 MCDONOUGH

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; call 866-579-9496 to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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.

An analysis of the impact of intraoral scanners on the orthodontic practice WAUGH 1.

2.

3.

4.

5.

_________ was/were first used in dentistry in the late 1970s/early 1980s in Europe. a. Computer-aided design/computer-aided manufacturing (CAD/CAM) b. Traditional impressions c. Algorithms d. Appliance prescriptions for labs According to an informal survey conducted by the Journal of Clinical Orthodontics, ______ of respondents indicated they now use an intraoral scanner. a. 25% b. 42% c. 62% d. 80% Actual timesavings come from eliminating the additional steps associated with _____________. a. preparing for impressions/models b. working with impressions/models c. shipping traditional impressions/models to the lab d. all of the above Integration with other ___________ enables clinicians to quickly access the information they need with minimal clicks, further improving the treatment workflow. a. types of impression-taking technologies b. imaging equipment c. practice management software d. both b and c As many as ______ of the traditional impressions arriving at the lab are inadequate, due to a failure to follow guidelines and a lack of evaluating impressions before sending them to the lab. a. 10% b. 25%

22 Orthodontic practice

Congenitally missing mandibular premolars — treatment options for space closure MCDONOUGH

c. 37% d. 54% 6.

7.

8.

9.

The file format accepted (either .STL or .PLY) __________. a. varies from lab to lab b. is the same for each lab c. should be in a closed format d. should prohibit remote viewing The side-oriented tip is designed to make it easier to obtain buccal surface scans, and the tip height is generally ________ than the standard tips. a. less flexible b. equal to c. longer d. shorter The Centers for Disease Control (CDC) recommend that heat-tolerant semi-critical items in dentistry (items that come into contact with mucous membranes) be sterilized _________. a. by wiping with a disinfectant b. using flash sterilization c. using heat d. using cold sterilization When parents observe _________ — they may become advocates for the state-of-theart technology and the practice that uses it. a. the image acquisition process b. the resulting images c. how calm and cooperative their children are d. all of the above

10. A digital model is presentation-ready as soon as __________. a. the dentist fabricates it b. scanning is complete c. the model is received at the office d. it is poured up

1.

Unilateral agenesis has been reported to consist in up to _______ of the agenesis cases. a. 20% b. 30% c. 50% d. 60%

2.

Missing second premolars are more common in __________. a. the mandible than the maxilla b. the maxilla than the mandible c. females than in males d. males than in females

3.

4.

5.

6.

Since the introduction of _________, the unilateral space closure without other extractions has become more popular since the midline can be maintained while the space is closed. a. palatal bars b. temporary anchorage devices (TADs) c. Herbst appliances d. the U-shaped wire If the primary second molar is to be maintained, the goal is to maintain the tooth with the alveolar bone for __________. a. possible future implant b. prosthetic reconstruction c. easier future extraction d. both a and b It has been shown that if the primary molar is extracted prior to age 11, and the second molar has not erupted, about ______ of the space will be closed through “driftodontics” within 4 years, leaving a residual space of about 2 mm. a. 20% b. 30% c. 50% d. 80% These age differences between male and

female patients make prosthetic replacement _______ since it can often be completed prior to leaving for college or entering the workforce. a. more favorable in females b. more favorable in males c. equally as favorable in males and females d. equally as risky for males and females 7.

Due to the loss of ridge width, space maintainers are ________ after extraction of second primary molars due to decay or root resorption even if implants are planned. a. highly recommended b. not recommended c. the best treatment solution d. equally recommended as other treatment options

8.

If the primary molars have healthy roots ______, the decision may be made to maintain these teeth into adulthood — many case reports of primary posterior teeth surviving until the patient attains 40 to 60 years of age. a. with no carious lesions b. with no large restorations c. are not ankylosed d. all of the above

9.

Usually, third molars have their initial calcification at age 9 and would be considered missing only after age _____. a. 12 b. 14 c. 20 d. 25

10. In general, patients with minimal crowding, ______, or flat mandibular lanes may be best managed from nonextraction. a. deep overbites b. retrusive incisors c. decreased lower facial heights d. all of the above

Volume 8 Number 4

CE CREDITS

ORTHODONTIC PRACTICE CE

Dr. Mark W. McDonough discusses recognition and treatment planning for congenitally missing second premolars Introduction The orthodontist often identifies missing second premolars in the mixed dentition using routine panoramic radiographs. The early decisions that orthodontists make for the congenitally missing teeth often have an impact on dental health for the rest of their patient’s life. Therefore, this finding should result in a comprehensive set of diagnostic records in order to evaluate the patient in all three planes of space and establish a problem list and treatment alternatives.

These records often need to be shared with the restorative dentist and other specialists in order to consider all viable alternatives and formulate a proper treatment plan.

The clinician must make the proper decision at the appropriate time regarding the maintenance of the primary molar, the prosthetic replacement of the missing second premolar, or the closure of the space from the missing premolar.

The objectives of this review are to direct the orthodontist through a diagnostic sequence of recognizing and treatment planning for congenitally missing second premolars. The emphasis of this article is the most appropriate time and cost-effective way for closing the space for the missing premolar.

Three different methods of space closure will be highlighted.

Mark W. McDonough, DMD, has a Bachelor of Science in Biology from Fordham University in New York, New York, and a Doctorate of Dental Medicine from the University of Pennsylvania in Philadelphia. He completed his General Practice Residency at Lenox Hill Hospital in New York and Postgraduate Orthodontic Training at Albert Einstein Medical Center in Philadelphia. He is a board-certified orthodontist with the American Board of Orthodontics (ABO) and has earned the esteemed designation of Diplomate of the ABO. He has been a clinical instructor at Albert Einstein Medical Center in Philadelphia since 1995. He is also an active member of the following professional societies: Greater Philadelphia Society of Orthodontists (President 2016– 2017), Mercer Dental Society (President 2002–2003), Society of Educators for the American Association of Orthodontists (2013–present), American Association of Orthodontists, Middle Atlantic Society of Orthodontists, Pennsylvania Association of Orthodontists, New Jersey Association of Orthodontists, American Dental Association, and the New Jersey Dental Association. Dr. McDonough also has authored articles and is on the educational advisory board of Orthodontic Practice US.

Volume 8 Number 4

Educational aims and objectives

This article aims to direct the orthodontist through a diagnostic sequence of recognizing and treatment planning for congenitally missing second premolars.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 22 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize some diagnoses of missing mandibular premolars.

•

Realize some treatment options for mandibular premolars.

•

Identify critical factors to consider to avoid complications.

•

Identify three different methods of space closure from the case studies presented.

General concepts about missing mandibular premolars Diagnosis of missing mandibular premolars Congenitally missing mandibular second premolars are the second-most frequent type of agenesis, after the third molar, with an incidence of 2.5% to 5% of the population in the United States and Europe.1 Agenesis of the second premolars can usually be reliably diagnosed around age 9 on a panorex, but there have been reports in the literature of slow development of this tooth. AlexanderAbt2 reported a case of a 12-year-old female whose panoramic radiographs revealed apparent agenesis of tooth No. 20. The progress panorex 13 months later revealed initial crown formation of tooth No. 20. Unilateral agenesis has been reported to consist in up to 60% of the agenesis cases.3 Missing second premolars are more common in the mandible than the maxilla.

Treatment options Upon the diagnosis of agenesis, two main options are usually considered: extraction of the primary second molar or its maintenance in the arch. If the primary second molar is extracted, the goal is usually to mesialize the first permanent molar in conjunction with the orthodontic treatment. If the other three premolars can be extracted as well due to crowding or procumbent incisors, the agenesis is a minor finding. The

more complex problem is if the patient would not normally require extractions. Since the introduction of temporary anchorage devices (TADs), the unilateral space closure without other extractions has become more popular since the midline can be maintained while the space is closed. If the primary second molar is to be maintained, the goal is to maintain the tooth with the alveolar bone for possible future implant and prosthetic reconstruction.

Critical factors to consider 1. Dental and skeletal age of the patient Treatment to close the space before or close to the peak of the pubertal growth spurt will be more successful. Since definitive diagnosis of agenesis of the second premolar cannot be made until the patient is 9 years old, the question arises, When is it too late to close the space? It has been shown that if the primary molar is extracted prior to age 11, and the second molar has not erupted, about 80% of the space will be closed through “driftodontics” within 4 years, leaving a residual space of about 2 mm.4 2. Gender Female facial growth is generally complete around age 17 and males not until around age 21.5 It is important to note that these ages are averages, and it is always best to confirm cessation of vertical facial growth with annual Orthodontic practice 23

CONTINUING EDUCATION

Congenitally missing mandibular premolars — treatment options for space closure

CONTINUING EDUCATION serial cephalometric radiographs prior to there will be a more favorable bone for quadrant, which may be found in 48% of placement of implants. This is a critical the implant.6 This may result in longer patients.9 Usually, third molars have their role the orthodontist can provide to the orthodontic treatment time but a better initial calcification at age 9 and would be final result for the implant. interdisciplinary team since orthodontists considered missing only after age 14. are best able to evaluate cephalometric 5. Maintaining the primary second This also creates a treatment planning radiographs. These age differences molar Primary molars are shorter than dilemma in the mandibular arch since permanent molar crowns, and therefore between male and female patients make the decision to close the space may be prosthetic replacement more favorable in a marginal ridge discrepancy is to be made prior to definitive knowledge of the females since it can often be completed expected and is not an automatic indipresence of the third molar. If the space cation of ankylosis. If the primary molars prior to leaving for college or entering is closed in the mandibular arch, the the workforce. For male patients who have healthy roots with no carious lesions maxillary second molar may not have a are away at college, it is often difficult to or large restorations and are not ankyvertical stop if the mandibular third molar coordinate implant placement and proslosed, the decision may be made to is congenitally missing or does not erupt. thetic treatment. Many times, finances maintain these teeth into adulthood — 7. The overall malocclusion In general, are limited upon completion of college, many case reports of primary posterior patients with minimal crowding, deep and the patients are often no longer teeth surviving until the patient attains 40 overbites, retrusive incisors, decreased covered by their parents’ insurance, to 60 years of age.8 However, there is a lower facial heights, or flat mandiblack of long-term studies for the survival further limiting the ability to have costly ular planes may be best managed by prosthetic replacement. rate of retained primary molars from nonextraction. These patients should 3. Ankylosis of the primary second molar adolescence to adulthood. Maintaining maintain the primary molars for as long Percussion of the primary second molar the primary molar can create an anteroas possible. Patients with significant is often used to diagnose ankylosis, but posterior arch-length discrepancy since crowding, dental protrusion, minimal it can be inaccurate. The most reliable the primary molars are 2 mm-3 mm larger overbites or open bites, and increased method to diagnose primary molar ankythan their permanent successor and facial heights often benefit from extraction and space closure. losis is to evaluate the interproximal bone results in an “end-on” molar relationship 8. Cost considerations Orthodontics to when the canines are Class I. This has levels on a bitewing radiograph. Flat bone led to some clinicians to slenderize the levels between the primary molar and the close an edentulous premolar space is primary molar mesially and distally. The adjacent permanent teeth indicate the more cost-effective and is often more primary molar is erupting evenly with key is to remove sufficient tooth structure periodontally sound. When the space is the adjacent teeth. If there is an oblique to create space but not enough to cause closed, the patient incurs only the cost of angle, the primary tooth is ankylosed.6 pulpal necrosis. A bitewing radiograph is orthodontic treatment. When the space 4. The condition of the primary second useful to determine the width of the pulp is maintained, the patient incurs the cost horns. In general, 2 mm per side can be molar Root resorption of the primary of orthodontic treatment, possible preremoved resulting in a 7 mm-8mm-wide second molar or large restorations and/ prosthetic bone grafting, implant placeor decay often lead to the decision to tooth. It is recommended that light-cured ment, and prosthetic restoration costs. extract the primary second molar. Once composite be placed over the exposed Then there are the future costs of maintedentin to help minimize the risk of caries this decision is made to extract the nance of implants, which is much greater primary second molar, care should be to the narrowed primary molar.6 There than the cost of maintaining healthy taken during the extraction to maintain are no long-term studies to show the natural teeth. For the above reasons, longevity of narrowed primary molars, the cortical plates, especially in cases priority should be given to space closure treatment whenever possible. of ankylosis. Following extraction, it has but it has been observed that there is been shown that the ridge narrows by more root resorption following reduction, 25% during the first 4 years after extracand this method is recommended when Case Reports implant replacement is planned. tion and another 5% during the next The following three cases were chosen 6. Presence of third molars Unfortunately, 3 years for a total loss of 30% after 7 to highlight three different methods of space closure. They all presented with years. The authors also found that the agenesis of second premolars is often ridge narrows more on the buccal side associated with the absence of other different malocclusions but shared the diagthan the lingual side, resulting in a more teeth, especially third molars in the same nosis of congenitally missing mandibular lingual placement of the implant.7 second premolars.

Due to this loss of ridge width, space maintainers are not Case 1 recommended after extraction A 9-year 8-month-old female presented for an initial consultation. of second primary molars due to decay or root resorption even The panorex (Figure 1) revealed if implants are planned. The that the developing first premolars adjacent teeth will drift into the had resorbed the mesial root of the space and when the teeth are primary second molars on both sides uprighted for creating space for and ectopic eruption of the LL3 and the eventual implant, the ridge LL4. She had a Class I molar relaFigure 1: Case I pretreatment panorex reveals congenitally missing mandibular will largely be maintained, and tionship, deep bite, and mandibular premolars with root resorption of the primary molars 24 Orthodontic practice

Volume 8 Number 4

Therefore, for this patient the initial decision was easy.

Her progress records at 11 years 1 month reveal favorable space closure (Figure 3), but only mild mesial drift of the first molars with some deepening of the bite with increased overjet (Figure 4). The Phase II consultation with the parents and patient included both space closure and space opening treatment plans. Ultimately, the decision was made to close the space due to the parents’ desire not to have prosthetic replacements with the additional cost and time required for the “final result.” The goal was to utilize Class II elastics, and if there was poor cooperation with elastics, a Forsus™ appliance would be utilized.

The final result after 23 months of active treatment reveals a solid Class III molar with Class I canines and favorable facial esthetics (Figure 5). The patient wore Class II elastics

for 5 months, and the panorex (Figure 6) revealed that the mandibular third molars have a mesial angulation but a good chance to erupt. These patients understand that it is critical to wear their maxillary Essix retainers until the mandibular third molars erupt to prevent supraeruption of the maxillary second molars. The cephalometric superimpositions (Figure 7) from initial presentation at age 9 to deband at age 13 shows maintenance of the mandibular incisor angulation and favorable mandibular growth, which was beneficial to improving the facial esthetics. The 18-month posttreatment photographs (Figure 8) show excellent stability.

This patient demonstrates that space closure can be achieved with early extraction of the primary second molars (age 9 years 8 months), drifting of the adjacent permanent teeth into the edentulous area, and excellent cooperation with Class II elastics for 5 months.

Treatment to close the space before or close to the peak of the pubertal growth spurt will be more successful.

Figure 2: Case I pretreatment photographs

Figure 4: Case I progress photographs show favorable space closure with some deepening of the bite and increased overjet Volume 8 Number 4

Figure 3: Case I progress panorex after extraction of primary teeth

Figure 5: Case I final photographs reveal favorable space closure with improvement of the occlusion Orthodontic practice 25

CONTINUING EDUCATION

crowding (Figure 2). Full orthodontic records were completed with a Phase I case presentation. Since the long-term prognosis was poor for the primary molars, she was referred for extraction of the primary molars as well as the LLD to aid in the eruption of the ectopic LL3 and LL4. The LLC was maintained initially to help prevent shifting of the midline.

The LLC was eventually extracted once the premolars fully erupted. At the initial case presentation, it was decided to reevaluate once she entered into the adult dentition if the missing teeth would be prosthetically replaced or the spaces closed. The decision would be based on future skeletal growth as well as the amount of space closure that was achieved. Remember that if the spaces close from the extraction of the mandibular primary second molars, and the decision to open them for prosthetic replacement is eventually made, the ridge width will be much healthier.

CONTINUING EDUCATION

Figure 6: Case I final panorex shows good root parallelism in the area of the congenitally missing mandibular premolars

Figure 7: Case I cephalometric superimpositions from initial presentation at age 9 to the final result at age 13

Case 2 A 13-year 1-month-old male presented for the first time, and his panorex (Figure 9) revealed congenitally missing mandibular second premolars and maxillary third molars.

This is the most favorable combination of missing teeth for space closure. The retained primary molars had significant root resorption and were unlikely to be retained for very long.

He had a Class I malocclusion with procumbent maxillary and mandibular incisors with minimal overjet and overbite (Figure 10). Due to the obtuse nasolabial angle, it was decided that the goal would be to maintain the upper incisor position (no extractions in the maxillary arch). The case presentation reviewed the options of prosthetic replacement of the missing teeth with narrowing of the primary molars so the mandibular crowding could be relieved and eventual prosthetic replacement would take place around age 19-21 when facial growth had been completed. It was anticipated the primary molars would be lost during orthodontic treatment. This would

Figure 8: Case I 18-month posttreatment photographs show favorable stability

require fixed retention with a bonded heavy wire to maintain the space until growth is complete. The alternative plan was to extract the primary molars and protract the permanent molars into a Class III relationship. Given the high anchorage values of the mandibular molars and the relatively low anchorage of the incisors, there would be unfavorable lingual tipping and/or retraction of the incisors if conventional space closure was used.

Therefore, temporary anchorage devices (TADs) were proposed to aid in anchorage for mesial movement of the mandibular first and second molars. The family decided to close the space primarily due to the shorter total treatment time and overall less financial costs even with the additional cost for TADs. They understood that space closure in this type of patient often adds 6-8 months to the orthodontic treatment.

Six months into treatment, the TADs were placed

Figure 9: Case II pretreatment panorex reveals retained primary molars with root resorption 26 Orthodontic practice

between the L 3s and 4s (Figure 11) utilizing direct anchorage and sliding jigs to protract the first molars. These sliding jigs allow for a horizontal force to be applied to the molars through the approximate center of resistance which should result in faster space closure. However, the mechanical advantage seems to be negligible. A simpler set up of placing the TADs between the L 2s and 3s and utilizing indirect anchorage (Figure 12) seems to have less force on the TADs, which increases the percentage of TADs that survive to the end of treatment — this is my current preferred method of space closure.

Historically, TADs have an 80% survival rate with the indirect anchorage set up having a slightly higher percentage of success. It is important not to band the second molars until after all space closure is achieved since

Figure 10: Case II pretreatment photographs Volume 8 Number 4

Figure 12: An alternative method to close mandibular spaces using TADs with indirect anchorage. This method places less stress on the TADs

they will generally follow the first molars, and banding them would increase the anchorage and friction on the space closure system.

Even with the TADs, some minor increase in overjet was observed, and 5 months of sleep-time Class II elastics was necessary to achieve a full-cusp Class III molar with proper overjet.

After 24 months of treatment, the appliances were removed (Figure 13) with a solid Class III molar and Class I canine. The posttreatment panorex (Figure 14) revealed favorable development of the mandibular third molars with anticipation that they would erupt into occlusion. The cephalometric superimpositions (Figure 15) reveal no significant change in the mandibular incisal angulation with significant mesial movement of the mandibular molars.

Case 3 This patient presented at age 11 years 4 months of age with a full cusp Class II Division 2 malocclusion, incisal crowding, maxillary constriction, and congenitally missing mandibular second premolars (Figure 16 and 17). At the initial case presentation, it was decided to address the maxillary skeletal transverse deficiency first with a palatal expander and reevaluate the decision for the mandibular primary molars. The family was unable to commit to a preference of prosthetic replacement or space closure, and it was decided to consult with their restorative dentist and take progress records after expansion was completed. Seven months after the initial records, the family had discussed the treatment options with their restorative dentist, and the progress records revealed no significant skeletal change. The Volume 8 Number 4

Figure 13: Case II posttreatment photographs shows favorable occlusion and space closure in the mandibular arch

Figure 14: Case II posttreatment panorex reveals the mandibular third molars should erupt into occlusion

Figure 15: Cephalometric superimposition shows maintenance of the incisor angulation with significant mesial movement of the mandibular first molar

The decisions the orthodontist makes for these patients will have a lifetime impact on the patients’ dental health. family decided that space closure for the missing premolars was their first choice.

This option did not lend itself to utilizing TADs like the previous patient since there was a skeletal discrepancy and a deep bite.

A space-closing Herbst appliance (Figure 18) was utilized to protract the mandibular first molar, procline the maxillary incisors, and help open the bite. A space-closing Herbst utilizes stainless steel crowns on the U 6s and L 4s with bands on the L 6s. A lingual sheath on the L 6s slides along the lingual holding arch. Nitinol closed-coil springs are used on the buccal with elastic thread on the lingual to protract the molar in a bodily fashion. After 12 months of Herbst treatment, the spaces were closed, and the patient had full bands and brackets for 13 months to complete her treatment. She finished with locked-in Class III molars, favorable facial changes, and a solid Class III molar with Class I canines

(Figure 19). The panorex revealed favorable space closure with the third molars in a position to erupt (Figure 20). The cephalometric superimpositions revealed vertical changes with significant mesial movement of the mandibular first molar (Figure 21).

This patient had an extended treatment time due to the combination of skeletal discrepancies and a significant malocclusion with a lack of commitment to the decision to maintain or close the space at the initial treatment consultation. It demonstrated that patients and parents often need time to digest the problem list, and it is important to move forward with the initial step, which also allowed me to establish the patient’s level of cooperation. Clearly, this was the more complicated orthodontic plan as opposed to maintaining the primary molars, but it yielded the most benefit for the patient since no further treatment is necessary.

Orthodontic practice 27

CONTINUING EDUCATION

Figure 11: Case II method of space closure using TADs and direct anchorage to a sliding jig

CONTINUING EDUCATION

Figure 17: Case III pretreatment panorex shows congenitally missing mandibular second premolars

Figure 16: Case III pretreatment photographs reveals a Class II Division 2 malocclusion

Figure 18: This is the design of the space-closing Herbst appliance used to protract the mandibular first molars and procline the maxillary incisors

Figure 19: Case III posttreatment photographs shows favorable dental and facial changes since the initial presentation

Conclusions Congenitally missing mandibular second premolars are a common problem. The critical factors to consider in the decision to maintain the primary molar or close the space from the congenitally missing second premolar were reviewed. Maintenance of the primary molar is often appropriate if the tooth is not ankylosed, has good roots, and no decay or restorations. These teeth can often be maintained well into adulthood.

Three different methods of space closure were presented, and each patient achieved a healthy, functional, and esthetic outcome.

The key to each plan was that the lower incisor position was not compromised, and a solid Class III molar was achieved with a high probability that the mandibular third molar would erupt into occlusion. This type of treatment often takes longer than space maintenance, but the priority should be given to space closure treatment to maximize the overall periodontal health as well as the reduced overall long-term cost of treatment. The decisions the orthodontist makes for these patients will have a lifetime impact on the patients’ dental health. OP 28 Orthodontic practice

Figure 20: Case III posttreatment panorex reveals that the mandibular spaces were closed, and the mandibular third molars have a good chance of erupting

REFERENCES 1. Fines CD, Rebellato J, Saiar M. Congenitally missing second premolar: treatment outcome with orthodontic space closure. AM J Orthod Dentofacial Orthop.

2003;123(6) 676-682.

2. Alexander-Abt J. Apparent hypodontia: A case of misdiagnosis. Am J Orthod Dentofacial Orthop. 1999;116:321-323.

3. Vastardis H. The genetics of human tooth agenesis: new discoveries for understanding dental anomalies. Am J Orthod Dentofacial Orthop. 2000;117(6):650-656.

4. Mamopoulou A, Hagg U, ShrÓ§der U, Hansen K. Agenesis of mandibular second premolars. Spontaneous space closure after extraction therapy: a 4-year follow-up. Eur J Orthod. 1996; 18(6):589-600.

5. Fudalej P, Kokich VG, Leroux B. Determining the cessation

Figure 21: Case III cephalometric superimposition reveals the mandibular first molars were protracted significantly

of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants. Am J Orthod Dentofacial Orthop. 2007;131(suppl 4):59-67.

6. Kokich VG, Kokich VO. Congenitally missing mandibular second premolars: clinical options. Am J Orthod Dentofacial Orthop. 2006;130(4):437-444.

7. Ostler M, Kokich VG. Alveolar ridge changes in patients congenitally missing mandibular second premolars. J Prosthet Dent. 1994;71(2):144-149.

8. Zimmer B, Schelper I, Seifi-Shirvandeh N. Localized orthodontic space closure for unilateral aplasia of lower second premolars. Eur J Orthod. 2007;29(2):210-216.

9. Vastardis H. The genetics of human tooth agenesis: new discoveries for understanding dental anomalies. Am J Orthod Dentofacial Orthop. 2000;117(6):650-656.

Volume 8 Number 4

STEP-BY-STEP

Bye-bye cold air — say hello to comfort Dr. David A. Chenin discusses the advantages of an air-free handpiece

W

ith the excitement that their orthodontic treatment is complete, many patients dread the actual braces removal procedure. How can you make one simple change to revolutionize patients’ experience for braces removal? Don’t use a handpiece that expels ice-cold air on their teeth!

With traditional handpieces, this patient sensitivity is especially true in orthodontics, where the teeth are not anesthetized, have enlarged PDLs, and as a result, are more cold-air reactive with sensitivity from recent orthodontic tooth movement. Medidenta’s 90-degree handpiece does NOT expel air from the head of the handpiece. Instead, the air is directed out of the rear of the handpiece away from the patient. Thus, the Air-Free 90 degree has become my favorite handpiece ever.

It’s also important to note that this powerful titanium-coated handpiece is built rock solid and generates an ultra-smooth high-speed polishing action. As a result, vibrations on the tooth surface are eliminated making for a more comfortable experience as compared to traditional handpieces.

Here are some tips for using the Air-Free handpiece: • When removing adhesive/cement, use a short stroking movement while lifting up the bur and guiding it across the area with adhesive.

This allows the tooth to cool and is the single most important control factor to reduce any heat generated. Letting off the rheostat as you move from tooth to tooth is also very helpful.

• Avoid stone burs for complete removal of adhesive due to heat buildup.

• Less friction and heat is generated with carbide burs.

David A. Chenin, DDS, MSD, is a Diplomate of the American Board of Orthodontics, a member of the Schulman Study Group, and an Adjunct Orthodontic Faculty member at the University of the Pacific School of Dentistry.

Disclosure: Dr. Chenin is a beta test doctor for Medidenta and received no compensation for this article.

30 Orthodontic practice

Figure 1: When removing adhesive/cement, use a short stroking movement while lifting up the bur and guiding it across the area with adhesive

Significant time-saving has been seen during my braces removal appointments because of fewer pauses due to sensitivity issues. ...

Figure 2: Consider using fewer fluted carbide burs for the initial adhesive removal

• Consider using fewer fluted carbide burs for the initial adhesive removal (e.g., 12 fluted) and then using a higher fluted bur (e.g., 30 fluted carbide) gently across the upper anterior teeth as the last step to eliminate bur marks and to give high luster and shine.

• Know your bur design: Spiral flutes are designed to give a smoother finish and act as if they had more flutes. This tends to increase surface area/friction and generate a little more heat and remove adhesive a little more slowly. Straight fluted burs (compared to the same number of

flutes in a spiral fluting design) will remove the adhesive more quickly because of how the flutes are spaced apart and result in less heat generation and time-savings, but they do not have as smooth as a finish.

• To further control cold or heat, suction closer or farther from the tooth depending on patient feedback.

Significant time-saving has been seen during my braces removal appointments because of fewer pauses due to sensitivity issues, and a much better patient experience is the result. OP This information was provided by Medidenta.

Volume 8 Number 4

R

R

PRODUCT PROFILE

AcceleDent® Optima — what’s new in accelerated orthodontics What are the exciting features of AcceleDent Optima?

What led to the creation of the AcceleDent App?

AcceleDent® Optima is the first and only orthodontic device that directly connects patients and practices with usage monitoring, direct messaging, and virtual rewards via the state-of-the-art AcceleDent App. An FDA-cleared vibratory orthodontic device, AcceleDent Optima was designed with enhanced patient convenience in mind, so it is smaller, sleeker, and lighter than its predecessors, AcceleDent Aura and AcceleDent Classic. The device is also waterproof. Its Bluetooth® connectivity allows Optima to charge wirelessly and sync with the HIPAAcompliant app.

The development of the AcceleDent App was a natural innovation progression for OrthoAccel because it furthers the company’s commitment to enhancing the patient treatment experience, enabling orthodontists to achieve increased practice efficiency.

Having listened to feedback from patients and practices, we believe that the features of the app will encourage patients to remain engaged and motivated throughout treatment, which will also help them maintain optimal compliance.

Available via iTunes® and Google Play™, the easy-to-use AcceleDent App is similar to popular fitness tracking apps.

How does AcceleDent Optima compare to its predecessor AcceleDent Aura?

The third-generation vibratory accelerated orthodontic device from OrthoAccel®, AcceleDent Optima is powered by the same patented SoftPulse® Technology as AcceleDent Aura and AcceleDent Classic.

AcceleDent Optima produces pulsating forces clinically shown to stimulate cellular activity in orthodontic treatment and speed up bone remodeling.

When used for 20 minutes a day by patients, the prescription-only device speeds up treatment with braces or aligners by as much as 50% while reducing discomfort.

How will practices achieve increased efficiency with AcceleDent Optima?

Orthodontic practice staff can view real-time compliance data from each of their AcceleDent Optima patients via a web portal that is customized for each AcceleDent provider. This 24/7 access to compliance data enables clinical staff to make more informed scheduling decisions. For instance, an orthodontist who identifies a low-compliant patient can reschedule that appointment since it is unlikely that the patient has progressed to the stage of treatment predicted by the orthodontist. This opens up an appointment for other patients

AcceleDent Optima

and ultimately fosters more proactive case management for the practice.

While many practices have turned to social media to communicate with patients and to provide various types of reward programs that keep patients motivated throughout treatment, the AcceleDent App provides a streamlined, innovative solution.

Through the app’s “Achievements Screen,” patients can earn virtual awards, and through the “Message Board,” practice staff can securely send messages about compliance and scheduling or respond to patient questions.

What will likely interest patients the most about AcceleDent Optima?

AcceleDent Optima and the AcceleDent App are designed to help patients get the healthy, beautiful smile they want faster and with reduced discomfort. Compliance with the 20-minute daily routine is an important factor in patients achieving their desired treatment outcomes, so the ability to set reminder notifications, earn awards, and compare usage to other AcceleDent users helps keep patients on track and motivated.

Parents can also download the AcceleDent App to track their child’s usage and send reminder messages.

How can orthodontists and practice staff learn more about AcceleDent Optima?

Orthodontists interested in learning more about AcceleDent Optima can visit AcceleDent.com to watch an introductory video or call (866) 866-4919, option 1. OP AcceleDent App 32 Orthodontic practice

This information was provided by OrthoAccel®.

Volume 8 Number 4

Oral health professionals of all specialties are invited to take their practice to the next level at the 2017 Global Oral Health Summit.

This is a 2-day immersive learning experience designed for professionals looking to enhance their workflow by either learning more about the software and equipment they already have or by introducing new technology to their practice. The Summit, hosted by Carestream Dental, takes place November 10-12, 2017, in Orlando, Florida. In addition to courses geared toward tackling everyday challenges, discussing the latest industry trends, and exploring innovation in diagnostic techniques, Carestream Dental trainers will also lead hands-on courses specifically designed for CS OrthoTrac, CS PracticeWorks, CS SoftDent, CS WinOMS and imaging software. Whether they’re Carestream Dental technology users or not, the Summit is geared toward clinical and front office team members, endodontists, general dentists, oral and maxillofacial surgeons, orthodontists, pedodontists, periodontists, prosthodontists, and treatment coordinators. Courses will appeal to all learning levels, from new team members to seasoned professionals, with entry/intermediate and advanced courses. While there are specific tracks based on specialty, attendees are encouraged to pick and choose the courses that best fit their learning requirements and goals.

For more information, call 888-777-2072, or visit www.carestream.com.

Will Smith joins celebrity roll at Dentsply Sirona World Actor, musician, producer, and philanthropist Will Smith is joining the agenda at Denstply Sirona World. Regaling event attendees during a one-on-one interview led by Dr. Mike DiTolla, followed by an open Q&A with the audience, Smith is the perfect addition to this educational festival. You won’t want to miss this witty exchange between the pair on Thursday evening, September 14. Dentsply Sirona World, hosted at The Venetian and The Palazzo® in Las Vegas, September 14-16, combines premium education with exceptional entertainment.

Visit www.dentsplysironaworld.com to register to view the complete event agenda.

For additional information on Dentsply Sirona World 2017, contact the help desk by email at events@dentsplysironaworld.com or by phone at 1-844-462-7476.

Volume 8 Number 4

EVENT NEWS

Carestream Dental’s 2017 Global Oral Health Summit

We like to keep things simple.

This is a clear aligner.

It straightens teeth.

You can get as many (or as few) as you like for $95 plus $30 per aligner.

We call that Flex.

What could be simpler?

Unlimited, that’s what. $1495 covers all the aligners (and retainers) you want for five full years.

Treat any case, either way.

Your choice.

C L E A R C O R R E C T.C O M / F L E X Orthodontic practice 33

PRACTICE DEVELOPMENT

How social media can help your SEO performance Ian McNickle, MBA, discusses the impact of search engine optimization

B

y now most people are aware of social media and its prevalence in the world.

Over 70% of U.S. adults who are online use Facebook®, and around 30% use other popular channels such as Instagram®, Pinterest, Twitter®, and LinkedIn®. As I lecture around the country, one of the most common questions I encounter focuses on the actual benefits of social media for a practice.

Social media itself can have numerous benefits for a practice, but the focus of this article is on the impact of search engine optimization (SEO). SEO commonly refers to the set of activities that affect how a website will rank on Google® and the other search engines. Google looks at over 200 variables to determine how highly to rank a website for a given set of terms and geography.

Google says social media is not a ranking factor What is interesting about social media is that Google has stated that social media is not a ranking factor. However, many SEO agencies have done studies and found a high correlation with certain aspects of social media and search rankings. If you create interesting posts, and lots of people interact with your posts, then the shares create links back to your social media pages and to your website. Incoming links to your website are a well-known factor to help SEO rankings.

In the dental industry, the most important social media channel is clearly Facebook due to its large audience and useful business tools (boosted posts, geo-targeted ads, and engagement dashboard). A well-designed Facebook campaign would include a large percentage of “personal”-type posts, which highlight the personality and human side of the practice.

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 Online Marketing and Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@weomedia.com, or by calling 888-246-6906. For more information, you can visit online at www.weodental.com.

34 Orthodontic practice

For example, let’s say it’s Sally’s birthday, and you’re all in the break room having some birthday cake. Someone feeds Sally a piece of cake and smears it on her face.

Everyone laughs! Since you caught this on video with your phone, you can easily post it to your practice Facebook page. This type of post will generate FAR more engagement (and potential SEO benefit) than your clinical posts. While you should have clinical topic-type posts, please remember the personal posts will generate much more engagement.

The key is to create frequent and interesting content on Facebook in order to generate positive SEO benefit.

What about YouTube While most people understand Google is the largest overall search engine, many find it surprising to learn YouTube is the second largest search engine. The major difference is, of course, people searching on Google are in “research/buying” mode, whereas searchers on YouTube are in “social” mode.

This means despite the massive search volume on YouTube, people are not using YouTube to search for a dentist or specialist.

So how does YouTube help with SEO? The best strategy for using YouTube is to create a series of videos that are hosted on YouTube and also reside on other online

properties such as your website, Facebook page, etc. Google and other search engines look at videos as high-quality content (assuming they are properly optimized with a title and description). Therefore, embedding videos into your website should help the website SEO and search rankings.

Since Google purchased YouTube years ago, Google has integrated YouTube videos into their search results. Let’s say you have 10 videos on your YouTube channel. If you properly optimize these video titles and descriptions, then there is a chance some of these videos can appear in search results just like your website. This essentially multiplies your online presence.

While there are many aspects of social media that can help your online marketing efforts, we highly recommend posting frequent, interesting content on Facebook, and leveraging videos on YouTube, Facebook, and your website. These simple strategies can yield nice results indeed.

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 Volume 8 Number 4

It’s More Than Our Chair.

It’s Our Promise To You. We know that the future of orthodontics rests solidly in the skilled, talented hands of orthodontists like you who provide the compassionate, trusted, advanced care their patients deserve.

That’s why our promise is to

craft every Boyd chair to be worthy of all that you stand for. And we honor our promise by using the finest materials, making our chairs affordable, building each one in our own factory in the US, further ensuring its durability with the most rigorous quality control, while giving you the highest level of customization.

And all this is accomplished by Boyd craftsmen

who are as committed to excellence — and to the future of orthodontics — as you are.

Exam and Treatment Chairs, Delivery Systems, Doctor and Assistant Seating, LED Exam Lights, Custom Sterilization Centers and Video Game Consoles.

Built to last.

Built for you.

Built by Boyd.

800-255-2693 727-561-9292 Fax: 727-561-9393

www.boydindustries.com

Boyd Industries 12900 44th Street N, Clearwater, FL 33762 © BOYD INDUSTRIES 2017

1957 – 2017

BOOK REVIEW

Aligner Orthodontics: Diagnosis, Biomechanics, Planning and Treatment Werner Schupp, Julia Haubrich with contributions from Wolfgang Boisserée, John Morton, and Kenji Ojima Quintessence Publishing Co., Chicago, Illinois

T

he authors of this volume on orthodontic aligner therapy have no interest in promoting or proving the scientific basis for the treatments they display; rather they simply want to offer assistance to clinicians with the diagnosis, treatment planning, and therapy with these appliances.

The diagnostic chapter presents detailed illustrations of the authors’ diagnostic

regimen, which includes a thorough examination of the craniomandibular system (CMS) and musculoskeletal system (MSS). This involves the inflexible use of centric relation as a starting point for subsequent diagnostic decisions and the use of mounted models to simulate findings in the mouth.

The chapter on biomechanics of aligner therapy offers only the most rudimentary

advice and is the only chapter totally approved

by Invisalign® (Align Technology, Inc.) It illustrates with clear images how clinicians can apply the SmartForce® attachments and offers the theory behind this important addition to the aligner armamentarium.

The book has only five chapters. The first three chapters occupy only 41 pages, while the fourth and most clinical of the book takes up 301 of the 368 pages. This significant chapter displays aligner treatments of various malocclusions. If you think that aligner therapy mainly corrects rotated incisors, then the offerings of this principal section should completely disabuse you of that simplistic notion. The authors show treatments of open bites, closed bites, Cl II malocclusions, Cl III malocclusions, treatments with periodontally challenged patients, craniomandibular dysfunctions, asymmetric occlusions, and so on.

The authors have not supplied any posttreatment cephalometric superimpositions, so readers have no idea how the teeth have responded, but they have provided ample and matchless photographs before, during, and after treatments.

Neither have the authors given more than a partial page of bibliographic references, but they have introduced this tome as a clinician’s guide and not as a researcher’s manual.

The publication has all of the expected virtues of the Quintessence Publishing Co. with thick durable pages, unsurpassed images, and attractive page layouts. The narratives are succinct yet clear and to the point. The abundant photographs make this an easy book to consult for specific malocclusions amenable to aligner therapy, and one that clinicians should have at the ready. OP Review by Dr. Larry White

36 Orthodontic practice

Volume 8 Number 4

20 WATTS SUPER-PULSED

POWER CHARRING

TISSUE TAG

TISSUE PULLING

Traditional Diode Laser

Gemini Diode Laser

1 Watt Average Power, 400 micron fiber, Robotically Controlled Speed

800.552.5512 | ultradent.com © 2017 Ultradent Products, Inc. All Rights Reserved.

SMALL TALK

Leading through change Dr. Joel C. Small discusses methods for orderly and peaceful change

L

eading our staff through periods of change and uncertainty is one of the most critical roles for us as leaders. We must recognize that not everyone is comfortable with change and that which we may perceive as minor change may be viewed as a major upheaval for certain members of our team. It is important that we introduce new and different ideas or processes in a manner that reduces staff concerns and ultimately staff pushback. Here are a few tips that may assist you in bringing about orderly and peaceful change within your practice.

1. Develop trust The essential key element necessary for voluntary change to occur is trust. Unfortunately, trust takes time to develop. New practitioners, especially those who have purchased a mature practice, should avoid the fatal mistake of introducing significant change within the practice before establishing a bond of trust with the staff. This scenario will often lead to failure, frustration, and potential loss of staff.

2. Speak with one voice The entire leadership team must be unified in their support of change. For solo practitioners, this is a simple task, but when a practice manager or other doctors are involved, it is imperative that all key players present a common message in support of the suggested change. Division among the leadership team will send a negative and confusing message to the staff.

3. Be perfectly clear

Nothing incites confusion, concern, and pushback more than poor communication about a desired change. In the absence of

“Progress is impossible without change, and those who cannot change their minds cannot change anything.”

— George Bernard Shaw

clarity, the staff members are left to draw their own conclusions about the nature of change and its impact on them. Unfortunately, when this lack of clarity occurs, the staff is more likely to assume the worst possible scenarios regarding the desired change.

4. Present the vision If we expect change to occur, we better have a clear vision of what the change will look like once it is implemented, and we need to be able to communicate the vision so that it is shared by our staff. Included in a well-presented vision is an explanation of why change is necessary, what will need to change for the vision to become reality, and how the change will benefit the practice and staff.

5. Seek out early adopters It is important to identify those staff members who are not threatened by change and can buy in to the vision and necessary change early in the process. These staff members will have a calming and reassuring effect on the more skeptical and uncertain members of the team. We must let these early adopters know how much their support means to us and how important their input is to achieving the overall vision.

Joel C. Small, DDS, MBA, ACC, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. **To receive a free copy of my “Core Values Exercise,” please contact me at joel@joelsmall.com. I am also available for a complimentary coaching session to discuss your practice-related issues.

38 Orthodontic practice

6. Engage the staff For those of us who have seasoned veterans for staff, we simply need to define the desired result and allow the staff to determine the process for achieving the result. This technique encourages maximum buy-in by the staff because by using their own creativity and resourcefulness, they feel more relevant and essential in facilitating the change and making the vision a reality. With less seasoned staff, we may need to play a bigger role in defining the process, but we should always allow the staff to provide feedback and feel like they are vital to the process.

7. Be patient and supportive Taking a supportive role is essential for our staff during a time of change. Change does not occur spontaneously or without potential issues in a healthcare practice.

By accepting that there will be a learning curve and by making allowances for inevitable mistakes and miscues, we create a psychology safe environment for our staff, and they will be more willing to contribute their feedback and best efforts toward making the vision a reality.

Finally, we must always remember that change is inevitable and necessary, yet change also presents a degree of uneasiness as we move beyond our familiar comfort zone toward an unfamiliar future we have yet to experience. Knowing how to guide our staff through what may be a difficult journey for them will ultimately solidify our position as leaders and provide them with the security they desperately need throughout the change process. OP

Volume 8 Number 4

CUSTOM CLASS II FIXED APPLIANCES

Specialty’s M4™ MiniScope® Herbst is known for durability and patient comfort. The compact design offers room for orthodontic bracket therapy while simultaneously correcting the class II malocclusion. M4 also delivers the greatest range of motion, allowing 40 degrees of lateral movement and a maximum incisal opening of 64mm.

Request Applecore Screws for any herbst design and we will provide them at no additional charge!

Specialty’s custom M.A.R.A. is a simple and predictable appliance for mandibular advancement on class II patients.

The appliance is attached to the first molars, or the deciduous second molars, with crowns or Specialty’s ROC crowns.

Adjustments are achieved by adding shims and/or bending the removable upper elbow. Expansion can be incorporated into each arch as needed.

Specialty Appliances is a full service orthodontic laboratory, manufacturing more than 250 premier products.

800.522.4636 • SpecialtyAppliances.com 4905 Hammond Industrial Drive, Suite J • Cumming • Georgia 30041

INDUSTRY NEWS MicroRNA study earns funding Dr. Phimon Atsawasuwan, Assistant Professor, Orthodontics, and his collaborator, Dr. Xiaofeng Zhou, Associate Professor, Periodontics, both University of Illinois at Chicago College of Dentistry, have earned $30,000 in a Biomedical Research Award from the American Association of Orthodontists for their study, “Roles of Secretory miRNA-21 and -29 during Orthodontic Tooth Movement.”

Dr. Jaleena Fischer Jessop appointed Ultradent’s Director of Clinical Affairs

Dentsply Sirona expands and extends relationship with Pacific Dental Services, LLC The Dental Solutions Company™ announced that the Company has again extended and expanded its relationship with Pacific Dental Services, LLC (PDS). The new, larger 5-year agreement between Dentsply Sirona and PDS will provide PDS and the more than 1,600 dentists they support with access to new technologies, and unique marketing, sponsorship, and training opportunities, in addition to the entire Dentsply Sirona consumables offering. In 2012, the two companies set an industry record that resulted in CEREC® CAD/CAM technology being integrated into every PDSsupported practice. The latest agreement continues providing PDSsupported practices with leading Dentsply Sirona equipment and technology such as CEREC and the entire consumables portfolio.

PDS supports over 580 dental practices in 17 states.

For more information, contact www.dentsplysirona.com.

Ultradent Products, Inc., a global manufacturer and distributor of dental materials and equipment, announced the appointment of Dr. Jaleena Fischer Jessop as the company’s Director of Clinical Affairs. As the Director of Clinical Affairs, Dr. Jessop, a practicing dentist, will oversee all phases of product development to ensure that the clinician’s point of view is considered in every aspect. Additionally, Dr. Jessop will head a new clinical team at Ultradent that will work with other departments to ensure clinical input and accuracy in every area of the company. Dr. Jessop will also continue to work in her dental practice 3 days a week, applying her hands-on clinical experience to her work at Ultradent.

Dr. Jessop began her undergraduate work at the University of Utah, studying medical biology prior to attending dental school.

She then went on to graduate with honors in oral surgery from Loma Linda University School of Dentistry in 2002. She later completed a 2-year certification for straight-wire orthodontics from the American Orthodontic Society. Dr. Jessop has served for 2 years on the Utah Dental Association board and has served for 3 years on the national advisory board at the University of Utah Dental School. She also currently works as an adjunct professor at the University of Utah Dental School.

For more information, call 800-552-5512, or visit ultradent.com.

Satish Hemachandran named Carestream Dental’s new general manager of practice management software CONFADENT Oral Health Care and Global Dental Relief announce joint venture CONFADENT Oral Technology and Global Dental Relief (GDR) announced a new, 3-year commitment to provide much needed preventive fluoride treatments to children around the globe. GDR provides first-time and ongoing dental care to children who otherwise lack the access or resources for care. The partnership will allow GDR to provide 1,000 fluoride treatments to children each year. With CONFADENT’s 3-year commitment, GDR can plan its budget, continuing to grow and expand services to the communities in which they are active, including Nepal, India, Guatemala, Kenya, and Cambodia.

For more information, visit confadent.com.

40 Orthodontic practice

Carestream Dental is pleased to announce that Satish Hemachandran has accepted the position of general manager of its practice management software business. In this role, he will be responsible for the overall strategy, resource allocation, operational execution, and customer experience for dental practice management solutions (DPMS). As part of Carestream Dental’s initiatives this year, Hemachandran will lead the software business as it delivers meaningful enhancements and resources for users with quicker turnaround time. The recently launched EMR Elite module for CS WinOMS v 9.0 is an example of one such enhancement, with more to come throughout the year.

For more information, call 800-944-6365, or visit www. carestreamdental.com.

Volume 8 Number 4

The Most Advanced Progression In Passive Self-Ligation Efficiency Design elements that benefit today’s practicing Orthodontist most:

CONVENIENCE THROUGH

M I DAT L A N T I C O R T H O.C O M 800-255-3525

Reduced Slot Dimension (.020X.026) for increased control over torques and rotations through all working and finishing phases of treatment

No Drop Pins Needed

as FiT.20 Hooks are integral to the bracket structure itself

FiT.20 Has A ‘Reciprocal’ Clip Mechanism reducing the amount of force and stress upon the tooth itself when opening

FiT.20 Clip Opens Occlussally

reducing premature clip opening due to directional chewing forces

True Twin Tie Wing Undercuts

easily accommodates Ties and Chain

Compatible With A Broader Array Of Wires

from square sizes to FiT.20 extra broad archforms for full treatment expression

Mechanical Locking Base for consistently reliable bonds

The FiT.20 System is a solution long overdue for both .018 and .022 users alike as it compensates for variable programming and tolerances so you don’t have to. It is the biggest leap forward in 3D Control and Full Expression to date.

Dr. Robert “Tito” Norris BOARD CERTIFIED ORTHODONTIST AND FIT.20 DESIGNER

Aquarium 3 ©

Patient education software

Third Molar Extraction (Full Boney Impaction)

Maxillary Advancement with Mandibular

Total Arch Restoration

TAD Two Arch Protraction Plate

Aquarium Intuitive Interface • Stunning 3D Movies • Comprehensive Library • Network-Ready In addition to orthodontic and pediatric content, Dolphin’s patient education software contains nearly 100 movies focused on oral surgery topics. Use its clinically accurate, 3D animated full-motion videos to demonstrate surgical procedures such as block bone graft, sinus lift, implants, maxillofacial surgery, and more. Surgery content is developed under the guidance of Board Certified oral and maxillofacial surgeons. Aquarium works beautifully on all monitor sizes and resolutions. To learn more, visit www.dolphinimaging.com/aquariumopus.

Management

Imaging

3D

Aquarium

©

© 2017 Patterson Dental Supply, Inc. All rights reserved.