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clinical articles • management advice • practice profiles • technology reviews September/October 2017 – Vol 8 No 5


ON PAGE 1 & 17


Dr. Payam Ataii

A comparative review of mandibular advancement devices and continuous positive airway pressure

Digital workflow allows for strategic approach Dr. Robert Waugh




Drs. George J. Cisneros and Oliver F. Nicolay with Benjamin J. Goldstein


Addressing sleep disorders with combination therapy

Featured Damon patients treated by Dr. Todd Bovenizer.

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


hen we began our careers as orthodontists 30 years ago, it was challenging to treat cases that presented with difficult tooth movements predictably. Additionally, these cases took several years to finish and often required the use of heavy mechanics and forces. Now with so many advancements in our profession, we’re achieving quality finishes that match our predicted outcomes faster and more comfortably. While there are still some orthodontists who may not be as confident treating these difficult cases, we are positive that understanding and utilizing new technologies increase our clinical efficiency. We know every orthodontist wants only what is best for his/her patients, so we encourage our peers to do as we did and explore continuing education opportunities that show how technology can help approach difficult cases in a more efficient manner. For instance, after being exposed to the technology, attending lectures, and reviewing many clinical cases a few years ago, we began offering AcceleDent® at our respective practices, OP Smiles and Sellers Orthodontics. Patients at Sellers Orthodontics and OP Smiles are treated with either clear aligners or Ormco’s Damon® self-ligating brackets and with AcceleDent, and we feel these tools can help us treat cases confidently regardless of difficulty. Clinically proven to safely and effectively accelerate tooth movement and reduce discomfort, FDA-cleared AcceleDent enables orthodontists to treat severe rotations, crossbites, blocked canines, high cuspids, and other difficult movements because of the added precision and predictability it offers. At OP Smiles, many patients are completing treatment in 8 or 9 months, up to 50% faster than initially planned. The vibratory action of AcceleDent’s SoftPulse Technology® allows the archwires in the self-ligating bracket to be expressed more efficiently, especially those with the more complicated movements. This allows progressing through wire changes faster, yet comfortably, expediting treatment completion — something patients and doctors greatly appreciate! We’ve encountered patients who have been previously denied aligner therapy by other orthodontists because they presented as a difficult-to-treat Class II or Class III. There are actually very few cases that can’t be treated with aligners. In fact, it’s often more appropriate to treat an open bite case with aligners because they give more vertical control than braces. With AcceleDent and a 4-day tray change protocol, nearly all aligner patients at Sellers Orthodontics complete treatment within 12 months. Patient satisfaction is important to us, but so is quality and proficiency. We both lecture frequently at study clubs, universities, and various conferences, showing remarkable cases with results that sometimes surprise our peers. The lesson that we convey through our case studies and lectures is the importance of continuing education as well as practicing and studying clinical cases from our peers. Our treatment philosophy is to deliver quality clinical results while providing a more desirable treatment experience for patients. The clinical advantages of AcceleDent, along with the patient benefits, enable us to exceed these goals. To review our accelerated case studies that demonstrate precision and predictability when treating difficult cases, visit

Drs. Michael Mayhew and Keith T. Sellers

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 5

Michael Mayhew, DDS, MS, is a partner with Dr. Scheffler of OP Smiles in Boone, North Carolina. The first to be dual trained and board certified practicing both pediatric dentistry and orthodontics in North Carolina, Dr. Mayhew is a member of the American Association of Orthodontists, the American Academy of Pediatric Dentistry, and several other dental organizations. Keith T. Sellers, DDS, MS, is the owner of Sellers Orthodontics in Charlotte, North Carolina. An Invisalign® Top 1% Provider, Dr. Sellers is a member of the Schulman Study Group, the Progressive Study Club, and the Damon Study Club. He spends 50 to 100 hours each year in continuing education and lectures several times a year to various orthodontic and dental groups. Disclosures: Dr. Mayhew serves with Ormco’s speaker bureau for national and international symposiums. Drs. Mayhew and Sellers have no financial interest in AcceleDent® and received no compensation for writing this introduction.

Orthodontic practice 1


September/October 2017 - Volume 8 Number 5

Difficult tooth movements: achieving quality results efficiently and effectively


Case study Going for the goal: Digital workflow allows for strategic approach to bring in impacted canines


Industry Awards Cellerant “Best of Class” Technology Awards 2017 .......................................................22

Dr. Robert Waugh discusses how a digital workflow yielded positive results for a teenage girl

Continuing education A comparative review of mandibular advancement devices and continuous positive airway pressure in patients with mild to moderate obstructive sleep apnea

Case study


Rapid, nonsurgical open-bite closure with a passive self-ligating bracket system using a differential bonding technique Drs. Michael Choy and John Burnheimer discuss closing a patient’s severe anterior open bite in 4 months

Drs. George J. Cisneros and Oliver F. Nicolay together with Benjamin J. Goldstein compare the efficacy of oral appliance therapy and CPAP therapy ....................................................... 24

ON THE COVER Cover photo courtesy of Dr. Payam Ataii. Article begins on page 29.

2 Orthodontic practice

Volume 8 Number 5

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Continuing education



Addressing sleep disorders with combination therapy: clear aligners and sleep appliance therapy

The perception of orthodontists and laypeople on the esthetics of teeth treated with Icon® resin infiltration for the resolution of white spot lesions after the removal of fixed orthodontic appliances

Book review

Drs. Helena Kilic, Daniel J. Rinchuse, and Thomas Zullo describe a study on the effectiveness of Icon in the resolution of white spot lesions........ 34

Dr. Payam Ataii discusses a sleep appliance specifically designed to be used in conjunction with clear aligners

Orthodontic and Surgical Management of Impacted Teeth Vincent G. Kokich, DDS, MSD, and David P. Mathews, DDS. Quintessence Publishing Co., Chicago, Illinois .......................................................44

Industry news...............46 Materials & equipment.........................47 Practice development SEO: Scam or critical marketing service? Part 1 Ian McNickle, MBA, defines SEO and discusses its importance.................42

Small talk What we don’t know continues to hurt us Dr. Joel C. Small discusses selfawareness and motivation to change .......................................................48

PUBLISHER | Lisa Moler Email: EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: ASSISTANT EDITOR | Elizabeth Romanek Email: NATIONAL SALES DIRECTOR | Kristin Sammarco Email: NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: FRONT OFFICE MANAGER | Terri Burud Email: MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 | SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

4 Orthodontic practice

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Volume 8 Number 5


Going for the goal: Digital workflow allows for strategic approach to bring in impacted canines Dr. Robert Waugh discusses how a digital workflow yielded positive results for a teenage girl


hen the goalie on my daughter’s soccer team presented for an exam at my orthodontic practice, my heart sank when I realized she had retained her primary maxillary canines. “MK,” a 12-year-old female, first came to me on January 18, 2014. As the granddaughter of a dental office manager, she had been followed for years by the general practitioner her grandmother worked for. However, the GP had not taken

a current panoramic image in 5 years and had somehow missed that MK still retained her primary maxillary canines although all her other teeth were permanent. To me, it was clear what we were facing: Impaction. Cephalometric and panoramic radiographs were taken using a Carestream Dental multi-modality imaging system. Two visible knots in the palate confirmed sector 4 impaction of the bilateral maxillary canines.

Figures 2 and 3: Initial clinical exam

Figure 1: Initial clinical exam

Figure 4: Initial ceph

Figure 5: Initial pano Dr. Robert Waugh has practiced orthodontics full time in Athens, Georgia, since 1989 and is also an assistant professor at the Dental College of Georgia’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 advanced modalities in hygiene, patient scheduling, treatment delivery, and more. Dr. Waugh graduated from the Medical College of Georgia School of Dentistry in 1987 with both a DMD and a master’s in oral biology and was elected to OKU dentistry’s honor society. He earned his orthodontic certification and a second master’s degree at Baylor University in 1989. In 2000, he was board-certified 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 and American Colleges of Dentists.

Figures 6 and 7: CBCT scans 6 Orthodontic practice

Volume 8 Number 5

Hybrid treatment: How everything works together Peter Kierl, DDS, MS Edmond, OK

A suresmile case study:

Jeff Johnson, DDS, MS

What’s in a smile arc? elemetrix Advanced Diagnostics and Appliance Design built on suresmile technology

A digital lingual day with Dr. Alex Yusupov A consulting opinion Digital orthodontics is changing everything Louis G. Chmura DDS, MS

ISSUE 4 | Summer 2017

to be sure.

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

Treating an asymmetrical class II case with suresmile


Figure 8: Digital impression

Figure 10: Digital separation performed by lab

Figures 12 and 13: Delivery of TPA taken March 2015

Figure 14: CBCT scan of UL1 taken June 2015 8 Orthodontic practice

Figure 9: Lab prescription

Figure 11: Duplicated in stone for fabrication

Further examination revealed short roots on her upper central incisors and external root resorption of the upper lateral incisors as well. The resorption was so great; I was concerned she’d lose her front teeth, which would be mortifying for anyone but even more so for a preteen girl. A cone beam computed tomography (CBCT) scan was ordered using the Carestream Dental imaging system to confirm the advanced resorption. As the scans were manipulated in 3D, the tomographic cuts confirmed resorption on the central incisors, but also lingual resorption on the roots of the laterals. The crown-to-root ratio on the centrals was less than 1:1. Only a millimeter existed between the canine and the pulp on the lingual of the upper laterals. It was amazing that she wasn’t experiencing any symptoms. The CBCT scan clearly showed the canines on the palatal side, with no indication of proper eruption any time soon. Therefore, exposing the permanent canines became a top priority to slow the resorption. Unfortunately, based on the radiographs, there was no room to use braces to move the teeth to make way for the permanent canines. The CBCT scan also showed the existing bone was so thin that the palatal teeth had forced the permanent incisors into a forward position. This case required careful strategy for how to best bring the teeth in. Since there was no room for braces on the canines, an auxiliary appliance would be needed to bring the canines in lingually, away from the other teeth. A digital impression was captured using a Carestream Dental intraoral scanner. Specialty Appliances would handle digital separation, so the patient was able to be scanned without placing spacers. The digital impressions were then sent to Specialty Appliances for fabrication of a modified transpalatal arch (TPA) with mesial extensions. These arms would attach to the canines once they were

Figure 15: CBCT scan of UL2 taken June 2015 Volume 8 Number 5



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Figure 16: CBCT scan of UR1 taken June 2015

Figure 17: CBCT scan of UR2 taken June 2015

Figure 18: July 2015

Figure 19: August 2015

Figure 20: October 2015

Figure 21: December 2015

Figure 22: January 2016

Figure 23: May 2016

exposed to draw them away from the front teeth to both cease the chemical signal triggering the resorption and also allow for the future placement of brackets. Once the TPA was received from the lab, the canines were exposed and the appliance placed (Figures 12 and 13). After 3 months, a second CBCT scan was taken to document the movement of the teeth and check on the resorption. Fortunately, there was no further resorption. The appliance was allowed to move the teeth for a total of 5 months. The teeth moved a distance of 3 mm, allowing us

to place her braces (Clarity™ ADVANCED, 3M) and have the primary canines removed. MK finished treatment in September 2017. Rarely do we see an orthodontic emergency that has to be treated immediately. However, in this particular case, each step of the clinical exam confirmed my fears and gave an even greater sense of urgency. Fortunately, following a digital workflow allowed me to plan and work quickly. Digital radiography confirmed the need for quick action and allowed for a strategy and design for bringing in the impacted canines. Most significant in this case was the ability to quickly and easily communicate with the lab to fabricate the modified TPA. Since Specialty

Figure 24: June 2016

10 Orthodontic practice

Volume 8 Number 5

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Figure 25: May progress pano

Figure 26: June 2016

Appliances was able to segment the teeth as part of the digital setup and move them with a virtual spacer, it meant the patient did not need to come in for a third appointment to fit spacers. In addition to quicker turnaround times, submitting digital impressions led to a more accurate fit of the appliance, so that we could begin treatment sooner without concerns about refits. The end result was a more predictable outcome — delivered at a critical time in this young patient’s life. OP Figure 27: Final

Figure 28: Final

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Rapid, nonsurgical open-bite closure with a passive self-ligating bracket system using a differential bonding technique Drs. Michael Choy and John Burnheimer discuss closing a patient’s severe anterior open bite in 4 months Abstract An 8-mm anterior open bite in an 18-year-old man was closed in 4 months by means of a passive self-ligating system using a differential bonding technique without extractions, surgery, miniscrews, or multiloop archwires. Ideal overjet and overbite of the anterior teeth were created, and an Angle Class I molar relationship was preserved. A functional occlusion was obtained, a consonant smile arc was created, and an acceptable gingival display was achieved.

Clinical relevance This severe 8-mm anterior open bite was closed in 4 months’ time.

Objectives statement The reader should understand the clinical advantages of the Damon® System in closing anterior open bite malocclusions.

Introduction One of the most difficult malocclusions to treat is anterior open bite (AOB) malocclusion, defined as a lack of vertical overlap between the maxillary and mandibular incisors. It can be classified as either primarily dental or skeletal with a prevalence that varies between ethnic and age groups.1,2 Like many orthodontic problems, open bite malocclusion is multifactorial. Individuals with skeletal AOB generally present with many common cephalometric values — such as increased gonial, mandibular, and occlusal plane angles — and common facial features — such as increased lower anterior facial height (LAFH) and noticeable lip strain.3,4 Due to its multifactorial etiology and high Michael Choy, DDS, is in private practice in Dallas, Texas. John Burnheimer, DMD, MS, is an Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, University of Pittsburgh, Pennsylvania. Disclosure: Drs. Burnheimer and Choy have no financial interest in the Damon® System.

14 Orthodontic practice

Figure 1: Pretreatment photographs

tendency to relapse, skeletal AOB in adults is regarded as one of the most challenging malocclusions to treat.1,5 In the past, extractions for adult patients were often prescribed to allow the orthodontists to obtain bite closure by combining incisor extrusion (or uprighting) and molar intrusion, ideally obtaining a counterclockwise rotation of the mandible.1 More recently, non-extraction therapy with multiloop archwires has been reported to intrude posterior teeth while extruding the anteriors. This seems to produce dramatic dental changes without significant changes in the skeletal pattern.6 However, for nongrowing patients, Carano, et al.,7 describe rapid molar intrusion (RMI) and obtained significant skeletal changes. Another common approach that has been used in the past few years is skeletal

anchorage devices such as miniscrews or miniplates.8,9 Both these therapies can be used for molar intrusion and often dental and skeletal changes take place.9-11 Posterior buildups are also an effective option, which can intrude and control eruption of the posterior teeth.12 Finally, orthognathic surgery for correcting AOB malocclusion commonly consists of performing a LeFort I osteotomy and, in some cases, mandibular ramus osteotomy, thereby repositioning the maxilla and allowing the counterclockwise rotation of the mandible.13 Even though most of the aforementioned treatments are successful, the amount of time to close the open bite varies considerably. In this case report, we introduce the use of a passive self-ligating bracket system with differential bonding technique to close an Volume 8 Number 5

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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.


CASE STUDY 18-year-old male’s severe anterior open bite in four months without extractions, surgery, skeletal anchorage, or multiloop archwires.

Diagnosis and etiology The patient was an 18-year-old male with chief complaints of anterior open bite. The patient’s medical history was unremarkable. He admitted to a habit of tongue thrusting; however, lips were competent. A convex profile due to a retrognathic mandible was noted. A shallow labiomental fold, an increased lower facial height, and minimal musculature strain on lip closure were observed. Both midlines were deviated to the left of the facial midline, and a nonconsonant smile arc was present. Intraorally, the patient had an Angle Class I molar relationship with a severe anterior open bite of 8 mm and moderate spacing in both the maxillary and mandibular arches (Figures 1 and 2). Periodontal tissues were within normal limits. No symptoms of temporomandibular disorder were detected. The lateral cephalometric analysis showed a skeletal Class II jaw relationship with mandibular retrusion (ANB, 4.7) and a high mandibular plane angle (FMA, 35.0). Both the maxillary and mandibular incisors were proclined labially (Table 1). The panoramic radiograph was unremarkable and included fully erupted third molars. This patient was diagnosed with an Angle Class I malocclusion with a skeletal Class II base, a high mandibular plane angle, and a severe anterior open bite.

Treatment objectives The treatment objectives were to close the open bite while achieving a consonant smile

Figure 2: Pretreatment lateral cephalogram, tracing, and panoramic radiograph

arc by using a passive self-ligating system. Other goals included to level and align the dental arches, to normalize the overjet and overbite relationships, to center the midlines, and to establish a functional occlusion.

Table 1: Cephalometric values Norm



SNA (o)




SNB (o)




ANB (o)




SN-GoGn (o)




FMA (o)




U1-NA (mm)




U1-FH (o)




L1-NB (mm)




L1-MP (O)




Lower lip to E-plane (mm)




Upper lip to E-plane (mm)




ANS-Me (%)




N-ANS (%)




16 Orthodontic practice

Treatment alternatives With the severe anterior open bite and the high mandibular plane angle (FMA, 35.0º), a LeFort I osteotomy with posterior maxillary impaction was considered.13 Another option would have been to use miniscrews or miniplates to intrude the maxillary posterior dentition.14 Additionally, extraction of the premolars or the first molars could also have been indicated to help decrease the vertical dimension while helping reduce the anterior and soft tissue protrusion. The patient immediately declined the surgical option. Without careful management and good cooperation, extractions could lead to over extrusion of the anterior teeth during retraction, which could cause an unwanted gingival display and an unattractive smile arc.15 Extractions were therefore not chosen for this patient. A passive self-ligating system using a differential bonding technique was chosen because it was noninvasive and required neither surgery, miniscrews, extractions, nor complicated multiloop archwires. Volume 8 Number 5


Figures 3 and 4: 3. Fixed appliances placed using differential bonding technique with initial archwires and elastics. 4. Open bite closed 4 months later

Treatment progress Passive self-ligating appliances (Damon® 3) were bonded on both arches for initial alignment and leveling. The differential bonding technique positions the brackets more occlusal on the posterior teeth and more gingival on the anterior teeth to minimize posterior extrusion while allowing open bite closure. Initial archwires were 0.014 CuNiTi with elastics (5/16 in, 3.5 oz) in a triangle configuration from U3s to L3-4s (Figure 3) progressing to 0.018 CuNiTi and triangle elastics (1/4 in, 3.5 oz) from U3s to L2-3s. After 4 months, maxillary and mandibular 0.014 x 0.025 CuNiTi archwires were placed at which time the open bite had closed (Figure 4). Three months later, maxillary and mandibular 0.018 x 0.025 CuNiTi were placed for 6 weeks while continuing elastics and space closure. After 10 months, bracket repositioning was performed, and re-leveling was initiated. Finishing and detailing was performed in 0.017 x 0.025 TMA with anterior box elastics at night. After debonding, full records were taken, and a maxillary wraparound Hawley retainer and bonded 3-3 retainer were delivered. Total treatment time was 28 months.

Treatment results There were little changes in the facial profile except for a more everted upper lip. The deficient chin remains, and the lower facial height was unchanged (Figure 5). The open bite was closed in 4 months, ideal overjet and overbite of the anterior teeth were created, and an Angle Class I molar relationship was maintained (Figure 6). There was no gingival recession after the orthodontic treatment. The panoramic radiograph showed no obvious apical root resorption, and root parallelism was acceptable (Figure 6). A functional occlusion was obtained, and the occlusion appears stable 6 months post debond. 18 Orthodontic practice

Figure 5: Final photographs

Discussion The treatment of severe open bites has often involved a combination of orthodontics and orthognathic surgery. Even though the success of this combined procedure has been proven, many patients reject it for financial constraints or concerns of surgery. Much effort has been made to develop techniques that can help in the treatment of severe open bite orthodontic problems. Successful treatment results have been reported in the literature with various types of mechanics and techniques. However, the long-term treatment stability remains to be determined. This young adult patient was treated conservatively without extractions, surgery,

miniscrews, or multiloop archwires. Careful control of the vertical dimension and essentially no autorotation of the mandible were achieved as noted on the superimposition (Figure 7). The maxillary and mandibular superimpositions show control of the molars and retraction and extrusion of the incisors. Accordingly, over retraction of the anterior teeth with extraction therapy could have increased the gingival display to an unacceptable degree and worsened the smile arc. Together, for these and other reasons it was decided to treat non-extraction. Certainly, this patient could have been treated with any of the other treatment options to a successful result, but few Volume 8 Number 5


CASE STUDY could have closed the anterior open bite this quickly. With the exception of shorter treatment times, most studies have shown no advantage to the passive self-ligating system when compared to conventional preadjusted edgewise brackets.16,17 This case affirms the rapidity of a passive self-ligating system using differential bonding, as this severe open bite was closed in 4 months. In this patient, the closing of the open bite and the restoration of full arch interdigitation solely by an orthodontic approach were generally acceptable.

Conclusions A severe open bite with a skeletal Class II base and a high mandibular plane angle can be corrected by using a passive selfligating system and preventing eruption of the molars, minimal to no rotation of the mandible, ideal restoration of overjet and overbite, and a consonant smile arc. Further clinical research is needed to assess this consistency of this rapid treatment modality. OP

Figure 6: Final lateral cephalogram, tracing, and panoramic radiograph

Figure 7: Cephalometric superimpositions 20 Orthodontic practice

REFERENCES 1. Sarver DM, Weissman SM. Nonsurgical treatment of open bite in nongrowing patients. Am J Orthod Dentofacial Orthop. 1995;108(6):651–659. 2. Ng CS, Wong WK, Hagg U. Orthodontic treatment of anterior open bite. Int J Paediatr Dent. 2008;18(2):78–83. 3. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite malocclusion: a longitudinal 10-year postretention evaluation of orthodontically treated patients. Am J Orthod. 1985;87(3):175–186. 4. Bell WH, Creekmore TD, Alexander RG. Surgical correction of the long face syndrome. Am J Orthod. 1977;71(1):40–67. 5. Deguchi T, Kurosaka H, Oikawa H, et al. Comparison of orthodontic treatment outcomes in adults with skeletal open bite between conventional edgewise treatment and implantanchored orthodontics. Am J Orthod Dentofacial Orthop. 2011;139(suppl 4):S60–S68. 6. Kim YH. Anterior open bite and its treatment with multiloop edgewise archwire. Angle Orthod. 1987;57(4):290–321. 7. Carano A, Machata W, Siciliani G. Noncompliant treatment of skeletal open bite. Am J Orthod Dentofacial Orthop. 2005;128(6):781–786. 8. Hart TR, Cousley RRJ, Fishman LS, Tallents RH. Dentoskeletal changes following mini-implant molar intrusion in anterior open bite patients. Angle Orthod. 2015;85(6):941–948. 9. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treatment: a cephalometric evaluation. Angle Orthod. 2004;74(3):381–390. 10. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J Clin Orthod. 2002;36:455–459. 11. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open bites by intruding molars with titanium miniplate anchorage. Am J Orthod Dentofacial Orthop. 2002;122(6):593–600. 12. Vela-Hernández A, López-García R, García-Sanz V, ParedesGallardo V, Lasagabaster-Latorre F. Nonsurgical treatment of skeletal anterior open bite in adult patients: Posterior build-ups. Angle Othod. 2017;87(1):33-40. 13. Proffit WR, Bailey LJ, Phillips C, Turvey TA. Long-term stability of surgical open-bite correction by Le Fort I osteotomy. Angle Orthod. 2000;70(2):112–117. 14. Fukui T, Kano H, Saito I. Nonsurgical treatment of an adult with an open bite and large lower anterior facial height with edgewise appliances and temporary anchorage devices. Am J Orthod Dentofacial Orthop. 2016;149(6):889-898. 15. Sarver DM. The importance of incisor positioning in the esthetic smile: The smile arc. Am J Orthod Dentofacial Orthop. 2001; 120: 98-111. 16. Eberting JJ, Straja SR, Tuncay OC. Treatment time, outcome, and patient satisfaction comparisons of Damon and conventional brackets. Clin Orthod Res. 4, 2001;228–234. 17. Chen S, Greenlee GM, Kim J-E, Smith CL, and Huang GJ. Systematic review of self-ligating brackets. Am J Orthod Dentofacial Orthop. 2010;137:726.e1-e18.

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ith a barrage of emerging technologies in the dental marketplace, clinicians seek expert advice to guide them toward the most innovative, impactful products that can provide significant benefits for their practices, their teams, and their patients. For the past 9 years, the prestigious Cellerant “Best of Class” Technology Awards have been doing just that — distinguishing outstanding products and services from the competition and establishing true leaders in their categories. The awards have received acclaim for their integrity and have been recognized by every major dental journal in North America and the American Dental Association. The

winners are decided by the Best of Class Advisory Board, comprised of respected experts in dental technology, Paul Feuerstein, DMD; John Flucke, DDS; Marty Jablow, DMD; Parag Kachalia, DDS; and creator and founder of the award, and president of Cellerant Consulting Group, Lou Shuman, DMD, CAGS. Each year, at the Chicago Dental Society’s Midwinter Meeting, the board convenes to review innumerable hours of

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research they have compiled regarding practice-changing technologies over the past year. The rigorous process is unbiased and non-profit. If a technology is not considered exemplary, then no winner is chosen for that category. Any panelist with a consulting relationship with a company is exempt from voting in that specific category. The Cellerant “Best of Class” Technology Awards provide dentists with a “go-to list” of products that they can trust as remarkable and critical components of their technologyforward dental practice. Orthodontic Practice US is excited to showcase these winners and shine a spotlight on the best and the brightest in dental technologies. OP

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A comparative review of mandibular advancement devices and continuous positive airway pressure in patients with mild to moderate obstructive sleep apnea Drs. George J. Cisneros and Oliver F. Nicolay together with Benjamin J. Goldstein compare the efficacy of oral appliance therapy and CPAP therapy Introduction Sleep-disordered breathing (SDB) is a pathological state in which there is periodic and recurrent snoring and obstructive sleep apnea (OSA).1 Individuals with untreated OSA have associated unfavorable health outcomes such as cardiovascular disease, stroke, hypertension, and atrial fibrillation. Patients also suffer from a decreased quality of life, daytime sleepiness, and an increased mortality rate.2 Continuous positive airway pressure (CPAP) therapy has been proven successful in treating OSA by improving the quality of life (QOL), the Apnea-Hypopnea Index (AHI), and oxygen saturation parameters.3 Despite these improvements, patient compliance and adherence to this treatment has been an issue. Patients either reject this treatment or partially comply with it. In fact, the benefits of CPAP treatment may be negated by poor patient compliance and acceptance.4 Recently, oral appliances have been quite popular in the medical and dental communities in treating OSA. Although

Educational aims and objectives

The purpose of this article is to present a critical analysis of the literature to compare the efficacy of MAD use with CPAP therapy and focus on already established factors of treatment success that have been recognized in the literature.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the various symptoms of sleep-disordered breathing. •

Identify various therapies for sleep-disordered breathing.

Identify the multi-system sleep tests that are used to diagnose sleep disorders.

Realize the efficacy of both CPAP and MAD therapy on sleep-disordered breathing.

Recognize some side effects of the various treatments.

CPAP therapy is still the “gold standard” in managing the condition, oral appliance therapy (OAT) has become an acceptable alternative for those patients suffering with mild to moderate OSA because of its ease of use and increased patient compliance. Generally, OAT can be divided into tongue-retaining devices and mandibular

George J. Cisneros, DMD, MSc, received his BS from Manhattan College, DMD from the University of Pennsylvania School of Dental Medicine, and MMSc from Harvard University School of Dental Medicine. He is a Professor of Orthodontics at New York University College of Dentistry and is a Diplomate of the American Board of Pediatric Dentistry and the American Board of Orthodontics, and is a board examiner for both. Dr. Cisneros is a reviewer for various journals, including the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the Journal of Dentistry for Children, and the Journal of Pediatric Dentistry where he also served as a member of the editorial board. Olivier F. Nicolay, DDS, MMSc, is Chair and Clinical Associate Professor – Department of Orthodontics at NYU College of Dentistry. He has a DCD from the Universite Paris Descartes in France, a DDS from Columbia University, and a Certificate in Orthodontics, Masters in Medical Sciences from Harvard. After graduation, Dr. Nicolay joined The Ohio State University where he taught postgraduate students and was involved in research. In 1989, he assumed the position of Program Director at Columbia University, pursuing his interests in research and teaching orthodontics. He has been member of the NYU College of Dentistry since 2002. He is a Diplomate of the American Board of Orthodontics, a Member of Angle East, component of the Angle Society of Orthodontists, the American Association of Orthodontists, and the American Dental Association. Benjamin J. Goldstein is a 4th-year dental student at New York University. He is a DDS candidate for the graduating class of 2018. He has received honors from the OKU society for his academic achievements. Goldstein plans to pursue postgraduate education in orthodontics following his graduation from NYU.

24 Orthodontic practice

advancement devices. This critical analysis of the literature seeks to compare the efficacy of MAD use with CPAP therapy and will focus on already established factors of treatment success that have been recognized in the literature. A PubMed database search was used with the keywords: “Mandibular Advancement Devices,” “Continuous Positive Airway Pressure,” and “Obstructive Sleep Apnea.” No restrictions were placed on the filter search engine.

Apnea-Hypopnea Index (AHI) and oxygen saturation Polysomnography (PSG) is a multisystem sleep test used to diagnose sleep disorders that monitors the patient’s breathing patterns, oxygen levels in the blood, heart rhythms, and limb movements. One of the numerous data sets provided by the PSG is a valuable measurement tool called the Apnea-Hypopnea Index (AHI). The AHI is a measure of the amount of apnea (a temporary cessation of breathing, especially during sleep) or hypopnea (abnormally slow or shallow breathing) events per hour of sleep.5 Mild OSA is a condition that can register less than 15 events per hour, while Volume 8 Number 5

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between treatments.3 In the Gagnadoux and colleagues’ randomized controlled study, this pattern was also present as they also saw an enhanced reduction in AHI in patients using CPAP (73.2%) when compared with those using MAD (42.8 %).7 In fact, Ferguson and co-workers concluded in their study that patients undergoing CPAP therapy were 1.9 times more likely of achieving an AHI of 10 or less.8 In a recent systematic review and metaanalysis looking at 15 RCTs that included 491 CPAP patients and 481 patients receiving MAD therapy, it was found that OAT devices were successful in generating a significant reduction in AHI, whereas the reduction of nightly events were 6.24 times greater with CPAP therapy. This same systematic review evaluated the oxygen saturation in 346 patients that received MAD devices versus 354 patients undergoing CPAP therapy. The authors reported that there was a 3.11% difference in the oxygen levels set forth by both treatment modalities in favor of CPAP.9 The largest oxygen saturation difference of 11.9% in favor of CPAP was found in a prospective cohort study by Ferguson, et al.8


MAD effect

Silent Nite®


Figure 1A: Oral Appliance Therapy (OAT): Mandibular Advancement Devices (MAD) – The top part of Figure 1A illustrates how Mandibular Advancement Devices (MAD) work by moving the mandible forward during sleep, thus increasing the size of the airway and reducing airway resistance. The amount of advancement needs to be carefully titrated over time to effect an improvement and varies for each individual being treated. The lower half of the above figure shows only four examples of the more than 100 MADs currently available Volume 8 Number 5

The above reports strongly suggest that CPAP therapy is more effective than MAD therapy in reducing the AHI index while it increases oxygen saturation levels in both mild and moderate OSA patients.

Quality of life (QOL) The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease.”10 It can follow from here that the measure of health is not only the measure of the frequency and the severity of the disease process but also a measurement in the quality of the life (QOL) that follows with that pathological state. OSA and its treatments can be assessed using various subjective questionnaires to evaluate the QOL. Such questionnaires include the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire (FOSQ), and the Item Short Form Health Survey (SF-36). Doff, et al., compared the efficacy of CPAP versus MADs in 104 patients over a 2-year time period. Using a randomized controlled format with 52 patients in the CPAP group and 52 patients in the MAD group, they assessed subjective improvements in sleepiness (ESS), functional status (FOSQ), and health perceptions (SF-36) — each measured at yearly intervals. They observed no significant differences in improvement between both treatment groups, underscoring the therapeutic potential using either option.5 In another randomized controlled trial, Lam, et al., compared the efficacy of both treatment modalities using 101 mild to moderate OSA patients to assess the QOL using the Sleep Apnea Quality of Life Index (SAQLI). Both the MAD and CPAP appliances improved QOL, but as before, no significant difference was found between the two therapeutic approaches.6 Barnes, et al., in another randomized study, also found that both treatment devices were equally effective in 110 mild to moderate sleep apnea patients using the ESS and SF-36 scales. Moreover, they also reported no statistical difference in overnight PSG results.11 And lastly, Hoekema and colleagues looking this time specifically at more severe OSA patients (moderate and severe) found an improvement in FOSQ in both appliance types (13.7 ± 3.1 to 16.6 ± 2.8 for MADs and 13.9 ± 3.7 to 16.7 ± 3.1 with CPAP therapy). These investigators also found a reduction in ESS with a 12.9 ± 5.6 at baseline to 6.9 ± 5.5 following treatment with an OAT and found a comparable reduction with CPAP therapy (14.2 ± 5.6 to 5.9 ± 4.8), Orthodontic practice 25


those with moderate OSA can have an AHI ranging from 15-30 events. Individuals with severe OSA have an AHI greater than 30. A number of studies have documented that CPAP can significantly improve AHI when compared with MADs.3,6,7 A randomized controlled study by Lam, et al., evaluating the effectiveness of OAT versus CPAP in 101 patients with an average AHI of 21.4, noted a 90% reduction in AHI (to <5 events/hr) with CPAP and a 50% reduction using OAT over a 2-month period. They also reported a 4.5% increase in oxygen saturation when using CPAP therapy.6 In a more recent randomized controlled study by Phillips, et al., it was also noted that there was a statistical difference in the reduction of AHI by CPAP over MAD therapy. In their study, 108 participants with a mean AHI of 25.6 were selected to determine the efficacy of MAD versus CPAP therapy. After 1 month of therapy, there was an 83% average reduction in AHI when using CPAP versus a 58% reduction for those selected to participate using MAD therapy. The same study recorded a 3.5% statistically significant difference in the oxygen saturation

CONTINUING EDUCATION yielding no statistical difference between treatment modalities.12 Systematic reviews looking at QOL criteria have also found similar outcomes. In a 2015 systematic review that looked at 10 RCTs specifically looking at daytime sleepiness found an insignificant .08% increase with CPAP treatment compared to MAD.9 A recent systematic review and meta-analysis done on four RCTs found that MADs were equivalent to CPAP when improving the quality of life in patients with mild to moderate sleep apnea. A non-significant improvement of 2.18% was found in CPAP, and the two methodologies were still considered equivalent and efficient in improving subjective sleep parameters.9 One can see that both CPAP and MAD therapy can be useful methods to improve QOL measurements as the research suggests that both produce equivalent outcomes. By using either treatment modality, patients can improve their cognitive, social, and physical well-being.

Arousal Index and Sleep Architecture Arousal Indices and Sleep Architecture measurements can also be used for comparing these two treatment modalities. The Arousal Index measures how many arousals a patient has per hour, or in other words, how many sleep disturbances a patient has per hour. Sleep Architecture is the measure of rapid eye movement (REM) during sleep. These are important measurements as they help to quantify an objective calibration as to the quality of sleep experienced.

A recent systematic review evaluating six RCTs with a total of 274 patients using MADs and 272 patients treated with CPAP noted that the latter had an overall significant mean reduction of 3.57 events/hr more than those treated with MAD.9 Barnes, et al., reported higher mean reduction of 5.50 arousals/hr, again suggesting that CPAP was more effective than an oral device.13 However, a number of other studies did not show any difference in the Arousal Index. Phillips, et al.,3 Aarab. et al.,14 and Randerath, et al.,15 all showed no significant differences between CPAP and MADs with regards to the Arousal Index. With respect to the percentage of REM sleep, a systematic review was completed looking at eight RCTs with 244 patients in the CPAP group and 244 in the MAD group. A meta-analysis showed no significant difference between the two treatment groups, showing that although they both increased the amount of REM sleep, one did not do better than the other. From the preceding reports, it is suggestive that both treatments for OSA can have a significant effect on sleep efficiency. By using either treatment approaches for OSA, patients can better their chances for having a more productive and less interrupted sleep.

Hypertension One of the biggest concerns with having untreated OSA is cardiovascular disease. The most measured cardiovascular outcome in OSA studies has been blood pressure. A systematic review on multiple RCTs on the effectiveness of MADs lowering BP

was completed. A weighted average was calculated based on the included papers. The mean reduction in systolic BP was 2.09 mmHg and 3.15 mmHg in diastolic pressure. Another meta-analysis completed stated that there was no significant difference in the reduction of BP with either CPAP or MAD therapy.9 Although there may not be a difference in the effectiveness between these treatment modalities, it has been suggested in the literature that a reduction of 2 mmHg may have long-term benefits by reducing cardiovascular risk.16 Similarly, there have been many other studies that have reported no reduction in the BP with either treatment modality. Trzepizur, et al.,17 and Phillips, et al.,3 reported no significant changes in posttreatment BP measurements with either CPAP or any other oral device. Whether there is a reduction or not, it is clear that either OSA treatment devices has very little impact on BP measurements, and hypertensive patients should be monitored and controlled by conventional methods as supervised by their physician.

Side effects Follow-up with patients during or after a study gives us crucial information regarding the various treatments. We can learn about compliance, adherence, and side effects of the proposed treatment plan. In OSA, the clinician needs to assess the patient for signs and symptoms of improving or worsening OSA. Side effects of any oral appliance type include sore gums, sore teeth, increased salivation, TMJ discomfort, difficulty with

Figure 1B: OAT â&#x20AC;&#x201C; Tongue Retaining Device (TRD) â&#x20AC;&#x201C; In this appliance, the tongue goes into the anterior bulb. Pushing the tongue forward and giving the bulb a little squeeze create a suction that holds the tongue in a forward position. It is a lab-fabricated appliance and is made out of a flexible polyvinyl material 26 Orthodontic practice

Volume 8 Number 5


chewing in the morning, and changes in occlusion.6,18 Side effects common with CPAP machines included dry mouth and throat, throat and nasal irritation, feelings of suffocation, rhinitis, claustrophobia, noise bothering, and facial irritation.8 Doff, et al., did make the point that patients should expect to see craniofacial changes, such as mandibular protrusion, with the continued use of MADs for more than 2 years.5 Interestingly, Tsuda, et al., assessed the craniofacial changes in adult subjects with OSA and found that use of nasal CPAP for greater than 2 years resulted in a significant retrusion of the anterior maxilla, a retroclination of maxillary incisors, a retrusive position of both B point and chin, a decrease in maxillarymandibular discrepancy, and a decrease of convexity in the facial profile.21 A meta-analysis evaluating eight RCTs on the discontinuation rates due to side effects of MADs versus CPAP documented that the overall odds of discontinuing OSA therapy due to the chronic use of a MAD versus CPAP machine were 0.54:1.9 This would suggest that the respective side effects that would lead to discontinuation were more pronounced with the use a CPAP machine. Therefore, the evidence suggests that the frequency and severity of the side effects in CPAP tended to be more of an obstruction for patients than they were with the use of MADs.

Figure 2: Continuous Positive Airway Pressure (CPAP) machine â&#x20AC;&#x201C; The top half of the figure above illustrates the use of the (CPAP) machine; the lower half shows a nasal CPAP on the left and a full face CPAP mask on the right and one of the most commonly used CPAP machines in the middle. A CPAP machine is prescribed by a physician and delivers just enough air pressure to a mask to keep upper airway passages open, preventing snoring and sleep apnea. The precise amount of air is carefully titrated and tested during a PSG study

Adherence and preference Like many other disease processes, the success of OSA treatment is dependent upon patient compliance and adherence to the prescribed treatment regimens. Barnes, et al., reported in a randomized control trial of 110 mild to moderate OSA patients that the average usage for CPAP machines was 3.6 hours per night. This measurement was taken objectively through a meter that clocked time and pressure. The MAD group kept a diary, and the average time spent with the oral device was 5.3 hours per night.13 Lam, et al., conducted a randomized control trial with 101 mild to moderate OSA patients. They found the average meteredclock time with the CPAP machine was 4.2 hours per night. This compared to a selfreported usage of 5.2 hours per night with the MAD appliance.6 Ferguson, et al.,8 Clark, et al,19 and Randerath, et al.,15 all reported that although there were side effects with each treatment, patients overwhelmingly chose MADs over CPAP for the long-term management of OSA. Furthermore, patients were surveyed, and the majority felt that MADs were Volume 8 Number 5

user-friendlier than CPAP machines. Phillips, et al., reported in a RCT that there was a 51% preference rate for MADs versus a 21.3% preference rate for the CPAP machine. It was also reported that measured compliance rate for CPAP in 126 patients with mild to moderate OSA was 5.2 hours per night. This compared to a larger compliance rate of 6.5 hours per night with MADs.3 Dieltjens, et al., reported a discontinuation rate of 8.8% after a 1-year follow-up with MADs. This compared to a variable 20%-50% discontinuation rate of CPAP after 1-year follow-up. They also reported an average compliance rate of 5.6 hours per night with MADs and a 5.2 hour per night with CPAP therapy.20 These nightly rates are consistent with the other studies of their kind. Lastly, a systematic review conducted looking at 11 RCTs concluded that the MADs had better overall adherence, with a mean subjective adherence rate of .70 hours of compliance over CPAP. Three of the 11 RCTs included had adherence rates that were more than an hour more than CPAP. Moreover, seven of those RCTs indicated

that the future use of MADs would be more prevalent than CPAP.9 It is clear from the literature that there is a preference for oral devices over the CPAP machine alternative. Over the years, it has been maintained in the area of sleep medicine that CPAP was the primary choice for OSA therapy; however, healthcare providers may need to keep in mind that the MADs may show superior results for some patients due to the higher satisfaction and compliance ratings.

Conclusion For some time now, CPAP therapy has been the gold standard in the treatment of OSA. However, despite its therapeutic advantages, adherence and compliance are known problems. Many patients simply stop using the CPAP machine over time. Health outcomes and QOL indices were similar in patients with mild to moderate OSA for both treatment modalities. While CPAP may have the ability to enhance AHI and oxygen saturation parameters, this benefit could be negated by its poor compliance Orthodontic practice 27

CONTINUING EDUCATION and adherence. And just as orthodontists do throughout treatment, it is recommended that all treating and supervising clinicians should be conducting rigorous follow-up throughout the therapeutic course to evaluate the evolution of OSA symptoms, with the added benefits of collecting a wealth of information available from doing so. Perhaps patient lifestyles and social preferences and preconceptions should be more thoroughly assessed by clinicians before prescribing a specific therapy since studies tend to suggest a preference for MAD over CPAP. This perspective could even potentially challenge the current practice parameters that tend to limit the usage of MADs to only mild to moderate OSA cases. In time, it could also lead to the possible usage of MADs as a primary treatment modality. With the advent of titratable and customizable oral devices, many more patients might end up preferring such devices for the long-term management of OSA. This developing trend in the area of sleep medicine challenges us as clinicians to be aware and prepared for the demand for our expertise. So as the role of the oral healthcare provider has become more relevant to the field of sleep-disordered breathing, we also need to be absolutely focused on the necessity for us to take part in the team approach for the successful treatment of OSA. OP

Figure 3: Summary of Results Apnea-Hypopnea Index/O2%

Quality of Life

Arousal Index/ Sleep Architecture


Side Effects


50% reduction in AHI. Lower O2%6


90% reduction in AHI. Higher O2%6

Adherence/ Preference

Increase in QOL9,10,13

No Significant Difference9

No Significant Difference15,19

Less Impactful9


Increase in QOL9,10,13

No Significant Difference9

No Significant Difference15,19

More Impactful9


Figure 3: Above is a brief review of the data. CPAP and MAD therapy both are viable treatment options when treating mild to moderate obstructive sleep apnea. Although CPAP therapy may have a more dramatic effect on AHI (90% reduction) and O2 parameters, MADs are comparable to conventional CPAP machines in improvement in QOL indices. It is interesting to note that the side effects of CPAP machines were more of a hindrance to successful therapy. When discussing treatment with patients, the clinician should keep in mind the longer patient adherence and higher self-reported preference to oral appliance therapy.

List of acronyms associated with sleep-disordered breathing Apnea-Hypopnea index (AHI) Continuous positive airway pressure (CPAP) Epworth Sleepiness Scale (ESS) Functional Outcomes of Sleep Questionnaire (FOSQ) Mandibular Advancement Devices (MADs) Obstructive sleep apnea (OSA) Oral appliance therapy (OAT) Polysomnography (PSG) Quality of life (QOL) Rapid eye movement (REM) Short Form Health Survey (SF-36) Sleep Apnea Quality of Life Index (SAQLI) Sleep-disordered Breathing (SDB)

REFERENCES 1. Young T, Palta M ,Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230–1235. 2. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283(14):1829–1836. 3. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879–887. 4. Engleman HM, Martin SE, Douglas NJ. Compliance with CPAP therapy in patients with sleep apnoea/hypopnoea syndrome. Thorax. 1994;49(3):263–266, 5. Doff MH, Hoekema A, Wijkstra PJ, et al. Oral Appliance Versus Continuous Positive Airway Pressure in Obstructive Sleep Apnea Syndrome: A 2-Year Follow-up. SLEEP. 2013;36(9):1289–1296. 6. Lam B, Sam K, Mok WYW, et al. Randomized study of three non-surgical treatments in mild to moderate obstructive sleep apnoea, Thorax. 2007;62(4):354–359. 7. Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J. 2009;34(4):914–920. 8. Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. 1997;52(4):362–368. 9. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Sherene M. Thomas, Ph , Chervin RD. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med. 2015;11(7):773-827. 10. Measuring the quality of life. World Health Organization. WHO/MSA/MNH/PSF/97.4. Page 1 1997. 11. Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170(6):656–664 12. Hoekema A, Voors AA, Wijkstra PJ, et al.. Effects of oral appliances and CPAP on the left ventricle and natriuretic peptides. International Journal of Cardiology. 2008;128(2):232–239. 13. Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170(6):656–664. 14. Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial. Respiration. 2011;81(5):411–419. 15. Randerath WJ, Heise M, Hinz R, Ruehle KH. An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest. 2002;122(2):569–575. 16. Turnbull F. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively designed overviews of randomized trials. Lancet. 2003;362(9395):1527–1535. 17. Trzepizur W, Gagnadoux F, Abraham P, et al. Microvascular endothelial function in obstructive sleep apnea: impact of continuous positive airway pressure and mandibular advancement. Sleep Med. 2009;10(7):746–752. 18. Holley AB, Lettieri CJ, Shah AA. Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome. Chest. 2011;140:1511–1516. 19. Clark GT, Blumenfeld I, Yoffe N, Peled E, Lavie PA. crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest. 1996;109(6):1477–1483. 20. Dieltjens M, Braem MJ, Vroegop AV, et AL. Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest. 2013;144(5):1495–1502. 21. Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA. Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea. Chest. 2010;138(4):870–874.

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Volume 8 Number 5

Dr. Payam Ataii discusses a sleep appliance specifically designed to be used in conjunction with clear aligners Two parallel and related trends Two parallel and related growth trends are occurring in the United States: the growth of clear aligner treatment and the rise of diagnoses for sleep-disordered breathing. Over the past year, over 650,000 patients in North America sought clear aligner treatment, and the market is growing by 28% per year.1,2,3 New indications for clear aligners are being introduced, and patients increasingly see the esthetic benefits of clear aligners. At the same time, another trend in the U.S. is growing as strongly as clear aligners — the diagnosis of sleep-disordered breathing. Approximately 3.5 million sleep tests are ordered each year in the U.S., a number growing at nearly 13% annually.4,5 The prevalence of sleep-disordered breathing is astonishing. The National Center on Sleep Disorders Research (NCSDR), an organization within the National Institute of Health (NIH), states that about 70 million Americans suffer from sleep problems, with approximately 60% of these having a chronic disorder.6 Given the prevalence in the U.S. population, it is not surprising that orthodontists and general practitioners see many patients in their practice who show signs of sleep disorders that need to be treated. This problem cannot be ignored. The NCSDR cites that “Sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national health care bill.”6 A variety of sleep appliances have been available for years to treat these patients, but the question has always been, “How do we treat patients with sleep disorders while addressing their chief complaint — to fix their

Educational aims and objectives

The purpose of this article is to present the complexities and the solutions for combining clear aligner therapy with a new, FDA-approved custom dental sleep device.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize some trends in the growth of clear aligner treatment and the rise of diagnoses of sleep-disordered breathing. • Realize the integration between orthodontics and dental sleep medicine. • Identify the clinical benefits of the design of the Aligner Sleep Appliance in conjunction with clear aligner therapy. • See a case where a patient’s orthodontic needs and medical needs were both accounted for during the treatment process.

smile?” Traditional sleep appliances cannot be used in conjunction with clear aligners since both appliances need to be worn while the patient sleeps. Now, there is a solution to this problem — the Aligner Sleep Appliance (ASA)® is an FDA-cleared, custom device specifically designed to address this issue.

Integrating dental sleep medicine within a clear aligner practice Dental sleep medicine and orthodontic practices go hand in hand. The correlation between malocclusions and sleep disorders has been established in the journals for some time now.7 Malocclusions can compromise the space within the oral cavity, limiting the capacity and functionality of the tongue. Especially when patients lie on their back during sleep, if malocclusions are limiting the tongue from properly resting at the roof of the palate, there is a high likelihood that these patients will suffer from compromised airways. These compromised airways can

Payam Ataii, DMD, is an award-winning graduate of Tufts Dental School who has treated more than a thousand patients with clear aligners and sleep oral appliances as mono and combination therapies at his private practice in Laguna Hills, California. Dr. Ataii has been an Invisalign® faculty member for more than 10 years and was awarded the “North America Educator of the Year” award in 2016. As an author, Dr. Ataii has been published in national and international peer-reviewed publications, as well as mainstream press and television. Over the years, Dr. Ataii has presented lectures to thousands of his peers, sharing the results of his research and his innovative practice growth techniques. Dr. Ataii has developed and continues to develop solutions to improve and simplify how dentistry is delivered to patients. He serves on multiple company boards and is a recognized key opinion leader. Disclosure: Dr. Ataii is the co-inventor of the Aligner Sleep Appliance (ASA)®.

Volume 8 Number 5

present themselves as snoring, as chronic fragmented sleep (Upper Airway Resistance Syndrome), or as complete obstruction by the tongue and/or soft tissues (Obstructive Sleep Apnea). With the advent of CBCT technology, practices may better identify midfacial developmental deficiencies that may be contributing factors to collapsed airways and sleep disorders. Given these complexities, choosing the right service partners for both clear aligners and dental sleep is important for orthodontic practices. For clear aligners, working with a reputable clear aligner company can be helpful to make the process simple and gain access to the necessary tools. On the dental sleep side, proper diagnosis of the patient’s sleep disorder as well as a comprehensive treatment plan that identifies the orthodontic considerations and type of appliances that may address the patient’s airway is critical. SleepArchiTx is an example of a dental sleep services company that provides this type of expertise with integration of board-certified sleep physicians, orthodontists, and general sleep practitioners. When treating dental sleep patients, it is important to work with board-certified sleep physicians who may diagnose these conditions through high-quality home sleep tests or in-lab sleep tests. Most diagnostic companies or sleep laboratories are focused on identifying patients who suffer Orthodontic practice 29


Addressing sleep disorders with combination therapy: clear aligners and sleep appliance therapy

CONTINUING EDUCATION from Obstructive Sleep Apnea — and that is good — however, there are other breathing disorders that patients will present with. A diagnostic partner should also be able to properly identify the other possible disorders that orthodontists and general practices could treat, such as, Upper Airway Resistance Syndrome or sleep bruxism. Given the correlation between malocclusions and sleep disorders, working with companies that have orthodontic expertise in treatment planning for sleep cases is imperative. The choice of which appliances to use affects the patients’ comfort and their clinical outcome. Often, dental labs or sleep services companies offer only one or few appliance options and expect those to work with every patient. Orthodontists should not be limited to a single appliance or small handful of choices because factors such as cranio-facial structure and degree of malocclusion will dictate the attributes of the sleep appliance that is needed. In addition, chosen custom sleep appliances must be FDA-cleared and fabricated by an FDAapproved laboratory.

Aligner Sleep Appliance (ASA)® The Aligner Sleep Appliance (ASA)®, available exclusively through SleepArchiTx,

is an innovative option that concurrently treats sleep-disordered breathing in patients undergoing clear aligner treatment. The ASA is designed to support the jaw in a slightly forward, protrusive position to help maintain an open airway while the orthodontic tooth movements are being addressed with the clear aligners. Sleep test results have shown that this combination therapy is an effective treatment option for snoring and Obstructive Sleep Apnea patients who are being treated with Invisalign® or any other clear aligner treatment.8

How do the appliances work together? The Aligner Sleep Appliance is a patented, FDA-cleared, custom-made appliance designed to fit over the patient’s clear aligners throughout the course of treatment. To fabricate the ASA, practices submit either a 3D intraoral scan or physical impressions of upper and lower arches. These impressions must be taken while the patient is wearing his/her current clear aligner trays. It should be noted that some intraoral scanners are not able to accurately detect the clear aligners when fitted over the teeth. If that is the case, instead, submit poured cast models, or PVS impressions to SleepArchiTx.

The ASA is fabricated with a proprietary process of calibrating the patient’s final aligner ortho stage. This process allows the patient to use the same sleep appliance during the entire clear aligner treatment. This means that while the patient’s malocclusion is being resolved, and the programmed clear aligner trays are changed every 1-2 weeks, the ASA is designed to accommodate for the estimated tooth movements without being loose or flimsy. During follow-up visits, dentists may also perform chairside titration adjustments to the ASA by controlling the position of the mandible using the bilateral acrylic fins and/or the customized sagittal and horizontal calibration screws.

ASA Case Study A 29-year old female presented to the practice seeking a better looking smile. During patient evaluation, it was determined that patient felt tired throughout the day, suffered from headaches, and was almost involved in vehicle accident due to being drowsy while driving. The patient’s intraoral evaluation presented with a high palate, narrow dental arches, upper anterior overjet, and lower anterior dental crowding. A sleep study was prescribed, and the patient was diagnosed with Upper Airway Resistance Syndrome (UARS).

Figure 2: Preoperative CBCT image showing airway

Figure 1: Office patient assessment form 30 Orthodontic practice

Figure 3: The Aligner Sleep Appliance (ASA)® is an FDA-cleared dental sleep appliance that fits with clear aligners to enable simultaneous clear aligner and dental sleep treatment, co-invented by Dr. Payam Ataii and Dr. Rob Veis Volume 8 Number 5

Figure 4: Patient without ASA


Treatment Combination therapy with Invisalign trays and Aligner Sleep Appliance. The Invisalign trays were changed weekly during the 6-month course of treatment. The patient was concurrently custom fit with an ASA that repositioned the mandible. Proper positioning was verified with CBCT. One ASA was custom fabricated to adjust to all Invisalign trays. The patient's constricted arch — caused in part by her tipping teeth — was addressed using Invisalign clear aligners on both upper and lower arches. This helped to upright posterior teeth and round out upper and lower anterior teeth for better tooth position and alignment. The ASA was adjusted up to 4 mm during treatment and used post-treatment in combination with the Vivera® Retention System on the upper arch and a fixed retainer on the lower arch. The patient’s postoperative instructions were to wear the ASA at night both during orthodontic phase as well as post-retention. The same appliance was used throughout the treatment along with stabilization and retention period of the patient’s treatment.

Figure 5: Patient with ASA

Figure 6: Before

Treatment outcome The malocclusion was corrected while maintaining a patent airway. The patient’s sleep symptoms of daytime sleepiness, fatigue, and even neck posture showed significant improvement along with better intraoral occlusion and tongue space. A follow-up sleep study confirms that the patient no longer suffers from UARS while wearing the ASA.

Conclusion The Aligner Sleep Appliance was used to successfully treat this patient’s sleep disorder while enabling simultaneous clear aligner treatment. Neither the patient’s orthodontic needs nor her medical needs were compromised during the treatment process. This case highlights how the practices can offer clear aligner treatment and dental sleep treatment that work in tandem. OP

Figure 7: Invisalign® and Aligner Sleep Appliance (ASA)® treatment

REFERENCES 1. Tindera M. Out Of Silicon Valley, A Billion-Dollar Orthodontics Business Built With Plastic And Patents. Forbes. April 25, 2017. michelatindera/2017/04/25/out-of-silicon-valley-abillion-dollar-orthodontics-business-built-with-plastic-andpatents/#172c562030c2. Accessed August 24, 2017.

Figure 8: After

2. Align Technology, Inc. 2016 Annual Report. http://files. /35244CC1-3ECE-48FE-97B9-EB8D8804134B/SECALGN-1097149-17-9.pdf. results.cfm. Accessed August 24, 2017

4. NovaSom. Economics of Home Sleep Testing. https:// Accessed August 24, 2017.

3. Align Technology, Inc. Financial Results Q2 2017: Financial Slides 072717. downloads/ALGN/5058245059x0x951104/8A 2DAC90-4DC8-4EDD-82D6-EF9C3B6222F3/

Volume 8 Number 5

ALGN_Q217_Financial_Slides_072717.pdf. http://investor. Accessed August 24, 2017.

5. Persistence Market Research. Global Market Study on Sleep Testing Services: Increasing Prevalence of Sleep Disorders Attributes Double Digit Growth of the Sleep Testing Services During Forecast Period, 2015-2021. http://www. Accessed August 24, 2017.

6. The National Center on Sleep Disorders Research (NCSDR). Accessed August 24, 2017. 7. Kandasamy S, Goonewardene M. Class II malocclusion and sleep-disordered breathing, Semin Orthod. 2014;20(4):316-323. 8. Ataii PC. Patient studies of Aligner Sleep Appliance (ASA)™ sleep oral appliance use with and during Invisalign orthodontic treatments: review. dr-payam-ataii-aligner-sleep-appliance-asa/, https://ataii. com/clinical-resources/. Accessed August 24, 2017.

Orthodontic practice 31

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A comparative review of mandibular advancement devices and continuous positive airway pressure in patients with mild to moderate obstructive sleep apnea

Addressing sleep disorders with combination therapy: clear aligners and sleep appliance therapy ATAII






Individuals with ______ have associated unfavorable health outcomes such as cardiovascular disease, stroke, hypertension, and atrial fibrillation. a. untreated OSA b. treated OSA c. delayed sleep phase syndrome d. restless leg syndrome Continuous positive airway pressure (CPAP) therapy has been proven successful in treating OSA by improving _______. a. the quality of life (QOL) b. the Apnea-Hypopnea Index (AHI) c. oxygen saturation parameters d. all of the above Although CPAP therapy is still the “gold standard” in managing the condition, oral appliance therapy (OAT) has become an acceptable alternative for those patients suffering with mild to moderate OSA because of its ______. a. ease of use b. increased patient compliance c. saturation parameters d. both a and b _______ is a multisystem sleep test used to diagnose sleep disorders that monitors the patient’s breathing patterns, oxygen levels in the blood, heart rhythms, and limb movements. a. Epworth Sleepiness Scale (ESS) b. Polysomnography (PSG) c. Continuous positive airway pressure (CPAP) d. Functional Outcomes of Sleep Questionnaire (FOSQ) The ____ is a measure of the amount of apnea (a temporary cessation of breathing, especially during sleep) or hypopnea (abnormally slow or shallow breathing) events per hour of sleep. a. PSG b. ESS c. AHI d. OAT

32 Orthodontic practice






Individuals with severe OSA have an AHI greater than _____. a. 5 b. 10 c. 20 d. 30 The reports mentioned in the “Apnea-Hypopnea Index (AHI) and oxygen saturation” section strongly suggest that CPAP therapy _______ reducing the AHI index while it increases oxygen saturation levels in both mild and moderate OSA patients. a. is more effective than MAD therapy in b. is less effective than MAD therapy in c. is just as effective as MAD therapy in d. should be the only therapy for By using either treatment modality (CPAP or MAD therapy), patients can improve their _______ well-being. a. cognitive b. social c. physical d. all of the above Sleep Architecture is the measure of ________ during sleep. a. restless legs syndrome (RLS) b. Apnea-Hypopnea Index (AHI) c. rapid eye movement (REM) d. continuous positive airway pressure (CPAP) Over the years, it has been maintained in the area of sleep medicine that CPAP was the primary choice for OSA therapy; however, healthcare providers may need to keep in mind that _______ may show superior results for some patients due to the higher satisfaction and compliance ratings. a. the MADs b. the TRDs c. alpha-2 agonists d. a tonsillectomy






Over the past year, over 650,000 patients in North America sought clear aligner treatment and the market is growing by ____ per year. a. 28% b. 38% c. 50% d. 70% Approximately _______ sleep tests are ordered each year in the U.S., a number growing at nearly 13% annually. a. 1 million b. 2.5 million c. 3.5 million d. 5 million The National Center on Sleep Disorders Research (NCSDR), an organization within the National Institute of Health (NIH), states that about ______ Americans suffer from sleep problems, with approximately 60% of these having a chronic disorder. a. 10 million b. 30 million c. 50 million d. 70 million Malocclusions can compromise the space within the oral cavity, limiting the ______ of the tongue. a. capacity b. functionality c. taste sensation d. both a and b These compromised airways can present themselves as _______. a. snoring b. chronic fragmented sleep (Upper Airway Resistance Syndrome)

c. complete obstruction by the tongue and/or soft tissues (Obstructive Sleep Apnea) d. all of the above 6.

With the advent of ______, practices may better identify mid-facial developmental deficiencies that may be contributing factors to collapsed airways and sleep disorders. a. 2D digital radiographs b. transillumination technology c. CBCT technology d. panoramic imaging


When treating dental sleep patients, it is important to work with _______ who may diagnose these conditions through high-quality home sleep tests or in-lab sleep tests. a. board-certified sleep physicians b. oral surgeons c. ENT physicians d. orthodontists


The choice of which appliances to use affects the patients’ _______. a. radiography options b. comfort c. clinical outcome d. both b and c


Chosen custom sleep appliances must be _____. a. FDA-cleared b. fabricated by an FDA-approved laboratory c. made with a specific type of plastic d. both a and b

10. The ASA is designed to support the jaw in a slightly forward _______ to help maintain an open airway while the orthodontic tooth movements are being addressed with the clear aligners. a. clenching position b. lateral position c. protrusive position d. retrusive position

Volume 8 Number 5




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Practice Growth




The perception of orthodontists and laypeople on the esthetics of teeth treated with Icon® resin infiltration for the resolution of white spot lesions after the removal of fixed orthodontic appliances Drs. Helena Kilic, Daniel J. Rinchuse, and Thomas Zullo describe a study on the effectiveness of Icon in the resolution of white spot lesions Abstract Objective: To determine the effectiveness of Icon® in the resolution of white spot lesions (WSLs) after the removal of fixed orthodontic appliances as perceived by orthodontists and laypeople. Materials and methods: Nineteen patients (mean age, 16.4) who underwent fixed orthodontic treatment received an application of Icon® for the treatment of white spot lesions, after the removal of all fixed appliances. One maxillary tooth was selected on each patient to be treated with Icon®. Pre- and post-Icon photographs (T1 and T2) were taken of each individual tooth. A 12-week follow-up (T3) photograph was taken to assess the stability. After randomization, photographs were rated by six orthodontists and 24 laypeople to assess the esthetic improvement of each treated tooth. From this data, the improvement of the esthetic appearance of the WSL at each time point was determined for each rater. Helena Kilic, DMD, MS, MBA, attended the University of Massachusetts, Amherst, where she graduated with a bachelor of science in Biochemistry and Molecular Biology. She then pursued her doctorate degree at Tufts University School of Dental Medicine. Dr. Kilic completed her orthodontic specialty at Seton Hill Center for Orthodontics, where she received a Master of Science in orthodontics and Master of Business Administration. She currently practices at Kravitz Orthodontics in Northern Virginia. Dr. Kilic is a member of the American Association of Orthodontics. Daniel J. Rinchuse, DMD, MS, MDS, PhD, is professor and program director at Seton Hill University graduate program in orthodontics. He is an ABO Diplomate. He received his DMD, MS (pharmacology), MDS (Orthodontics), and PhD (Higher Education), from the University of Pittsburgh. Thomas Zullo, PhD, is Adjunct Professor of Biostatistics, Seton Hill Graduate Program in Orthodontics, Greensburg, Pennsylvania. Disclosure: The device (Icon resin infiltration) used in this study was independently financed and was not financially sponsored in any way by the makers of the Icon® treatment system. Furthermore, no members of the research team were being compensated by or had any affiliation with the makers of the Icon® treatment system, DMG America.

34 Orthodontic practice

Results: There was a statistically significant difference in the esthetic improvement of WSLs between T1-2 and T1-3 (P=0.0004, P= 0.0004) for both the orthodontists and the laypeople. There was a mean difference in the data between the orthodontist and laypeople raters, but the difference was not statistically significant. There was no difference between the male versus female raters. Conclusions: Icon® resin infiltration appears to show an improvement on the esthetic appearance of teeth in the treatment of WSLs, and also seems to be relatively stable at the 12-week follow-up. Both orthodontists and laypeople seem to perceive the effectiveness of the product.

Introduction A major problem that exists with fixed orthodontic appliances is enamel demineralization, also known as white spot lesions (WSLs), that occurs during orthodontic treatment. As described by Heyman, et al., WSLs are one of the most common side effects of orthodontic treatment and could have a negative impact on the dental esthetics.1 WSLs develop when a change occurs in the equilibrium of the enamel; in a healthy tooth, mineralized enamel and demineralized enamel are present in approximately equal amounts. However, when there is more demineralization of enamel than there is remineralization of enamel, WSLs form. As defined by Murphy, et al., a WSL is a clinically visible opaque white area, resulting from the loss of minerals in the outer layer of enamel.2 These demineralized areas usually develop because of prolonged plaque build-up on the enamel.3 Furthermore, it has also been shown by Ogaard, et al., that fixed orthodontic appliances increase the difficulty of the routine oral hygiene care for patients.4 The combination of white spots and plaque buildup can lead to unesthetic conditions

that could sometimes offset the esthetic result from orthodontic treatment. Despite orthodontic practitioners’ attempts to eliminate or minimize the occurrence of WSLs in multiple ways — such as repeating oral hygiene instructions, prescribing fluoride rinses and toothpastes, using fluoridated sealers, and minimizing the amount of bonding agents around the bracket — WSLs are inevitable.5 It was demonstrated by Gorelick, et al., that the most common teeth affected by WSLs are the maxillary laterals followed by the canines, first premolars, and central incisors.6 The same group also noted that of 121 patients who were debonded, 49.6% had at least one white spot lesion. A study conducted by Ballard., et al., indicated that the gingival and middle thirds of the surface of the crowns of laterals incisors, canines, and first molars are the areas most affected by WSLs.7 WSLs have a range of severity, from noncavitated and barely visible to cavitated. A cavitated lesion should not be treated in the same manner as a non-cavitated lesion. A cavitated lesion should be restored, and a non-cavitated lesion should be approached with a preventative plan to help arrest and remineralize the lesion.8 According to Knosel, et al., there are two principle ways of addressing a WSL: first, to arrest the lesion by remineralization or, second, to correct the unesthetic appearance.9 Intervening when the WSL is non-cavitated will require less invasive treatment than would be needed for a cavitated lesion. Infiltrations of WSLs can be used to help reduce the progression of the non-cavitated WSLs, as well as improve the tooth esthetics. Surfaces treated with resin infiltration are found to have an increased micro hardness when compared to smooth surface initial caries lesions, an increased resistance to surface abrasion from brushing when compared to normal enamel, and also Volume 8 Number 5

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RESEARCH an increased resistance to further demineralization.10 The resin infiltration technique used to treat WSLs is a more comprehensive approach than simply bleaching the tooth surface of the WSL for the esthetic improvement.8 In addition to being a comprehensive and less invasive treatment option, it was shown that resin infiltration does improve the esthetic appearance of white spot lesions.11 Oral hygiene is considered essential in preventing white spot lesions.13 Maxfield, et al., reported that the patient bore the greatest responsibility for preventing white spot lesions.12 It would, therefore, be fundamental to focus on the communication between the patients, parents, and orthodontists, to reinforce the patient’s oral hygiene to help prevent WSLs.12 Unfortunately, no matter how much effort is attributed to the communication and reinforcement for the oral hygiene, WSLs often times occur. The purpose of this study was to determine the effectiveness of Icon in the resolution of WSLs after the removal of fixed orthodontic appliances as perceived by orthodontists and laypeople.

Materials and methods After the approval of the study by the Institutional Review Board at Seton Hill University Center for Orthodontics, 19 subjects were recruited to participate in the study. The subjects had completed fixed orthodontic treatment at Seton Hill University, with any clinically visible WSL, on any tooth, between the maxillary left first premolar to the maxillary right first premolar. The device (Icon resin infiltration) used in this study was independently financed and was not financially sponsored in any way by the makers of the Icon® treatment system. Furthermore, no members of the research team were being compensated by or had any affiliation with the makers of the Icon® treatment system, DMG America. The patients were between the ages of 11-18. After the risks were explained, and the consent form was reviewed and signed by each subject and parent, all 19 subjects with clinically visible WSLs underwent one Icon treatment. The Icon protocol was followed exactly as described by the manufacturer’s protocol. The principal investigator

The combination of white spots and plaque buildup can lead to unesthetic conditions that could sometimes offset the esthetic result from orthodontic treatment. (Dr. HK) selected the teeth for treatment by conducting a clinical examination. The inclusion criteria included patients in the permanent dentition who had not been using any fluoride regimens other than over-thecounter toothpaste since the removal of their orthodontic fixed appliances. The exclusion criteria excluded patients who were using a fluoride regimen, cavitated WSLs, restoration on the facial surface of the selected tooth, deciduous teeth; patients with any medical conditions that would prevent them from sitting through the treatment; and patients who had decalcification present on the teeth prior to the start of their orthodontic treatment. During the trial, the subjects were given the same manual toothbrush and toothpaste (Colgate Total®) for their home oral hygiene care. Photographic records were taken before the Icon treatment (T1), immediately after the procedure (T2), and at the 12-week follow-up (T3). The digital intraoral camera used for all of the photographs was a Nikon D7100 with the same settings for each photograph (M 1/200, F:22, Zoom 140). The principal investigator took all photographs during the study at a constant distance. The photographs were taken in a light-controlled environment with a pre-set protocol. The shade of the tooth and the background for each patient were matched as closely as possible within each time point. There were two rater groups, which consisted of six orthodontists and 24 laypeople of equal gender. The orthodontists were randomly selected from the Western Pennsylvania area. The laypeople were selected from the waiting room area at Seton Hill Center for Orthodontics in Greensburg, Pennsylvania. Parents of the subjects were excluded from participating as laypeople raters in the study to prevent any discomfort

Table 1: Judge Group. Measure: White spots Judge Group


Std. Error

Statistical analyses Statistical analyses were performed using IBM SPSS Statistics version 24. A two-way analysis of variance was used to analyze each time line with the different rater group, where sphericity is assumed. A Pairwise comparison was completed to show the difference between each time line. A correlation coefficient was completed to measure the intra- and inter-rater reliability.

Results The data in Table 1 shows that there was a large difference in the means between the two rater groups: orthodontists (48.444%) and laypeople (62.028%). However, the difference was not statistically significant (F= 3.468, P=0.074). This may be due to the difference in the sample size between the two groups. As noted in Table 2, tests for the main effect of time revealed a statistically significant difference across the 3 time points (F=27.386, P=0.0004). The pairwise comparison showed that the difference between T1 and T2, and T1 and T3 were statistically significant (P=0.0004, P=0.0004,

Table 2: Time Points. Measure: White spots

95% Confidence Interval Lower Bound

from rating their own child and to avoid any biases. Each rater evaluated 54 photographs that were randomized using Excel, Microsoft software, with six repeated photographs for the reliability assessment, for a total of 61 photographs. Each rater evaluated the photographs on a Visual Analogue Scale of 100 mm. The left extremity represented the least esthetically pleasing tooth surface, and the right extremity represented the most esthetically pleasing surface tooth surface. Raters were instructed to evaluate only the tooth surface, and to exclude in their ratings the size or shape of the tooth and the tissue around the tooth.

Upper Bound



Std. Error

95% Confidence Interval Lower Bound

Upper Bound


























36 Orthodontic practice

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Figure 1: Patient 1. T1: Before Icon application. T2: Immediately after Icon application. T3: 12-weeks’ follow-up

respectively), while the difference between T2 and T3 was not statistically significant (P=1.000). The pattern in regards to the effect of time remained constant for both rater groups (orthodontist versus laypeople). The photographs in Figures 1 and 2 are examples of two separate patients, demonstrating the differences between T1-T3. The data in Table 3 demonstrates that there was not much difference in the mean between the gender of the judges, and the difference was not statistically significant (F 0.424, P=0.521). It was noted that the female orthodontist judges scored lower than the male orthodontist judges, and the female laypeople scored higher than the male laypeople. However, as mentioned earlier, these differences were not statistically significant. The intra-judge reliability was 0.789, and that can be considered moderately reliable. A potentially higher reliability could have been achieved if the size of the orthodontist judge group had been closer to the size of laypeople judge group. The inter-rater reliability within the orthodontist group was only 0.917, 0.936, and 0.965 at T0, T1, and T2, respectively. This data demonstrated great reliability on their ratings.

Discussion The aim of the study was to determine the effectiveness of Icon in the resolution of WSLs after the removal of fixed orthodontic appliances as perceived by orthodontists and laypeople. As demonstrated by Table 2, there was a significant difference between T1-T2, and T1-T3 (P=0.0004, P=0.0004,


Std. Error

Figure 2: Patient 2. T1: Before Icon application. T2: Immediately after Icon application. T3: 12-weeks’ follow-up



95% Confidence Interval Lower Bound

Upper Bound











38 Orthodontic practice


respectively), which demonstrated the effecmore critically by orthodontists than dentists tiveness of Icon in the resolution of WSL. or laypeople.20 The stability of the products Table 2 also showed that there was no major also seemed to be consistent for both groups difference between T2-T3. Although this was of raters (Table 4). The results showed that both the orthodontist and laypeople groups only a 12-week follow-up, this data revealed some stability from the product. Kosnel, noticed a significant improvement of the et al., saw similar results in the previously facial surface from T1-T2 and T1-T3. Furtherdemonstrated study — that resin infiltration more, there was little variance in the evaluaimproves the appearance of WSLs.16 tions of T2-T3 between the groups. As stated In the study, the data showed that there earlier, orthodontists would be expected to was a large difference in the mean perception be more critical in their ratings. However, this between the two judge groups of orthodonshouldn’t be a major problem, since typically, tists (48.444%) and laypeople (62.028%). laypeople interact with laypeople, and orthoThe orthodontists, being trained specialists, dontists interact with other dental specialists most likely have more experience and are on a daily basis. This leads to the importance of patient more critical than laypeople at evaluating autonomy versus paternalism in their treatphotographs of teeth. Although there was ment options and choices. As patients are a large mean difference between the orthodontist and laypeople group, the results were becoming more aware and informed of not statistically significant, possibly due to new products and different technologies, the difference in the sample size between the there has been a shift from the practitionertwo groups. The judge group is underpowcentered treatment to patient-centered ered, and a contributing factor to that is the treatment plans. Since the laypeople raters lower number of orthodontist judges. Also, observed similar positive changes on the the number of orthodontists and laypeople tooth surface after the application of the in the community is also not proportional. product, their preferences should be incorAlthough as noted in Table 3, that there porated throughout their treatment. Therewas no difference between the genders of fore, it is important for the orthodontist to the raters, the results revealed that both the stay away from the traditional paternalistic orthodontist judges and laypeople judges treatment method and allow greater patient noticed an improvement after the use of Icon input into treatment planning.21 This can also on the teeth, but that orthodontists’ ratings be a good practice management strategy were more critical (Table 4). It was demonstrated by Table 4: Judge group at each time points. Kokich, et al., Measure: White spots that esthetic dis95% Confidence Interval Std. harmony is rated Judge Group Time Mean

Table 3: Judge Sex. Measure: White spots Judge Sex



Lower Bound Upper Bound































Volume 8 Number 5

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RESEARCH for the orthodontists, and the patients will benefit from the results since they do notice the esthetic improvement from the product. One limitation from the study is that the follow-up to assess the stability was short-term. A future study could evaluate a long-term stability of the product, such as a year follow-up. It would also be interesting to incorporate the perception from different age groups of laypeople raters, such as the typical age group of patients who undergo fixed orthodontic treatment.

Conclusion It can be concluded from the results that it may be worth promoting the Icon in our orthodontic offices, since it seems that laypeople do notice the benefit from the product. This service can be used as a practice management tool, to reduce the appearance of the WSLs after orthodontic treatment. However, there may be a dilemma when deciding whether the orthodontist or the general dentist should perform the treatment. OP

40 Orthodontic practice

REFERENCES 1. Heyman GC, Grauer DA. A contemporary review of white spot lesions in orthodontics. J Esthet Restor Dent. 2013;25(2):85-93. 2. Murphy TC, Willmot DR, Rodd HD. Management of postorthodontic demineralized white lesions with microabrasion: a quantitative assessment. Am J Orthod Dentofacial Orthop. 2007;131(1):27-33. 3. Guzmán-Armstrong S, Chalmers J, Warren JJ. Ask us: White spot lesions: prevention and treatment. Am J Orthod Dentofacial Orthop. 2010;138(6):690-696. 4. Ogaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. part 1. lesion development. Am J Orthod Dentofacial Orthop. 1988;94(1):68-73. 5. Chapman JA, Roberts WE, Eckert GJ, Kula KS, GonzálezCabezas C. Risk factors for incidence and severity of white spot lesions during treatment with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop. 2010;138(2):188-194.

of caries lesions: an efficacy randomized trial. J Dent Res. 2010;89(8):823-826. 12. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer SJ. Development of white spot lesions during orthodontic treatment: perceptions of patients, parents, orthodontists, and general dentists. Am J Orthod Dentofacial Orthop. 2012;141(3):337-344. 13. Bishara SE, Ostby AW. White spot lesions; formations, prevention, and treatment. Semin Orthod. 2008;14(3): 174-182. 14. U.S Food and Drug Administration. 510(k) Premarket Notification. cfPMN/pmn.cfm?ID=K081493 Accessed July 10, 2015. 15. Robertson MA, Kau CH, English JD, Lee RP, Powers J, Nguyen JT. MI Paste Plus to prevent demineralization in orthodontic patients: a prospective randomized controlled trial. Am J Orthod Dentofacial Orthop. 2011;140(5):660-668.

6. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98.

16. Knösel M, Eckstein A, Helms HJ. Durability of esthetic improvement following Icon resin infiltration of multibracketinduced white spot lesions compared with no therapy over 6 months: a single-center, split-mouth, randomized clinical trial. Am J Orthod Dentofacial Orthop. 2013;144(1):86-96.

7. Ballard RW, Hagan JL, Phaup AN, Sarkar N, Townsend JA, Armbruster PC. Evaluation of 3 commercially available materials for resolution of white spot lesions. Am J Orthod Dentofacial Orthop. 2013;143(suppl 4):78-84.

17. Shungin D, Olsson AI, Persson M. Orthodontic treatmentrelated white spot lesions: a 14-year prospective quantitative follow-up, including bonding material assessment. Am J Orthod Dentofacial Orthop. 2010;138(2):136.e1-136.e8.

8. Stahl J, Zandona AF. Rationale and protocol for the treatment of non-cavitated smooth surface carious lesions. Gen Dent. 2007;55(2):105-111.

18. Azizi Z. Management of white spot lesions using resin infiltration technique: a review. Open Journal of Dentistry and Oral Medicine. 2015;3(1):1-6.

9. Knösel M, Attin R, Becker K, Attin T. External bleaching effect on the color and luminosity of inactive white-spot lesions after fixed orthodontic appliances. Angle Orthod. 2007;77(4):646-652.

19. Huang GJ, Roloff-Chiang B, Mills BE, et al. Effectiveness of MI Paste and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2013;143(1):31-41.

10. Paris S, Schwendickes F, Seddig S, Müller WD, Dörfer C, Meyer-Lueckel H. Micro-hardness and mineral loss of enamel lesions after infiltration with various resin: influence of infiltrant composition and application frequency in vitro. J Dent. 2013;41(6):543-548.

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

11. Paris S, Hopfenmuller H, Meyer-Lueckel H. Resin infiltration

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

Volume 8 Number 5

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

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 8 Number 5


Disclosure of financial interest

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

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

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

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

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

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

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

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

(Multiple) Doe JF, Roe JP

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

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

Orthodontic practice 41


SEO: Scam or critical marketing service? Part 1 Ian McNickle, MBA, defines SEO and discusses its importance


he world of online marketing can be quite confusing, if not downright aggravating. It can be challenging to know what to do, how to do it, and who should do it for you. One of the most popular services discussed these days is “Search Engine Optimization” (SEO). Most people understand that SEO is a sort of mysterious service that somehow gets you ranked highly on Google and the other search engines.

“What exactly is SEO?” SEO can be defined as a set of ongoing monthly activities that must be performed in order for your website to rank highly on Google and the other search engines. SEO includes both “on-page” optimization and “off-page” optimization. On-page optimization includes items done on the website itself (code, content, images, videos, sitemap, blogs, etc). Off-page optimization includes items that are on the Internet, but not the website (online reviews, social media, directories, backlinks, etc). So in a nutshell, SEO is some combination of all these things performed each month. Determining which items should be done and how much of each item should be done depends on your goals and local competition.

“I’ve tried SEO and got ripped off!” I frequently lecture all over North America about SEO and many other online marketing topics. If I had a dollar for every time I’ve heard a doctor complain about getting ripped off, I could probably retire. I feel their pain and frustration. It’s real. Hiring an SEO company is kind of like taking your car to the mechanic. You hope they are honest and

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, or by calling 888-246-6906. For more information, you can visit online at

42 Orthodontic practice

Receive your free marketing consultation today: 888-246-6906 or good at what they do so you’ll get value for your money, but it is difficult for you to assess that ahead of time (or even afterwards). In my estimation, SEO is indeed one of the most misunderstood services, and therefore, a lot of doctors get taken advantage of when hiring an SEO company. My goal with this article series is to educate doctors and staff to prevent you from getting ripped off, or at least from making bad decisions.

“How does it work?” In order to understand why SEO needs to be done a certain way, it is important to first understand a little bit about how search engines operate. For most average websites, the search engines review your website about every 30 days. When a search engine reviews your website, it actually indexes (reads and stores on its servers) every line of content and code on your website. Each time it does this, it compares all of your code and content to what it indexed 30 days prior and looks for improvements, new content, etc. Search engines also take into account your online reviews (Google, Yelp, Healthgrades, Facebook, etc), as well as social media activity and engagement (Facebook, Instagram, Pinterest, Twitter, You Tube, etc). A well-designed SEO program will involve some combination of many of these activities every month so that each time the search engines index your website and online activity, your practice will be rewarded with

higher rankings (or at least by not dropping in the rankings). SEO takeaway No. 1 — SEO activities must be done every month in order to be rewarded by search engines. If not, your search rankings will plateau or decline.

“How can I tell if I’m getting real SEO?” Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so practices will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines. In part 3 of our series, we will discuss questions to ask when interviewing SEO companies and how to spot scams (and low-end SEO services).

Marketing consultation If you have questions about your website, SEO, 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 Volume 8 Number 5

October 27-28, 2017 Hilton Anatole Dallas

New Speakers Join MKS Scott Law is a wet-fingered orthodontist overseeing the clinical aspects of Smile Doctors, an orthodontist-owned orthodontic group. In 2009, he and his wife Jessica purchased a small practice in Killeen, Texas. Using techniques based on customer service, fun, empowerment and excellence they grew that location to one of the largest practices in the U.S. and now have 70 locations.

Joseph M. Hogan joined Align

Technology in June 2015 as President, CEO and a Director. Previously he served as CEO of ABB, a $40 billion global power technologies company where he oversaw a 25% increase in revenues. He spent 25 years at GE and more than doubled revenues from $7 billion to $16 billion at GE Medical.















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Orthodontic and Surgical Management of Impacted Teeth Vincent G. Kokich, DDS, MSD, and David P. Mathews, DDS Quintessence Publishing Co., Chicago, Illinois


r. Vince Kokich and his colleague, Dr. David Mathews, felt that since little had been written on the interdisciplinary manner of diagnosing and treatment of impacted teeth that it warranted a comprehensive text illustrating theirs and others’ experiences with these vexing problems. Sadly, Dr. Kokich died before finishing the last chapter, but his son, Vince Kokich Jr.; his daughter, Mary; and his wife, Marilyn; helped Dr. Mathews finish this fine text. In this book, which contains 177 pages and 422 photographs and images, the authors have attempted to address practically every type of dental impaction with simple but complete narratives supplemented by more than 400 unusually clear photographs and illustrations. They have dedicated chapters to impacted maxillary central incisors, labially impacted maxillary canines, palatally impacted canines, impacted premolars, impacted mandibular molars, and a final chapter on complications and adverse sequelae. Drs. Kokich and Mathews acknowledge that the most commonly impacted teeth are the mandibular third molars, which they do not speak to, followed by maxillary canines, mandibular second premolars, and maxillary central incisors. They emphasize the importance of maintaining the integrity of the dental follicle of permanent teeth while removing supernumeraries. The doctors describe four methods for uncovering impacted maxillary central incisors: gingivectomy, apically positioned flap, the closed eruption technique, and surgical replantation. They use these and variations of them in the treatment of other impactions. Once teeth are uncovered, the doctors use a variety of techniques to bring the teeth into position, which includes the useful Ballista loop. Labially impacted maxillary canines occur only one-third of the time, while palatally impacted canines occur two-thirds of the time. Drs. Kokich and Mathews emphasize the need to properly diagnose the impaction before choosing a method to uncover 44 Orthodontic practice

Orthodontists and surgeons won’t find a better or more comprehensive guide. the teeth. They do not neglect interceptive treatment of potential maxillary canine impactions and counsel that extractions of primary canines and primary molars can often prevent impactions if performed early enough. More than 40% of the book pages concern maxillary canine impactions, which illustrates the complications these teeth offer surgeons and orthodontists. These superb clinicians show some truly heroic therapies, but wisely advise readers to prudently consider removing the impacted canines rather than jeopardize adjacent teeth and expose patients to unnecessary trauma.

Surprisingly, the shortest chapter deals with the uncovering and alignment of impacted mandibular second molars, which is usually as clinically troublesome as the impacted maxillary canines. The final chapter addresses complications and adverse sequelae, while acknowledging that inappropriate treatment of impacted teeth is a principal cause of litigation in orthodontics. Drs. Kokich and Mathews analyze each unfavorable outcome and offer diagnostic and therapeutic advice that avoids the problem — e.g., do not ligate impacted teeth and use judicious bone removal during the uncovering. This paperback publication has durable pages with appealing layouts and clear fonts. The images offer first-rate clarity. Clearly, orthodontists and surgeons need to study this book together to strategize the complicated therapy that impacted teeth require.They won’t find a better or more comprehensive guide. OP Book review by Dr. Larry White. Volume 8 Number 5

INDUSTRY NEWS Palmero announces X-Ray Apron Recycle/Trade-in Program Palmero Healthcare, a Hu-Friedy subsidiary, is pleased to announce its latest green initiative, Palmero’s X-Ray Apron Recycling Program. The new eco-friendly and environmentally responsible program rewards participants for supporting greener dentistry. According to the EPA, recycling lead aprons is the preferred method since it keeps lead out of landfills. All materials will be responsibly disposed of, and all lead liners will be properly distributed for processing back to base material. Here is how to recycle: RECYCLE 1 X-Ray Apron, receive 1 FREE Apron Hanger. 1. Purchase a new Palmero X-Ray Apron. 2. Collect old or unwanted X-Ray apron of any brand. 3. Contact Customer Service for a Return of Authorization Number (RA#) to register for recycling. 4. Submit invoice with RA# via Fax 203-377-8988, or email Include ship-to address, phone, and email. 5. Ship your old apron with RA# for responsible disposal to: Palmero Healthcare LLC Attn: X-Ray Recycle/Trade-In Program 120 Goodwin Place Stratford, CT 06615 6. Acquire a new X-ray apron hanger, an $18.00 retail value for your participation. For more information, visit

Ultradent donates $50,000 to Hurricane Harvey relief efforts and launches special discount program to help affected dentists rebuild practices In response to the catastrophic devastation caused by Hurricane Harvey, Ultradent Products, Inc., will donate $50,000 to the Saint Bernard Project (SBP) as they work to aid in the rescue, relief, and rebuilding efforts of all those affected by the storm. Additionally, Ultradent is launching a discount program to help dentists whose practices have been damaged by Hurricane Harvey. Beginning Monday, August 28, 2017, Ultradent will offer dentists negatively affected by Hurricane Harvey $500 worth of free products, with 40% off all consumable products, and 15% off all equipment purchases exceeding the initial $500, in the hopes of providing some aid in the rebuilding efforts of the dental community. To find out more about Ultradent’s disaster relief efforts, please visit

Ormco’s Insignia™ Global Users Meeting set to take place in New York City, October 19 – 21.

Tess Oral Health helps dentists give back while buying back this Halloween Tess Oral Health is once again supporting the Halloween Candy Buy Back program in which thousands of dentists across the nation trade cash, toothbrushes, and rewards for excess Halloween candy post-trick-or-treating and then ships the candy to U.S. troops overseas. The Halloween Candy Buy Back program enables children to have the fun of trick-or-treating and the ability to earn rewards for their candy all while saving their teeth from excessive sweets. Tess Oral Health is supporting the program not only by making a monetary donation, but also by sending one toothbrush to U.S. troops for every box of “Happy Halloween” toothbrushes sold. For more information, contact

46 Orthodontic practice

Ormco™ Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, will host its seventh annual Insignia™ Global Users Meeting in New York City at the Intercontinental New York Barclay, October 19 – 21, 2017. With all new clinical presentations, a focus on CBCT root data integration (TruRoot™), advanced and beginner tracks, a dedicated staff program, mentoring sessions, and numerous networking opportunities, the meeting will provide both visionary and practical views on how Insignia can empower clinical excellence and drive practice growth. Notable speakers and leading orthodontists from over 25 countries around the world are expected to attend. From discussing new and upcoming software enhancements to spotlighting the latest insights from leading orthodontists around the world, the Insignia Global Users Meeting’s clinical program aims to enhance day-to-day practice workflow, patient results, and overall efficiency. The meeting fosters a collaborative learning environment where attendees share their Insignia experiences, challenges, and insights. Workshops, mentoring sessions, and presentations are all focused on relevant topics, from initial smile design to detailed methods for achieving consistent results with challenging cases. For more information about the Insignia Global Users Meeting, visit, or connect with Ormco on Facebook at, and on Twitter via @Ormco.

Volume 8 Number 5

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

CS Airway module aids in airway analysis The CS Airway module is Carestream Dental’s latest enhancement for CS 3D Imaging software. This advanced tool aids general practitioners and orthodontists in quickly analyzing the airway in 3D for clearer visualization, faster analysis, and enhanced communication with patients. The CS Airway module gives doctors a colorcoded 3D view of the pharyngeal region to help them visualize constrictions in airway passages. Doctors can customize the color scale with their preferred threshold to suit their individual needs. Colored 3D renderings allow doctors to easily communicate with patients by showing before-and-after treatment volumes. Additionally, images can be easily shared with referrals, patients, or insurance companies. The module further enhances airway analysis by providing segmentation in as few as two clicks. CS Airway can also automatically calculate total volume, minimum cross-sectional area, minimum anterior-posterior and left-right measurements. These measurement values are displayed in real time as the user browses the slice or changes the angulations of the view. CS Airway is an optional module for CS 3D Imaging and is compatible with CS 9300 and CS 9300 Select volumes. The CS 9300 features Low Dose mode, which can capture images at a dose lower or equal than 2D panoramic imaging* making it ideally suited for airway exams. For more information, call 800-944-6365, or visit www.

3Shape TRIOS® optimizing Narval CC MRD fit and patient comfort ResMed announced that intraoral scanning with 3Shape TRIOS® optimizes its Narval CC Mandibular Repositioning Device (MRD) fit, improves patient comfort, shortens lead times as well as time spent by doctors at chairside. The 3Shape TRIOS intraoral scanner creates digital impressions, used for the computer design of ResMed’s Narval CC MRDs, which are later 3D-printed to create a totally digital workflow from start to finish. The TRIOS integration has enabled ResMed to provide the first customized MRD in Europe. ResMed says that the digital workflow with TRIOS makes the Narval CC fit even better to the patient’s individual anatomy, significantly reducing the level of adjustments needed at chairside. In addition, the 3Shape TRIOS intraoral scanner* allows dental practitioners to take and send patients’ dental impressions digitally, thereby removing the need to make and post plaster models or regular impressions. ResMed noted that digital impressions taken with the 3Shape TRIOS intraoral scanner are characterized by a high degree of accuracy in their reproduction of the maxillary and mandibular arches. Research found that 95% of the devices made out of a digital imprint from 3Shape TRIOS were found to fit well in the mouth even before practitioners made any adjustments. The scanning process was also found to be fast and considered to be convenient or very convenient by 98% of the practitioners who tested it for a Narval CC. Furthermore, it was concluded that the scanner took up little space in the mouth, reducing the level of discomfort for patients, particularly for those who suffered from gag reflex. Overall, 76% of the patients who experienced intraoral scanning with 3Shape TRIOS to receive a Narval CC felt that the process was more comfortable and faster than standard impressions. For more information, visit * 3Shape TRIOS® is the first intraoral scanner to receive a validated workflow from ResMed.

* Based on a study by John B. Ludlow, University of North Carolina, School of Dentistry, August 2014, utilizing the CS 9300 low dose protocol and on a study by John B. Ludlow, University of North Carolina, School of Dentistry, June 2011, measuring the CS 9300 doses and comparing them to panoramic exams dose.

Ormco™ partners with WEO Media to expand marketing services and capabilities for orthodontists Ormco™ Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, announced an exclusive partnership with WEO Media — a fullservice dental marketing and communications company — that will provide Ormco doctors with a variety of comprehensive marketing solutions. Ormco doctors will be granted access to promotional co-marketing packages, preferential pricing, and more. Intended to help orthodontists identify specific marketing needs, generate exceptional ROI, and ultimately grow a practice, WEO Media’s full range of capabilities include custom and mobile website creation, search engine optimization (SEO), pay-per-click ads (PPC), social media management, online patient reviews/reputation management, premium Healthgrades profiles, Yelp advertising, custom video production, direct media marketing, patient newsletters, graphic design, branding, and more. For more information, visit

Volume 8 Number 5

Orthodontic practice 47


What we don’t know continues to hurt us Dr. Joel C. Small discusses self-awareness and motivation to change


xtensive research into behavioral change has identified various stages that lead to purposeful and sustainable behavior modification. The transtheoretical model (Prochaska and Velicer, 1997) of behavioral change describes an initial stage of “precontemplation” in which people are unaware that a behavioral problem exists and, therefore, fail to recognize the consequences of their behavior.1 Such individuals show little interest in changing their behavior because they are simply clueless that their behavior is creating a problem. Abraham Maslow, a noted American psychologist, is attributed with another similar finding that deals with the development of competence. His four stages of competence describe an initial phase of “unconscious incompetence” in which the individual fails to recognize, or is unconscious of his/her own incompetence and, therefore, is unreceptive to learning a new and useful skill that will likely move him/ her toward the competence that he/she so desperately needs. What Maslow describes is, in my opinion, the leading cause of suffering, dissatisfaction, and burnout in the healthcare industry. As a healthcare coach, I spend much of my time helping clients come to the awareness that we are often our own worst enemies by failing to recognize our behaviors that create personal and professional barriers to our fulfillment. This significant blind spot leaves us in a state of limbo — chronically suffering the symptoms of a curable malady yet lacking the capability to acknowledge its existence. Furthermore, our formal education, while teaching us to be masterful technicians, has failed us in the arena of entrepreneurship and leadership competence. Michael Gerber, in his bestselling book, The E Myth, describes a technician as someone who eventually

suffers disillusionment with his/her chosen profession because he/she lacks awareness of the necessary entrepreneurial skills that are essential ingredients for long-term success and fulfillment. I see this problem often in the healthcare industry because, as technicians, healthcare providers create systems to manage and use them as a substitute for entrepreneurism and leadership. Gerber uses the analogy of a juggler with too many balls in the air. Eventually, the juggler is overcome by the task, and the first ball falls, creating a domino effect as the remaining balls follow suit. This, in my opinion, is what happens when healthcare technicians adopt a systems management approach rather than an entrepreneurial and leadership philosophy. Systems management is burdensome and tedious, and unless properly delegated, it becomes overwhelming. No wonder we are prone to disillusionment and burnout. We adopt a systems philosophy that is incompatible with our desired success and fulfillment. Quite simply, we are not suffering because we lack intelligence or even financial success; we are suffering because we lack self-awareness and the motivation to change. Because we suffer from unconscious incompetence, we fail to recognize the real cause of our suffering and tend to blame external forces for our disillusionment. We lack the awareness that we are the ultimate arbiter of our “emotional success.” Our suffering and frustration are both caused by and resolved by us. Once we come to this awareness, we can begin the process of turning frustration into fulfillment, finding passion, and creating energy where burnout once existed. By acknowledging that a problem exists and that we are the cause, we become motivated to acquire the knowledge and skill that will lead to sustainable behavioral change.

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 I am also available for a complimentary coaching session to discuss your practice-related issues.

48 Orthodontic practice

It goes without saying that we cannot solve a problem when we fail to acknowledge its existence. Some of us accept our suffering and dissatisfaction with our profession because we have come to believe that it is part and parcel of our job. We see no realistic resolution to our pain, and we begin to feel trapped and helpless. Metaphorically, we become captives in a cage with no bars. The greatest and saddest irony of all is that our chosen profession is unique in that it offers us the greatest freedom to purposefully create our ideal environment. Many of us chose the healthcare profession for this very reason; we are our own boss. No one can fire us except our regulatory boards. We can work when we want, how we want, and for as long as we want. We can create a large mega practice or find our fulfillment in a small boutique clinical practice. The choice is and always has been ours. Trust me when I say that many of those working in a corporate environment envy us for our degree of freedom and would gladly trade places. Currently, the level of disillusionment in corporate America is approaching epidemic levels2 as budget restraints require more work from fewer people, and corporate layoffs along with the need for retraining have left many loyal workers unemployed with no prospect of a bright future. The good news is that we are not meant to suffer from disillusionment and burnout. With proper guidance and the implementation of some basic entrepreneurial skills, we can find sustainable joy, fulfillment, and financial reward in our clinical practices. If you are currently experiencing frustration or burnout with your chosen profession, seek answers now. Acknowledge that a problem exists and that you likely are the cause of the problem. Also acknowledge that you hold the key to resolving the problem. Seek help, and never accept the false narrative that pain and suffering go with the territory. With the proper mindset and the motivation to change, a better future awaits you. OP REFERENCES 1. Adams S. Most Americans Are Unhappy at Work. Forbes Online. June 20, 2014. susanadams/2014/06/20/most-americans-are-unhappyat-work/#5a6bff30341a. Accessed July 6, 2017. 2. Prochaska JO, Velicer WF. The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion. 1997;12(1):38-48.

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Orthodontic Practice US September/October 2017  
Orthodontic Practice US September/October 2017