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March/April 2018 – Vol 9 No 2

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PROMOTING EXCELLENCE IN ORTHODONTICS Accelerated orthodontics using photobiomodulation Dr. Bill Kottemann

Using suresmile® aligner design therapy to enhance patient care Dr. J. Peter Kierl

A conversation with Dr. Tom Mulligan An alternate approach: closing anterior open bites with low pulsatile forces without relying on vertical elastics

A new perspective on Aligner Design.

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clinical articles • management advice • practice profiles • technology reviews

Dr. Straty Righellis

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INTRODUCTION

The times, they are a-changin’

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s specialists, we lead. We lead in innovative diagnosis and therapeutics, implementation of state-of-the-art technology and, most importantly, quality of patient care. I say that as much as a reminder to myself as I do to my specialist colleagues. Because, to paraphrase Bob Dylan’s song, “The times they are a-changing.” So, what’s happening? In the most general sense, much of what we do clinically today involves digital technology, one way or another. From archwires to aligners, from lingual treatment to IDB, there is almost always a digital option for us to choose at every stage of treatment. Dr. Mark Feinberg There is no question that these new technologies afford us expanding opportunities to deliver predictable and optimal outcomes through enhanced diagnostic and therapeutic capabilities, achieving new levels of efficiency, predictability, and precision. As orthodontists, we tend to be creative and independent-minded as we seek better ways to care for our patients. Direct bonding was a major innovation not so long ago. Now virtually all of us do it. Esthetic brackets formed in plastic or ceramics have become standard, something that would have been hard to imagine in 1970. Wire formulations have become much more sophisticated — and continue to do so — giving us all a broader armamentarium in tooth movement. Even digitally produced aligners, something many, if not most of us, resisted back in the day, have become a standard treatment option. One of the most dynamic and interesting things about this course of constant change and refinement is that much of it has been driven by one of our own. Just go down the list of bracket prescriptions developed by our brilliant colleagues. And even as we make our choices, many of us can’t refrain from tweaking what comes from our manufacturer friends to make it our own. That probably includes you. It’s this path of clinical innovation that’s a defining characteristic of orthodontics in the diagnosis and treatment of our patients. Our predecessors achieved excellent results with fully banded cases and, in the process, began creating new expectations of results — faster, more comfortable, more predictable — and better. Today, as many of our minds have the digital switch flipped, most of us are using many of the different technologies now available. I have integrated the suresmile® system in my practice, the state-of-the-art technology digital treatment system that gives me more flexibility, and precision than I’ve ever had. For diagnostics, planning, and treatment, it’s invaluable and incredibly powerful. Using a digitally designed series of archwires, I’m able to move teeth more predictably than I would have ever thought possible. I also use aligner therapy when it is an appropriate clinical choice, and my treatment goals for our patients can be achieved. Using a hybrid approach of aligners in conjunction with brackets and wires has also provided synergies in our practice, which heretofore were not possible. If you choose CBCT integration, you’ll be able to visualize root, bone, and the safety profile of projected tooth movement. Yes, the times are changing, and I have no doubt that they are changing for the better, for both orthodontists and our patients. The power of digital and the appropriate digital tool sets dramatically advance our ability to deliver excellence in orthodontic care to our patients — and that’s something we should all be passionate about.

Mar/Apr 2018 - Volume 9 Number 2

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 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

Dr. Feinberg received his BS from Fairfield University and his DMD from the University of Connecticut School of Dental Medicine. He completed his certification in orthodontics at Columbia University and then joined the orthodontic practice of his father. Dr. Feinberg is a Diplomate of the American Board of Orthodontics and is currently a clinical associate professor at the University of Connecticut Orthodontic Department. Dr. Feinberg has been a suresmile® doctor since September 2004 and has completed more than 500 cases.

© FMC 2018. All rights reserved. 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.

ISSN number 2372-8396

2 Orthodontic practice

Volume 9 Number 2


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TABLE OF CONTENTS

My strong advice, particularly for young orthodontists, is to become absolutely glued to cause/effect relationships.

A conversation with ... Dr. Tom Mulligan

8

An interview by Dr. Larry White

Case study Micro-osteoperforation as an adjunct to Carriere® Motion 3D™ Dr. Dave Paquette discusses a combination treatment that reduces time in orthodontic treatment........... 24

Orthodontic concepts A conversation with Dr. Carl F. Gugino Dr. Rohit C.L. Sachdeva discusses the revitalization of the ZeroBase Contemporary Bioprogressive Philosophy with today’s dental practices in mind............................. 28

Book review Bell’s Oral and Facial Pain Seventh Edition; 2014 • by Jeffrey P. Okeson, DMD. Quintessence Publishing Co., Chicago, Illinois....... 32

Orthodontic insight Expanding the possibilities: Using suresmile® aligner design therapy to enhance patient care

Clinical 14 A modification of the Wits appraisal is proposed for patients with high FMA or with long lower face height — a supplementary assessment Dr. John L. Hayes discusses an alternative to the Wits appraisal for certain types of patients

4 Orthodontic practice

Dr. J. Peter Kierl discusses how his practice incorporates aligner therapy .......................................................34

Staging clear aligners Dr. John Wise shares his strategies for creating clear aligners in-office......... 42

Volume 9 Number 2


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TABLE OF CONTENTS

Continuing education An alternate approach: closing anterior open bites with low pulsatile forces without relying on vertical elastics Dr. Straty Righellis discusses an alternative treatment option for correcting occlusion and smile esthetics with braces........................48

Continuing education

55

Accelerated orthodontics using photobiomodulation

Dr. Bill Kottemann examines the process of photobiomodulation to accelerate orthodontic tooth movement

Product profile Insignia™ Advanced Digital Orthodontic Solution

Practice management

Your vision, customized...................62

“The secret sauce” — more than the golden rule: part 2

New software enhancements improve workflow in orthodontic offices

Dr. Donald J. Rinchuse discusses the many facets of a customer serviceoriented practice..............................82

Carestream Dental’s latest updates .......................................................64

Orthodontic perspective Correcting the least emphasized feature of orthodontic therapy Dr. Larry White relates the quality of oral hygiene and tooth-brushing regimens to orthodontic outcomes .......................................................66

Research study Adult perceptions of orthodontic appliances Drs. Richard Patterson, Daniel Rinchuse, Thomas Zullo, Lauren Sigler Busch, and Kay Youn, MFA, study the connection between braces and positive perceptions.........................72 6 Orthodontic practice

Legal matters Risk management: supplemental informed consent documents Drs. Donald J. Rinchuse and Dara L. Rinchuse suggest some helpful information on informed consent .......................................................92

Industry news.............102 Product profile 3Shape Ortho System™ 2017 software for orthodontics 3Shape Indirect Bonding workflow receives FDA 510(k) market clearance .....................................................104

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkmedia.com ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER | Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com OFFICE MANAGER/EXECUTIVE ASST. | Mystey Helm Email: mystey@medmarkmedia.com OFFICE ASSISTANT | Lauren Drake Email: lauren@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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Volume 9 Number 2


A CONVERSATION WITH ...

Dr. Tom Mulligan An interview by Dr. Larry White

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r. Tom Mulligan came to the attention of the orthodontic community in 1980 when he published a series of articles in the Journal of Clinical Orthodontics entitled “Common Sense Mechanics,” which he subsequently published in a book that has undergone three editions. Common Sense Mechanics has been one of the most popular and useful books on orthodontic biomechanics ever written and is destined to be so for many years.

Tom, you finished dental school at Marquette and then studied orthodontics at Indiana University under Dr. Charles Burstone. Tell us something about that experience. Following the completion of dental school at Marquette, I entered the graduate program in orthodontics at Indiana in 1960. I had no idea that such programs could differ significantly at various universities. Like my basic training in the military, I assumed the majority of schools would subject me to what essentially was basic training. However, I was exposed to a program that was unique — something I did not fully realize until graduation. When I joined the Arizona Orthodontic Study Group following my graduation, as a new member I was required to give a summary of my Indiana Orthodontic Training under Dr. Charles Burstone. This was my very first experience in lecturing. When I finished, no one had any idea of what I was talking about, and this came as a complete shock to me — especially since the Arizona Orthodontic Study Group had a reputation of being one of the best at that time. Orthodontists throughout the world were familiar with the name, “Dr. Charles Tweed,” who practiced orthodontics in Tucson, Arizona. He was world famous for the Tweed Technique. It was now clearly time for Dr. Charles Burstone to thoroughly teach mechanics.

Had Dr. Burstone developed his concepts of orthodontic biomechanics when you started your residency? And was his segmented mechanics part of your training, and did you ever use it? Dr. Burstone became famous worldwide for the Segmented Arch Technique, 8 Orthodontic practice

and our class was exposed to orthodontic mechanics that simply did not exist in any other orthodontic program. Many aspects of Burstone mechanics were contrary to generally taught orthodontic mechanics. At that time, Burstone mechanics were not widely applied throughout the world due to its presumed complexity. I felt fortunate to have entered this program, as I was raised in a large family of 10 children and always questioned everything because I was very “cause/effect” oriented. I wanted to understand every aspect of Burstone mechanics and constantly asked the question, “Why?” I am sure I drove people crazy, including Dr. Burstone, but he answered all of my questions patiently, thoroughly, and completely. Dr. Burstone always provided the cause/ effect relationships and the rationales for applying his mechanics. In 53-plus years of orthodontic practice, I never used the Segmented Arch Technique, but this is not to imply that I disagreed with Dr. Burstone’s concepts. I simply applied the mechanics in a different way that met my needs, but without violating the equilibrium concepts, etc., that apply to all tooth movements and were the basis of his mechanics. Many excellent orthodontists frequently violate these biomechanical fundamentals and simply don’t recognize them, but as a result, find it necessary to use various auxiliaries to overcome side effects that many clinicians consider common and unavoidable in orthodontics.

You illustrate in your book partial bonding, such as two molars and four incisors or two molars and six anterior teeth, rather than a complete bonding that includes all of the teeth. Why do you recommend that approach? When I started my career, full appliances were considered an absolute requirement in order to obtain excellent results. I rarely began treatment with full appliances and applied mechanics based on cause/effect relationships. Most orthodontists were taught that second molars should always be banded. If they were in a normal position with a normal Curve of Wilson or a normal Curve of Monson, I did not place a tube on

Dr. Tom Mulligan

the second molars contained in the normal curve unless I intended to change the anterior/posterior positions of such molars. Many individuals failed to appreciate the significance of these “functional curves,” and, as a result, unintentionally overlooked the stability intended by their long axis relationships during occlusal function. This in itself is often responsible for the prolonged need of retainers and therefore responsible for relapses that occurred with loss of retainer(s) or not wearing retainers as instructed. Placing full orthodontic appliances routinely results in the creation of instability in various locations — just the opposite of what is intended. When a full appliance is placed and continuous archwires fully engaged, as clinicians frequently do, teeth that require no movement whatsoever frequently move undesirably, as they became “participants” in the total force system produced as a result of the requirements for static equilibrium. A continuous archwire does not restrict itself to correction of only the malposed teeth. The requirements for static equilibrium must always be met without exception and the effects clearly recognized. When the orthodontist places archwires, three conditions create automatically for static equilibrium: 1) The sum of the vertical forces equals zero. 2) The sum of the horizontal forces equals zero. 3) The sum of the moments around a common point equals zero. If we fail to recognize the forces and moments beyond the movements we are attempting, we can witness side effects that are totally unpredictable. Such failure to recognize the significance of these Volume 9 Number 2


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A CONVERSATION WITH ... requirements has led to an unbelievable assortment of appliances intended to prevent undesirable side effects, such as lingual arches, palatal arches, elastics, removable appliances, functional appliances, etc. All of these mentioned factors led me to begin the vast majority of my treatments with a partial appliance — usually a 2 x 4 or 2 x 6. The static requirements led me to avoid rectangular wire except in very rare situations. As a result, I became accustomed to the use of round archwires, partial appliances, etc., and avoided second molars unless they needed movement of one kind or another.

To give readers an idea of your edgewise appliances, could you tell us what type of brackets, bands, wires, etc., you typically use, and why you chose those instruments? Many other so-called requirements involving bracket slots, torque, width, angulation, etc., as taught by various schools and courses, has become almost a necessity by most orthodontists. I was able to substitute these needs with the use of standard stainless steel brackets containing no angulated slots and stainless steel round wire, none of which were ever intended to fill the bracket slots. Orthodontists claimed that round wire could not provide the torque required in many malocclusions. For example, if incisors intrude with a partial appliance using only round wire, the molars extrude. What would prevent the molars from moving lingually due to the eruptive forces acting through the molar tubes and buccal to the Center of Resistance, which results in lingual crown moments on the molars? The answer is so simple, and I did this throughout my orthodontic career. Forty-five degree bends, placed distal to the canines and acting in a buccal direction relative to the molars, produce molar buccal crown moments larger than the lingual crown moments produced by the vertical forces acting through the molar tubes. Remember that Force X Distance = Moment. This produces a net buccal force acting through the molar tube resulting in a buccal crown moment. This is where a partial appliance is so special. A full appliance would not direct the buccal force to the molars with the 45 degree bend. Now you can see that the use of round wire with partial appliances allows the operator to produce moments in different planes of space with the same archwire, at the same time, without suffering the various consequences of rectangular wire and the side effects that may occur with 10 Orthodontic practice

My strong advice, particularly for young orthodontists, is to become absolutely glued to cause/effect relationships.

the higher magnitudes of force, including occlusal-plane tipping, etc. To sum up this procedure, vertical forces with round wire can cause moments that can create a problem, but the addition of horizontal forces, as described, can correct or prevent such a problem. Why? Because the vertical forces acting through the molar tubes act at a shorter perpendicular distance to the Center of Resistance, while the horizontal forces act at a significantly longer perpendicular distance to this same Center of Resistance, thus creating a net moment in the horizontal plane, which eliminates the need for rectangular wires and tubes or brackets that permit the development of torque within the brackets.

You often use tip-back bends on Class II maxillary molars to achieve a Class I occlusion, but doesn’t the presence of a second molar limit the effect of the tip-back bend? The question as to whether the presence of second molars limits the effect of tip-back bends in the correction of a Class II depends on a number of issues. First of all, the presence of a Class II malocclusion may exist at various ages. When the situation involves diminishing growth and the tip-back bends are being used to simply maintain the AP position of the molars as growth continues, there is no problem. If the molars involve a Class II with mesial tipping of the molars, the tip-back bends are very effective. The important thing to remember is that tip-back bends produce differential moments with relatively light vertical forces due to the large interbracket distances involved. Remember also that these vertical forces produce lingual crown moments that can be easily overcome with buccal crown moments if required, as previously explained. These vertical forces in a partial appliance do not increase the vertical dimension of the patient because of relatively low magnitudes, so “what you see is what you get.” One of the most significant aspects is that the tip-back bends do not require cooperation from the

patient as does a headgear. Both produce distal crown moments, but only one requires patient compliance. This isn’t magic, but rather simplicity in which the orthodontist determines the outcome rather than the patient who must wear the headgear.

In the latest edition of Common Sense Mechanics, you don’t mention the use of headgears. Was that intentional, or did you evolve in your treatment mechanics to not need them? I did use headgear minimally, but I didn’t use them for the past 25-30 years and have relied only on tip-back bends. There were times when I used Class II elastics knowing it would create instability in certain cases, but this typically had to do with facial profiles or some type of compromise.

You had practiced orthodontics about 10 years before Straight Wire Orthodontics was introduced. Did you ever use the SWO technique and, if not, why? I have never used the Straight Wire technique in orthodontics because I was comfortable with the approach I used by applying Dr. Burstone’s teachings. I don’t mean to imply that one method is right and the other wrong, but as I have already said, I am very cause/ effect oriented.

One of the most significant developments in orthodontics has been nitinol wire, but I have heard you mention that you have never felt the need to use it, nor do you use any loops to decrease the force of wires and increase the range of wire action. Why is that, and what is your alternative? The answer is simply absolutely not. Keep in mind that because of 2 x 4 and 2 x 6 treatment — at least in the earlier stages of treatment — my patients experienced relatively light forces, since load-deflection rates involve significantly larger interbracket Volume 9 Number 2


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A CONVERSATION WITH ... distances than full appliances. Also, keep in mind that load-deflection rates vary inversely to the cube of the length. Excessive force magnitudes were not a consideration in my practice, as I did not have to worry about an increase in vertical dimension due to excessive force magnitudes.

Over the past 30 years in orthodontics, so-called noncompliance bite correctors such as Herbst appliances, Forsus™, MPAs, Jasper Jumpers, and so on have had an enormous appeal. Have you ever used these appliances and, if not, why? I understand the excitement so many orthodontists experience with Herbst appliances, Forsus, MPAs, Jasper Jumpers, etc. However, I am not one of them. I don’t mean that I think I am better or smarter. That is simply not the case. But because of my training under Dr. Burstone, I cannot help but look at the “entire mechanics” from the first day of treatment rather than deciding what appliance(s) I might choose “along the way.”

Most orthodontists rely on edgewise wires within the brackets to deliver maxillary incisor lingual root torque, but is this the most efficient or even the most desirable way of torquing anterior teeth? Many orthodontists have asked me why I don’t use rectangular wire to torque teeth. It is because of a number of things. First of all, I don’t like high force magnitudes. Labial or lingual torque of the incisor segment can produce tipped occlusal planes because of the balancing forces. Lingual root torque

of the incisor segment, for example, if left for a sufficient period of time, can result in posterior open bites, possible canting of the occlusal plane, not to mention increases in anterior overbite. With round wire, there are various ways to incorporate intrusive forces that lie anterior to the Center of Resistance in the incisor segment while avoiding posterior eruption of teeth due to the relatively long interbracket distances to the posterior segments. Remember that with partial appliances – rather than full appliances – the vertical forces reduce significantly, not to mention that one-half of that force goes to each side.

Currently, one of the most emphasized features of orthodontic therapy is the mini-screws for osseous anchorage. Did you ever make these a part of your armamentarium and, if not, why? I have never used miniscrews for osseous anchorage because with partial appliances and round stainless steel wire, I can use differential moments to create the needed anchorage.

Can you explain how you prepare patients for retention and how you retain them long term? When it comes time to retain a patient, I typically removed all archwires for a minimum of 6 weeks to check on stability. I frequently did this during treatment as well in order to predict the degree of retention one might expect, if any. Very often retention was not indicated although I usually provided nighttime retainers with the explanation that for many individuals, some mandibular

crowding tends to develop with time — with or without orthodontic treatment. Retainers, when provided, are worn day and night for 6 weeks, then night only (usually up to 6 months), and then “try-in only each night” for the rest of their lives! Why the latter? Somewhere liability must be transferred. I didn’t want any patients coming to my office 10 years later and saying they lost their retainer “several years ago.” Frankly, I really never had a problem with this approach, although I give credit to the partial appliances that, for the most part, preserved the normal position of teeth and therefore served as references for the correct position of the malposed teeth, thus increasing the odds of stability.

What advice would you offer young orthodontists just beginning their careers? My strong advice, particularly for young orthodontists, is to become absolutely glued to cause/effect relationships. Always mentally “see” the entire force system associated with whatever tooth movement you attempt. If you are only rotating a bicuspid, do not allow yourself to simply “view” the moment required. Learn to always visualize the entire force system, as there will be other teeth affected. If you fail to make this approach, I can assure you that you will be making unnecessary orthodontic purchases throughout your career. An understanding of fundamental mechanics will help you avoid buying what you shouldn’t need.

Thank you, Dr. Mulligan, for taking the time to share your professional life with our readers. OP

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12 Orthodontic practice

Volume 9 Number 2


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CLINICAL

A modification of the Wits appraisal is proposed for patients with high FMA or with long lower face height — a supplementary assessment Dr. John L. Hayes discusses an alternative to the Wits appraisal for certain types of patients Abstract The proposed Wits modification uses a newly constructed “normal” occlusal planemandibular plane angle (NOP-MP) of 17 degrees (15 degrees for patients less than 12 years old) to replace a patient’s actual occlusal plane-mandibular plane angle (OPMP) in certain situations. Perpendiculars from the new NOP to points A and B are drawn in the same manner as with the conventional Wits measurement. The NOP was derived from our study of the “lateral radiographic tracings,” which are part of the Bolton Standards of Dentofacial Development Growth. The Bolton Standard Study data base includes over 5000 “normal” patients.1 A modified Wits appraisal has advantages in the cephalometric evaluation of anteroposterior harmony for patients with high FMA or patients with long lower face height; ANB and Wits are unreliable in those situations. The modified Wits measurement has a second advantage in that it highlights untoward vertical skeletal growth noted at the anterior body of the mandible (L1 Tip to Menton, as viewed on a lateral cephalometric film). A third advantage of the proposed modified Wits measurement is that it takes the guesswork out of occlusal plane construction for patients with an anterior open bite (AOB). Accordingly, the modified Wits appraisal is supplementary to the conventional Wits assessment.

Introduction Jacobson’s “Wits” assessment was introduced in 1975 in the American Journal of Orthodontics.2 Jacobson’s Wits manuscripts John L. Hayes, DMD, MBA, received his dental degree from the Boston University, H.M. Goldman School of Graduate Dentistry and his orthodontic certificate from the University of Pennsylvania, School of Dental Medicine, Orthodontic Department where he is a Clinical Associate. He continues to research and lecture on the advantages of early interceptive treatment and on the etiology of malocclusions. Dr. Hayes is in private practice in Williamsport, Pennsylvania, with his wife, Sharon, who is also an orthodontist. He can be reached at jhayesortho@comcast.net.

14 Orthodontic practice

appeared again in the American Journal of Orthodontics (19763 and 19804), the Angle Orthodontist (1988),5 and was included in the first edition of his textbook, Radiographic Cephalometry.6 Jacobson’s “Wits” assessment was seen by many to be a breakthrough in sagittal skeletal diagnosis versus the ANB appraisal. In his update manuscript (1988),5 Jacobson listed several authors who published followup studies on the Wits assessment.7-12 In his 1975 manuscript, Jacobson chose four different scenarios to help illustrate the diagnostic advantages of “Wits”: Scenario No. 1: Two patients with significantly different skeletal profiles were shown. However, both featured an ANB of 7 degrees, while the Wits values were significantly different as one would expect — 10 mm and 0 mm. Scenario No. 2: Two patients with significantly different skeletal profiles were shown.

However, both featured an ANB of 6 degrees, while the Wits values were significantly different as one would expect — 6 mm and 0 mm. Scenario No. 3: Two patients both with an ANB of 1 ­ .5 degrees with Wits values of neg. 1.5 mm and neg. 12 mm. Scenario No. 4: Two patients with an ANB of 9 degrees and 8 degrees with Wits values of neg. 8 mm and neg. 2.5 mm, respectively. The case for the use of the Wits appraisal was clear — Jacobson’s examples revealed that Wits was superior to ANB, at least for the cases that Jacobson chose to present. Jacobson did not cover those potential situations where Wits and ANB might be equally diagnostic and where Wits would not be diagnostic. Some readers may not have been aware that the Wits assessment had some shortcomings. Jacobson5 warned of concerns with the Wits assessment: 1. “Assessment of anteroposterior apical base discrepancy by applying

Glossary 1. A point — “Subspinale [is] the most posterior midline point in the concavity between the anterior nasal spine and the prosthion.”6 2. ANB — angle formed by lines drawn from A point to nasion to B point. 3. B point — “Supramentale [is] most posterior midline point in the concavity of the mandible between the most superior point on the alveolar bone overlying the lower incisors (infradentale) and pogonion.”6 4. FMA — Angle formed by intersection of Frankfort horizontal line and the mandibular plane (MP). 5. Frankfort horizontal — A line drawn from porion to orbitale. 6. LFH — Lower face height is the measured length from menton to anterior nasal spine (ANS). 7. LFH/TFH — The percentage of lower face height given the total face height. 8. Modified Wits assessment — The horizontal distance in mm on the NOP (17 degrees from the mandibular plane [MP], 15 degrees if the patient is less than 12 years old) found by perpendiculars drawn from both A and B points to the NOP. 9. MP — Mandibular plane is a line drawn from gonion to menton (Jacobson used gonion to gnathion). 10. MP angle — Angle formed by intersection of MP and SN. 11. NOP-MP — Normal occlusal plane-mandibular plane is an angle 17 degrees from the MP, which represents the normal occlusal plane the value of which was determined from the Bolton Standards of Dentofacial Development Growth (15 degrees is used for patients less than 12 years old). The line passes between the 6 year molars as with the OP, and extends beyond the central incisors. 12. OP — Occlusal plane or functional occlusal plane (FOP) is a line draw between the 6 year molars in areas of maximum intercuspation in occlusion to the middle of the incisor overlap [or bisecting the distance between non occluding molars] or bisecting the incisor occlusal tips in open bite situations. 13. SNA — An angle formed by lines drawn from sella-to-nasion-to A point. 14. SNB — An angle formed by lines drawn from sella-to-nasion-to B point. 15. TFH — Total face height is the sum of LFH and UFH. 16. UFH — Upper face height is the measured length from nasion to anterior nasal spine (ANS). 17. Wits — The horizontal distance in mm on the OP found by perpendiculars drawn from both A and B points to the OP.

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CLINICAL

Figure 2: Occlusal plane to mandibular plane increases slightly with age1

Figure 1: Occlusal plane to mandibular plane increases slightly with age1

the Wits appraisal is largely dependent upon correct location or representation of the occlusal plane.” 2. “No single parameter in cephalometrics should be relied upon entirely and interpreted as an absolute value.” In our opinion, it cannot be emphasized enough that a small difference in the location of the OP or NOP can have an important effect on the Wits and modified Wits diagnosis. Jacobson promoted linear versus angular measurements: “While there is no compatibility between angular and physical units, the study of Baumrind and Frantz (1971) showed that the absolute values of errors and the variability among replicated estimates tend to be greater for angular measures than for linear measures.”5 Dissatisfactions with the ANB and Wits assessments are not new. Many authors have expressed their disappointments. Some proposed their own creative ANB and Wits replacements.13-30 The proposed Wits modification uses a newly constructed “normal” occlusal planemandibular plane angle (NOP-MP) of 17 degrees (15 degrees for patients less than 12 years old) to replace a patient’s actual occlusal plane-mandibular plane angle (OP-MP) in certain situations. Perpendiculars from the new NOP to points A and B are drawn in the same manner as with the conventional Wits measurement. The NOP was derived from our study of the “lateral radiographic tracings,” which are part of the Bolton Standards of Dentofacial Development Growth. The Bolton Standard Study data base includes over 5000 “normal” patients.1 A modified Wits appraisal has advantages in the cephalometric evaluation of anteroposterior harmony for patients with high FMA or patients with long lower face height; ANB and Wits are unreliable in those situations.13-30 The modified Wits measurement has a second advantage in that it highlights untoward vertical skeletal growth (growth beyond “normal”) noted at the anterior body of the mandible (L1 Tip to Menton, as viewed 16 Orthodontic practice

Table 1: Proposed suggestions for application of ANB, Wits, and modified Wits Item

Cephalometric value

Wits (A and B to OP)

ANB

1

Low Angle FMA ≥ 23º

2

Normal Angle FMA 25º (24º-26º)

3

High Angle FMA ≤ 27º

4

Low SNA ≥ 80º

5

Normal SNA 82º (81º-83º)

6 7 8

Normal SNB 80º (78º-82º)

9

High SNB ≤ 83º

Modified Wits (A and B to NOP)

X

OK

X

OK

OK

OK

X

X

OK

X

OK

OK

OK

OK

OK

High SNA ≤ 84º

X

OK

OK

Low SNB ≥ 77º

X

OK

OK

OK

OK

OK

X

OK

OK

10

Short LFH/TFH ≥ 53%

OK

OK

X

11

Normal LFH/TFH 55% (54%-56%)

X

OK

OK

12

Long LFH/TFH ≤ 57%

X

X

OK

Key: X = not recommended OK = recommended

Table 2 Case No.

ID

MP-OP degrees

ANB degrees

Wits OP-MP mm

Modified Wits NOP-MP mm

SNA degrees

SNB degrees

LFH/ TFH %

Mand. Plane MP/SN degrees

FMA

Private Practice Cases 1

7989

30.2

9.4

13.1

neg. 0.5

84.6

75.2

62%

41.7

34.6

2

9044

23

3.5

neg. 2.6

neg. 9.5

80.5

77

57%

43.9

31.8

Cases from Jacobson’s 1975 Manuscript 3

9B

21.2

8.4

0

neg. 6.0

85.9

77.5

58%

43.3

41.3

4

14B

28.7

7.2

0.6

neg. 8

83.4

76.3

57%

50

44/AOB

on a lateral cephalometric film). A third advantage of the proposed modified Wits measurement is that it takes the guesswork out of occlusal plane construction for patients with an anterior open bite (AOB). Accordingly, the modified Wits appraisal is supplementary to the conventional Wits assessment.

Materials and methods The data for the determination of normal occlusal plane-mandibular plane (NOP-MP) values (17 degrees and 15 degrees depending on patient age) came from the Bolton Standards of Dentofacial

Development Growth lateral radiographic tracings1 (Figure 1 and Figure 2). • “The Bolton Study is fortunate in being one of the largest longitudinal studies of this nature ever conducted.” • “The Bolton Standards ... have been derived from actual cases that present a so-called normal condition of dentofacial morphology as well as alignment … they are a representation of the ‘optimum’[and not a statistically averaged condition]”1 [our brackets]. The Bolton Study lateral radiographic tracings (ages 4 through 18 years) were digitized Volume 9 Number 2


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CLINICAL using Dolphin Imaging 11.8 Premium. An individual tracing was entered as a “new patient” time point, scanned (Epson V750 Pro), captured, and then digitized. An individual tracing was entered as a “new patient” time point, scanned, captured, and then digitized. This allowed cephalometric data (including OP/MP) to be graphed and studied for cephalometric landmark changes. Two patients from private practice were also digitized in a similar manner as well as two cases from Jacobson’s 1975 manuscript.5 We used 3M PP2500 transparency film with the 15 and 17 degree angles printed on the film as a reusable overlay (Figure 2). The transparency film was placed over the lateral cephalometric tracing with the gonion and menton aligned at the lower border — the film was then moved fore and aft to intersect the 6-year molars at maximum intercuspation — estimating the approximate central fossa location with a dot. Another dot was marked at the extension on or near the central incisors. The film was removed and a line connecting the dots was drawn which represents the normal occlusal plane (NOP). Perpendiculars from the new NOP to points A and B were drawn in the same manner as with the conventional Wits measurement.

Discussion In a perfect world, a “one-size-fitsall” sagittal skeletal assessment might be possible — however, the world is not perfect. We hope to use an appraisal from a selection of assessments for a reliable patient fit. What is the most reliable appraisal for a patient? Table 1 suggests conditions where ANB, Wits, and the modified Wits are most reliable and also situations where they are not; the ANB, Wits, and modified Wits assessments were each graded against 12 cephalometric situations. The 12 cephalometric situations were chosen from insights gained from the manuscripts listed previously.13-30 Table I also reveals among other things that in 6 out of 12 situations, conventional Wits should be more trusted than ANB for diagnosis. There was no situation where ANB should be more trusted than conventional Wits. In 2 out of 12 situations, modified Wits should be more trusted than conventional Wits; those two situations are important because they can involve orthognathic surgery in the treatment plan. Accordingly, we have proposed the modified Wits assessment as a supplementary assessment to conventional Wits. When FMAs are “high” and lower face heights are “long” or when there is an anterior open bite — both ANB and conventional Wits become unreliable. When FMA, SNA, and 18 Orthodontic practice

Figure 3: Case 1. ANB angle of 9.4 degrees; Wits of 13.1 mm and modified Wits of neg. 0.5 mm. An ANB of 9.4 degrees suggests moderate CLII; Wits of 13.1 mm suggests surgical CL II case; modified Wits of neg. 0.5 mm suggests CL I pattern. The high angle of 34.6 degrees suggests that the modified Wits might be the best choice. The treatment plan would depend on the assessment chosen: Wits (a mandibular advancement) or modified Wits (non-surgical treatment or maxillary impaction surgery – FMA 34.6 degrees)

Figure 4: Case 2. ANB of 3.5 degrees; Wits of neg. 2.6 mm; modified Wits of neg. 9.5 mm. An ANB of 3.5 degrees suggests mild CL II; Wits of neg. 2.6 mm suggests some CL III tendency; modified Wits of neg. 9.5 mm suggests CL III surgical risk pattern. The FMA of 31. 8 degrees rules out both ANB and Wits. Low SNA and SNB rule out the ANB measurement. A treatment plan based on the modified Wits assessment would be recommended Volume 9 Number 2


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CLINICAL SNB are “normal,” ANB, conventional Wits and modified Wits are equally diagnostic. From one private practice, two digitized cases (Nos. 1 and 2), were chosen and are shown in Figures 3 and 4. Two digitized cases from Jacobson’s 1975 Wits study case (Nos. 3 and 4), were also chosen to help illustrate situations not covered by Jacobson and are shown in Figures 5 and 6. As an aid for visualization, the NOP is shown as a dashed red line in Figures 3-6, while the actual OP is shown as a black line. By counting the number of red circled items for each patient on Table 3, the best sagittal assessment can be determined. Table 2 provided the cephalometric values to be checked against the 12 items in Table 3. The modified Wits measurement is based on normal vertical growth; thus, the NOP-MP angle also helps reveal untoward growth. The accurate location of the occlusal plane with anterior open bite (AOB) situations becomes a non-issue when the NOP-MP is used. For growing patients, the easy identification of untoward vertical growth can be helpful for treatment planning. The mandibular plane angles chosen (15 or 17 degrees) for a normal occlusal plane (NOP-MP), in our opinion, are generally representative and have proven reliable in over 2 decades of trial in private practice; the occlusal plane increases slightly with age (digitized data from the Bolton Growth Study,1 Figure 1). In order to assign an exact NOP value for a given patient — if that were to be feasible — an individual’s facial vertical growth along the NOP continuum would need to be known in real time.

Figure 5: Case 3. ANB of 8.4 degrees; Wits of 0 mm; modified Wits of neg. 6.0 mm. Jacobson2 suggested that this case was closer to a CL I pattern than a strong CL II. The modified Wits assessment suggests otherwise — a CL III patient. Given the high FMA of 41.3 degrees, the treatment plan should be based on the modified Wits assessment

Conclusions 1. The proposed reliability of ANB, Wits, and modified Wits, and the eventual choice of the most reliable sagittal skeletal assessment can be determined by a patient’s fit with 12 cephalometric situations (Table 1). 2. We found two situations out of 12 where modified Wits was more reliable than conventional Wits (high-angle FMA and long LFH/TFH) (Table 1).These two situations are important as they can involve orthognathic surgery in the treatment plan. 3. The modified Wits measurement has a second advantage in that it highlights untoward vertical skeletal growth noted at the anterior body of the mandible (L1 Tip to Menton, as viewed on a lateral cephalometric film). 4. A third advantage of the proposed modified Wits measurement is that it takes the guesswork out of occlusal plane 20 Orthodontic practice

Figure 6: Case 4. ANB of 7.2 degrees; Wits of 0.6 mm; modified Wits of neg. 8 mm. Jacobson2 suggested that this case was more of a CL I situation rather than a CL II; the modified Wits of neg. 8.4 mm suggests a moderately severe CL III situation. The high mandibular plane angle of 44º causes both ANB and Wits to be less reliable. We would recommend a treatment plan based on the modified Wits assessment Volume 9 Number 2


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CLINICAL Table 3A: Case 1 from private practice ID 7989 Item

Cephalometric value

Table 3B: Case 2 from private practice ID 9044

ANB

Wits (A and B to OP)

X

OK

X

1

Low Angle FMA ≥ 23º

OK

OK

OK

2

Normal Angle FMA 25º (24º-26º)

Modified Wits (A and B to NOP)

Item

Cephalometric value

ANB

Wits (A and B to OP)

X

OK

X

OK

OK

OK

Modified Wits (A and B to NOP)

1

Low Angle FMA ≥ 23º

2

Normal Angle FMA 25º (24º-26º)

3

High Angle FMA ≤ 27º

X

X

OK

3

High Angle FMA ≤ 27º

X

X

OK

4

Low SNA ≥ 80º

X

OK

OK

4

Low SNA ≥ 80º

X

OK

OK

5

Normal SNA 82º (81º-83º)

OK

OK

OK

5

Normal SNA 82º (81º-83º)

OK

OK

OK

6

High SNA ≤ 84º

X

OK

OK

6

High SNA ≤ 84º

X

OK

OK

7

Low SNB ≥ 77º

X

OK

OK

7

Low SNB ≥ 77º

X

OK

OK

8

Normal SNB 80º (78º-82º)

OK

OK

OK

8

Normal SNB 80º (78º-82º)

OK

OK

OK

9

High SNB ≤ 83º

OK

10

Short LFH/TFH ≥ 53%

11 12

X

OK

OK

9

High SNB ≤ 83º

OK

OK

X

10

Short LFH/TFH ≥ 53%

Normal LFH/TFH 55% (54%-56%)

X

OK

OK

11

Long LFH/TFH ≤ 57%

X

X

OK

12

Table 3C: Case 3 from Jacobson2 ID 9B Item

Cephalometric value

X

OK

OK

OK

X

Normal LFH/TFH 55% (54%-56%)

X

OK

OK

Long LFH/TFH ≤ 57%

X

X

OK

ANB

Wits (A and B to OP)

Modified Wits (A and B to NOP)

X

OK

X

OK

OK

OK

Table 3D: Case 4 from Jacobson2 ID 14B

ANB

Wits (A and B to OP)

X

OK

X

1

Low Angle FMA ≥ 23º

OK

OK

OK

2

Normal Angle FMA 25º (24º-26º)

Modified Wits (A and B to NOP)

Item

Cephalometric value

1

Low Angle FMA ≥ 23º

2

Normal Angle FMA 25º (24º-26º)

3

High Angle FMA ≤ 27º

X

X

OK

3

High Angle FMA ≤ 27º

X

X

OK

4

Low SNA ≥ 80º

X

OK

OK

4

Low SNA ≥ 80º

X

OK

OK

5

Normal SNA 82º (81º-83º)

OK

OK

OK

5

Normal SNA 82º (81º-83º)

OK

OK

OK

6

High SNA ≤ 84º

X

OK

OK

6

High SNA ≤ 84º

X

OK

OK

7

Low SNB ≥ 77º

X

OK

OK

7

Low SNB ≥ 77º

X

OK

OK

8

Normal SNB 80º (78º-82º)

OK

OK

OK

8

Normal SNB 80º (78º-82º)

OK

OK

OK

9

High SNB ≤ 83º

X

OK

OK

9

High SNB ≤ 83º

X

OK

OK

10

Short LFH/TFH ≥ 53%

OK

OK

X

10

Short LFH/TFH ≥ 53%

OK

OK

X

11

Normal LFH/TFH 55% (54%-56%)

X

OK

OK

11

Normal LFH/TFH 55% (54%-56%)

X

OK

OK

12

Long LFH/TFH ≤ 57%

X

X

OK

12

Long LFH/TFH ≤ 57%

X

X

OK

Key: X = not recommended OK = recommended

construction for patients with an anterior open bite (AOB). That advantage accrues from the use of a “normal” occlusal plane (NOP), as a replacement for the actual occlusal plane (OP). 5. Our analysis could not find a parameter where ANB was superior to Wits — although ANB appears to be equally reliable versus Wits in four out of 12 situations (Table 1). 6. For normal angle FMA, normal SNA and normal SNB … ANB, Wits and modified Wits are equally diagnostic (Table 1). 7. For short LFH/TFH … ANB, and Wits are equally reliable (Table I). OP REFERENCES

5. Jacobson A. Update on the Wits appraisal. Angle Orthod. 1988;58(3):205-219.

19. Freeman RS. Adjusting A-N-B angles to reflect the effect of maxillary position. Angle Orthod. 1981;51(2):162-171.

Jacobson A. Radiographic cephalometry. 1st ed. Carol Stream, Il: Quintessence Publishing Co, Inc.; 1995.

20. Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engle GA. Orthodontic diagnosis and planning. Rocky Mountain Data Systems. Denver, CO; 1982

6.

7. Sperry TP, Speidel TM, Isaacson RJ, Worms FW. Differential treatment planning for mandibular prognathism. Am J Orthod. 1977;71(5):531-541. 8. Kim Y, Vietas J. Anteroposterior dysplasia indicator: an adjunct to cephalometric differential diagnosis. Am J Orthod. 1978;73(6):619-633. 9. Rotberg S, Fried N, Kane J, Shapiro E. Prediction the “Wits” appraisal from ANB angle. Am J Orthod. 1980;77(6):636-642. 10. Bishara SE, Fahl JA, Peterson LC. Longitudinal changes in the ANB angle and Wits appraisal. Am J Orthod. 1983;84(2):133-139.

22. Chang HP. Assessment of anteroposterior jaw relationship. Am J Orthod Dentofacial Orthop. 1987;92(2):117-122. 23. Oktay H. A comparison of ANB, Wits, AF-BF, and APDI measurements. Am J Orthod Dentofacial Orthop. 1991;99(2):122-128. 24. Nanda RS, Merrill RM. Cephalometric assessment of sagittal relationship between maxilla and mandible. Am J Orthod Dentofacial Orthop. 1994;105(4):328-344

11. Jarveninen S. An analysis of the variation of the ANB angle: a statistical appraisal. Am J Orthod. 1985;87(2):144-146.

25. Haynes S, Chau MNY. The reproducibility and repeatability of the Wits analysis. Am J Orthod Dentofacial Orthop. 1995;107(6):640-647.

12. Sherman SL, Woods M, Nanda RS. The longitudinal effects of growth on the Wits appraisal. Am J Orthod Dentofacial Orthop. 1988;93(5):429-436.

26. Foley TF, Stirling DL, Hall-Scott J. The reliability of 3 sagittal reference planes in the assessment of Class II treatment. Am J Orthod Dentofacial Orthop. 1997;112(3):320-329.

13. Taylor CM. Changes in relationship of nasion, point A, and point B and effect on ANB. Am J Orthod. 1969;56(2):143-163.

27. Ishikawa H, Nakamura S, Iwasaki H, Kitazawa S. Seven parameters describing anteroposterior jaw relationships: postpubertal prediction accuracy and interchangeability. Am J Orthod Dentofacial Orthop. 2000;117(6):714-720.

14. Chinappi AS, DiPaolo RJ, Langley JS. A quadrilateral analysis of lower face skeletal patterns. Am J Orthod. 1970;58(4):341-350.

1. Broadbent B H Sr., Broadbent BH Jr., Golden WH. Bolton Standards of Dentofacial Development Growth. St. Louis, MO: C.V. Mosby Company; 1975.

15. Beatty EJ. A modified technique for evaluating apical base relationships. Am J Orthod. 1975;68(3):303-315.

2. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod. 1975;67(2):125-138.

16. Ferrazinni G. Critical evaluation of the ANB angle. Am J Orthod. 1976;69(6):620-626.

3. Jacobson A. Application of the “Wits” appraisal. Am J Orthod. 1976;70(2):179-189.

17. Binder RC. The geometry of cephalometrics. J Clin Orthod. 1979;13(4):258-263.

4. Jacobson R L, Jacobson A. Point A revisited. Am J Orthod. 1980;77(1):92-96.

18. Moyers RE, Bookstein FL. The inappropriateness of conventional cephalometrics. Am J Orthop. 1979;75(6):599-617.

22 Orthodontic practice

21. Galvão CA,, Maderia MC. Comparative study between the Wits appraisal and I line. Angle Orthod. 1985;55(3):181-185.

28. Palleck S, Foley TF, Hall-Scott J. The reliability of 3 sagittal reference planes in the assessment of Class I and Class III treatment. Am J Orthod Dentofacial Orthop. 2001;119(4):426-435. 29. Polk CE, Buchanan D. A new index for evaluating horizontal skeletal discrepancies and predicting treatment outcomes. Am J Orthod Dentofacial Orthop. 2003;124(6):663-669. 30. Del Santo M Jr. Influence of occlusal plane inclination on ANB and Wits assessments of anteroposterior jaw relationships. Am J Orthod Dentofacial Orthop. 2006;129(5):641-648.

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CASE STUDY

Micro-osteoperforation as an adjunct to Carriere® Motion 3D™ Dr. Dave Paquette discusses a combination treatment that reduces time in orthodontic treatment

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he concept of “accelerated orthodontic treatment” has gained much notoriety lately. Although patients of all ages want to stay in orthodontic treatment for the shortest time possible, adults are particularly sensitive to their treatment duration before committing to start the process.

For patients with sagittal issues, I believe that correcting the sagittal issue first using the Carriere® Motion 3D™ for Class II or Class III correction can significantly reduce time in either aligners or fixed appliances. The Sagittal First approach is beneficial because patients can actually see their progress early

in treatment, which tends to reinforce compliance and thus reduces treatment time. For many adults, there may be a short delay or “lag” before tooth movement begins. One method of eliminating this “lag” phase is to utilize micro-osteoperforation (MOP) using a Propel driver to stimulate the bone, and to

Patient 1: 45-year-old female half step, 6 weeks’ motion

Figures 1A-1C: A. Initial B. Place motion/MOP C. Six weeks’ motion

Patient 2: 54-year-old male two-thirds step, 4 months’ motion

Figures 2A-2C: Initial

Figures 3A-3C: Placed motion Dave Paquette, DDS, received his dental degree from UNC School of Dentistry in 1979 and a Master’s in Pediatric Dentistry from UNC in 1983. His Master’s thesis won a national research award that same year. He is board certified by the American Board of Pediatric Dentistry. He obtained his Master’s degree and specialty certificate in orthodontics from the St. Louis University in 1990. Dr. Paquette’s Master’s thesis in orthodontics won the coveted Milo Hellman award in 1991. He is an active member of the Schulman Group. Dr. Paquette is passionate about advancing the art and science of orthodontics. He has published numerous articles and lectures nationally and internationally. Dr. Paquette maintains a private practice limited to orthodontics in Charlotte, North Carolina. Disclosure: Propel Orthodontics provided financial support to the author.

24 Orthodontic practice

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CASE STUDY

Figures 4A-4C: MOP on the right side

Figures 5A-5C: Removed motion 4 months

Patient 3: 53-year-old female full step, 6 months’ motion

Figures 6A-6C: Initial

Figures 7A-7C: Placed motion

Figures 8A-8C

Figures 9A-9C: MOP 26 Orthodontic practice

Volume 9 Number 2


CASE STUDY

Figures 10A-10C: 6 months

create areas of regional accelerated phenomenon (RAP), a tissue reaction that increases the healing capabilities of the affected areas. Using MOP to initiate RAP in the areas of desired tooth movement is very effective because the orthodontist has control over the targeted areas. Although the initial MOP hand driver was time-consuming, it still is useful for limited areas. Now, the MOP power driver can create perforations faster and more comfortably, which is an advantage for both the patient and the doctor. Typically, I make perforations in the following areas: two mesial and distal to the upper canines, one perforation between the premolars, and two perforations mesial and distal to the first molar. Verbiage is very

Volume 9 Number 2

important to the patient; some doctors prefer these terms or phrases: dimples, dental acupuncture, stimulate the area, and micro-osseous perforations. I simply refer to them as perforations The therapeutic effect of the perforations is to create spiderweb-like radiating cortical plate fractures, extending roughly 5 mm from the perforation, that stimulate RAP formation. By stimulating RAP formation, the time in treatment with the Motion 3D is the same or less than that with adolescents, typically being around 12 weeks, although I have had adult female patients complete their sagittal correction in as few as 6 weeks. I consider it a great adjunct to keep treatment on track in a predictable time frame.

Accelerating tooth movement using a natural, gentle, and uniform force like Carriere Motion has become a significant part of reducing treatment time for my patients. Adding MOP to the treatment plan uses the body’s own inflammatory response to accelerate bone remodeling and tooth movement in a productive way. When shortening treatment time is the deciding factor for starting orthodontic therapy, having several options for controlled acceleration that fit patients’ individual needs is a welcome addition to the orthodontic practice. The Excellerator™ is the first and only device cleared by the U.S. Food and Drug Administration (FDA) for micro-osteoperforation in orthodontic and dental operative procedures.  OP

Orthodontic practice 27


ORTHODONTIC CONCEPTS

A conversation with Dr. Carl F. Gugino Dr. Rohit C.L. Sachdeva discusses the revitalization of the ZeroBase Contemporary Bioprogressive Philosophy with today’s dental practices in mind Carl, you have reframed ZeroBase Orthodontics. What triggered this change? We are revisiting, rethinking, and revitalizing the Contemporary ZeroBase Bioprogressive Philosophy. Many years of teaching around the world have given me the opportunity to be a more “global” thinker than most. Today, the world is getting smaller, and similar experiences are available to nearly everyone by way of electronic connectedness and technology, including artificial Intelligence, algorithms, and instantaneous translation of languages. To create worldwide peace and inner order, we, as doctors of medical dentistry and as part of the universal health care team, need to exercise the Art of Acceptance while incorporating the Art of Innovation into our daily practices.

So what is the Art of Acceptance? To conduct ourselves with a global appreciation for others, using love, wisdom, respect, compassion, and friendship with our office team, our patients, and the world at large.

To create worldwide peace and inner order, we, as doctors of medical dentistry and as part of the universal health care team, need to exercise the Art of Acceptance while incorporating the Art of Innovation into our daily practices.

to the needs or special circumstances of an individual or the basic difference between individuals. What do most techniques do? They work on the “average.” Harvard graduate and author Todd Rose explores the need for individualization in his book, The End of Average, which explains people’s innate need for individualization. You want to individualize your treatment design to the diagnosis of the individual patient. Let me also add, individualization is the backbone of everything. What is required for effective treatment? The answer is individualization based on the degree of difficulty of the individual patient.

One major concept of ZeroBase is Individualization of patient care. Can you elaborate?

Doesn’t this add to the complexity of care?

“Individualization” is the ability to adapt

On the contrary, no. Being Italian, let me

Rohit C.L. Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use. He also works with the dental industry in product design and development. He is the co-founder of the Institute of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder and former Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. In the past, he has held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.blogspot.com. Please contact rcsorthocoach@gmail.com to access information. Carl F. Gugino, DDS, graduated from the University of Buffalo in New York in 1953 and served in the United States Navy Dental Corps from 1953-1955. Following that, he entered a group dental practice and then attended his residency in Orthodontics at the University of Buffalo, New York, which he completed in 1961. In 1962, he developed the ZeroBase Contemporary Bioprogressive Philosophy with Drs. Robert M. Ricketts, Ruel W. Bench, and James J. Hilgers. He has delivered more than 2,000 presentations and courses around the world since 1964 and is honorary president of the Bioprogessive study club in Japan, Italy, France, and Spain. Dr. Gugino currently still offers lectures, courses, and coaching worldwide.

28 Orthodontic practice

quote a famous polymath — Leonardo da Vinci said, “Simplicity is the ultimate sophistication.” Your goal is to simplify things. You don’t want to get over detailed, unless the details are helping you — helping you in your information gathering, helping you by reducing your cost, helping you by reducing your treatment time. People are looking for less treatment time today.

ZeroBase is developed around the organizing principles of systems integration. Kindly share with us your perspectives on this subject. Yes, my approach at looking at systems is based on channeling the flow of energy most efficiently in a collaborative environment. Futurist and author David Houle described the inner experience on a personal level as one where there is an order in the flow to the individual consciousness — a systematic, orderly flow of energy or attention that is focused on realistic goals. When the person’s skills connect with his/her actions in pursuit of a goal, it brings order and awareness, as in awareness/wellness training, because that person must direct attention to the task at hand. In orthodontics, focusing on the end goal (a positive holistic care outcome) is the trigger that should generate the systematic actions. This, I believe, requires a more robust strategy to implement than Volume 9 Number 2


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ORTHODONTIC CONCEPTS the common operational management techniques. We need awareness/wellness training of the entire team to bring about system cohesion. This is a much undervalued skill. Effective use of a series of systems based on a bedrock of mindfulness and wellness mindset defines Contemporary ZeroBase Bioprogressive thinking!

approach allows you to continually evaluate change.

What is your philosophy on preventative care in orthodontics? In ZeroBase, the main idea of prevention is that “the earlier you treat, the more the face adapts to your treatment/concept; the later you treat, the more your concept has to fit

Love what you do. Practice the art of acceptance. Keep questioning, and evaluate the what, the how, the why, and the if. Live “a balanced life,” and let your practice reflect your style and your comfort zone.

Your thoughts on flow of energy are captivating. What is the human dimension to this notion? Energy in an office is super important; it takes positive energy to bring change. You want that positive energy to abound in your office, so that when people come in, the dentist and staff feel good and proud of the care they provide to patients. It is this sense of pride that provides the fuel to bring about change in the practice. And might I add that this energy, to revitalize the practice ecosytem, has to be selectively channeled. Success in improvement efforts are best accomplished when they truly reflect the persona of the team.

And what do you see as the role of technology in systems integration? Technology is necessary to take your practice into the digital world. Technologies should be used to help increase your information gathering, decrease your costs, and decrease your treatment timing. You need systems to help you incorporate these technologies, with your goal being to simplify your flow of information. So it’s almost a “chicken-and-egg” story — technology drives system integration and, in turn, systems integration maximizes the benefit of technology. Also a systems 30 Orthodontic practice

the face.” In the Contemporary ZeroBase Bioprogressive Philosophy, diagnosis and treatment of the functional matrix is vital in prevention.

Orthodontics has not aged you one bit. Any thoughts on preventing burnout in orthodontics? Love what you do. Practice the art of acceptance. Keep questioning, and evaluate the what, the how, the why, and the if. Live “a balanced life,” and let your practice reflect your style and your comfort zone.

Would you kindly share the Contemporary ZeroBase Orthodontics charter with us? Yes, by all means. It is a 10-point charter that provides the loadstar for the contemporary zero-based practice. 1. Our primary goal in orthodontics is a satisfactory outcome. Diagnosis and treatment management are merely a means to an end; results come first. The question is, “How do we get our results consistently?” 2. The practice of orthodontics in the future may be different from what it is today or has been in the past. 3. Orthodontics, being the oldest specialty in dentistry, should be the

leader in initiating true preventive procedures for the future. Therefore, early treatment is essential. 4. Early treatment has to be part of future orthodontic planning. It is essential in true preventative procedures. If, for no other reason, general practitioners and pedodontists will do it. 5. Success is a pattern; failure is only a few mistakes. 6. Nothing will be accomplished if we look at every objection as something to be overcome. 7. Quantity is not necessarily an enemy of quality, if quality comes first. 8. Orthodontists need to better understand the field of communication with associates, parents, patients, and the public (which is marketing). 9. Occlusion is the common point of dentistry. 10. Time is really the fourth dimension (4D) and is one of our most valuable assets.

The ZeroBase Orthodontics’ mission statement remains universal for all orthodontists, irrespective of the philosophies of care they practice. I know many of our colleagues would appreciate being reminded of it. Please share it with us. Certainly. And might I remind you that this mission statement very much remains intact and gives me a reason to wake up every day and do better for a profession that I so much love. “To improve the quality of life and enhance the self-esteem of our patients. We will accomplish this by being one of the leading healthcare professionals in treating patients to achieve their maximum, occlusal, esthetic, and functional potential stressing the importance of oral health to overall health. Patient needs will be addressed employing ethics, integrity, innovation, excellence, and the highest quality in everything we do.

Carl, thank you so much for giving your time for this interview and for your devotion to the betterment of our profession and patient care. OP Volume 9 Number 2


BOOK REVIEW

Bell’s Oral and Facial Pain Seventh Edition; 2014 by Jeffrey P. Okeson, DMD Quintessence Publishing Co., Chicago, Illinois

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he seventh edition of this book gives evidence of its importance to the profession and its relevance to teachers, researchers, and clinicians. For good reason, Bell’s Oral and Facial Pain has become the most used text on this subject, not only in the United States, but also throughout the world. Dr. Okeson has kept this classic text updated with the latest discoveries in pain research and divides the book into three sections: • Normal neuroanatomy and function of the trigeminal system • Classification of the various orofacial pain disorders, while describing history and examination procedures • Management consideration for each orofacial pain disorder Readers grasp the importance of understanding pain, especially chronic pain, upon learning that in the U.S., it consumes $635 billion each year in treatment and lost productivity. To this end, Dr. Okeson supplies plenty of documented information so readers can apprehend what pain is, how it behaves, and how clinicians might manage it. He also develops a useful classification system that augments a systematic insight to its ramifications and offers practical diagnostic advice by which clinicians can identify and successfully treat pain disorders. The nebulous nature of pain and the inadequate knowledge of physicians and dentists about the subject causes patients to unnecessarily suffer and even endure harmful therapy. Clinicians probably violate the first maxim of the healing arts, “first do no harm,” more often when dealing with pain than with a combination of all other chief complaints together. This misunderstanding often has tragic but avoidable consequences if clinicians simply understood more of the common but unappreciated knowledge about pain. This important book seeks to remedy 32 Orthodontic practice

that cognitive defect and does it in an altogether marvelous manner. This book has all of the characteristics of a Quintessence Publication — e.g., thick, durable pages, excellent layout, superlative illustrations and photographs, complete bibliographies, and succinct narrative with readable type. Aside from the unparalleled anatomical, physiological, and functional descriptions, this book offers readers a veritable bargain through a review of the 35 patient therapies

offered. Just reading those will give clinicians pause before galloping into an undiagnosed therapy with all of its unknown consequences. Every dentist should own this book and completely understand its contents. Before Dr. Welden Bell, the progenitor of this volume, died, he confided why he had chosen Dr. Okeson as his successor. He said,”Jeffrey has the ability to learn.” Indeed he did, and indeed he has. OP Review by Dr. Larry White. Volume 9 Number 2


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ORTHODONTIC INSIGHT

Expanding the possibilities: Using suresmile® aligner design therapy to enhance patient care Dr. J. Peter Kierl discusses how his practice incorporates aligner therapy

A

s suresmile® users since 2005 with over 4,000 finished suresmile cases, we first incorporated suresmile elemetrix aligner therapy into our practice in 2013. We are a multi-doctor practice since 2011, with three locations. My co-practitioners are Dr. Philip Kierl and Dr. Heather Kierl.

Getting real in today’s market In case you haven’t noticed, aligners are a reality in today’s orthodontic (and general dental) market. In our practice, we sought to determine what aligners can do well, and how we can feel comfortable in delivering quality care that our patients should expect from a specialist. As with any practice, we also keep an eye on cost management and achieving cost-effectiveness with aligner care. Just to give you an idea of the road we’ve traveled, in 2013, aligners made up exactly 0% of our cases; today, some aligner therapy is used in about 25% of them. The cost factor is just not there with suresmile, which is why we are not afraid of multiple scans. Most patients will accept a short period of time of fixed appliance therapy. Think what is achievable, and what will limit your time in treatment. Patients will say “yes” if you explain treatment times and therapeutics to them. If it makes sense, they will accept the case plan.

Figure 1

Simplicity is our approach In this context, we determined that our fundamental goal was to limit patient time in fixed appliances. We introduced a hybrid J. Peter Kierl, DDS, MS, graduated from the University of Oklahoma College of Dentistry, completed his orthodontic residency at the University of Iowa, and received his master’s degree in Orthodontic Sciences. He has been in private practice for more than 33 years in Edmond, Oklahoma. Dr. Kierl has been a clinical professor in the Graduate Clinic in the Department of Orthodontics at the University of Oklahoma College of Dentistry since 1982. He achieved his certification with the American Board of Orthodontics in 1993. Dr. Kierl has been a 100% suresmile® practice since July 2006. He has completed more than 3,000 suresmile cases and more than 250 lingual cases using the suresmile system.

34 Orthodontic practice

Figure 2

Figure 3

approach when appropriate to our case planning, usually treating with fixed appliances for a short period of time (approximately 3 months). Our aligner practice is based on finishing cases in aligners, using aligners prior to fixed appliance therapy and, when appropriate, using aligners as the sole tooth-moving

appliance. We also try to limit the number of attachments we need for each case. To summarize, here are our principle applications of this versatile appliance: • Phase 1 treatment with aligners • As active retention appliances • In combination with the use of attachments Volume 9 Number 2


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ORTHODONTIC INSIGHT

Figure 5

Figure 4

Figure 6

Figure 8

Figure 7 Figure 9

Combination or hybrid therapy

Figure 10 36 Orthodontic practice

When clinically appropriate, we use fixed appliances for approximately 3 months for one or both arches. In our experience, fixed appliances are best used in cases with large rotations or those cases requiring extrusion/intrusion of the anterior teeth. We have found that teeth respond well to aligner therapy after fixed appliances due to the activation of cellular activity in the tooth-moving process. This patient population resides in your practice and gives you an effective clinical approach to meeting the demand

for aligner therapy while maintaining your commitment to high quality treatment.

Active retention by design When our cases are near finishing, we scan prior to the deband. We add tooth movements to the model, if necessary, and retention aligners are prepared and ready at the deband appointment.

Case 1 statistics (Figures 1-10) • 6 months’ treatment time • 10 weeks in fixed appliances • 10 total visits Volume 9 Number 2


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ORTHODONTIC INSIGHT

Figure 11

Figures 12 and 13

Figure 14

Figure 15

Patients will say “yes” if you explain treatment times and therapeutics to them. Figure 16 38 Orthodontic practice

Figure 17 Volume 9 Number 2


ORTHODONTIC INSIGHT

Figure 18

Figure 19

Case 2 statistics (Figures 11-25) • • • •

2 scans 28 aligners 7 months’ treatment time 11 total visits OP

This article was provided by suresmile® and previously published in suresmile IN PRACTICE, Issue 4, Summer 2017.

Figure 20

Figure 21

Figure 22

Figure 23

Figure 24

Figure 25

40 Orthodontic practice

Figure 26 Volume 9 Number 2


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ORTHODONTIC INSIGHT

Staging clear aligners Dr. John Wise shares his strategies for creating clear aligners in-office

A

lbert Einstein once said that the most powerful force in the universe was the time value of money. It was powerful because of the nature of exponential growth. Double anything over a long period of time, and you will have something pretty powerful. The same is true for technology. Moore’s Law, which states that computing power will double every 2 years, has continued unabated for 25 doublings. Fifty years after he made that prediction, technology is doing more things for us than ever before. Unfortunately, as the exponential curve turns upwards, we are faced with the reality that humans think and act on a linear trajectory, and we are being left behind in so many areas of society.1 Some argue that the profession of orthodontics is a flat line with virtually no upward movement and that we’ve been moving teeth essentially the same way as my father did when he graduated from orthodontic school in 1958. The world changed dramatically in 2007. In January of that year, Steve Jobs unveiled the iPhone® at the annual stockholder’s meeting for Apple®. Jobs’ company had been struggling in the years leading up to that announcement. Now Apple is one of the most valuable companies on the planet, and its iPhone literally has changed the world. A similar technological breakthrough occurred in 1998 when Align Technology introduced CAD/CAM orthodontics to our specialty. At that time, the company was using 1998 technology to create a new way of proposing tooth movement and a robotic process to create clear aligners, which had been done old school with plaster models

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

42 Orthodontic practice

Figure 1

Figure 2 Volume 9 Number 2


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ORTHODONTIC INSIGHT prior to this time. Orthodontics would be changed forever. Now with 10 more doublings of technology under our belt, orthodontists have the capability of mimicking the CAD/CAM process for tooth movement in our own offices. Every tool needed for aligner design and production is available to us with a tiny investment of capital but a large investment of time and critical thinking. The dashed line in the drawing in Figure 3 represents our practices’ needed trajectory to get up to speed with the rest of the world. Relying on third-party technology companies that spoon-feed us remnants of 1990s’ technology so they can maintain market share is so old school. We must be more prepared than Kodak when digital photography began to threaten traditional film. That was in the 1980s when Kodak missed that jet plane to the future. In previous articles,2,3 I laid out clear methods for technology needs and even workflows for offices to move into the realm of clear aligner design and production. Individually, we need to get up to speed to move the line. This article will delve into another of my favorite topics: aligner staging. Once you have settled on your software for moving teeth and creating STL files (I like suresmile® elemetrix™ from OraMetrix), you’ll need to become expert at staging. Creating the final result is the easy part. Computer algorithms can do this pretty well. The hard part is figuring out how to get from point A (crooked teeth) to point B (straight teeth). That’s staging, and it requires a keen mind and an excellent imagination. Third-party companies will have us make a limitless number of aligners for each case, spoiling our inventive spirit and ability to be creative when moving teeth is involved. Orthodontists are still the best at imagining how teeth need to move to achieve a result. Artificial intelligence is catching up, but it will be a few years before it passes us. You have time to apply this tooth movement stuff to clear aligners. Most of my cases involve some amount of simple movements such as bucco-lingual, small rotations, intrusion, or space closure. Clear aligners do great at that with just a small amount of thought and planning. The complex movements such as tipping, large rotations of round teeth, extrusion, and bodily movement take an orthodontist’s brain to achieve success. My cases are full of these, too. As you examine your patient, you need to realize what it is you are looking at. By the way, this is something that an at-home impression 44 Orthodontic practice

Figure 3

The hard part is figuring out how to get from point A (crooked teeth) to point B (straight teeth). That’s staging, and it requires a keen mind and an excellent imagination. or kiosk scan will never be able to do — to mimic the eye of a trained orthodontist. You’ll discover a world of cases full of simple movements in which clear aligners can perform beautifully and at a fraction of the cost of conventional bracket and wire treatment. You’ll also see some cases that will need various auxiliaries to move teeth in a complex manner. Many modern software programs allow you to create “attachments” virtually and then create them in your aligner set. Other auxiliaries, like buttons for elastics, even brackets and wires, can also be added at your direction.

Bodily movement and tipping To move a tooth along an arch form in the mesio-distal realm (bodily movement) or to tip a tooth, you need contact with as much of the tooth as you can get your arms (clear plastic) around. You need space mesial and distal, so the plastic can grab that tooth and move it, roots and all. So, in cases where you have some of this, stage the case so those specific teeth that require bodily movement or tipping will have spaces available before you attempt the movement. Clear aligners

can achieve bodily movement and tipping very effectively, but you need to be aware of this necessary factor. No attachment can re-create the same physics as circumferential contact of plastic to tooth. It’s not as good as braces and wires, but it “ain’t” bad.

Large rotations of round teeth Good luck getting this with attachments. You’ll need an auxiliary and some good ol’ latex stretched out to create force where you want it. Custom trimming of the aligner in your in-office lab will do the trick. Make no attempt to rotate these teeth until you are ready with your staging. Then deliver your custom-trimmed aligners so that a small, smooth button can be affixed to the tooth in question. Attach a chain or instruct the patient on how to attach an elastic. The teeth can’t tell the difference. And they will rotate for you. Get ready. Once in position, remove the auxiliary and deliver aligners without the cutouts.

Extrusion Nothing can extrude a tooth as readily as good ol’ fashioned brackets and wires Volume 9 Number 2


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ORTHODONTIC INSIGHT from the pre-iPhone era. But our modern patients are not digging that method right now. The young hipsters all want to go to brunch with their cool friends, and they do not want braces, doctor! You’ll need to stage your aligners in such a way that the extrusion you seek is re-created in an aligner so that the teeth in need of extrusion can be guided there by an elastic. You’ll need some more auxiliaries attached to the teeth at the appropriate locations and well-educated patients who can apply the elastics right after they are done with brunch. This is one place where I am a fan of attachments. They have minimal chance of creating extrusive forces, but a great chance at holding those teeth there once extruded. A simple ovoid attachment and an accompanying aligner will do the trick. Leave the blob of composite there for as long as the hipsters will let you. They don’t like to sport attachments during brunch either, doc.

Figures 4 and 5: Lateral extrude

Figure 6: Extrude

Crowding Most of my clear aligner cases involve eliminating crowding of some amount. Those easy cases handled with an at-home impression or kiosk scan are great at this. The hipsters stopped wearing their aligners while they were brunching through college, so a lower incisor jumped out of place. Do you want to treat these cases, or would you prefer them treated by some nameless, faceless technician who wants to be you? Get good at doing these cases so you can compete on cost and blow the hipsters away on results. Staging these cases to expand the arch with a 3:1 ratio of bodily movement to positive torque is your answer (0.3 mm buccal, 1 degree torque). As we move a tooth digitally in the purely buccal direction, we have to know in our orthodontic brain that the tooth is also going to tip buccally (that’s the positive torque part) in the mouth. Plan for it with your staging, and allow the aligners to fit all the way through your staged movements. An aligner that fits well can move the teeth as you want, mostly. IPR can also help you here, but remember that no hipster enjoys having his/ her teeth sanded down interproximally. Do a little expansion/torque. The IPR eliminates tooth collisions, which is computer speak for teeth that can’t rotate inside a shell of plastic because there’s no room. Teeth need a place to move into, or they’ll just stay where they are. Remember, the at-home services or kiosk scanners do not have the ability to perform IPR, and they will use that fact 46 Orthodontic practice

Figure 7: Attachments

Figure 8: Extrude final

Figure 9: Elastics, buttons, and custom trimming

against us in their marketing. “Orthodontists file your teeth down,” they will claim. “At Kiosk Aligner Company, our magic system does not require this.” Hmmm. Whom will the young hipster believe? My challenge to you is to create staging for the in-your-office clear aligner method that dramatically reduces the number of aligners you will require to treat a case. Limitless aligners have spoiled us into believing that we must rely on Clear Aligner Company for their 1990s’ era technology

spoon-fed to us. With 2018 technology, orthodontists can do it better, faster, and less expensively. And, as an added benefit, we’ll have time for brunch. OP

REFERENCES 1. Friedman TL. Thank you for being late. An optimist’s guide to thriving in the age of accelerations. New York: Picador; 2017. 2. Wise J. Keeping the “special” in the orthodontic specialty: part 1. Orthodontic Practice US. 2017;8(3):30-34. 3. Wise J. Keeping the “special” in the orthodontic specialty: part 2. Orthodontic Practice US. 2017;8(4):8-14.

Volume 9 Number 2


CONTINUING EDUCATION

An alternate approach: closing anterior open bites with low pulsatile forces without relying on vertical elastics Dr. Straty Righellis discusses an alternative treatment option for correcting occlusion and smile esthetics with braces Abstract/Introduction Treating anterior open bite patients without surgical solutions presents two challenges for orthodontists. The first challenge is closing the open bite with anterior elastics, and the second is the stability once the bite is closed: This article focuses on the former. Studies show that there is a 35%1 chance of relapse when closing open bites with vertical elastics. While this is the traditional treatment approach for anterior open bites, relying on vertical elastics for closure presents a significant treatment barrier to orthodontists that is out of their control. Typically, there is low compliance and lack of cooperation among patients when they are instructed to wear anterior elastics for the amount of time prescribed. Patients find the elastics cumbersome to work with, unattractive, difficult to fit in their daily routines, and painful. As an alternative, the author found that it is possible to achieve high-quality clinical results in anterior open bite braces (fixed appliances) cases by incorporating low pulsatile forces and reducing or eliminating reliance on vertical elastics to close the bite. The four adolescent patients in these case reports were treated with Forestadent FACE™ Evolution self-ligating brackets, and each of them was instructed to use AcceleDent®, an FDA-cleared, noninvasive vibratory orthodontic device that employs low pulsatile forces to increase the rate of tooth movement. Patients bite down on the device’s acrylic mouthpiece for 20 minutes daily, and the gentle vibrations stimulate bone movement at the cellular level.2 Patients in this

Educational aims and objectives

The purpose of this article is to discuss treating anterior open bite cases with low pulsatile forces and limited or no elastic wear.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 54 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize how to achieve treatment efficiency through accurate diagnosis. •

Identify three treatment options for open bite cases and the characteristics that are applicable for each.

Recognize how low pulsatile forces provide a predictable treatment for open bite cases.

private practice have been more accepting of a 20-minute daily routine with gentle vibrations that make their teeth and gums feel better instead of the nearly all-day routine required for elastic wear.

Closing anterior open bites with low pulsatile forces When open bite patients present for an orthodontic consultation, it’s important to begin with the end in mind by identifying the patient’s desired end results as well as what must be corrected from a clinical standpoint. While there are several approaches to treating open bite patients, the premise demonstrated in this article of using low pulsatile forces with minimal or no elastics is only being suggested for correcting occlusion and smile esthetics with braces. When the goal is to correct occlusion, facial symmetry, smile esthetics, and airway, orthognathic surgery is the recommended treatment approach. Skeletal anchorage with anchor plates is a viable treatment option for correcting occlusion, facial symmetry, and smile esthetics.

Straty Righellis, DDS, is a Diplomate of the American Board of Orthodontics, graduated from UCLA Dental School, and received his orthodontic specialty certification from University of California at San Francisco. He maintains a private practice in Oakland, California, while serving as an Associate Clinical Professor at the University of the Pacific and University of California at San Francisco schools of dentistry. Dr. Righellis is on the Editorial Review Board for the American Journal of Orthodontics and has lectured extensively to over 250 national and international groups on Excellence and Clinical Orthodontics. He is a member of the American Association of Orthodontists and is past President of the Edward H. Angle Society, Northern California. Dr. Righellis is a chapter contributor on “Treatment Efficiency and Excellence” in the textbook Goal-Directed Orthodontics. Disclosure: Dr. Righellis is a faculty member at the FACE USA postgraduate teaching program. He is an OrthoAccel key opinion leader, but he did not receive any payment for mentioning products in this article. He does receive a modest honorarium to cover his cost and time for speaking engagements such as webinars.

48 Orthodontic practice

The serendipitous discovery of the effectiveness and efficiency of using low pulsatile forces as a treatment adjunct for this author’s anterior open bite patients started with a noncompliant adolescent female patient — Patient 1. When treatment began, Patient 1 was instructed to wear vertical elastics at night only. One month into treatment, the patient’s mother noted that the patient was not compliant with the elastics and inquired about the low pulsatile vibratory device to speed up the treatment. The patient began using this device during the 2nd month of treatment, which is when she also stopped wearing her elastics, and was finished in 17 months. This garnered the author’s attention because he was able to achieve a quality result with only sporadic elastic wear in the first 2 months of treatment. Comparing this case with other anterior open bite cases that followed the traditional treatment approach with elastics and without low pulsatile forces, the author deduced that vibration is what is at play at here (Figure 2). For nearly 40 years, there have been studies showing that pulsating forces positively impact the rate of tooth movement.4 Since the 1980s, pulsatile stimulation of bone has helped heal bone fractures and osteoporosis. When orthodontic patients began demanding faster treatment, this led to the commercialization of low pulsatile force vibration. Under low pulsatile forces, there is engorgement of the blood supplies in the craniofacial sutures.5 This vibration stimulates bone metabolism molecules that regulate Volume 9 Number 2


Adapting wire sequencing and patient appointments with accelerated tooth movements When using the low pulsatile force alternative treatment approach to correct anterior open bites, it’s critical to change the archwires more frequently. During Stage 1 of anterior open bite treatment with low pulsatile forces, teeth are going to move faster than normally expected, so the archwires need to be changed every 4 weeks to advance the wire sequences. The goal is to place the .0195 x .025 stainless steel wire within 4 months from initial bracket placement. In Stage 2 with a .0195 x .025 stainless steel wire, the patients are scheduled every 6 to 7 weeks. Stage 2 goals are transverse, vertical, and AP changes. In the finishing stage, Stage 3, the focus is on detailing to ensure patient satisfaction and a high-quality clinical result is achieved. Volume 9 Number 2

CONTINUING EDUCATION

the quantity and activity of osteoclasts and osteoblasts.6 The factors that increase the rate of bone remodeling also increase the rate of tooth movement.7 This explains how using the low pulsatile vibratory forces accelerates orthodontic tooth movement by increasing osteoblastic activity and reducing hyalinization formation. Additionally, pre- and posttreatment cephalometric analysis demonstrated there was no molar extrusion that can happen in treating anterior open bites (Figure 1). Typically, the upper and lower molars extrude with brackets unless also using headgear or skeletal anchorage. With the application of low pulsatile forces in these cases, the molars actually intruded slightly as the incisors moved toward each other. From these results, the author also infers that vibration helps flexible archwires to move the anterior teeth. In clinical practice, using the low pulsatile vibratory device shortens the length of treatment during Stage 1 (aligning, leveling, and arch coordination) and Stage 2 (group and AP movements), giving orthodontists plenty of time to detail during the finishing stage. Treatment time for anterior open bites in this author’s practice, using the traditional approach with elastics and without this device, averaged between 16 to 18 months. Using low pulsatile forces and limited or no elastic wear, these cases can be finished within 12 months. As is the case with Patient 1, using low pulsatile forces offered improved predictability, regardless of acceleration of treatment time, when low patient compliance could foster unpredictable treatment results.

Figure 1: "Righellis Theory" on how it works in open bite cases

A.

B.

C.

D.

E.

F.

G.

H.

Figures 2A-2H: A-B. Patient 1. Treatment time: 17 months. Months 1-2: Sporadic elastic wear. Months 3-17: No elastics. C-D. Patient 2. Treatment time: 14 months. Months 1-2: Nighttime wear Class III elastics for 1 month. Month 3: Nighttime wear triangular elastics for 1 month. Months 4-14: No elastics. E-F. Patient 3. Treatment time: 10 months. Months 1-3: Nighttime wear box elastics cuspids and first bicuspids. Months 4-10: No elastics. G-H. Patient 4. Treatment time: 12 months. Months 1-3: No elastics. Month 4: Left side vertical elastics at first bicuspids for 1 month. Months 5-12: No elastics Orthodontic practice 49


CONTINUING EDUCATION Case summaries All cases are diagnosed from models mounted in seated condylar position (SCP) with additional measurements quantifying the distance from maximum intercuspation to SCP. The next step in treatment planning is diagnosing the position of the upper incisor relative to the relaxed upper lip both vertically and antero-posteriorly from the “converted” lateral cephalometric image. Various smile and relaxed facial images are used to crosscheck our cephalometric data. Patient 1 (14-year-old female) treatment highlights Diagnosis: Class I skeletal and dental open bite with vertical growth history. Nonextraction. (Figure 3) Conventional approach: Band upper and lower teeth, vertical control with TPA and vertical elastics. Mechanics and actual treatment approach: Self-ligating brackets, infrequent elastic wear (<2 months), AcceleDent (16 months) • Months 1-2: Sporadic elastic wear • Month 2: Patient given AcceleDent • Month 4: Orthodontist eliminated use of vertical elastics (Figure 4) o Treatment progression was slowed at this point because of the delay in LL5 eruption. Typically, the orthodontist would have waited to begin this case until the second bicuspids were fully in, but the patient was anxious because of the high cuspids. Results • Total treatment time = 17 months, including 16 months with AcceleDent and sporadic elastic wear during first 2 months (Figures 5 or 7) • No radiographic evidence of root resorption (Figure 6)

Figure 3: Patient 1

A.

B.

C. Figures 4A-4C: Patient 1. A. No low pulsatile force device on braces placement day (6/2014). B. Second month: Triangular elastics, no low pulsatile force device, patient admitted elastics worn infrequently. C. Fourth month: Low pulsatile force device and no elastics

B.

A.

Figures 6A-6B: Patient 1. A. No radiographic evidence of root resorption. B. Vertical control with no high pull headgear and <2 months' wear of vertical elastics

Figure 5: Patient 1 50 Orthodontic practice

Figure 7: Patient 1 Volume 9 Number 2


Figure 8: Patient 2

A.

B. Figures 9A-9B: Patient 2. A. Class III elastics for 1 month worn at night only (3/2016). B. Triangular elastics for 1 month worn at night only (5/2016).

Patient 3 (17-year-old male) treatment highlights Diagnosis: Class 1 with anterior open bite and upper arch crowding (Figure 13 or 14) Conventional approach: Band upper and lower teeth with extensive use of vertical elastics

Figure 11: Patient 2. Treatment completed in 14 months

A.

B.

Figures 12A-12B: Patient 2. A. No radiographic evidence of root resorption. B. Primarily incisor changes and "holding molars" in space

Figure 10: Patient 2

A.

B. Figure 13: Patient 3 Volume 9 Number 2

Figures 14A-14B: Patient 3. A. Maximum intercsupation. B. Seated condylar position Orthodontic practice 51

CONTINUING EDUCATION

Patient 2 (14-year-old female) treatment highlights Diagnosis: Midface deficiency with anterior open bite. (Figure 8) Conventional approach: Band upper and lower teeth with extensive use of Class III and vertical elastics Mechanics and actual treatment approach: Self-ligating brackets, Class III elastics (1 month of nighttime wear), AcceleDent • Months 1-2: Nighttime wear Class III elastics for 1 month (Figure 9) • Month 3: Nighttime wear triangular elastics for 1 month (Figure 9) • Months 4-14: No elastics Results • Total treatment time = 14 months (Figure 10 or 11) • No radiographic sign of root resorption (Figure12)


CONTINUING EDUCATION Mechanics and actual treatment approach: Self-ligating brackets, box elastics (3 months of nighttime wear), AcceleDent • Months 1-3: Nighttime wear box elastics cuspids and first bicuspids • Months 4-10: No elastics Results • Total treatment time = 10 months (Figure 16) • No radiographic sign of root resorption (Figure 17) Patient 4 (15-year-old female) treatment highlights Diagnosis: Class 1 anterior open bite to molars (Figure 18 or 19) Conventional approach: Band upper and lower teeth and skeletal anchorage to intrude upper molars and allow for auto rotation of the mandible to “close the bite” (Figure 20) Mechanics and actual treatment approach: Self-ligating brackets, vertical elastics (1 month), AcceleDent • Months 1-3: No elastics • Month 4: Left side vertical elastics at first bicuspids for 1 month • Month 5-12: No elastics Results • Skeletal anchorage was initially planned, but not needed as bite was closing traditional (Figure 21) • Total treatment time = 12 months (Figure 22) • No radiographic sign of root resorption (Figure 23)

A.

B.

C. Figures 15A-15C: Patient 3. A. Initial appliance placement (7/2016). B. Progress 1 month later. C. Progress 2 months later

Figure 16: Patient 3. Treatment completed in 10 months with 3 months' posterior vertical elastics

Summary The clinical benefit of using low pulsatile forces to help doctors correct anterior open bite cases without elastics is that

A.

B.

Figures 17A-17B: Patient 3. A. No radiographic evidence of root resorption. B. Primarily incisor changes and "holding molars" in space

Figures 19A-19B: Patient 4. A. Maximum intercuspation. B. Seated condylar position

Figures 18: Patient 4 52 Orthodontic practice

Figure 20: Patient 4. Skeletal anchorage was planned Volume 9 Number 2


CONTINUING EDUCATION

A.

B.

C. Figures 21A-21C: Patient 4. A. Initial appliance placement (6/2016). B. Progress 1 month later. C. Progress 2 months later

B.

A.

Figure 22: Patient 4

C.

Figures 23A-23C: Patient 4. A. No radiographic evidence of root resorption. B. Pretreatment. C. Posttreatment

A.

B.

Figures 25A-25B: Patient 4. A. Some incisor changes and slight molar intrusion. B. Molar intrusion and mandibular autorotation

orthodontists have greater predictability because of the unpredictability of low patient compliance with elastics. In this authorâ&#x20AC;&#x2122;s private practice experience, patients respond more favorably to a 20-minute daily routine of AcceleDent than having to wear elastics for at least 20 hours daily. During follow-up appointments, patients have reported that the device is simple to use and fits into their daily routines easily. Compliance with the device was high among all four patients and is high among all of the authorâ&#x20AC;&#x2122;s patients regardless of their treatment diagnosis. While scientific publication review of low pulsatile forces is exhaustive,2-6 the Volume 9 Number 2

effectiveness of the treatment adjunct for closing anterior open bites can be deduced only from clinical experience. From comparing these four cases to other open bite cases without low pulsatile forces, the author believes the difference results from the vibration (Figure 2). It seems that the low pulsatile, vibratory forces are at work to hold molars from vertical movements as wire form returns to the original form (Figure 1). The vibration provides control to keep the upper and lower molars in space as the incisors come together. While more case reports and documentation of this intervention is needed, the results of these cases show that orthodontists should

Figure 24: Patient 4. Some incisor changes and slight molar intrusion

consider the realm of possibilities of treating open bite cases with noninvasive, low pulsatile forces without elastics. Other types of vibration are in use for indications such as aligners, but these cases focus on treatment with braces, and AcceleDent is FDA cleared for use with both braces and aligner therapy. The orthodontist maintains contact with these patients to continue monitoring retention and stability of the corrected bite. Additional clinical evidence is now being gathered in the orthodontistâ&#x20AC;&#x2122;s private practice to observe the effectiveness of low pulsatile forces to treat non-growing, adult patients who present with anterior open bites, as well as the integration of this low pulsatile vibratory device with posterior bite tabs. OP REFERENCES 1. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite closure malocclusion: a longitudinal 10-year post retention evaluation of orthodontically treated patients. Am J Orthod. 1985;87(3):175-86. 2. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Seminars in Orthodontics. 2015;21(3):187-194. 3. Shapiro E, Roeber FW, Klempner, LS. Orthodontic movement using pulsating force-induced piezoelectricity Am J Orthod. 1979;76(1):59-66. 4. Kopher RA, Mao JJ. Suture growth modulated by the oscillatory component of micromechanical strain. J Bone Miner Res. 2003;18(3):521-528. 5. Vij K, Mao JJ. Geometry and cell density of rat craniofacial sutures during early postnatal development and upon in vivo cyclic loading. Bone. 2006;38(5):727-730. 6. Nishimura M, Chiba M, Ohashi T, et al. Periodontal tissue activation by vibration: intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats. Am J Orthod Dentofacial Orthop. 2008;133(4):572-583.

Orthodontic practice 53


REF: OP V9.2 RIGHELLIS

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An alternate approach: closing anterior open bites with low pulsatile forces without relying on vertical elastics RIGHELLIS 1. The first challenge (in treating open bite cases) is _______, and the second is the stability once the bite is closed. a. closing the open bite with anterior elastics b. retention c. instability d. appointment intervals 2. Studies show that there is a _____ chance of relapse when closing open bites with vertical elastics. a. 25% b. 35% c. 45% d. 55% 3. While this is the traditional treatment approach for anterior open bites, relying on _______ for closure presents a significant treatment barrier to orthodontists that is out of their control. a. jaw surgery b. pulsatile forces c. anchorage devices d. vertical elastics 4. Patients find the elastics _____, and painful.

54 Orthodontic practice

a. cumbersome to work with b. unattractive c. difficult to fit in their daily routines d. all of the above 5. While there are several approaches to treating open bite patients, the premise demonstrated in this article of using low pulsatile forces with minimal or no elastics is only being suggested for correcting ____. a. occlusion with braces b. smile esthetics with braces c. airway issues. d. both a and b 6. Under ______, there is engorgement of the blood supplies in the craniofacial sutures. a. low pulsatile forces b. elastics c. self-ligating braces d. TADs 7. The factors that increase the rate of ____ also increase the rate of tooth movement. a. hyalinization formation b. bone remodeling c. pain

d. vibration 8. Using low pulsatile forces and limited or no elastic wear, these cases can be finished within ________. a. 12 months b. 16 months c. 18 months d. 24 months 9. When using the low pulsatile force alternative treatment approach to correct anterior open bites, itâ&#x20AC;&#x2122;s critical to change the archwires ___. a. less frequently b. only periodically c. more frequently d. just biweekly 10. During Stage 1 of anterior open bite treatment with low pulsatile forces, teeth are going to move faster than normally expected, so the archwires need to be changed every _________ to advance the wire sequences. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

Volume 9 Number 2

CE CREDITS

ORTHODONTIC PRACTICE CE


Dr. Bill Kottemann examines the process of photobiomodulation to accelerate orthodontic tooth movement Introduction Opinion among orthodontists on the topic of acceleration can vary greatly based on the hands-on user experience and case types. Today, there are two basic options in patient handheld devices: vibration and light therapy. Light therapy uses a process called photobiomodulation, which is the technology behind OrthoPulse® made by Biolux Research. This article will examine the process of photobiomodulation, and its use in acceleration, its safety, and considerations when choosing which patients will benefit from this cutting-edge technology.

Light energy and the application in orthodontics A simple example of light energy is photosynthesis — the process of chemical energy fueling plant organisms’ activity such as growth. Human cells, particularly mitochondria, also have the ability to absorb photons from light to enhance cellular activity. This general philosophy correlates to the light energy conversions of photobiomodulation: “The application of therapeutic light in the near-infrared wavelength (NIR) range (600 nm-1000 nm) generated by using low-energy laser or light-emitting diode (LED).” Photobiomodulation has been observed to increase mitochondrial metabolism.1 This process can be used in orthodontics to help benefit the biological effects in stressed tissues as teeth are moved.

Biological explanation of photobiomodulation

Educational aims and objectives

This article aims to discuss acceleration of orthodontic treatment using photobiomodulation.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 60 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Explain the biological process involved in photobiomodulation. •

Realize some of the history of the process.

Identify a device that uses photobiomodulation and how it is used in conjunction with orthodontic treatment.

View two cases where photobiomodulation resulted in positive treatment outcomes.

production of ATP energy, allowing the tissues to metabolize normally. ATP production has been shown to be upregulated twofold by infrared light, also known as photobiomodulation.2 During the tooth movement phase, higher ATP production is enhanced, leading to cells “turning over” more efficiently. Light-accelerated orthodontic therapy shows promise in producing a noninvasive stimulation of the dentoalveolar complex with a potential impact on ATP production by mitochondrial cells. The assumption is that an increase in ATP at a localized site will induce cells to undergo remodeling — stimulating both apposition and resorption to enhance tooth movement.3 Light-accelerating orthodontics (LAO) may also be functioning through increased vascular activity, which would also contribute to the rapid turnover of the bone. A number of clinical case studies have

suggested an enhanced impact by LAO, increased velocity of canine movement, decreased pain, and a significantly higher acceleration of retraction of treated canines.4

Over 80 years of research in photobiomodulation More than 5,000 articles have been published on the effects of photobiomodulation. The German biochemist, Otto Warburg (1883-1970), was awarded the Nobel Prize for discovering cytochrome c oxidase (CCO), the terminal enzyme in the mitochondrial oxidative respiration chain. In his research, he found that applying specific frequencies of light to mitochondria stimulated their activity. Warburg also demonstrated that carbon monoxide inhibited CCO function and could be displaced by a flash of light. Displacing carbon monoxide allows oxygen to bind again and resume CCO function and

Mitochondrial enzymes can absorb photons from light and increase the Bill Kottemann, DDS, MS, has been practicing orthodontics since 1978 with two locations in the Minneapolis/St. Paul, Minnesota area. He has used OrthoPulse® technology extensively for the past 18 months for his acceleration cases. He has been a member of the Speakers’ Bureau for Align Technology for the past 9 years and is a member of its teaching faculty. He has treated over 2,300 patients with Invisalign® since 2000. Dr. Kotteman is a Diplomate of the American Board of Orthodontics and holds two patents related to esthetic orthodontic wires. Disclosure: Dr. Kottemann does not have a financial interest in Biolux Reasearch, and he is not on the company’s Clinical Advisory Board nor is he a paid speaker.

Figure 1: Stressed cells (left) and initiation of photobiomodulation (right) producing the increase in energy ATP Volume 9 Number 2

Orthodontic practice 55

CONTINUING EDUCATION

Accelerated orthodontics using photobiomodulation


CONTINUING EDUCATION respiration. Photobiomodulation activates cytochrome c oxidase and increases mitochondrial electron transport, which leads to increased ATP production. Confirmation that cytochrome c oxidase is the photoacceptor in the red to near-infrared (NIR) spectral range can be found in the article “Photobiomodulation accelerates orthodontic alignment in the early phase of treatment.”4

OrthoPulse® safety The product that utilizes photobiomodulation, OrthoPulse®, is a U.S. FDAcleared Class II medical device for patients receiving fixed appliance or aligner treatment. Regulatory approvals have also been received in the European Union, Canada, Australia as well as other countries. Biolux Research continues to sponsor and support research at the Forsyth Institute, University of Southern California, Kyung Hee University, European University College, United Arab Emirates University, University of Sydney, and Tufts University. The device is designed to be used by patients on a daily basis for 5 minutes in each arch, either at home or while traveling. The clinical evidence acquired to date shows a significant reduction in treatment time for patients undergoing orthodontic treatment.4 Light therapy device The intraoral device is integrated with light-emitting diode arrays, which emit a continuous 850 nm near-infrared light toward the buccal alveolar mucosa to promote bone remodeling. The energy density is 19.5 J/ cm2 when used for 5 minutes per arch daily. Application of light in dentistry has been clinically proven to be safe without adverse events such as root resorption, pathologic tooth mobility, and gingival recession. For OrthoPulse, the power output is low, and treatment occurs at temperatures below 43°C.5 Since 2003, there have been over 30 OrthoPulse clinical trials as well as in vivo and in vitro studies. In vivo research findings show a 3.3-fold faster rate of tooth movement6 and 80% less root resorption in animals treated with 620 nm light.7 For both aligner and fixed appliance patients, adding light-accelerated orthodontics using photobiomodulation at 850 nm wavelength facilitates bone remodeling on a molecular level without adverse effects. The shorter the wavelength, the more it is absorbed in soft tissue; and the longer the wavelength, the deeper the penetration through soft tissue, and hence into the bone. 56 Orthodontic practice

Figure 2: Light spectrum chart showing photobiomodulation at 850 nm, well within the safe range between 600 nm and 1000 nm

A number of clinical case studies have suggested an enhanced impact by LAO, increased velocity of canine movement, decreased pain, and a significantly higher acceleration of retraction of treated canines. The 850 nm wavelength is considered within the near-infrared spectrum.

Photobiomodulation use in the orthodontic practice Biolux Research has a general guideline that once patients start orthodontic treatment, they should begin OrthoPulse immediately using 5 minutes per arch daily. If an Invisalign® case involves challenging movements such as a large translation in opening/closing spaces (i.e., molar distalization or extraction), acceleration with photobiomodulation can help keep the case on track and increase predictability. In general, on a 7-day Invisalign aligner case, patients change their aligners every 5 days using OrthoPulse — a 20% reduction in treatment on an already shortened case with a 7-day versus 14-day change rate. However, it is very important to review the case when the challenging movements and IPR are staged. If it’s simple anterior crowding, then a 3.5-day change rate will most likely work well. If a series of aligners is distalizing the posterior segment, adjust to a 5-day change rate. For all Invisalign cases, I have noted a 20% refinement rate in my practice. Adding acceleration with OrthoPulse on these cases has not increased the low refinement rate percentage. Regarding costs, our practice adds $500 to the case fee for patients who want to accelerate their treatment. This is a loss leader on paper due to the cost of the unit. The reduction in treatment time and number of appointments, plus increasing predictability and generating very happy patients with a

positive experience, makes up for the $300plus cost differential. The shorter treatment time allows the practice to open schedules for additional patients. Patients keep their payments on the same schedule as if they had not accelerated their treatment time. For example, a normally 18-month case would be reduced to 12 months or less through photobiomodulation. The payment schedule remains at 18 months, plus $500 for the unit.

Case studies The following two cases are part of a study that I am involved with regarding OrthoPulse and aligner treatment, analyzing the results of 5- and 3.5-day change rates. Case 1: Class I deep bite with 5-day change rate with Invisalign and OrthoPulse Peter, a 26-year-old male, presented with Class I occlusion. He was congenitally missing all four second bicuspids. X-rays show tipping of teeth into edentulous sites and a deep overbite. The treatment plan would upright posterior teeth to restore the missing second bicuspids with implants. Peter was put in the part of the study that mandated 5-day aligner changes. In addition, I added these instructions to Peter’s ClinCheck setup: “Please leave 7s in crossbite. Make upper pontic spaces both 8.0 mm. Make both lower pontic spaces 8.4 mm. Reduce gingival margin height on pontics to make the pontics the same length as the molars and bicuspids. IPR lower 3,2|,|2,3 to account for Bolton discrepancy. Volume 9 Number 2


CONTINUING EDUCATION

Figure 3: Initial records for Peter

Figure 4: Initial records (left) versus final records with implant (right)

Upper arch over-corrections: • Rotate 2|mesial-out 5 degrees and Rotate |1 mesial-in 5 degrees Lower arch over-corrections: • Rotate 2| mesial-out 5 degrees and Rotate 1| mesial-out 5 degrees Thank you.” Peter’s case was completed in 4 months with 19 aligners. With photobiomodulation, Peter changed the aligners every 5 days. Retainers were fabricated at stage 17, and everything tracked very well. By integrating Invisalign with OrthoPulse into his treatment plan, not only was the long-term stability of his implants increased by the segmental uprighting of the posterior teeth, but also his overall function was greatly improved in less time. Volume 9 Number 2

Figure 5: Final X-rays

Figure 6: A side-by-side comparison on final ClinCheck images and actual results Orthodontic practice 57


CONTINUING EDUCATION

Figure 7: Initial records for Jessica

Figure 8: A side-by-side comparison initial versus final records

Figure 10: Final treatment records versus ClinCheck 58 Orthodontic practice

Figure 9: Final X-rays

Case 2: Mild crowding/diastema correction with a 3.5-day change rate with Invisalign and OrthoPulse Jessica, a 34-year-old female, came into our office with Class I occlusion and enamel erosion of upper anterior teeth. She also presented with maxillary spacing, a 2 mm diastema, and mandibular crowding with mild bimaxillary protrusion. The treatment plan included intruding and retracting the upper and lower arches, and IPR the lower arch to address the Bolton discrepancy. In addition, we wanted to intrude the upper and lower incisors to allow for upper incisor crowns. As part of the clinical study, Jessica was put into the 3.5-day aligner change group. The patient was instructed to change aligners on 2 specific days of the week at 3- and Volume 9 Number 2


Volume 9 Number 2

We have also referred her for crowns on the upper incisors. I was pleased with the results of the 3.5-day change rate, and Jessica told us that she was thrilled. Reducing treatment time to 9 weeks versus the almost 5 months it would have taken for treatment, if we had not used photobiomodulation, was remarkable. The convenience for the patient makes it a win/win situation for her and our office.

Conclusion Photobiomodulation in orthodontics is an exciting next frontier for our profession. I am pleased with the results I am seeing in my practice and the real efficiency and predictability. I feel comfortable recommending OrthoPulse® to my patients with the expectation it will reduce their treatment time by half. It can definitely generate a new generation of patients who want their treatment done more quickly and can differentiate my practice in a competitive market. This technology and

its use of the photobiomodulation process is based on solid science. OP

REFERENCES 1. Zhang R, Mio Y, Pratt PF, et al. Near infrared light protects cariomyocytes from hypoxia and reoxygenation injury by a nitric oxide dependent mechanism. J Mol Cell Cardiol. 2009;46(1):4-14. 2. Ad N, Oron U. Impact of low level laser irradiation on infarct size in the rat following myocardial infarction. Int J Cardiol. 2001;(2-3):109-116. 3. Oron U, Illic S , De Taboada L, Streeter J. GA-As (808 nm) laser irradiation enhances ATP production in human neuronal cells in culture. Photomed Laser Surg. 2007;25(3):180-182. 4. Kau CH, Kantarci A, Shaughnessy T, et al. Photobiomodulation accelerates orthodontic alignment in the early phase of treatment. Prog Orthod. 2013;14:30. 5. Nimeri G, Kau CH, Corona R, Shelly J Clin Cosmet Investig Dent. 2014:6. 6. Chiari S, Baloul S, Goguet-Surmenian E, Dyke T, Kantarci A. Photobiomodulation-induced tooth movement using etraoral transcutaneous phototherapy on rat periodontium. In review. 7. Ekizer A, Uysal T, Güray E, Akkuş D. Effect of LED-mediated-photobiomodulation therapy on orthodontic tooth movement and root resorption in rats. Lasers Med Sci. 2015;30(2):779-785.

Orthodontic practice 59

CONTINUING EDUCATION

4-day intervals, respectively — for example, changing aligners every Tuesday and Friday. This makes it very easy for the patient to remember and stay compliant. In addition, I added these instructions to Jessica’s ClinCheck setup: “Upper 1|1 to be restored. Leave upper 1| shorter than |1. Set overbite to 0.5 mm at |1 to allow for future crowns. OK to leave spaces mesial and distal to upper 2|,|2 if Bolton discrepancy. Upper arch over-corrections: • Rotate |2 mesial-in. Lower arch over-corrections: • Move 2|,|2 lingual, Rotate 1|,|1 mesial-out, and Move |3 labial Thank you.” Jessica finished her treatment in 9 weeks with 18 upper and lower aligners changed every 3.5 days with acceleration through photobiomodulation. Her upper and lower Invisalign retainers were made at stage 17.


REF: OP V9.2 KOTTEMANN

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Accelerated orthodontics using photobiomodulation KOTTEMANN

1. This general philosophy correlates to the light energy conversions of photobiomodulation: “The application of therapeutic light in the near-infrared wavelength (NIR) range (________) generated by using low-energy laser or light-emitting diode (LED).” a. 100 nm-300 nm b. 400 nm-500 nm c. 600 nm-1000 nm d. 1,500 nm-1,800 nm 2. Photobiomodulation has been observed to _______ mitochondrial metabolism. a. decrease b. increase c. eliminate d. confirm 3. Mitochondrial enzymes can absorb photons from light and increase the production of ______, allowing the tissues to metabolize normally. a. oxidases b. ATP energy c. oxygen d. enzymes 4. ATP production has been shown to be upregulated ______ by infrared light, also

60 Orthodontic practice

known as photobiomodulation. a. twofold b. threefold c. fourfold d. fivefold 5. The assumption is that an increase in ATP at a localized site will induce cells to undergo remodeling — stimulating ________ to enhance tooth movement. a. CBO function b. apposition c. resorption d. both b and c 6. A number of clinical case studies have suggested an enhanced impact by LAO, _________. a. increased velocity of canine movement b. decreased pain c. a significantly higher acceleration of retraction of treated canines d. all of the above 7. In his research, he (Otto Warburg) found that applying specific frequencies of light to mitochondria ______ their activity. a. stimulated

b. inhibited c. reacted adversely with d. stopped 8. Application of light in dentistry has been clinically proven to be safe without adverse events such as _______. a. root resorption b. pathologic tooth mobility c. gingival recession d. all of the above 9. For both aligner and fixed appliance patients, adding light-accelerated orthodontics using photobiomodulation at _____ wavelength facilitates bone remodeling on a molecular level without adverse effects. a. 357 nm b. 562 nm c. 850 nm d. 976 nm 10. A normally 18-month case would be reduced to 12 months or less through _________. a. ATP reduction b. mitochondrial metabolism c. photosynthesis d. photobiomodulation

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Insignia™ Advanced Digital Orthodontic Solution Your vision, customized

I

nsignia™ is a comprehensive digital design and treatment system that empowers you to achieve the ideal finish for each patient efficiently and consistently. Invented by orthodontist and engineer, Dr. Craig Andreiko, Insignia was developed based on traditional orthodontic principles and was designed to elevate the treatment experience of doctors and patients. Dr. Andreiko says, “Insignia goes beyond, but does not dismiss, traditional cephalometric analysis by adding accurate 3D visualization of the desired result and then providing the specific appliances that encourage that result.” The goal of Insignia is to minimize the many complex variables involved in each orthodontic case and provide consistent quality results across a wide spectrum of case types. The Insignia approach offers millions of treatment options per tooth — with each prescription based on the patient’s needs, the clinician’s preferred philosophy, human variability, and the algorithm built into Insignia’s Approver software. The result is fully customized appliance fabrication based on your smile design — with custom brackets, custom wires, and custom placement jigs.

The Insignia advantage Based on research conducted by experienced Insignia users, the treatment solution generates proven results on improved predictability, precision, efficiency, and consistency. Using Insignia’s clear placement guides, the bonding accuracy rate was 98% across cases bonded by staff members with different levels of bonding experiences.1

Insignia workflow

Compared to traditional treatment methodology, cases treated by Insignia experienced on average 37% reduction in treatment time and 15% fewer visits per patients.2 Brackets repositioned per case were reduced on average by 84%. And 81% of the cases were finished without any bracket repositioning.3 In addition, the newly launched TruRoot™ feature combines CBCT root data with crown data from intraoral scanners or impressions for uncompromising accuracy in the representation of patients’ root positions. Of Insignia TruRoot users interviewed, 87.5% found the feature significantly improved their ability to visualize and predict root and tooth movement.4

Tailored to your style and goals Insignia doctors from all around the globe have experienced increased staff delegation, streamlined practice management, and significant business growth. No matter what your goals are, Insignia has a custom solution for your practice and your patient. To learn more about how Insignia empowers each doctor and patient, visit us at our AAO booth or online at Ormco.com/ insignia2018.

About Ormco Ormco has a distinguished 50-plus year history of providing the orthodontic profession with high-quality, innovative products backed by attentive customer service, and educational support. For more information, visit ormco.com, call 800-854-1741, or email insignia.support@ormco.com. OP This information was provided by Ormco.

REFERENCES 1. Data provided by Dr. Leon Verhagen, Lichtenvoorde, Netherlands, based on over 105 Insignia SL cases (September 2017) 2. Data based on AJO-DO article published in December 2015

Skeletal Class III, severely crowded maxilla, treated without extraction Case treated by Dr. Ashley Smith of Toowoomba, QLD, Australia 62 Orthodontic practice

3. Data collected by Dr. Timothy Bandeen, Battle Creek, Michigan, comparing cases treated with Insignia SL from 2009 to 2015 vs. cases treated with Damon SL prior to 2009 4. Data based on 2017 Insignia customer satisfaction survey

Volume 9 Number 2


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New software enhancements improve workflow in orthodontic offices

P

erhaps the only thing a member of a modern orthodontic practice looks at more than teeth is a computer. Scrolling, clicking, and navigating between screens has become as much a part of the day-to-day practice workflow as an adjustment appointment. When software is intuitive and streamlines the most tedious tasks in a practice, it gives clinicians and staff more time to focus on patients and their needs. The latest updates to Carestream Dental’s orthodontic practice management system and modeling software applications streamline practice workflow by addressing the common challenges and pain points within an orthodontic office. CS OrthoTrac v14 offers a complete redesign of the treatment card specifically focused to address concerns around clinical workflow efficiency. An all-new feature in the CS OrthoTrac software, universal aligner tracking, helps practices track treatment for the growing number of aligner cases — regardless of manufacturer, brand, or if made in-house. Critical data such as which tray the patient is wearing, how many aligners are given to a patient, and treatment progress are now available at a glance, eliminating the need to scroll through notes or generate one-off reports. The new treatment card also features a compliance section to help track treatment progression. Patients and their guardians often become frustrated with delays in treatment, but the new compliance tracker makes it easy for clinicians and front desk staff to quickly see a history of missed appointments, broken wires, and other factors that could affect treatment. With this information at their fingertips, team members can coach the patient on ways they could get back on track with their treatment.

Treatment card aligner tracking

Other updates include a standalone light bar, which offers a real-time view of workflow performance outside of the treatment card, plus a family member’s information is always just a click away for easy access to treatment information, appointments, and even financials. The update also includes an enhanced financials section with an expanded snapshot of a patient’s balance, payment schedule, and adherence. All important patient information is centralized in a modern interface, so team members spend less time searching for clinical information and more time focusing on patient treatment, communication, and satisfaction. Software can also play a role in streamlining workflow by automating the valuable, yet time-consuming, task of analyzing models and creating treatment setups. Rather than simply re-creating a manual process digitally, new CS Model+ software redefines the orthodontic workflow by automatically segmenting, setting up, analyzing, and presenting digital models within minutes,

eliminating the most cumbersome parts of the process — allowing orthodontists to undertake this valuable exercise once reserved for only the most complicated or unique cases. After capturing a digital impression, CS Model+ automatically detects, segments, and labels the patient’s dentition, with no clicks required on behalf of the user. However, clinicians may take as much or as little control as they’d like, as easy-to-use tools allow for the manual modification of tooth contour, tooth labeling, mesiodistal orientations, and tooth position wherever needed. The software can also quickly assess the level of difficulty and even offers visual simulations of various treatment options and the resulting occlusion to ensure that the desired treatment outcome is met. CS Model+ compiles all this robust data into customizable reports that can also automatically merge data from cephalometric tracings in CS Orthodontic Imaging software, so there is no need to search for values and manually enter them. Yet another benefit to practice workflow is the fact that users can quickly and easily access CS Model+ directly from the patient’s imaging chart in OrthoTrac. This seamless integration keeps all patient records digital and centrally located. Increasing demands from patients, new treatment options, and competition among practices mean that today’s orthodontic practice experiences even more pressure than in the past to stand out. Advanced software can improve workflow, aid in treatment, and help team members stay organized in order to offer efficient and superior patient care. OP This information was provided by Carestream Dental.

64 Orthodontic practice

Volume 9 Number 2


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CS OrthoTrac v14: new and improved and ready to wow. Carestream Dental may be a new standalone company, but we have a long history of defining practice management and imaging technology. Our strong legacy brands—which include Eastman Kodak and OrthoTrac—have paved the way for the new realm of digitalization. In the newest release of OrthoTrac, version 14 optimizes your digital workflow with a newly designed treatment card that gives you one-click access to all of your important patient data. With new clear aligner tracking, patient compliance monitoring, and other information at your fingertips, you are better equipped to assess treatment, make decisions and engage your patients. With OrthoTrac v14, the legacy of innovation continues. © 2018 Carestream Dental LLC. 16820 OR OrthoTrac AD 0318 OrthoTrac is a trademark of Carestream Dental Technology Topco Limited. Kodak is a trademark of Eastman Kodak Company.

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ORTHODONTIC PERSPECTIVE

Correcting the least emphasized feature of orthodontic therapy Dr. Larry White relates the quality of oral hygiene and tooth-brushing regimens to orthodontic outcomes Abstract Dental plaque often gains unusual vigor throughout orthodontic therapy and has the ability to damage the teeth and gingiva irreversibly, which often cancels the esthetics of optimal alignment. Orthodontists have applied several strategies to minimize the destructive effects of caries, decalcification and gingivitis — i.e., oral hygiene instruction, dietary counseling, fluoride varnish and rinses, sealants, and chlorhexidine rinses, etc. — but the results remain equivocal and imprecise. Most of the damage from decalcification, aka, white spot lesions, occurs at the gingival margin of the teeth, and this clearly is the area that needs emphasis in the oral hygiene regimen. Unfortunately, this feature has not received the profession’s attention until now with the development of a specially designed tooth brush that addresses this oral hygiene deficit. This article will display this brush and its unique ability to apply cleansing to this area, while simultaneously showing a dramatic way of bringing this to the patient’s attention.

Introduction All of the elements of orthodontic therapy gather plaque — e.g., brackets, bands, elastics, elastomerics, springs, wires, plastic sleeves, etc.,1,2 (Figure 1) — and despite orthodontists’ best attempts to limit the destructive results of plaque such as caries, gingivitis, decalcification with products such as oral hygiene instruction, fluoride varnish and rinses, chlorhexidine, sealants, and dietary restrictions, researchers have discovered that oral bacteria increase significantly during orthodontic therapy.3 Other researchers4-7 discovered how the escalation of Streptococcus mutans during orthodontic treatment jeopardizes dental enamel for caries and/or decalcification. Grant8 has further shown how typical mouth bacteria

Larry White, DDS, MSD, FACD, is in Private Practice of Orthodontics in Dallas, Texas.

66 Orthodontic practice

can mutate into pathogenic types during orthodontic therapy, while Matassa9 demonstrated how oral bacteria use as nourishment dental composites with which orthodontists attach brackets to enamel. Orthodontic clinicians have known for several decades about the relationship between the quality of orthodontic outcomes and the patients’ quality of oral hygiene.10 Also, much research has revealed the relationship of plaque to gingival inflammation,11 which lowers patients’ pain tolerances.12 This lowering of tolerances leads to further neglect of oral hygiene, which ultimately results in a cycling from neglect to plaque accumulation, to gingival inflammation, to lowered pain tolerances, and back again to more neglect. This cycle of neglect contributes greatly to orthodontists’ inability to achieve consistently quality treatment outcomes with patients.13 Ample evidence exists that defines sensitivity among other temperaments as genetic traits14 and may well discourage dental clinicians from trying to seriously alter patients’ tooth brushing behaviors.

Commonly used strategies for limiting plaque Some currently used preventatives against plaque include intensive oral hygiene instructions,15,16 fluoridated rinses,17-20 and/ or fluoridated gels/pastes.16,20-23 Others have advocated fluoride varnishes,24-27 fluoride-containing adhesives/primers,19,20 and fluoride releasing/filled sealants,28 and/ or antimicrobial varnishes (e.g., chlorhexidine or cetylpyridinim chloride).18,29 Recently, light-cured filled sealants have shown some effectiveness in preventing enamel decalcification.30,31 Although these various techniques have shown effectiveness, they remain somewhat inefficient because some require reapplication by clinicians or recharging of fluoride ions through patient compliance.16,23,27 These features of compliance by both clinicians and patients have limited their clinical adoption. Even more disturbing, Derks, et al.,32 discovered that although orthodontists know about the

Figure 1: A typical example of chronically poor tooth brushing

various demineralization therapies available, few routinely use any of the strategies other than oral hygiene instruction.

A personal observation Regarding Derks’ study of routinely used anticaries/decalcification protocols by orthodontists, I have worked in 26 orthodontic offices over the past 25 to 30 years for colleagues who have died, had extended illnesses, or absences from their practices for various reasons. This has given me an unusual opportunity to experience firsthand what clinicians do as preventive measures. Outside of brief explanations at the beginning of treatment, little else occurs throughout the patients’ treatments that the clinicians might consider preventive measures. If patients have a lot of plaque or food on the teeth, they may return to the sink to brush — uninstructed. During this time, I have never encountered an office that used plaque stain to reveal to the patients where their brushing deficit existed. Nor have I witnessed any special technique of brushing or a particular toothbrush given to the patient. Poor tooth-brushing patients are almost without exception highly sensitive patients who display several dental behaviors that limit successful treatment:33 • Resisting wearing removable appliances • Salivating copiously • Frequently breaking appliances • Habitually failing to wear permissibleappliances, e.g., elastics, headgears, etc. • Hurting easily and frequently complaining of discomfort Volume 9 Number 2


ORTHODONTIC PERSPECTIVE • Having poor brushing behaviors because of discomfort caused by the brush against the gingiva • Gagging easily • Being predisposed to TMD problems • Having a susceptibility to apthous ulcers • Having easily injured feelings and don’t respond well to anything they interpret as criticism • Having easily fatigued jaw muscles that prevent them from keeping the mouth open during adjustments These patients present many problems for the clinician with few obvious answers, but the most important to control is gingival inflammation, which requires a special effort and habitual brushing protocol developed by the doctor and staff. Some suggestions that have helped in the past: • Insist on a thorough prophylaxis. • Use daily chlorhexidine applications via the toothbrush. • Teach a specific technique of brushing with a specific toothbrush and monitor and critique the patient actually performing it, while overcoming the two general features of poor tooth brushers — light pressure and slow velocity of the brush. Once patients habitually control inflammation, many of the chronic destructive behaviors lessen, but since sensitivity is a genetic gift, one should not expect complete cessation of damaging conduct. However, reinforcement of brushing protocols should at least continue during patient office visits. Once patients realize that doctors demand excellent oral hygiene, and that they cannot leave the office without a clean mouth, they will respond favorably to the office protocol.

A new brush design for the susceptible areas Dr. Salvatore DeRicco has concerned himself with the problem of enamel demineralization or white spot lesions for most of his orthodontic career (Figure 2). To combat this oral hygiene deficit, he has developed a specially designed toothbrush, the Spot Less Brush (Figure 3), which patients can easily and painlessly apply to the susceptible gingival margins of the teeth (www. stopwhitespotsnow.com). It consists of one row of shorter than average bristles, and the handle has a unique design that correctly positions the brush bristles against the gingival one-third margins of the teeth. When the thumb presses against one handle indentation, the bristles have an angle of 45° 68 Orthodontic practice

that accesses the maxillary gingival margins of teeth from the incisors through the molars. When the handle rotates, the bristles of the brush have an angle of 45° that accesses the mandibular gingival margins of teeth from the incisors through the molars (Figures 4A and 4B). Dr. DeRicco has also developed an electric version of the brush, and this augments the brush’s effectiveness even more (Figure 5). The Spot Less Brush places the brushing emphasis where enamel insults happen most frequently, and patients receive the message that this brush addresses a particular and threatening feature of their orthodontic therapies. When clinicians and/or their staffs give patients a generic toothbrush or tell them they can use any brush they choose, it gives them the perception that this aspect of treatment plays a minor or unimportant role in the overall treatment. When at clinical appointments, patients receive no feedback about their brushing. Whether good or inadequate. They easily surmise that brushing has no importance. If brushing poorly doesn’t matter enough to warrant corrective instruction and supervision, it should not surprise orthodontists that they seldom see improvement in a patient’s oral hygiene and other behaviors. If clinicians want improvement, they have to make brushing matter, at least when patients are in the orthodontic office. The AAO Bulletin recently published an article that described how the phenomenon of poor oral hygiene and its legal liability are beginning to vex orthodontists from disappointed and irate patients and parents at the treatment outcomes that leave teeth with unsightly white spots. The article said that the decalcification of teeth had become a major source of claims for the AAO Insurance Company.

Effectively presenting oral hygiene deficits Highly sensitive patients seem to have a serious visual impairment when it comes to seeing plaque on the teeth and brackets, so they benefit greatly from the use of plaque stain and close supervision of their brushing technique (Figure 6). Even after staining and brushing, some patients seem incapable of identifying areas where plaque remains by viewing their teeth in a mirror (Figure 7). To overcome the patients’ inability to see even the grossest accumulations, orthodontists and their staffs can use some useful camera techniques to graphically emphasize the quantity, quality, and location of plaque.

Figure 2: White spot lesions after orthodontic therapy

Figure 3: The Spot Less Brush

Figure 4A: Positioned for brushing the maxillary teeth

Figure 4B: Positioned for brushing the mandibular teeth

Figure 5: The electric Spot Less Brush Volume 9 Number 2


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The Future is Here. • Stunning Visualization • Quantifiable Results • Easy Data Processing The Dolphin 3D software is a powerful tool that makes processing 3D data extremely simple, enabling dental specialists from a wide variety of disciplines to diagnose, plan treatment, document and present cases. Dolphin 3D allows visualization and analysis of craniofacial anatomy from data produced by cone beam computed tomography (CBCT), MRI, medical CT and 3D facial camera systems. For more information, visit www.dolphinimaging.com/3d.

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ORTHODONTIC PERSPECTIVE

Despite orthodontists’ best attempts to limit the destructive results of plaque, researchers have discovered that oral bacteria increase significantly during orthodontic therapy.

spots after orthodontic treatment with multibonded appliances. Eur J Orthod. 1986;8(4):229-234. 6. Ahn SJ, Kho HS, Kim KK, Nahm DS. Adhesion of oral streptococci to experimental bracket pellicles from glandular saliva. Am J Orthod. 2003;124(2):198-205. 7. Ahn SJ, Lim BS, Yang HC, Chang YI. Quantitative analysis of the adhesion of cariogenic streptococci to orthodontic metal brackets. Angle Orthod. 2005;75(4):666-671. 8. Grant DA, Grant DA, Flynn MJ, Slots J. Periodontal microbiota of mobile and non-mobile teeth. J Periodontol. 1995;66(5):386-3390. 9. Matassa C. Microbial attack on orthodontic adhesives. Am J Orthod Dentofacial Orthop. 1995;108(2):132-141.

Figure 6: Stained plaque

Figure 7: Mirror monitoring of brushing

Figures 8 and 9: 8.Digital Canon Rebel dental camera. 9. Eye-Fi wireless memory card

I prefer a digital Canon Rebel camera with a ring flash (Figure 8) and an iPad® that will connect to the camera via a wireless memory card. One needs to equip the camera with a wireless secure digital (SD) memory card (e.g., SanDisk Eye-Fi wireless memory card). These cards look identical to a conventional card but establish a WiFi network and allow the quick transfer of photos and videos wirelessly from the camera to a computer, tablet, or smartphone (Figure 9). The patient’s camera photograph of stained teeth immediately transfers to the iPad where the patient and/or parent can see the plaque effect in magnification on the screen (Figure 10), or the clinician can elect to take the intraoral photograph with the iPad. However, since iPads do not have a flash, the photograph often has less definition and quality than those made with a digital camera and ring flash.

Summary Fifty-eight years of clinical dentistry has convinced me that if patients practice good oral hygiene, they will do just about anything you ask. There are some exceptions to this general observation, but not many. On the other hand, if patients will not brush well, they will hardly ever perform any other task that aids their orthodontic experience. Unfortunately, the emphasis on good oral hygiene remains a low priority in most clinics, and that is an error of the first order. Materials and methods now exist to correct this orthodontic deficit, but it requires a strong commitment from the doctor who must provide the personnel, time, investment, and office discipline to make it work. OP REFERENCES 1. Basdra E, Huber H, Komposch G. Fluoride released from orthodontic bonding agents alters the enamel surface and inhibits enamel demineralization in vitro. Am J Ortho Dentofacial Orthop. 1996;109(5):466-472. 2. Bibilova EZ, Stafilov T, Ivkoska AS, Sokolovska. Prevention of enamel demineralization during orthodontic treatment: an in vitro study using GC tooth mousse. Balk J Stom. 2008;12:133-137. 3. Bloom RH, Brown LR. A study of the effects of orthodontic appliances on the oral microbial flora. Oral Surg Oral Med Oral Pathol. 1964;17:658-667.

Figure 10: Camera image transferred and magnified on the iPad 70 Orthodontic practice

4. Gorelick L, Geiger AM, Gwinett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98. 5. Artun J, Brobakken BO. Prevalence of caries and white

10. DUMMETT CO. Orthodontics and periodontal disease. J Periodontol. 1951;22:33-41. 11. Arnim SS. The use of disclosing agents for measuring tooth cleanliness. J Periodontol. 1963;34(3):227-245. 12. Dubner R, Sessle BJ, Storey AT. The Neural Basis of Oral and Facial Function. New York, NY: Plenum Press; 1978. 13. Whit L. A new oral hygiene strategy. Am J Orthod. 1984;86(6):507-514. 14. Aron EN, The Highly Sensitive Person. 1st ed. New York, NY: Carol Publishing Group; 1996. 15. White LW. Efficacy of a sonic toothbrush in reducing plaque and gingivitis in adolescent patients. J Clin Orthod. 1996;30(2):85-90. 16. Derks A, Katsaros C, Frencken JE, van’t Hof MA, KuijpersJagtman AM. Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances. A systematic review. Caries Res. 2004;38(5):413-420. 17. 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. 18. Ogaard B., Larsson , Henriksson T, Birkhed D, Bishara SE. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod. 2001;120(1):28-35. 19. Bishara SE, Ostby AW. White spot lesions: Formation, prevention and treatment. Semin Orthod. 2008;14(3):174-182. 20. Ogaard B. White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. Semin Orthod. 2008;14(3):183-193. 21. Erickson RL, Glasspoole EA. Model investigations of caries inhibition by fluoride-releasing dental materials. Adv Dent Res. 1995;9(3):315-323. 22. Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed bracket treatment. Cochrane Database Syst Rev. 2004;3:CD003809. 23. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J Orthod. 2005;32(2):102-114. 24. Todd MA, et al. Effect of fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod. 1999;116(2):159-167. 25. Schmit JL, Staley RN, Wefel JS, Kanellis M, Jakobsen JR, Keenan PJ. Effect of fluoride varnish on demineralization adjacent to brackets bonded with RMGI cement. Am J Orthod Dentofacial Orthop. 2002;122(2):125-134. 26. Vivald-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The effectiveness of a fluoride varnish in preventing the development of white spot lesions. World J Orthod. 2006;7 (2):138-144. 27. Staley RN. Effect of fluoride varnish on demineralization around orthodontic brackets. Semin Orthod. 2008;14(3):194-199. 28. Soliman MM, Bishara SE, Wefel J, Heilman J, Warren JJ. Fluoride release rate from an orthodontic sealant and its clinical implications. Angle Orthod. 2006;76(2):282-288. 29. Al-Musallam TA, Evans CA, Drummond JL, Matasa C, Wu CD. Antimicrobial properties of an orthodontic adhesive combined with cetylpyridinium chloride. Am J Orthod. 2006;129(2):245-251. 30. Benham AA, Campbell PM, Buschang PH. Effectiveness of pit and fissure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod. 2009;79(2):338-345. 31. Van Bebber L, Campbell PM, Honeyman AL, Spears R, Buschang PH. Does the amount of filler content in sealants used to prevent decalcification on smooth enamel surfaces really matter? Angle Orthod. 2011;81(1):134-140. 32. Derks A, Kuijpers-Jagtman AM, Frencken JE, Van’t Hof MA, Katsaros C. Caries preventive measures used in orthodontic practices: an evidence-based decision? Am J Orthod. 2007;132(2):165-170. 33. White, L.W. A new paradigm of motivation. in: McNamara JA Jr, Trotman CA, eds. Creating the Compliant Patient. Craniofacial Growth Series. Center for Human Growth and Development, University of Michigan, Ann Arbor, MI; 1997.

Volume 9 Number 2


RESEARCH STUDY

Adult perceptions of orthodontic appliances Drs. Richard Patterson, Daniel Rinchuse, Thomas Zullo, Lauren Sigler Busch, and Kay Youn, MFA, study the connection between braces and positive perceptions Abstract Objective: The aim of this study was to investigate adults’ perception of adults who are wearing braces or clear aligners. Materials and methods: A pilot crosssectional study was conducted on eight photos with 20 lay adult raters, 10 male and 10 female, consecutively selected by investigator (RP) from Pittsburgh, Pennsylvania. Four questions were asked regarding each randomly ordered photo: 1. How attractive is this person? 2. Does this person appear to be intelligent? 3. Does this person appear to be honest? 4. Does this person appear to be successful? The outcome measure for each question was a 100 mm-long Visual Analog Scale. Results: This study found no significant difference in raters’ opinions regardless of appliances worn when it comes to their perceived honesty. There was a statistically significant difference when adult raters judged an adult target with and without appliances as well as between different appliances in relation to attractiveness, intelligence, and successfulness. Conclusions: In regards to attractiveness and intelligence, adults wearing clear aligners were rated as having higher attractiveness and intelligence than adults wearing metal braces. Male adult raters’ did not find any difference among the four Richard Patterson, DDS, is in Private Orthodontic Practice in Raleigh, North Carolina. Daniel Rinchuse, DMD, MS, MDS, PhD, is Professor and Program Director, Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics, Greensburg, Pennsylvania. Thomas Zullo, PhD, is Adjunct Professor of Biostatistics, Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics, Greensburg, Pennsylvania. Lauren Sigler Busch, DDS, is Adjunct Faculty Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics, Greensburg, Pennsylvania, and private orthodontic practice: 3466 Briargate Boulevard, Colorado Springs, Colorado. Kay Youn, MFA, was a Professor of Graphic Design at Seton Hill University, Greensburg, Pennsylvania, and Creative Director/CEO of Youn Graphic and Interactive Design LLC, at the time of this research.

72 Orthodontic practice

target models in respect to successfulness; however, female adult raters rated models who wore clear aligner appliances as being more successful than models wearing metal braces. Conversely, the control female and male adult target photos received higher scores for all four questions when compared to adults wearing any form of orthodontic appliances, including clear aligners.

Introduction There is a close relationship between physical appearance and attractiveness, with the face possibly being the most important part of the body in regards to attractiveness and interpersonal relationships.1-11 Attractive people are regarded as more friendly, intelligent, interesting, and more social, and are assumed to have more positive personalities overall.8-10 Because the mouth and teeth are essential elements in facial esthetic evaluations, orthodontists can play a large role in affecting how an adult is viewed by his/her peers.10 With this concept in mind, one could say that an individual’s perception of another will be somewhat based on his/her view of irregularities in the mouth or teeth. Nanda, et al., supported this belief by showing that irregularities in position of teeth and jaws can disrupt social interaction, interpersonal relationships, and mental well-being, and may lead to feelings of inferiority.11 For years, clinicians have been trying to understand what motivates patients to undergo orthodontic treatment. Research has investigated whether patients are motivated by improved function or more likely the desire to improve dental esthetics or the combination of function and esthetics.12 Studies have suggested that psychological and social gains from orthodontic treatment are more important than gains in oral health.12 The majority of studies involving esthetic perception and orthodontics have been performed using non-adult patients as the subjects in the evaluation of attractiveness, symmetry, and appearance of teeth. A systematic review from Samsonyanova, et al.,12 postulated that perhaps the reason is that most orthodontic patients are children and adolescents. Information regarding adult perceptions and

esthetic perception is lacking because most perception studies use raters and target models that are children and adolescents. The aim in this study is to evaluate how different types of orthodontic appliances on adults influence other adults’ perceptions. The goal is to answer the question that most adults ask themselves prior to orthodontic treatment, “Will my peers view me differently during orthodontic treatment?” This study specifically addresses the short-term impact that wearing orthodontic appliances has on adults’ appearance according to their adult peers. The study will correlate adults’ views on attractiveness, intelligence, honesty, and successfulness in relation to the type of orthodontic appliance an adult wears. Information garnered from this study will potentially aid in orthodontic appliance selection for adults by having a better understanding of how adults perceive other adults in orthodontic appliances.

Materials and methods Selection of target persons Prior to data collection, the project was approved by the Seton Hill University IRB in Greensburg, Pennsylvania. After IRB approval, three male and three female target patients were selected from Shutterstock. com (New York, New York), an online twosided marketplace for creative professionals to license photos. Shutterstock.com allows models to promote their image for license to professionals who need stock model photos. Each model has given written consent to use their image for creative purposes as long as the manipulation is not explicit in nature. Models have been categorized by Shutterstock.com to allow for a refined search based on gender and attractiveness. Pools of models were selected using keyword average and then keyword male/female smiling. Inclusion criteria for models were adult Caucasian subjects over the age of 21 with relatively symmetric facial features. Exclusion criteria for models were any moderate to severe dental malocclusion, skeletal asymmetry, or excessive makeup/hair color or hairstyles that would be distracting to the rater. Potential target subjects with any other distracting Volume 9 Number 2


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RESEARCH STUDY features, including, but not limited to, interincisor diastema, maxillary and mandibular crowding, skeletal and profile anomalies, and anterior open bites that would deviate from a non-ideal smile, were also excluded.13,15,16 Each target model was photographed smiling from a frontal facial view “social view” with a similar relative focal size and background. Photos were 5 x 6 inch, printed in color photo paper and mounted on a green background. After completing a faculty rater consent form — seven clinical faculty from Seton Hill Center for Orthodontics, six male and one female faculty, all Caucasian in race with ages ranging from 45-65 years, with 20-plus years of experience — each screened and rated the six model photos. The models were rated on attractiveness based on a Likert scale of 1-7 (1 – signifying least attractive and a 7 – signifying most attractive). One female and one male model photo were selected based on receiving a mean score closest to average, between 3 and 5. By selecting averagelooking models, the variable of attractiveness was effectively neutralized. Faces of average attractiveness were also used to prevent bottom and ceiling rating effects.15 Prior research showed that a person’s attractiveness has a significant effect on others’ perceptions of that person.13

Manipulation of target person photos The selected average level attractive models had his/her photo manipulated into four photos by the same expert operator (K.Y. Professor of Graphic Design, Seton Hill University and Creative Director/CEO of Youn Graphic and Interactive Design LLC) using Adobe Photoshop® (CS6; Adobe Systems, San Jose, California). Each model had his/ her image manipulated to show the following: one photo with metal braces, one photo with ceramic braces, one photo with clear aligners, and the final photo with no orthodontic appliance. Manipulations were only performed on the models’ teeth so that the other facial characteristics were controlled. The photo manipulations produced eight frontal facial photos, four male and four female, which were rated in the study. Raters The eight photos were judged by 20 lay adult raters, 10 male and 10 female, consecutively selected by the principal investigator (RP) from Renaissance Church in Pittsburgh, Pennsylvania, new members group, and rated for attractiveness and three personality traits: intelligence, honesty, success. The 20 raters (10 female/10 male) in the study were Caucasian in race and were age range of 21 to 65. Laypersons were used because they

are the “primary consumers of orthodontic treatment” according to McLeod, et al.14, and raters who have dental experience could have pre-existing bias toward orthodontic appliances. The raters were asked to review and sign a rater consent form prior to taking part in the study. They were given a script that briefly explains the study’s purpose but still kept them blind to the actual intent of the study. After signing voluntary consent forms, the raters received an 8.5" x 11" booklet that contained the eight 5" x 6" frontal facial photos, which were randomly assorted, each having a four-item questionnaire. The cover page of the booklet instructed the evaluators to answer the four questions after viewing each photo using a 100 mm visual analog scale. The cover page informed raters to notify the administrator if they knew or have had contact with either of the models. As expected, none of the raters had contact with either of the Shutterstock.com models. Outcome measures The images were accompanied with the following questions: 1. How attractive is this person? 2. Does this person appear to be intelligent? 3. Does this person appear to be honest? 4. Does this person appear to be successful?

Figures 1 and 2: 1. Female target person. 2. Male target person. A. Control. B. Clear aligner. C. Metal brackets. D. Ceramic brackets 74 Orthodontic practice

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RESEARCH STUDY Each question was presented along with a Visual Analog Scale from zero to 100 mm. This scale was a sliding scale, marked zero signifying complete disagreement, 50 for neutral, and 100 signifying complete agreement.9 The VAS, which is a reliable and commonly used scoring method in health research to generate parametric data,15 was used to correlate the eight independent variables to the four dependent variables. Each rater received a photo packet with randomly ordered target model photos to help with inter-rater reliability. This project methodology has been used previously for use in perception ratings because of its simplicity and rapidity.16 Because four questions were asked regarding each photo, and because there are eight photos, the questionnaire consisted of 32 questions. Upon receipt of the finished booklet the administrator (RP) marked whether the rater was male or female. After completion of the rater portion of the study, a debriefing session was offered to all raters discussing the intent of the research project. Data compilation and statistical analysis In this study the independent variables (intervention, exposure) were the target persons’ gender, the raters’ gender, and orthodontic appliance: metal braces on models’ teeth, ceramic braces on models’ teeth, clear aligners on models’ teeth, and control (no appliances). The dependent variables (outcome measures) were facial attractiveness, intelligence, honesty, and success as measured by the visual analog scale scores by the raters. The data was analyzed as a 2 x 2 x 4 MANOVA for two levels of rater gender, two levels of target photo gender, and four levels of modification. Because the only manipulation is the presence of a different type of appliance on the model photo, one could infer that any statistically significant difference from the control would show a difference in perception about that appliance versus the control. The scores for each question based on the corresponding model photo were compiled. The data was analyzed to see if this group of adults, at this given “slice of time,” showed a statistically significant difference in visual analog scale scores between a certain type of orthodontic appliance compared to the control photo with no orthodontic appliances, in regards to attractiveness, intelligence, honesty, or success. The data helped show which independent variable has a more positive or negative effect on each question’s VAS score by evaluators in relation to the control photo. The statistical analysis also 76 Orthodontic practice

Table 1: Means and Standard Errors of the Dependent Variables for Each Appliance 95% Confidence Interval Measure

Appliance

Mean

Standard Error Lower Bound

Attractiveness

Intelligence

Honesty

Successfulness

Upper Bound

Metal

55.732

2.805

50.053

61.411

Ceramic

58.520

2.566

53.327

63.714

Clear Aligner

62.207

2.793

56.553

67.861

Control

70.202

2.568

65.003

75.401

Metal

58.907

2.873

53.091

64.723

Ceramic

59.755

2.576

54.539

64.970

Clear Aligner

64.505

2.695

59.050

69.959

Control

68.345

2.751

62.776

73.914

Metal

59.411

2.787

53.770

65.053

Ceramic

61.055

2.490

56.014

66.095

Clear Aligner

59.641

2.788

53.996

65.286

Control

63.189

2.907

57.305

69.073

Metal

60.573

2.888

54.726

66.420

Ceramic

63.066

2.661

57.680

68.452

Clear Aligner

65.970

2.725

60.453

71.488

Control

69.714

2.643

64.364

75.064

allowed the researchers to evaluate any statistical significance between the rater’s gender and the model’s gender. SPSS software (version 24.0; Armonk, New York) was used to calculate a MANOVA for two levels of rater gender (male/female), two levels of target photo gender (male/ female), and four levels of modification (metal braces, ceramic braces, clear aligners, no appliance-control). Pairwise Comparisons (Bonferroni) (Tables 1 and 2) were performed to show the differences between the four appliance materials in relationship to attractiveness, intelligence, honesty, and successfulness in conjunction with the raters’ gender and target models’ gender. All data maintained a Type I alpha risk of .05 and a power of 80%.

Results A total of 20 (10 male/10 female) raters successfully completed the VAS evaluation of four dependent variables of attractiveness, intelligence, honesty, and successfulness based on eight independent variables made up of six appliance manipulated target model photos (3 male/3 female) as well as a female and male control photo. Multivariate tests resulted in the following: 1. There were no significant differences between male and female raters (F = 0.853, p = 0.503), male and female target models (F = 1.646, p = 0.185),

or the interaction between raters gender and target models gender (F = 0.489, p = 0.743) for the set of four dependent variables (attractiveness, intelligence, honesty, and successfulness) 2. There were statistically significant differences among the levels of modification (F = 4.701, p < 0.0004) for the set of four dependent variables (attractiveness, intelligence, honesty, and successfulness). Significant differences were found for attractiveness (F = 18.465, p < 0.0004), intelligence (F=8.52, p < 0.0004), and successfulness (F = 7.045, p < 0.0004). There were no significant differences for the independent variables in relation to honesty. 3. There is a moderate interaction effect (p = 0.046) between raters’ gender and target models’ photos for the set of four dependent variables. Univariate tests showed that only the variable successfulness exhibited a significant interaction (F = 3.093, p = 0.030).

Discussion Results did show a statistically significant difference when male and female adult raters judged a female or male adult target model with and without appliances in relation to attractiveness, intelligence, and Volume 9 Number 2


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RESEARCH STUDY Table 2: Pairwise Comparisons Among Appliances

successfulness. In regards to attractiveness and intelligence, clear aligners were appreciably more preferred by male and female adults than metal appliances. Male adult raters did not find any difference among the four target models in respect to successfulness: however, female adult raters favored clear aligner appliances over metal appliances in relation to successfulness. There was no statistical significance between ceramic braces adult target models and clear aligner adult target models when rated by adults in relation to attractiveness, intelligence, and success. Similar to Pithon et al,17 this study suggested that there is no significant difference in raters’ opinions whether female or male adults when judging a female or male adult target model with or without appliances when it comes their honesty. The findings of this study support the concept that the psychosocial impact of orthodontic appliances on adults’ perspectives is significant and may affect an adult’s decision to undergo orthodontic treatment. In regards to attractiveness and intelligence, clear aligners were preferred by male and female adults over metal appliances. Conversely, the control female and male target photos were preferred the most overall in relation to attractiveness, intelligence, and successfulness. Based on these results, orthodontists may assume that adults who are seeking orthodontic treatment may have a more negative outlook on metal orthodontic appliances and are more likely to favor clear aligner treatment or no treatment to metal appliance treatment. Second, female raters deemed adult target models with clear aligners as more successful than metal braces target models. Male raters’ did not find any differences among the target models for the dependent variable of successfulness. (Tables 3 and 4) This supports the idea that female adults are more influenced by orthodontic appliances in relation to an adult’s success. This research suggests that adult females seeking treatment are more likely to request clear aligner appliance treatment over metal bracket appliance treatment based on the overall results of this research. This research shows adults do perceive their peers as less or more attractive, intelligent, and successful based on what type of orthodontic appliance they are wearing. A recent study by Pithon, et al.,17 found that adults do perceive other adults differently in regards to attractiveness and intelligence based on their “social smile.” Limitations of this study are that it is observational, cross-sectional, and contain 20 adult raters, and therefore, it is limited in scope. 78 Orthodontic practice

Measure

Attractive

(I) Appliance

(J) Appliance

Ceramic Metal

Clear Aligner Control Metal

Ceramic

Clear Aligner Control Metal

Clear Aligner

Ceramic Control Metal

Control

Ceramic Clear Aligner

Intelligent

Clear Aligner

Ceramic

Successful

Metal

Clear Aligner

Control

-7.511

1.933

-6.475*

2.002

.015

-12.048

-.902

-14.470*

2.213

.000

-20.632

-8.309

2.789

1.696

.651

-1.933

7.511

-3.686

1.788

.277

-8.662

1.290

-11.682*

2.038

.000

-17.355

-6.008

6.475*

2.002

.015

.902

12.048

3.686

1.788

.277

-1.290

8.662

-7.995*

2.546

.020

-15.083

-.908

14.470*

2.213

.000

8.309

20.632

11.682**

2.038

.000

6.008

17.355

.908

15.083 4.471

Clear Aligner

-5.598*

1.988

.046

-11.132

-.064

Control

-9.439*

2.416

.002

-16.163

-2.714

.848

1.911

1.000

-4.471

6.166

Clear Aligner

-4.750

1.968

.124

-10.227

.727

Control

-8.591*

2.119

.001

-14.489

-2.693

Metal

5.598*

1.988

.046

.064

11.132

Ceramic

4.750

1.968

.124

-.727

10.227

Control

-3.841

2.336

.650

-10.344

2.662

Ceramic

9.439

2.416

.002

2.714

16.163

8.591*

2.119

.001

2.693

14.489

3.841

2.336

.650

-2.662

10.344

-1.643

2.418

1.000

-8.374

5.088

-.230

1.848

1.000

-5.373

4.914

Control

-3.777

3.106

1.000

-12.423

4.868

Metal

1.643

2.418

1.000

-5.088

8.374

Clear Aligner

1.414

2.392

1.000

-5.245

8.073

Clear Aligner

-2.134

2.410

1.000

-8.843

4.575

.230

1.848

1.000

-4.914

5.373

Ceramic

-1.414

2.392

1.000

-8.073

5.245

Control

-3.548

2.456

.941

-10.385

3.290

Metal

3.777

3.106

1.000

-4.868

12.423

Ceramic

2.134

2.410

1.000

-4.575

8.843

Clear Aligner

3.548

2.456

.941

-3.290

10.385

Ceramic

-2.493

1.868

1.000

-7.692

2.706

Clear Aligner

-5.398

1.559

.008

-9.736

-1.059

Control

-9.141

2.508

.005

-16.122

-2.159

Metal Ceramic

.651

-6.166

Metal

Control

1.696

.020

Control

Clear Aligner

-2.789

1.000

Ceramic Metal

Upper Bound

2.546

Clear Aligner Honest

Lower Bound

1.911

Metal Control

95% Confidence Interval for Differenceb Sig. b

-.848

Metal Ceramic

Standard Error

7.995*

Ceramic Metal

Mean Difference (I-J)

2.493

1.868

1.000

-2.706

7.692

Clear Aligner

-2.905

1.907

.816

-8.212

2.403

Control

-6.648

1.942

.009

-12.053

-1.243

Metal

5.398

1.559

.008

1.059

9.736

Ceramic

2.905

1.907

.816

-2.403

8.212

Control

-3.743

2.593

.942

-10.960

3.474

Metal

9.141

2.508

.005

2.159

16.122

Ceramic Clear Aligner

6.648*

1.942

.009

1.243

12.053

3.743

2.593

.942

-3.474

10.960

Based on estimaged marginal means. * The mean difference is significant at the .05 level. b Adjustment for multiple comparisons: Bonferroni.

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RESEARCH STUDY Conclusions

Table 3: Means for Rater Sex* Appliance for the Variable Successfulness 95% Confidence Interval Measure

Judge Sex

Material

Mean

Standard Error Lower Bound

Successful

Upper Bound

Metal

64.100

4.181

55.637

72.563

Ceramic

66.450

3.851

58.654

74.246

Clear Aligner

68.350

3.945

60.364

76.336

Control

67.700

3.825

59.956

75.444

Metal

57.045

3.986

48.976

65.115

Ceramic

59.682

3.672

52.248

67.115

Clear Aligner

63.591

3.761

55.976

71.205

Control

71.727

3.647

64.344

79.111

Male

Female

* The mean difference is significant at the .05 level.

Table 4: Pairwise Comparison for Rater Sex* Appliance for Successfulness

Measure

Judge Sex

(I) Material

Successful Metal

Ceramic

Mean Difference (I-J)

Standard Error

Ceramic

-2.350

2.704

Clear Aligner

-4.250

Control Metal

(J) Material

Sigb

95% Confidence Interval for Differenceb Lower Bound

Upper Bound

.390

-7.823

3.123

2.256

.067

-8.818

.318

-3.600

3.631

.328

-10.950

3.750

2.350

2.704

.390

-3.123

7.823

Clear Aligner

-1.900

2.760

.495

-7.487

3.687

Control

-1.250

2.811

.659

-6.940

4.440

Metal

4.250

2.256

.067

-.318

8.818

Ceramic

1.900

2.760

.495

-3.687

7.487

Control

.650

3.753

.863

-6.948

8.248

Metal

3.600

3.631

.328

-3.750

10.950

Control

Ceramic

1.250

2.811

.659

-4.440

Clear Aligner

-.650

3.753

.863

-2.636

2.578

-6.545*

Henson ST, Lindauer SJ, Gardner WG, Shroff B, Tufekci E, Best AM. Influence of dental esthetics on social perceptions of adolescents judged by peers. Am J Orthod Dentofacial Orthop. 2011;40(3):389-395.

2.

Bale C, Archer J. Self-perceived attractiveness, romantic desirability and self-esteem: a mating sociometer perspective. Evol Psychol. 2013;11(1):68-84.

3.

Momentemurro B, Gillen MM. Wrinkles and sagging flesh: exploring transformation in womenâ&#x20AC;&#x2122;s sexual body image. J Women Aging. 2013;25(1):3-23.

4.

Seidman G, Miller OS. Effects of gender and physical attractiveness on visual attention to Facebook profiles. Cyberpsychol Behav Soc Netw. 2013;16 (1):20-24.

5.

Ferreira C, Pinto-Gouveia J, Duarte C. Physical appearance as a measure of social ranking: the role of a new scale to understand the relationship between weight and dieting. Clin Psychol Psychother. 2013;20(1):55-66.

6.

Meyer-Mercotty P, Stellzig-Elsenhauer A. Dentofacial selfperception of adults with unilateral cleft lip and palate. J Orofac Orthop. 2009;70(3):24-236.

7.

Tatarunaite E, Playle R, Hood K, Shaw W, Richmond S. Facial attractiveness: a longitudinal study. Am J Orthod Dentofacial Orthop. 2005;127(6):676-682.

6.940

8.

Honn M, Goz G. The ideal of facial beauty: a review. J Orofac Orthop. 2007;68(1):6-16.

-8.248

6.948

9.

.313

-7.855

2.582

Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic treatment. Am J Orthod Dentofacial Orthop. 1990;113(1):29-39.

2.151

.004

-10.901

-2.190

-14.682*

3.462

.000

-21.689

-7.674

2.636

2.578

.313

-2.582

7.855

-3.909

2.632

.146

-9.237

1.418

-12.045*

2.680

.000

-17.471

-6.620

6.545*

2.151

.004

2.190

10.901

Ceramic

3.909

2.632

.146

-1.418

9.237

Control

-8.136

3.578

.029

-15.380

-.892

Metal

14.682*

3.462

.000

7.674

21.689

Ceramic

12.045*

2.680

.000

6.620

17.471

8.136*

3.578

.029

.892

15.380

Ceramic Metal

Clear Aligner Control Metal

Ceramic

Clear Aligner Control

Female Metal Clear Aligner

Control

Clear Aligner

* The mean difference is significant at the .05 level. b Adjustment for multiple comparisons: Bonferroni.

80 Orthodontic practice

REFERENCES 1.

Male Clear Aligner

1. In regards to adults rating other adults in orthodontic appliances, there was a statistical significance between orthodontic appliance types as it relates to attractiveness, intelligence, and successfulness. 2. Clear aligner adult target models rated higher than metal bracket appliance adult models in relation to attractiveness and intelligence. 3. Female adult ratersâ&#x20AC;&#x2122; favored clear aligner adult target models over metal bracket adult models in relation to successfulness. Male adult raters did not find any difference among the four target models in respect to successfulness. 4. Control adult target models without appliances were statistically preferred over metal, ceramic, and clear aligner adult target models in relation to attractiveness, intelligence, and successfulness. OP

10. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-yearold Danes. Am J Orthod Dentofacial Orthop. 1985; 87(2):110-118. 11. Nanda RS, Ghosh J. Facial soft tissue harmony and growth in orthodontic treatment. Semin Orthod. 1995;1(2):67-81. 12. Samsonyanova L, Zdenek B. A systematic review of Individual motivational factors in orthodontic treatment: facial attractiveness as the main motivational factor in orthodontic treatment. Int J Dent. 2014:2014:1-7. 13. Olsen JA, Inglehart MR. Malocclusions and perceptions of attractiveness, intelligence, and personality, and behavioral intentions. Am J Orthod Dentofacial Orthop. 2011;140(5):669-679. 14. McLeod C, Wiltshire W, Fields HW, Hechter F, Rody W Jr, Christensen J. Esthetics and smile characteristics evaluated by laypersons. Angle Orthod. 2011;81(2):198-205. 15. Kokich VO Jr, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics asymmetric and symmetric situations. Am J Orthod Dentofacial Orthop. 2006;130(2):141-151. 16. Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use. Am J Orthod Dentofacial Orthop. 1985;88(5):402-408. 17. Pithon MM, Naschimento CC, Barbosa GC, Coqueiro Rda S. Do dental esthetics have any influence on finding a job? Am J Orthod Dentofacial Orthop. 2014;146(4):423-429.

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PRACTICE MANAGEMENT

“The secret sauce” — more than the golden rule: part 2 Dr. Donald J. Rinchuse discusses the many facets of a customer service-oriented practice Abstract Part 2 of this essay discusses the importance of WOW customer service, which is the “secret sauce” in orthodontics. Financial profits are an outcome of incredible patient/ customer service, so clinicians must serve the customer to find success. Companies such as the Ritz-Carlton and Disney have realized the importance of customer service: If we don’t serve the customer, someone else will. We are reminded that the golden rule can be elevated to even a higher level and standard — “more than the golden rule”: Not to just treat patients as we would want to be treated, but to treat patients as we would want our children (and grandchildren) to be treated. In part 1, I discussed the following: • The history of advertising in dentistry • The legal challenge to uphold advertising • The contextual environment of orthodontic practice • The importance of belief in success — a positive attitude • The beginning of a detailed discussion of the “secret sauce” The secret sauce is a nebulous concept and is clearly not one factor for all practices. There is no real “secret” to the “secret sauce” for orthodontic success and profitability. Each practice has its peculiar niche in which a marketing plan can be developed. Some of the factors that practices can highlight

Donald J Rinchuse, DMD, MS, MDS, PhD, received his dental degree (DMD) and Master of Science degree (MS) in Pharmacology and Physiology in 1974, a certificate and Master of Dental Science degree (MDS) in orthodontics in 1978, and a PhD in Higher Education in 1985 — all from the University of Pittsburgh. He has been involved in orthodontics for more than 41 years. He is a Diplomate of the American Board of Orthodontics and a manuscript review consultant for several journals including the American Journal of Orthodontics and Dentofacial Orthopedics. He has 130 publications to his credit, which includes two books. He has given many lectures and presentations. Dr. Rinchuse is presently in corporate orthodontic practice in Greensburg, Pennsylvania.

82 Orthodontic practice

If we don’t serve the customer, someone else will.

are a special technique or appliance (e.g., self-ligating brackets, clear aligners, nonextraction treatments, and early treatments), sleep apnea,1 TMD, communications, WOW service, website, internal marketing, teledentistry, Adult Smile Center,2 and so on. This led to the consideration that there are arguably still three general factors that can predict success in orthodontics: price, results, and service. In part 1, I discussed “price” and “results,” and part 2 will consider “service” (Table 1).

Service Professional codes of ethics All dentists who care for patients should be cognizant of the principles of ethics established by the various dental/orthodontic professional organizations. The American Dental Association’s (ADA) Code of Professional Conduct has five principles: 1. Patient autonomy (“patient selfgovernance”) 2. Veracity (“truthfulness”), 3. Non-maleficence (“do no harm”) 4. Justice (“fairness”) 5. Beneficence (“do good”). The ADA believes that the dental profession must make a commitment to society that its members will adhere to act in the highest ethical standards because the dental profession holds a special position of trust within society. Other dental professional organizations have similar codes. For instance, the core values of the American College of Dentists are similar to that of the ADA: autonomy, beneficence, compassion, competence, and integrity. The values of the American Association of Orthodontists are

patient self-governance (“Autonomy”), do no harm (“Non-maleficence”), treat people fairly (Justice), do good (Beneficence), and truthfulness (Veracity). Many publications have addressed the ethical and professional considerations of patient management such as that by Rinchuse, et al.3 Business versus profession It is often discussed whether orthodontics is a business or a profession. In years past, dentistry and orthodontics were considered more of a profession than a business, emphasizing the service aspects(s) of practice over the business and profit side of practice. There were considerably fewer orthodontists with less competition and almost no advertising besides a listing in the Yellow Pages of the telephone book. You could just about set up your practice in any area you wished. The adage was that you just put your “sign up,” and patients would flock to your office. But nowadays graduates are coming out with significant educational indebtedness, and there are now orthodontists who consider themselves more so entrepreneurs than practitioners. There is much competition not only from other orthodontists, but also from general dentists doing orthodontics (e.g., Invisalign® and Six Month Smiles®). And as mentioned previously, there is the emergence of the tele-orthodontics. For sure, the business part of the profession is very important. Few orthodontists could survive if they choose to operate based on past thinking. Nonetheless, orthodontics has become more of a business than a profession in which the Volume 9 Number 2


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PRACTICE MANAGEMENT bottom line is the “almighty dollar” rather than service, albeit, only if service can be translated into an internal marketing plan that yields profits. Patient-centered care The old paradigm of patient care was “paternalism.” This is the view that the doctor is all knowing and is in control of all aspects and decisions in the treatment of patients — i.e., the “father knows best” philosophy. In keeping with this paradigm, the doctor looks down on the patient and has little to no interest and tolerance for the patient’s views. On the other hand, patient “autonomy” is the focal point of patient-centered care and stresses the importance of the patient’s views in the context of his/her treatment. The patient has a voice in how he/she will be treated. In this view, the doctor and patient sit face-to-face and jointly discuss the patient’s treatment in relationship to his/her views, concerns, and expectations. Humanism, empathy, and compassion are valued in patient-centered care (Table 2). Aristotle said about the doctor-patient relationship, “They wouldn’t care how much you know, until they know how much you care” (Table 2). In the patient-centered model, the doctor and staff should refer to the patient for more than their diagnosis and treatment. That is, rather than say, “The Class II, orthognathic, expander, or Invisalign patient is here,” say, for example, “Josh, Mary, Suzy, or Jack is ready for an adjustment in the next room.” Use the patient’s name, and use it often.4 Various aspects of patient management have been discussed in other publications,4-7 including the discussion of various educational-psychological principles5 (Table 3). Parenthetically, it may be important for graduate orthodontic residency programs to consider candidates with proven ethical and service-oriented values rather than attempt to “train” these values into current residents who may lack these values.8 Prearranged dialogues (“scripting”) for staff have merit to effectively communicate (verbal, written, social media) with patients and families. This typically involves the patient’s/family’s first contact with the office. Nonetheless, staff trained in the philosophy and concepts of patient-centered care can deliver high-level UN-scripted conversations with patients and families, which would be more genuine. How do you script humanism, empathy, and compassion?4,5 Importantly, the doctor-patient relationship is being challenged by a “product/ 84 Orthodontic practice

Table 1: The Environment of the Orthodontic Practice TYPE OF PRACTICE: Which affects all the other elements of a practice Private: solo, partnership, group (with general dentist, pediatric dentist, specialists, etc.) Corporate: only orthodontics, with specialty services, DMOs Associate/contracted: leading to partnership/ownership, not leading to ownership University Military MISSION: What is unique about the office, treatment, service Goals: long and short term Objectives “Branding” PRACTICE MANAGEMENT Building: own/rent, space (how large), if own > space for tenants Physical Environment

Number of operatories: type (open/closed bay) Front desk, operatories, lab, sterilization, private office, consultation room(s), game room, waiting (adult, children), coffee, fireplace, TV, fish, adults’ area, etc. Hardware: computers, iPads®, etc. Software program Website development and management/social media management Doctor(s)

Business Operations

Staff: reception, billing, insurance, lab tech, chairside assistants, treatment coordinator, marketing specialist (on staff or outside), etc. Scheduling/tracking Money management: billing, collections, aging accounts, etc. Audits HIPAA, OSHA, Material Safety Data Sheets, radiation safety and inspection (CBCT), HR department: sick days, vacations, health insurance, 401(k), bonus, sexual harassment training, employment law, workers’ comp, etc.

Insurances Advisories

Malpractice Other: office, auto, life, umbrella, health, etc. Attorney, accountant, financial, etc. Quality control of patient management not of results of treatment

Patient Management

Patient-centered environment Educational/psychological principles for patient management Marketing plan

Marketing

External: social media, printed media, website, branding, billboards, etc. Internal: WOW service, T-shirts and other giveaways, spin wheel, therapy dog Referring dentists versus general public Targets, critical systems, etc.

Practice Evaluation

Patient satisfaction survey, social media posts Key performance indicators: consultations, starts, conversion rate, gross versus net income, referral base

PRICE High end, low end, average fees Discounts/specials Medical assistant programs Insurance programs: PPO, HMO, etc. Unique/different appliance/treatment types: phase I, comprehensive, clear aligners, clear brackets, special appliances Comparisons with other practices

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PRACTICE MANAGEMENT consumer-driven” philosophy. As previously mentioned, the age of tele-dentistry and teleorthodontics is upon us. A patient need not see an orthodontist for treatment, or else see the orthodontist regularly. Clear aligners can be delivered directly to the patient’s doorstep with little to no direction from a dentist/ orthodontist. The American Association of Orthodontist and several state dental boards are challenging tele-orthodontics (Table 1). Physical environment The physical environment of an office is important for excellent patient service. It is essential for creating a brand. The geographical location of an office is the first consideration for an orthodontic office. The old adage that a doctor can just decide where he and his family want to live and then just set up an office is no longer true. A deliberate evaluation and analysis are needed to establish where, and possibly with whom, a new graduate will associate with or open an office on his/her own. Once a practice location is decided, there are some considerations. Can patients easily get to the office? Is there parking? How about the exterior of the office? What about signage and entrance to the office? Also, if an orthodontist decides to open a new practice, some reflection is needed to determine how big the office will be in square footage, number of operatories, décor, and so forth. The office should be clean, neat, and inviting. Successful orthodontic practices are “branded” according to the amenities and theme of their physical structure. An attractive office lifts the spirits of the doctor, staff, and patients. The doctor’s and staff’s clothing (uniforms) should reflect the practice brand. The layout of the office is important in regards to space for reception, billing, consultation, treatment, private office(s), lab, sterilization, staff lounge, lunch area, and so on. Special attention is needed to the design of the treatment area because this is where the product is delivered and made and, of course, the money produced. A recent feature of the treatment area is a “perch.”9 This is a discrete location for orthodontists to access their computers, have private conversations with staff, and so on, without going to a private office. It is a satellite to their private office.9 Adults versus children Orthodontic offices may focus their practice on children or adults. Some do both. A game room for children as well as 86 Orthodontic practice

Table 1: The Environment of the Orthodontic Practice (continued) RESULTS Special appliance(s) Quality control ABO finish versus what patients want versus what referring dentist may like Precision, effectiveness, efficiency Evidence-based treatment: study groups, journals, Facebook SERVICE “More than the golden rule” Patient-centered environment Autonomy versus paternalism Happy patient/happy referral base Disney and Ritz-Carlton customer service principles Staff understands and appreciates quality service “The best part of the patient’s day!”

Table 2: Principles of the Doctor-Patient Relationship and Healthy Living DOCTOR/PATIENT RELATIONSHIP Treat the patient as well as the disease — Patch Adams Movie (1999) The difference between a scientist and a doctor is people — Patch Adams Movie (1999) A doctor is more than a dispassionate intellectual who can rattle off a number of medical facts — Patch Adams Movie (1999) A doctor should offer counsel and hope to patients — Patch Adams Movie (1999) Medicine

One of the most important duties of a doctor is to serve others — Patch Adams Movie (1999) Love is the ultimate goal — Patch Adams Movie (1999) Laughter is the best medicine — Patch Adams Movie (1999) They won’t care how much you know until they know how much you care — Aristotle The art of medicine consists in amusing the patient while nature cures the disease — Voltaire It is more important to know what sort of person has a disease than to know what sort of disease a person has — Hippocrates We don’t treat malocclusions; we treat patients who happen to have malocclusions — Dr. Larry Jerrold

Orthodontics

A few years out of retention, patients won’t remember my name, or my team members’ names, but they will never forget the way we made them feel when they came into see us — Dr. Scott and Jessica Law We want to be the best part of our patient’s day — Dr. Scott and Jessica Law

HEALTHY LIVING Out of our tears and suffering will come great rewards and blessings! — Bible Change your thoughts, change your life — Dr. Wayne Dyer You become what you think about all day long — Earl Nightingale Do not look for miracles, see everything as a miracle — Dr. Wayne Dyer Don’t look for happiness (you can never find it) but bring happiness — Dr. Wayne Dyer In a time of need, plant a seed — Joel Olsteen

an isolated, Internet access room for adults could be offered. Also, the physical structure of operatories should offer private adult areas, distant to the treatment of children and

adolescences. In addition, there can various child-centered activities features in the office. Some orthodontists have a special area for adults. For instance, after 31 years in Volume 9 Number 2


PRACTICE MANAGEMENT practice, Dr. Herb Hughes decided to “design a new ‘Adult Smile Center’ to be a separate, spa-like area with comfortable leather seating in the waiting area, soft lighting, relaxing music, a coffee and tea bar, and partitioning in the clinic area that makes each station semi-private.”2

Table 3: Educational-psychological principles for exceptional patient care Shaping Operant conditioning

Reinforcement — positive/negative, punishment Cognitive-behavioral therapy

Pacing — using breathing, words, body language, and such that parallels that of the patient Hypnosis/distraction

A good listener Oprah Winfrey and Barbara Walters were considered two the best TV talk show/news host interviewers. TV celebrities would want to tell their stories to these two iconic figures. What did they have that the other TV talk show hosts and news celebrities did not have? For one, they empathized with their guests. We saw the pain of the guest written on their faces. Their questions were posed in a delicate and sensitive manner. They maintained eye contact and paced their guests in their speech and mannerisms. They repeated phases that the guests expressed back to them in their communications. They picked up on the guests’ nonverbal cues.5 How often when we have a new patient/ family for a first visit consult that we drift off to see what is going on in other aspects of the practice? This is a natural tendency. But we should be cognizant that breaking eye contact and attention to the patient and family is not good listening and communications. As mentioned, repeating back to the parent/family their chief complaints and concerns is requisite of good communications. Using the patient’s and parent’s names often in the conversation reflects the doctor’s concern for the family (Table 3).4,5 WOW service Dental financial guru, Dr. Roger Levine said, “In today’s crowded dental marketplace, you want to stand out from the competition. Exceptional service is always a differentiator, especially with new patients ... WOW customer service.”10 In regard to orthodontics, Dr. Larry Jerrold stated, “We don’t treat malocclusions; we treat patients who happen to have malocclusions. We must never forget that we are in the personal service business.”11 So how do we orthodontists stand out from the competition and deliver WOW patient service? Dr. Scott and Jessica Law believe that in our orthodontic practices we should strive “to be the best part of our patient’s day.”12,13 There may be many things that go wrong, or will go wrong, in a patient’s day, but it should not be in our practice. In addition, the Law’s add, “A 88 Orthodontic practice

Therapeutic metaphor — A metaphoric parable that has therapeutic benefit that relates to a patient and his/her difficulty that passes the conscious mind in order to get to the subconscious mind (subliminal message) Ground rules (patients/moms) — “Helicopter Moms” Know the patient for more than his/her diagnosis/treatment

Know the patient’s name and use it often

Learn patient’s hobbies and interests Compassion and empathy Communications … age appropriate For every word of criticism, give three words of praise/encouragement Praise delivered in front of parents is more powerful than delivered directly to patents Be the best part of the patient’s day Eye-level communications Open-ended questions Separate the uncooperative/disruptive child from the parent Rewards … contingency management program Symptom prescription … prescribe the behavior you want to remove to the extent that it becomes a chore Re-framing Progressions/backward chaining — teaching a skill (e.g., psychomotor) by breaking it down into smaller progressive steps. Backward chain is when the progression is ordered in reverse order, or at least several of the steps are in reverse order “More than the golden rule”

few years out of retention, patients won’t remember my name, or my team members’ names, but they will never forget the way we made them feel when they came in to see us.”12,13 The staff at Law Orthodontics are trained and conditioned to accept this philosophy into their hearts and apply it each day. What a credo for WOW customer service! If we look outside of dentistry and orthodontics to two of the largest companies that apply the principles of WOW customer service, it would arguably be the Ritz-Carlton and Disney. The Ritz-Carlton credo is, “A place where the genuine care and comfort of our guests is our highest mission; finest personal-service … guests will always enjoy a warm, relaxed, yet refined ambiance.” The Disney principle is, “Serve the customer to find success.” The business models of these companies revolve around exceptional custom service. That is, customer-focused and -driven service. “If we don’t take care of the customer, someone else will.”

The late Dr. Randy Pausch, in his book, The Last Lecture,14 tells a story about an exceptional customer service experience he had while visiting Disneyland and the profound affect it had on him and his family. Dr. Pausch stated that when his family (mom, dad, sister, and he) visited Disney for the first time, he and his sister decided to buy a set of Disney glass salt and pepper shakers for their parents as a thank you for taking them there. He and his sister were preteens. It so happened that during all the fun activities at Disney, the salt and pepper shakers broke. They decided to buy a new set to replace the broken ones. The shakers cost $10. When they went back to the Disney story to tell the store manager that they needed another set of shakers, the manager asked them why, and they told her about how they broke. To their surprise, the manager said that she would replace them for free. Dr. Pausch and his sister politely interjected and said that the salt and pepper shakers broke as a result of their negligence. But the store manager Volume 9 Number 2


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PRACTICE MANAGEMENT insisted, “Our packaging should have been able to withstand a fall due to a 12-yearold’s excitement.” Dr. Pausch and sister told their parents about their experience with the salt and pepper shakers, and the family was so impressed with the service that over the years they spent over $100,000 patronizing Disney. That is quite a return for Disney for a $10 set of salt and pepper shakers! The story illustrates the positive and lifelong impact that exceptional customer service can have on a business (Table 1).

“More than the golden rule” The golden rule is, “Treat others as you would want to be treated.” More than the golden rule is, “Treat others as you would want your children/grandchildren to be treated.” This is a higher calling than the golden rule. Certainly, parents want to be treated well in the healthcare environment, but parents love their children more than themselves, and would want and appreciate that their children would be treated better than they would. Can you imagine the impact an orthodontic practice would have by treating patients at this higher standard? Would this be the WOW patient service that we orthodontists are seeking to increase our “bottom line? Is this the “secret sauce,” and that which we can do on a day-to-day and minute-to-minute basis? So the secret sauce might be right in front of us every day and not some nebulous practice management and marketing gimmick. This may be one of the few things we orthodontists can really control — our love and passion for our patients and families. Do everything in, and with, love. Love patients into our practices. Orthodontists need to respond to patients and families with a kind heart. As the lyrics of one of Tim McGraw’s songs go, “Always stay humble and kind.” If the orthodontist’s personality is not necessarily the caring type, he/she needs to buttress this limitation by having staff that care about people. There are some who opine that only the perception of caring is needed, and the words and actions directed at patients and families can be scripted. There is some truth to this thinking, but this is not the best approach, and eventually staff will not be able to maintain this act and pretend for long.

Happiness Can the intense search and achievement of profitability, produce stress and unhappiness? Is the adage, money won’t make 90 Orthodontic practice

The secret sauce that we can all do, day-to-day, is incredible service; serve the customer to find success. you happy, true? We all have seen news reports of the countless celebrities who have fortunes but are not happy. Do orthodontists walk the fine line between success and happiness? Is it true that you can’t have it all? Did we not pursue orthodontics to have the greatest careers of all? And, of course, this leads to a happy and fulfilling life. For many orthodontists, this has been true. There is the belief that true happiness comes from serving and giving to others. Don’t look for happiness (you can never find it), but bring happiness. And, in times of need, plant seeds (help others). Orthodontists need to be generous with their blessings. Orthodontics can be the conduit to serving others and be a means to “pay it forward.” This could range from providing free or discounted fees for the indigent and underserved to supporting non-orthodontic outreach programs. For those (orthodontists) who have been given much, much is required in return. An orthodontist cannot practice and live in a vacuum and forget about the needs of others (Table 2).

What we don’t talk about One orthodontist’s financial success can be another’s loss. When one practice competes against others, one practice wins,

and the other loses, taking dollars away from the other. The dollar “pot” is not endless. And it may not be the smaller practices taking patients away from the very large practices, but the larger practices taking away from the small and average practices. Incidentally, it is not better orthodontics that generally drives patients into orthodontic practices, but better service, price, marketing, and the belief that the results will be superior. Of course, there are dental referrals that are independent of patient referrals, and the above may not necessarily apply.

Conclusions The secret sauce that we can all do, day-to-day, is incredible service; serve the customer to find success. Excellent patient management is an important component of exceptional practice management. Orthodontic offices must be apprised of the proven educational and psychological principles applicable to superior patient care. We are reminded that the golden rule can be elevated to even a higher level and standard — “more than the golden rule.” This is, not just to treat patient as we would want to be treated, but to treat patients as we would want our children (and grandchildren) to be treated. OP

REFERENCES 1. Kulkarni M. Changes lives, one airway at a time — rapid palatal expansion and reducing airway resistance. Orthotown. 2017;10(8):40-45. 2. Hughes H. Thirty-one years into practice, Dr. Herb Hughes updates his business model. American Association of Orthodontists. The Practice Management Bulletin. 2017;35(4):2-7. 3. Rinchuse DJ, Rinchuse DJ, Deluzio C. Ethical checklist for dental practice. J Am Coll Dent. 1995;62(3):45-48. 4. Rinchuse DJ, Rinchuse DL, Sweitzer EM. What is the patient’s name? Am J Orthod Dentofacial Orthop. 2004;126(2):234-236. 5. Rinchuse DJ, Rinchuse DJ. The use of educational-psychological principles in orthodontic practice. Am J Orthod Dentofacial Orthop. 2001;119(6): 660-663. 6. Rinchuse DJ, Ackerman MB, Rinchuse DJ, Rinchuse DL. Orthodontic treatment and Generation Y: managing “helicopter” parents and their progeny. Orthodontic Products. 2008;15(9):80-82. 7. Rinchuse DJ, Kandasamy S, Rinchuse DL, Rinchuse DN. The patient’s chief complaint. Orthodontic Practice US. 2012;3(2):48-52. 8. Rinchuse DJ, Rinchuse DJ. 2004;125(6):747-750.

Graduate orthodontic programs: who is admitted?

Am J Orthod Dentofacial Orthop.

9. LaTrace A. Make every square foot count. Orthotown. 2017;10(10):28-31. 10. Levine RP. New game, new rules. New playbook ... winning strategies for increasing production. Pennsylvania Dental Journal. 2017;84(5):210-222. 11. Jerrold L. Bringing skeletons out of the closet. Am J Orthod Dentofacial Orthop. Aug 2011;140:277-79. 12. Law S. Orthodontics is in the details. The Progressive Orthodontist. 2010:6-12. 13. Law J. The unique eye. The Progressive Orthodontist. 2010:27-28. 14. Pausch R, Zaslow J. The Last Lecture. Hyperion: New York; 2008.

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LEGAL MATTERS

Risk management: supplemental informed consent documents Drs. Donald J. Rinchuse and Dara L. Rinchuse suggest some helpful information on informed consent

T

he American Association of Orthodontists (AAO) has many patient “release” forms that are available to members. Examples include Medical and Dental History Forms, Consent for Treatment, Patient Informed Consent, Patient Declines Treatment, Transfer Form, Refunds, Mouth Guard Release Waiver, Photo Release, Premature Removal of Braces, Bisphosphonates Cautions, TADs, Lasers, Impacted Teeth, and so on. The above cited AAO Forms can be divided into various categories such as Histories, Consents, Transfer Form(s), Supplemental Informed Consent Forms, Waiver and Release Forms, and so on. The AAO forms are found on the website under “Practice Management” and then under “Practice Management Forms and Materials.” The AAO forms are valuable to the practicing orthodontist and can be an important part of a risk management program. The AAO Informed Consent Form, Premature Removal of Appliances, and the Supplemental Form for Impacted Teeth, are particularly useful. Incidentally, we (first author and colleagues) published an article1 on “impacted teeth,” which was then adopted by the AAO to develop the AAO’s Supplemental Form for Impacted Teeth. It should be mentioned that the clear aligner companies have their own informed consent documents. Prior to electronic records, it was quite easy to have the patients/guardians sign their names in the hard copy “Progress Notes” that they were informed of a particular event for that day. Arguably, it is more difficult to get patient/guardian signatures of acknowledgment and understanding nowadays with

digital records. In this digital age, signed patient forms can be scanned and then placed in the patient’s permanent records. “Patient informed consent” is not a onetime event. Topics and issues that are specifically relevant for each patient should be mentioned and discussed many times over the course of a patient’s treatment. The risk management experts advise orthodontists to document whenever possible. In addition, the informed consent laws vary from state-to-state. For example, there was a recent Pennsylvania Supreme Court Case, Shinal v. Toms, 162A.3d 429 (Pa. 2017), which clarifies a practitioner’s duty to obtain informed consent, and importantly, the non-delegate nature of it.2 The Court held in Shinal that “a physician cannot rely upon a subordinate to disclose the information required to obtain informed consent.”2 The application of this law to dentistry and orthodontics is that the informed consent dialogue must be “a direct, face-to-face, conversation between the dentist/orthodontist and the patient/parent/guardian, as only then can the dentist/orthodontist be confident that the patient understands the risks, benefits, likelihood of success, and alternatives.”2 Supplemental forms covering various aspects of orthodontics that are component sections of the general AAO Informed Consent Document can be important makings of a risk management program. That is, the supplemental forms expand on, and edify, specific topics covered in the general AAO Informed Consent Document. The forms are ancillary to a signed “AAO Informed Consent” document. Supplemental

Donald J Rinchuse, DMD, MS, MDS, PhD, received his dental degree (DMD) and Master of Science degree (MS) in Pharmacology and Physiology in 1974, a certificate and Master of Dental Science degree (MDS) in orthodontics in 1978, and a PhD in Higher Education in 1985 — all from the University of Pittsburgh. He has been involved in orthodontics for 42 years. Dr. Rinchus is a Diplomate of the American Board of Orthodontics and a manuscript review consultant for several journals, including the American Journal of Orthodontics and Dentofacial Orthopedics. He has 130 publications to his credit, which include 2 books. He has given many lectures and presentations. Dr. Rinchuse is presently in corporate orthodontic practice in Greensburg, Pennsylvania. Dr. Dara L. Rinchuse, DMD, earned her dental degree (DMD) from the University of Pittsburgh in 2008 and a certificate of advanced study in orthodontics from Jacksonville University, School of Orthodontics, in 2010. She has published articles in several orthodontic journals, including the American Journal of Orthodontics and Dentofacial Orthopedics. She owns and operates a private practice, Orthodontique, which includes three office locations. The main office is located in Belle Vernon, Pennsylvania.

92 Orthodontic practice

forms can be especially important today with orthodontists seeing more and more patients, as orthodontic practices get large and larger (in size, and each orthodontist owning more practices), as well as the consideration of more corporate type orthodontic practices. The authors have developed nine additional “Supplemental Informed Consent” Forms, which are not found in the AAO documents library. The nine Supplemental Informed Consent Forms deal with the following topics: root resorption, oral hygiene, enameloplasty, importance of retainers, fixed lingual bonded retainers, lower jaw growth, patient pretreatment contract, open bites, and interproximal reduction. The documents are found in Forms 1 through 9. Patients/parents/guardians are asked to sign the forms to acknowledge that they have read and understand the information. These nine forms are additions to the orthodontist’s/ assistant’s typed/written comments placed in the patient’s progress notes that attest that a discussion took place relevant to a particular topic/issue(s). If the issue is one of lack of cooperation, such as poor oral hygiene or lack of retainer wear, having the parent/ patient sign a formal document can at times motivate positive change. The signed form puts the family on notice that things have to change, or else there will be consequences. The forms are meant to be examples. It is best that the forms be modified and edited to abide by specific state informed consent laws, and best suit each practice’s particular needs. (Please read the disclaimer at the end of this article.) Each orthodontic practice can decide on how and when these forms are applicable. It should also be mentioned that there are some educational (and instructional) materials available dealing with many of the topics addressed in the forms in this article. However, they are not written and structured as supplemental informed consent documents. We have limited the number of supplemental informed consent forms for this publication to nine. However, we have created additional forms that represent all of the sections of the AAO Informed Consent Volume 9 Number 2


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LEGAL MATTERS Document. These additional forms include such topics as missing upper laterals incisors (to open or close space), “pegged-shape” lateral incisors (whether to enlarge), early treatment (Phase I), wisdom teeth (to extract, and when), jaw surgery, extractions, TMD, risks on removal of clear brackets, and so on. In addition, we have removed pictures from the forms for this publication that visually illustrate the topic for each of the nine forms.

Form 1: Root Resorption Form 1-Root Resorption is covered in the AAO Informed Consent document under the same heading, “Root Resorption.” This form provides a little more detail than that found in the AAO document. Form 1 can be used in a number of situations. For instance, if a patient is at a greater risk for root resorption (severe overjet, extended length of treatment, has some pre-existing root resorption, has impacted maxillary canines that may be erupting into the maxillary lateral incisors, etc.), this form may be of particular usefulness.

Form 2: Oral Hygiene Oral Hygiene (Form 2) is to a limited extent covered in the AAO Informed Consent document in the following sections: Decalcification and Dental Caries, Periodontal Disease, and Results of Treatment. It should be mentioned that there is an AAO supplemental informed consent Form for “periodontal disease,” but it is not for oral hygiene. Form 2 is useful in instances where the patient’s attention to, and cooperation with, oral hygiene is questionable, and this could include prior to orthodontic treatment. Importantly, Form 2 covers the situation when the patient is showing signs of decalcification and periodontal disease.

Form 3: Enameloplasty Enameloplasty (Form 3) is not directly addressed in the AAO Informed Consent document. There is a section on Occlusal

Form 1: Orthodontic Root Resorption In some instances during orthodontics, the end of the tooth root can become shorter (resorbs). This is call “orthodontic root resorption.” The extent of the root resorption is variable. Although it is not exactly known what causes root resorption, there are many natural- and unnatural- associated factors such as patient diet, hormones, root length, and structure (hardness of the cementum), original malocclusion, amount of tooth movement, type and extent of orthodontics forces, patient age, patient gender, length of orthodontic treatment, and so on. It takes a considerable amount of root resorption to jeopardize the longevity of a tooth, even for severely resorbed roots. Everyone who has had, or will have, orthodontic treatment runs the risk of root resorption. I hereby acknowledge that the topic and issues of orthodontic root resorption have been explained to me; I have had the opportunity to read this document; and I have had any questions answered. ______________________________________________________________ Patient/Parent/Guardian (Signature)

______________ Date

______________________________________________________________ Orthodontist (Signature)

______________ Date

______________________________________________________________ Witness (Signature)

______________ Date

Form 2: Oral Hygiene •

Cleaning of the teeth and braces is of extreme importance to avoid: decalcification (white marks on the teeth), decay, and periodontal disease (swollen and inflamed gums, gum recession, and alveolar bone loss > loss of some of the surrounding bone surrounding the teeth). • If oral hygiene does not improve, “braces” will have to be removed before orthodontic treatment is completed. • We like to use the term “cleaning” the teeth and brackets rather and “brushing.” A patient can honestly say they “brushed” his/her teeth (spent a few seconds doing this) but not get the teeth “clean.” Cleaning implies that the patient has gotten all the biofilm off of his/her teeth and this would take more than a few seconds, i.e., typically several minutes. To clean the teeth and brackets could involve brushing the teeth/brackets, flossing, “Proxabrush®,” water pick, and so on (one, or more of the listed). What ever it take to clean all surfaces of the teeth and brackets. • Your orthodontist may recommend using a fluoride mouth rinse. • In addition, your orthodontist may have given you a prescription (or the actual fluoride paste) for a fluoride gel. It is important to follow the instructions of its use and to do it daily. • Lastly, there is some evidence that supports what is termed, a “Slurry Rinse.” Before splitting out the toothpaste (fluoridated) after cleaning the teeth, swish it around in the mouth before expectoring. This will aid in applying the maximal concentration of the toothpaste (and fluoride) on the teeth. I (we) have read the above, and have had all questions answered concerning oral hygiene and orthodontics. ______________________________________________________________ Patient/Parent/Guardian (Signature)

_____________ Date

______________________________________________________________ Orthodontist (Signature)

_____________ Date

______________________________________________________________ Witness (Signature)

_____________ Date

Form 3: Enameloplasty When orthodontic appliances (or after the final aligner[s] ) are removed, the orthodontist may want to adjust the edges of the upper and/or lower front teeth to make them even and look better. A very slight amount tooth enamel is removed. This is a very routine procedure in orthodontics. This procedure is called an enameloplasty. The procedure is done with a rotary dental instrument (“dental drill”). I (we) give the orthodontist permission to perform an enameloplasty. ____________________________________________ _____________ Patient/Parent/Guardian (Signature) Date ____________________________________________ Witness (Signature)

94 Orthodontic practice

____________________________________________ _____________ Orthodontist (Signature) Date

_____________ Date

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LEGAL MATTERS Adjustment, which covers the topic of removing enamel, mostly from the posterior teeth, as a means to adjust the occlusion/ bite. In addition, in the Occlusal Adjustment section, there is a sentence that discusses interproximal reduction to flatten surfaces between the teeth to reduce the possibility of relapse. Enameloplasty, as in Form 3, deals with the common situation when the orthodontist decides to adjust the incisal edges of the upper and/or lower anterior teeth for esthetic and/or functional reasons.

Form 4: Importance of Retainers The Importance of Retainers (Form 4) is addressed in the AAO Informed Consent document Relapse and Results of Treatment section. Form 4 was designed to highlight to patients and parents the importance of wearing retainers and wearing retainers for a lifetime, irrespective of whether or not they are removable or fixed retainers. The form mentions, “If retainers are not worn for a lifetime, the teeth will move and ‘shift’ back, i.e., relapse.”

Form 5: Fixed Bonded Lingual Retainer(s) The Fixed Bonded Lingual Retainer(s) (Form 5) is not directly addressed in the AAO

Informed Consent document, but the general topic of retainers and relapse are contained in the Relapse section. Patients, and parents in particular, often ask about the fixed lingual retainers. They most often refer to them as

“permanent retainers.” The parents ask, “Are you going to use permanent retainers after my daughter’s braces are removed? My neighbor’s son has these type retainers.” Form 5 addresses the pros and cons of fixed retainers.

Form 4: Importance of Retainers There are several types of retainers. One is a clear removable type and another is a fixed lingual (back of the teeth) wire retainer. There is also an older type (Hawley), which is removable and has an outer wire and inner plastic. And there is still another type of removable appliance, which may be considered by some a retainer but it actually is made to be able to “move” teeth rather than retain (hold them in place). It is called a “Spring Aligner/Retainer.” • Irrespective of the type of retainer, it should be mentioned and understood that retainers (whether fixed or removable) are for life. If retainers are not worn for a lifetime, teeth will move back/”get crooked” (relapse). The longer retainers are worn, generally, the less relapse; but the teeth will move back if retainers are not worn forever. • It could be argued that the most important part of orthodontics starts when the braces (aligners) are removed because the long-term outcome of treatment is very much dependent on the continued wear of retainers. I (we) hereby acknowledge that the topic and issues, of retainer wear have been explained to me; I have had the opportunity to read this document; and I have had any questions answered. ______________________________________________________________ Patient/Parent/Guardian (Signature)

_____________ Date

______________________________________________________________ Orthodontist (Signature)

_____________ Date

______________________________________________________________ Witness (Signature)

_____________ Date

Form 5: Fixed Bonded Lingual Retainer(s) Patients (families) often ask about what they call “permanent retainers” (Fixed lingual retainers), i.e., a metal wire bonded (glued) on the lingual side of the teeth (or back side of the teeth). We tell patients that there is no orthodontic retainer that is permanent. Fixed lingual retainers do stay in place for some time, but sooner or later they will come loose/break. These retainers need to be constantly monitored to check to see if any part is broken and loose. Many times, the discovery that the retainer is loose or broken comes too late, and a tooth, or teeth, have already moved/relapsed. The patient may then have to go back into “braces” in order to move the teeth back into place. We recommend that if we place a fixed lingual, the patient also wears a removable, clear-type retainer several nights per week just in case the fixed retainer breaks loose in some area. When the fixed retainer does break, there is the decision then to re-bond (glue) the retainer back in place, or else go to a clear, removable retainer. There are pros and cons to the use of fixed retainers. The pros are: • For a while, the patient can be sure that the teeth will stay in place and not relapse. But as mentioned above, the patient should still be wearing a clear removable retainer several nights a week as a backup. • For patients who are noncompliant, this may be a temporary solution. The cons are: • These type of retainers do not last forever, and they will at some point in time break, with the teeth relapsing before the discovery is made. • The patient will have difficulty flossing and cleaning the teeth, especially where the fixed retainer was placed. • These retainers attract a lot of biofilm, including calculus, which may cause a gum (periodontal) problem. Dentists and hygienists do not like these type retainers for a number of reasons. • When patients are wearing fixed retainers, they may not be coming back to see the orthodontist as much, or at all. So the question is, Who is going to, and be responsible for, monitoring the retainers to see they are not loose and broken, and to monitor the condition of the teeth and gums as a result of their use/placement? Will the general dentist or hygienist do the monitoring? What if the patient does not regularly visit the dentist? What happens when a patient goes to college and does not regularly visit the dentist? Although some orthodontists may often use these type retainer, we do not routinely use them, only for special cases. The topic and issues of orthodontic fixed lingual retainers have been explained to me, and I have had the opportunity to have my questions answered. ____________________________________________ _____________ Patient/Parent/Guardian (Signature) Date ____________________________________________ Witness (Signature)

96 Orthodontic practice

____________________________________________ _____________ Orthodontist (Signature) Date

_____________ Date

Volume 9 Number 2


LEGAL MATTERS Form 6: Lower Jaw Growth Lower Jaw Growth (Form 6) is not directly covered in the AAO Informed Consent document. There are however three sections that might very remotely deal with this topic and issue: Length of Treatment, Orthognathic Surgery, and Non-Ideal Results. Mandibular growth could be an issue in that the mandible can outgrow the maxilla, and this is particularly relevant for boys who grow longer than girls. So a boy with a “prognathic mandibular” growth pattern may develop into a Class III, skeletal and dental malocclusions, even after orthodontics is completed. Form 6 addresses this issue and concern.

Form 7: Patient Pretreatment Contract Patient Pretreatment Contract (Form 7) is an interesting form. Typically, the parents/ guardians are asked to sign releases and contracts with the orthodontist. However, Form 7 is a pretreatment contract (agreement) between the pre-adult patient and the orthodontist. How many times have we orthodontists heard from parents when we are notifying them that their child is not cleaning his/her teeth and braces, or else not wearing their retainers as directed; “Tell it to him/her (the child) because I am tired of telling him/her. He/she does not listen to me, you need to tell him/her!” And, of course we orthodontists, “throw it” right back on to the parents and respond, “I have told him/ her.” So, a contract/agreement between the

Form 6: Lower Jaw Growth The upper and lower (mandible) jaws generally grow together at the same time and rate (at least to start); there are exceptions based on a number of factors, such as gender, facial type/growth pattern, and so on. This is generally more so true for girls versus boys who mature earlier than boys; i.e., less affected by differences in grow rates of upper and lower jaws. We all have experienced the situation when, for the junior high school dance, the girls are taller than the boys. Then at graduation time for the senior prom, the boys are taller than the girls. Typically, the upper and lower jaws for girls are done growing at about 12-14 years of age; and for girls this is about the same time that orthodontic treatment is completed. So, the impacted of growth on orthodontic relapse from differential and late growth of the lower jaw (mandible) is somewhat negligible for girls. However, for boys who start orthodontic treatment later (12-13 v. 10-11 for girls) than girls because they get there permanent teeth later, and also because their jaws can grow until about 18-21 years of age, there is the chance for what is termed, Class III type growth. This is, a continued, late and differential growth of the lower jaw (mandible) relative to the upper jaw. This can cause an anterior front teeth crossbite (underbite), or at least an edge to edge bite. What we mean by differential grow of the lower jaw versus the upper jaw is, the upper jaw stops growing before the lower jaw, so there is the potential for the lower jaw to “outgrow” the upper jaw and alter the “normal” relationship between the two jaws and teeth. As regards management and treatments for relapse in boys caused by a late mandibular growth, there are several options. For one, and the treatment that orthodontists and families dread, is lower jaw surgery to re-position the lower jaw backwards (and/or upper jaw forward). Another option is to extract one or two lower teeth to provide space to move the lower teeth backwards; this does not resolve the problem of the protruded lower jaw but only addresses the forward position of the lower teeth. And of course, there is the option to do nothing, and have the patient function with an anterior cross bite or edge to edge bite. I have read this document on lower jaw growth and have had the opportunity to have my questions answered. ______________________________________________________________ Patient/Parent/Guardian (Signature)

_____________ Date

______________________________________________________________ Orthodontist (Signature)

_____________ Date

______________________________________________________________ Witness (Signature)

_____________ Date

Form 7: Patient Pretreatment Contract ORAL HYGIENE I understand that “braces” attract more food and biofilm and that means that I will need to clean my teeth more often and more efficiently. This most often means cleaning my teeth and braces by brushing, flossing (or Proxabrush®), and possibly using a water pick. It also means that I will need to clean my teeth at the very least twice a day (preferably after eating and before going to bed) and spend at least 2 minutes each time. If I do not clean my teeth and braces, as I have been directed, I run the risk of tooth decay (cavities), decalcification (white scarring marks on my teeth), and periodontal disease (swollen and infected “gums” and loss of the bone around and supporting my teeth). I also understand that there will be certain foods that I will not be able to eat while I have braces. ____________________________________________ _____________ Patient (Signature) Date RETAINERS I understand that when my “braces” are removed I will need to wear retainers. This is irrespective of the type, i.e., fixed or removable. Removable retainers are worn full time (22-24 hours per day) for about the first 2-3 months (or as directed), and then I may be directed to wear them at nighttime only for about a year and a half, and then I may be told I need only to wear my retainers several times per week, FOREVER! If retainers are not worn as directed, my teeth will move back (relapse) and get crooked again. Retainers do NOT last forever, and I will have to have them remade periodically. The fee for orthodontics includes one set of retainers. There will be a charge/fee to make replacement retainers. The above is referring to the clear, removable retainers. At times, a fixed lingual (on the back side of the teeth) may be placed that is not removable. In this instance, I will need to have this type retainer check periodically to make sure it has not broke or loosened. ____________________________________________ _____________ Patient (Signature) Date

____________________________________________ _____________ Orthodontist (Signature) Date

____________________________________________ _____________ Parent/Guardian (Signature) Date

____________________________________________ _____________ Witness (Signature) Date

98 Orthodontic practice

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LEGAL MATTERS orthodontist and pre-adult patient (and not particularly the parents/guardian) would be of value. This type of contract is not legally binding in the sense that the minor patient is not of legal age to engage into a contract, but nonetheless, this form is useful. The first author recalls some years ago listening to an audiotape featuring Dr. Moody Alexander. Dr. Alexander spoke about a patient “IRA” (Individual Responsibility Agreement) that the patient signs. The minor patient agrees (IRA) to pay into the fee, his/her own money, if the length of treatment is extended due to poor cooperation. There are other examples of these types of contracts that deal with school work/grades, chores, sports, etc. Form 7 deals with two important aspects of orthodontic treatment in which patient cooperation is paramount — i.e., oral hygiene and retainer wear. So, even before the first bracket is placed, the patient reads and signs Form 7 that he/she understands the importance of these two aspects of orthodontics. Oral hygiene and retainer wear are discussed in the AAO Informed Consent document under the following sections: Results of Treatment, Decalcification and Dental Caries, and Periodontal Disease.

Form 8: Open Bites The topic and issues related to Open Bites (Form 8) have been of concern to orthodontists and patients for over a century. This is a reason that the AAO has established a registry for open bite cases submitted by its members. Open bites (particularly if they are both skeletal and dental) are problematic from the viewpoint of the difficulty in correcting them and, then if corrected, to maintain the correction. A tongue thrust swallowing pattern is often an etiologic factor. At times, the only solution for the correction of an open bite, and also a stable result, is orthognathic (jaw) surgery. Open bites are not directly discussed in the AAO Informed Consent document, but the following sections might indirectly relate: Results of Treatment, Length of Treatment, Relapse, and Orthognathic Surgery.

Form 9: Interproximal Reduction Interproximal reduction (IPR) is, to a very limited degree, discussed in the Occlusal Adjustment section, which specifically deals with IPR as a means to reduce the possibility of relapse by “flattening” the proximal surfaces of the incisors. In this section, it states, “It may also be necessary to remove a small amount of enamel in between the teeth, thereby ‘flattening’ surfaces in order to reduce the possibility of a relapse.” Form 9, discusses IPR in the context of using a metal 100 Orthodontic practice

Form 8: Open Bites Open bites can be dental or skeletal, or both. When an open bite has a skeletal component, it is more difficult to correct and keep corrected. Open bites are one of the most difficult types of orthodontic problems to correct. At times, jaw surgery is necessary to treat this type malocclusion. A tongue thrusting swallowing pattern is often an etiologic component of an open bite. Patients and parents must be advised that the orthodontist, in most cases, CANNOT give a guarantee that an open bite will be corrected with orthdontic treatment. The teeth will be straight, but the open bite will remain. When deciding on whether to have orthodontic treatment, the family must consider the fact that an open bite may not be corrected, and if corrected may relapse back. Orthodontics is an elective procedure (in most cases). I have read this document on open bites and have had the opportunity to have my questions answerd. ______________________________________________________________ Patient/Parent/Guardian (Signature)

_____________ Date

______________________________________________________________ Orthodontist (Signature)

_____________ Date

______________________________________________________________ Witness (Signature)

_____________ Date

Form 9: Interproximal Reduction Interproximal reduction (IPR) is a dental and orthodontic procedure in which a very small amount of the proximal enamel surfaces (the surfaces between the teeth) are removed by either the use of a sanded metal strip or else a dental drill with a bur or disk. It is now a routine orthodontic procedure. The main purpose of this procedure is to gain space in order to align (and straighten) crowded (crooked) teeth. The scientific evidence supports the view that the small amount of enamel that is removed does not harm the teeth. The topic and issues of interproximal reduction (IPR) have been explained to me, and I have had the opportunity to have my questions answered. ______________________________________________________________ Patient/Parent/Guardian (Signature)

_____________ Date

______________________________________________________________ Orthodontist (Signature)

_____________ Date

______________________________________________________________ Witness (Signature)

_____________ Date

(sanded) strip and/or a dental drill with a bur or disk (Air Rotor Stripping - ARS) to remove enamel between the proximal contact surfaces of the teeth in order to gain space to align crowded teeth. The orthodontist would have to decide which patients/parents this form would be of use. Most often, a verbal discussion would suffice.

Conclusion Patient release forms are an integral part of an orthodontist’s patient and risk management protocol(s). The authors have developed nine Supplemental Informed Consent Forms that are in addition to, and complement, the American Association of Orthodontists’ “Informed Consent” document. They include forms for root resorption, oral hygiene, enameloplasty, retention, fixed lingual retainer(s), lower jaw growth, patient

pretreatment contract, open bites, and interproximal reduction.

Disclaimer This article is intended to provide general information and is not intended as legal advice. The nine forms that appear in this article are not held as legal documents. The law, and interpretations of the law, may change, while each factual situation is distinct. The laws on informed consent vary among states and jurisdictions. For legal guidance, orthodontists/ dentists/healthcare providers should consult their attorneys. Nothing in this article is to be construed as defining the standard of care for practitioners. OP

REFERENCES 1. Rinchuse DJ, Jerrold L, Rinchuse DJ. Orthodontic informed consent for impacted teeth. Am J Orthod Dentofacial Orthop. July 2007;132(1):103-104. 2. Montgomery BE, Lontz T. Informed consent update: A new Pennsylvania Supreme Court Directive. Pennsylvania Dental Journal. Jan/Feb 2018;85(1):17-20.

Volume 9 Number 2


INTRODUCING THE

90° TITAN

AIR-FREE TITAN COUPLER

* 360° Swivel Coupler Sold Separately: $159.99

*PATENT PENDING

The Air Free 90 Titan may only be used with the Air-Free Titan Coupler, which provides a quick disconnect from your air line and offers a 360° swivel for smooth manuverability.

Handpiece: $629.99

REAR EXHAUST COUPLER

All air is rear vented through pilot holes located in the specially designed quick disconnect coupler.

AIR-FREE HEAD

No air is vented from the head of the handpiece. NT PE

PATE

The Air-Free 90 Titan is constructed of lightweight, high strength, pure titanium. Weighing 2oz the Air-Free 90 Titan provides better balance and reduces wrist fatigue.

Why is the Air-Free™ the Orthodontist’s Best Friend?

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LIGHTER THAN THE ORIGINAL

Traditional Handpiece

90° TITAN

Eliminates cold air sensitivity during debonding

Less pain means less stress for patients

Traditional handpiece blowing

The Air-Free does not blow air to

Allows debonding debris to slowly rise from the tooth directly into suction.

air to the debonding area

the debonding area resulting in

causing increased sensitivity.

added comfort for your patient.

Air

The Air-Free does not allow any air to vent out of the head of the handpiece.

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INDUSTRY NEWS The buzz on the HSO Orthodontic Excellence and Technology Symposium In February, the Henry Schein® Orthodontics (HSO) Orthodontic Excellence and Technology Symposium in Scottsdale, Arizona, was buzzing with energy and excitement, as clinicians shared the latest ideas and clinical solutions to advance orthodontics. Attendees were impressed by the powerhouse speakers and their views on some of the most progressive current topics in today’s orthodontic industry. The event featured product innovations such as Motion 3D Clear Appliances and the soon to launch all-new Carriere® SLX™ 3D Clear Bracket System*, as well as breakthrough treatment concepts such as Sagittal First, with clinically proven protocols for faster braces or aligner treatment. The symposium featured hands-on training and breakout sessions for both doctors and staff members. After learning about tools that differentiate orthodontic practices in today’s competitive market, attendees were invited to a fun and creative Carnivale party event organized by HSO. Sponsors reported very positive feedback and are looking forward to attending again next year. The Westin Resort was a spectacular venue, and the HSO organizers were exceptionally pleased with the result of the event. Get ready for next year’s event, February 21-23, in San Diego, California. For more information, visit https://hsosymposium.com/. * The Carriere® SLX™ 3D Self-ligating Bracket System is currently undergoing 510(k) premarket review by the FDA for orthodontic movement and alignment of teeth during orthodontic treatment.

Ormco appoints Matt Turner as president

Get into Digital with suresmile® | elemetrix® IDB Trays The suresmile® | elemetrix® IDB digital solution — now integrated with over 6,200 brackets from over 40 manufacturers — features a unique tray design with individual jigs combined into a sectionable tray. Brackets not currently in the system are added as required by user demand. Bracket-agnostic simulation software is easy-to-use, allowing for visualization of straight-wire treatment and highlighting potential interferences. 3D custom-printing achieves more accurate bracket positioning than traditional laboratory methods. Access to elemetrix digital diagnostic tools is also provided. For more information, call 888-672-6387, or visit elemetrix.com.

102 Orthodontic practice

Ormco Corporation, a Danaher corporation and leading manufacturer and provider of advanced orthodontic technology and services, announced the appointment of Matt Turner as president of Ormco Corporation. Turner most recently served as the vice president, sales and commercial, for General Electric’s (GE) Oil & Gas Surface division after spending nearly 10 years in its Power & Water division. Prior to GE, Turner consulted with McKinsey & Company and attained the rank of Captain in the U.S. Air Force. Throughout his 20 years of professional experience, he has demonstrated an aptitude for driving organic business growth, increasing profitability, developing go-tomarket strategies, and building high-performing, customer-focused global teams. Turner holds a Mechanical Engineering and Political Science degrees from MIT and earned his MBA from the Harvard Business School. For more information, visit ormco.com.

Volume 9 Number 2


LPS Large Practice Sales

LargePracticeSales.com 844-976-5332

Sell Part of Your Practice at Todayâ&#x20AC;&#x2122;s High Valuations Your practice may be worth more than you think, but you may not want to sell all of it just yet. Buyers are paying record prices today for larger orthodontic practices, but most of our clients are not ready to retire. In fact, the average age of our clients is well under 50. They want to take some cash off the table, secure their future, and grow more, but not retire. While we have clients who sell their entire practice, most doctors are opting for a structure in which they sell a piece of their practice for cash now, but remain running it with a new partner for years to come. Doctors get millions in cash up front AND monthly profit distributions for their retained ownership, and best of all, they have a new partner to fund growth with no risk! The growth you create with your partnerâ&#x20AC;&#x2122;s capital directly increases the value and cash flow of your retained ownership. Rough Example: Practice EBITDA: $1,000,000 Sale of 70%: $2,800,000 in cash, up front Retained Ownership: 30% Monthly Profit Distributions: $25,000 per month + compensation for working Plus, get an agreement for your new partner to buy out your remaining 30% stake in the future at a pre-determined multiple. NOTE: This is only an example, larger practices command higher values. Value is a function of many factors including the doctor, growth rate, area, service mix and many other factors. Transaction structures are unique to each buyer/seller. Your office does not change. No new brands or overlords telling you what to do. This is just one of many creative structures which are possible today. We represent only doctors in the sale of all or part of their practice. We only get paid when you do. To schedule a confidential call to learn what your practice could be worth, please visit LargePracticeSales.com or call 844-976-5332.


PRODUCT PROFILE

3Shape Ortho System™ 2017 software for orthodontics 3Shape Indirect Bonding workflow receives FDA 510(k) market clearance

T

he U.S. Food and Drug Administration (FDA) has granted 510(k) USA market clearance for 3Shape Ortho System™ 2017 software for orthodontics. This clearance includes 3Shape’s innovative digital indirect bonding placement and transfer media application (IDB), as well as appliance design and production workflows. With 3Shape’s new Indirect Bonding Module, bracket placement workflow starts with a 3Shape TRIOS intraoral scan. The patient’s malocclusion is shown onscreen, and the software suggests an ideal setup. It shows the malocclusion with brackets on one side of a split screen and the teeth in their final position on the other. Setup can be adjusted on either side of the screen, and the corresponding changes are made on the other. Once the ideal setup is approved, the software creates an optional full prescription table; setup preferences can be saved for future cases. Over 275 original manufacturer bracket libraries are integrated in the software, and appliances such as trays can be printed directly from it. 3Shape Ortho System enables orthodontic professionals to overlay DICOM, cephalometric, and 2D pictures, along with intraoral scans for orthodontic case analysis and planning, treatment simulations, and the design and production of FDA-cleared orthodontic appliances. The digital setup can be used in the planning of an indirect bonding bracket treatment as well as in creating the transfer media. 3Shape Ortho System intuitively guides the user through the design phase and the relevant production parameter settings.

104 Orthodontic practice

Like all 3Shape solutions, 3Shape Ortho System is open, so it puts the professional in control. Like all 3Shape solutions, 3Shape Ortho System is open, so it puts the professional in control. Professionals decide how much of the workflow they want to do in-house and/ or send to partners. Because the workflow is digital, treatment planning and simulations can be shared onscreen with patients as well as seamlessly between practice, lab, and third-party orthodontic solution providers via the 3Shape Communicate cloud platform. Allan Hyldal, Vice President of 3Shape Orthodontics, described the benefits of the system. “The documented accuracy and ease of use of our TRIOS intraoral scanners provides a perfect start to the digital workflow for orthodontists. Doctors and labs using the scans and Ortho System can plan bracket treatments as well as create and produce the transfer media and appliances in-house or at production partners. Coupled with our unrivalled ecosystem of treatment options, 3Shape is opening the doors to growth for practices, labs, and partners.”

Learn more at 3shape.com/indirectbonding.

About 3Shape 3Shape is changing dentistry together with dental professionals across the world by developing innovations that provide superior dental care. The company’s portfolio of 3D scanners and CAD/CAM software solutions for the dental industry includes the multiple award-winning 3Shape TRIOS intraoral scanner, the upcoming 3Shape X1 CBCT scanner, and market-leading scanning and design software solutions for dental labs. Today, 3Shape has over 1,200 employees in over 100 countries from an ever-growing number of 3Shape offices worldwide. 3Shape’s products and innovations continue to challenge traditional methods, enabling dental professionals to treat more patients more effectively. OP This information was provided by 3Shape.

Volume 9 Number 2


3Shape TRIOS Orthodontics Engage and excite your patients

Give a great treatment experience Excite patients by bringing digital impressions and treatments to life Get more open options Choose lab or in-house production, with access to an unrivalled ecosystem Grow your practice Advance case acceptance, expand your offer and boost profitability

Contact your reseller regarding availability of 3Shape products in your region.

Letâ&#x20AC;&#x2122;s change dentistry together

Take the next step in your digital journey by scheduling a demo today! Contact us: US.ortho@3shape.com or call 908-867-0144


Clinically-proven, FDA-cleared OPTIMA™

Building A Better Orthodontic Experience Increased predictability of clinical outcomes1 Reduction of pain by up to 71% for better patient compliance2 Faster tooth movement by up to 50%2 For use with brackets or aligners

A-P Correction | 60 Aligners, No refinements Initial

“AcceleDent® isn’t really about acceleration

Final

per se. Of far greater importance is the ability to manage a complex case with confidence, and having certitude that I can deliver the result that I told the patient I could.” Dr. Tommaso Castroflorio PROJECTED TREATMENT TIME:

30 MONTHS

ACTUAL TREATMENT TIME WITH ACCELEDENT:

18 MONTHS

Find out more about affordable AcceleDent Optima Schedule a presentation today

1-866-866-4919 | sales@orthoaccel.com

acceledent.com © 2018 OrthoAccel® Technologies, Inc. 1 Doctor Testimonials on file with OrthoAccel 2 Clinical research on file with OrthoAccel

2015, 2016 & 2017 Townie Choice Award Winner

Leader in Accelerated Orthodontics®

Orthodontic Practice US March/April 2018 Vol 9 No 2  
Orthodontic Practice US March/April 2018 Vol 9 No 2