Orthodontic Practice US September/October 2018 Vol 9 No 5

Practice Profile

New concepts in aligner therapy with the Orthocaps® system Dr. Wajeeh Khan

The optimized digital tool set Dr. Bruce Goldstein

Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time Dr. David Alpan

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YOUR SOLUTION TO COMPLEX CASES

Dr. Ricky Harrell

YOUR SOLUTION TO COMPLEX CASES

PROMOTING EXCELLENCE IN ORTHODONTICS

OPTIMA™

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September/October 2018 – Vol 9 No 5 • orthopracticeus.com

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clinical articles • management advice • practice profiles • technology reviews

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EDITORIAL ADVISORS

Economic opportunity of orthodontic innovation

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

© FMC 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.

I

t’s an exciting era in orthodontics as innovation continues to abound. Whether improvements to bracket and alignment systems or the emergence of completely new orthodontic technology, I’m a firm believer that these innovations enable us to deliver a more effective and efficient treatment experience to our patients.

It’s important though that we maintain high-quality clinical standards with newer technologies. That means that we have to stay abreast of the latest research, and even more valuable I believe, is learning from each other’s clinical experiences. Considering this input, decisions are ultimately made based on what we find works best in our own practices.

Dr. David S. Ostreicher Through experimenting with different products and systems, I’ve found that orthodontic innovation has contributed to the economic success of my practice in three areas: enhanced clinical capabilities, improved patient motivation, and increased referrals.

Many of the recent orthodontic innovations are designed to make the clinical process more efficient, resulting in less chair time for patients. Take, for instance, self-ligating brackets, digital scanners, improved plastics for aligners, or vibratory orthodontic devices. These technologies make it possible to reduce the number of appointments and streamline processes.

The “cool factor” of technology translates into improved patient motivation. One reason for this could be that consumers have become accustomed to technology playing a significant role in many aspects of their day-to-day routines. Think beyond just products, and consider how you can be innovative with your systems and protocols to improve patient cooperation.

Well before there was an official recommendation for weekly aligner changes, I “rewarded” patients who had good compliance by gradually reducing their aligner wear intervals at each appointment. We found this to be a great way to motivate patients in our practice and manage expectations.

Lastly, we’ve experienced an increase in patient referrals, which we believe is tied to the fact that we use the latest advancements in orthodontics to help patients finish treatment faster. These patients have been more eager to refer their family, friends, and colleagues to our practice. In this regard, technology pays for itself because the return on investment is evident in new patient starts.

For example, let’s take the impact that AcceleDent® has had on our bottom line to illustrate these points further. Clinically, the carefully calibrated micro-pulse technology that this device employs creates improved efficiency during treatment, enabling me to achieve better tracking with aligner patients and to reduce or greatly eliminate the need for refinements.

This results in patients finishing treatment faster, opening up chair time and appointments for me to see new patients. Since the patients use AcceleDent daily outside of the office, they are playing an important role in their treatment process, which has fostered increased patient cooperation throughout treatment, not just with AcceleDent, but also with elastics, aligner wear, and other aspects of treatment that rely on compliance. I emphasize that they get to actively participate in their own treatment — a wonderful motivating feature. These satisfied and impressed patients then go on to tell other people in our community about the technologically advanced treatment they experienced at our practice.

There is significant economic opportunity for practices in the wave of innovation that we’re currently experiencing in the orthodontic industry. With research and experimentation, it is possible to apply these technologies to improve patient satisfaction and enhance clinical outcomes, both of which positively impact the practice bottom line.

David S. Ostreicher, DDS MS, MPH Dr. David Ostreicher’s health-oriented orthodontic practice is in Long Island, New York. An Invisalign® Platinum Plus doctor and an Align Technology lecturer, Ostreicher has been offering AcceleDent for more than 5 years. He is professor emeritus at Columbia University and the University of New Haven. Ostreicher is a member of the American Dental Association, American Association of Orthodontists, American Public Health Association, and the Honorary Dental Society. After serving many years on the board of directors of the Nassau County Dental Society, he became president of the New York State Dental Association. Dr. Ostreicher graduated from Clark University and attended Columbia University School of Dental Medicine, where he received his dental degree and certificate of specialty in orthodontics.

ISSN number 2372-8396

Volume 9 Number 5

Orthodontic practice 1

INTRODUCTION

Sept/Oct 2018 - Volume 9 Number 5

TABLE OF CONTENTS

Case study Class II and fast too Dr. Bella Shen Garnett discusses accelerating treatment for patients with Class II malocclusions.....................18

Orthodontic insight The optimized digital tool set

Practice profile Ricky Harrell, DMD, MA

6

A career of compassionate care for Dr. Ricky Harrell, Program Director at Georgia School of Orthodontics

Dr. Bruce Goldstein discusses how SureSmileÂŽ technology provides the practitioner with tools to treat patients with greater efficiency and accuracy ....................................................... 24

A conversation with...

Dr. David Sukoff Dr. David Sukoff discusses being a patient alongside his son................. 34

Continuing education Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time

Clinical 12 The physics of Class II correction

Dr. David Alpan discusses how smart mechanics with accelerated orthodontics facilitates an improved clinical outcome in shorter time with less negative sequelae.............38

Dr. James J. Jasper discusses the efficacy of the Jasper VektorÂŽ Appliance

ON THE COVER Inset photo on cover courtesy of Dr. David Alpan.

Article begins on page 38.

2 Orthodontic practice

Volume 9 Number 5

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TABLE OF CONTENTS

Going viral The four pillars of cybersecurity for the orthodontic practice Gary Salman, CEO of Black Talon Security, discusses the reasons for protecting against cyberattacks to your patient files..............................54

Product profiles Extend™ LTR

Continuing education

46

New concepts in aligner therapy with the Orthocaps® system Dr. Wajeeh Khan discusses an alternative clear aligner technique

Reliance introduces a new addition to its lingual retention line.....................58

3Shape OPEN orthodontics opens new opportunities.........60

Research

Orthodontic perspective

Does having had premolar extractions affect how orthodontists treat their patients? A pilot study

In search of the etiology of malocclusions — a common discovery technique is proposed Dr. John Hayes discusses why finding the ideal treatment approach for any condition is identifying the cause......62

Technique Accelerating orthodontic treatment with the D2 Appliance™ Dr. Todd Dickerson discusses a method to correct an anteroposterior discrepancy early in treatment.........68

Marketing momentum Millennial Moms: Why they should be an important audience of your marketing strategy Marketing consultant Julie Yeomans discusses how to reach this important niche in a social media environment .......................................................76 4 Orthodontic practice

Drs. Zubad Newaz and Laurance Jerrold investigate whether providers’ own experiences correlate with their own treatment philosophies regarding extraction orthodontics ...................80

Small talk

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 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

Rules for giving and receiving feedback

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

Dr. Joel Small discusses methods for providing positive and generative feedback.........................................92

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

Book review

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Stability, Retention and Relapse in Orthodontics

by Drs. Christos Katsaros and Theodore Eliades.............................96

Event/Industry news

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.......................................................98 Volume 9 Number 5

PRACTICE PROFILE

Ricky Harrell, DMD, MA A career of compassionate care for Dr. Ricky Harrell, Program Director at Georgia School of Orthodontics What can you tell us about your background?

I graduated from the University of Alabama (UAB) School of Dentistry in 1979.

After 2½ years as a dental provider for the Navajo Area Indian Health Service in Arizona, I applied and was accepted into orthodontic school at UAB. Following graduation in 1984, I was in the private practice of orthodontics in Westminster, Colorado, for 23 years.

I became an educator in 2006 and spent 9 years at the University of Colorado Department of Orthodontics, 2 years as Program Director at Medical University of South Carolina in Charleston, and then came to the Georgia School of Orthodontics (GSO) in Atlanta in April 2017. GSO is a 36-month Advanced Specialty Education Program in Orthodontics and Dentofacial Orthopedics.

Dr. Harrell with a patient and GSO residents, Drs. Catharine Brannon and Keith Williams

typically use the MBT™ system, and despite the lack of popularity of the approach, I still firmly believe that extractions are appropriate in properly diagnosed cases that require them.

What training have you undertaken?

Ricky E. Harrell, DMD, MA

Why did you decide to focus on orthodontics?

My interest in orthodontics was piqued while serving in the Indian Health Service. I treated primarily children and was comfortable with operative and oral surgery for the patients but eventually decided I needed significant additional training in orthodontics in order to perform it well and safely.

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

I started practicing in 1984 so this year marks my 34th year as an orthodontist. I 6 Orthodontic practice

Numerous MBT courses, the Roth Course. I completed an MA in Education in 2015, and I am board-certified in orthodontics by the American Board of Orthodontists (ABO). In addition, I have both provided and received many, many continuing education courses.

Who has inspired you?

I have to give credit to the two primary educators in my residency training program, Drs. Alex Jacobson and P. Lionel Sadowsky.

I would also give credit to my chair at the University of Colorado, Dr. Larry Oesterle, for pushing me to pursue my advancements through the educational system over the past 11 years.

What is the most satisfying aspect of your practice?

In private practice, it was making a difference in the lives of my patients. I also very much enjoyed developing long-lasting relationships with the families in my practice.

In the educational career, it is producing competent, compassionate, caring, and ethical orthodontic practitioners to take over the profession I have so dearly loved over the past 4 decades.

Professionally, what are you proudest of?

In my educational career, it has been the achievement of the national pass rate for my residents at GSO in the program’s second year. These residents have clearly been highly successful in their education so far. From a purely professional standpoint, I am very proud of treating patients for 40 years without ever having a complaint filed.

What do you think is unique about your practice?

The practice within our residency program Volume 9 Number 5

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PRACTICE PROFILE incorporates a unique team approach to care where our board-certified orthodontists and resident dentists evaluate our patients’ treatment plans. We are also somewhat unique in that we emphasize use of advanced technology, such as CBCT scans, 3D scanning instead of alginate or polysiloxane impressions, reduced lab work for residents, and in my opinion, for an orthodontic residency program, we have one of the best practice management programs in the nation.

What has been your biggest challenge?

The biggest challenge within the institutional practice has been building a patient base that started at zero and within 2 years, having 2,500 established active patients in the residency practice.

GSO’s Atlanta clinic

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

I was leaning towards a career in biology (and to some extent, have had a career in biology) and thought about becoming a university instructor as I liked the atmosphere of a learning institution. Orthodontics has allowed me to do both.

What is the future of orthodontics and dentistry?

I think the future of orthodontics and dentistry is a bright one. Obviously, there is increased market pressure on orthodontists from corporate dentistry, expanded provision of orthodontic services by providers other than orthodontists, and provision of orthodontic services that bypass the provider completely. I think as a professional group, we have to continually educate the public to ensure they understand the advantages of having services provided by a specialist trained in the field of orthodontics.

GSO’s Atlanta clinic reception area (left) and GSO’s new Duluth, Georgia clinic (right)

Dr. Harrell lecturing residents (left) and Dr. Noam Green, Associate Professor, taking a digital X-ray with the i-CAT™ FLX (right)

What are your top tips for maintaining a successful practice?

My top tips go back to basic human behavior. Treat everyone in your practice, whether they be patients, parents, staff, or professional colleagues, as you would wish to be treated yourself. So very basic and yet so often overlooked. Everyone, until he/she proves otherwise, deserves the respect that you would expect to receive from someone else.

What advice would you give to budding orthodontists?

My advice to young, budding orthodontic practitioners would be to think outside the 8 Orthodontic practice

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PRACTICE PROFILE

GSO Residents Class of 2019 and Class of 2020

Resident, Dr. Ashley Kisling, using the 3Shape

Top favorites 1. Watching a western sunrise or sunset.

2. Observing a resident or young practitioner having an “aha” moment.

3. Having a positive impact on patients.

4. i-CAT™ CBCT: Great piece of imaging technology that adds that third dimension to diagnosis and treatment planning. We routinely use these for impactions, obvious surgical patients, asymmetries, and anything that arouses our suspicions with traditional imaging.

5. Creating an even more beautiful smile for patients (when possible) with some appropriate diode laser soft tissue surgery.

6. Gemini® laser (Ultradent): The most effective tissue cutting diode laser I have used. Has a very sleek, modern appearance, uses disposable tips, and is userfriendly. Can make the difference between a mediocre outcome and an excellent outcome. Also useful during treatment for minor soft tissue impaction exposures.

7. Dolphin Imaging Systems: The workhorse of orthodontic imaging. I very much like the MBT VTO feature for treatment planning. This VTO can quantify tooth movements and assist in a better-informed plan of treatment.

8. Having a resident contact me 10 years after graduating and still consult with me about treatment plans.

9. Ormco® VectorTAS™ TADs System: I think it is one of the more newer userfriendly TADs kits on the market with the color-coded screws and the deltaattachment coil springs.

10. 3D Systems’ medical modeling virtual surgical planning: This system allows for orthognathic surgical planning and does a 3D-model surgery, demonstrates the anticipated outcomes, and can manufacture the surgical splints on 3D-printed models.

11. Feeling the tug of a big fish on a fly line.

12. Powder skiing on an untracked backcountry run.

13. A good slab of BBQ pork ribs (especially if I did not have to cook them).

14. Building lasting relationships with the inheritors of my profession.

15. The sound of one of the great western rivers at night while camping.

10 Orthodontic practice

Dr. Harrell with the Gift of a Smile recipients who are receiving complimentary orthodontic care

traditional box of a practice in an upscale urban or suburban area. We don’t have a supply problem in orthodontics. We have a distribution problem. Do your homework, look at the data and statistics, and figure out where orthodontic services are in short supply. This often points to places outside of large metropolitan areas, but success will come much quicker and much easier going to these areas. Another bit of advice I would give is not to try to attain the “orthodontic lifestyle” that we hear so much about. Start small and basic, add things as the budget allows, not just in the office setting but in the home setting as well. Success will come to those who work hard, do good work, and exhibit some restraint on their early spending habits.

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

I love to fly fish, snow ski, mountain bike, pretty much anything outdoors. I also enjoy reading, both fiction and nonfiction, traveling with my wife, and spending time with my children and grandson. OP Volume 9 Number 5

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CLINICAL

The physics of Class II correction Dr. James J. Jasper discusses the efficacy of the Jasper Vektor® Appliance Introduction From the beginning of the modern orthodontic era, which began in the early 1900s to the present, orthodontic clinicians have had the perception that the etiology of Class II malocclusions resided in the maxillary arch.

Clinicians can imagine how that appreciation began and then escalated over time. Before the introduction of intermaxillary elastics, the only nonextraction treatment came from extraoral traction, which habitually applied to the more prominent maxillary arch. Furthermore, when elastics were later employed, the original intention was to retract the “protrusive” maxillary arch. That mindset continues to this day as many Class II appliances have the intended goal of “distalizing maxillary molars.” But is this etiologic belief warranted?

Some studies have questioned that conviction and have suggested that perhaps a retruded mandible or mandibular dentition might bear the main responsibility for Class II malocclusions.

The irony of the edgewise appliance Before Dr. Edward H. Angle1 produced and published on the edgewise bracket in 1928, orthodontic clinicians had to rely on linear vectors to move teeth, which often resulted in crown tipping. This sufficed in the correction of many Class II malocclusions (Figure 1). However, the edgewise bracket combined with a twisted edgewise arch wire allowed orthodontists to produce a curved vector known as a moment. When that created moment exceeded the force applied to the teeth by a ratio of 10:1, translation of the teeth occurred with an equivalency of

James J. Jasper, DDS, earned a Bachelor of Science degree from University of California, Berkeley, and a Pharmacology Master Degree from the University of California Medical Center – San Francisco. He then received his DDS and Orthodontic Certification from University of California Medical Center – San Francisco. He has lectured in 35 different countries and 28 states. He has also taught courses to students and professors in 32 orthodontic universities. Dr. Jasper has a private practice in Fairview, Oregon, and holds several patents on Class II correctors, which have been used around the world.

Disclosure: Dr. Jasper is the inventor of the patented Jasper Vektor® Appliance.

12 Orthodontic practice

Figure 1: Linear vector produced tipping

Figure 2: Curved vector known as a moment permitted translation of teeth

Figure 3: Vectors of Class II elastics

Figure 4: Vectors of many functional appliances on the maxillary molars and mandibular incisors

Installation of the appliance seldom requires more than 5 minutes.

Usually the overjet and overbite will correct within 4 to 6 months.

applying force to the center of rotation of those teeth (Figure 2).

Unrecognized by scores of professionals, many of the current Class II correction mechanisms continue to block the advantages of the edgewise appliance by using tipping vectors. For example, Class II elastics, the most common Class II corrector, work by attaching an elastic from the mandibular molar to a hook on the maxillary canine (Figure 3). This produces three counterproductive side effects that limit their efficacy and efficiency: 1. They tip and extrude the maxillary incisors.

2. They extrude the mandibular molars, which autorotates the mandible down and back.

3. As permissible appliances, they give the patient control over the correction rather than the doctor.

In 1981, McNamara2 published an article on the components of Class II malocclusions in 9- to 10-year-old children, which discovered that only 13% of Class II patients had protrusive maxillae. Forty percent of these children had retruded maxillae, while 47% had normally positioned maxillae. The take-away message of this article seems to posit that 87% of Class II patients need no retraction forces on the maxilla. Yet many appliances do exactly that — e.g., Jasper Jumper,3 Herbst,4,5 Forsus,6 MPA,7,8 Eureka Spring,9 etc. (Figure 4). Miethke10 more recently published an article regarding the appearance of frequently retruded mandibles in Class II malocclusions.

Volume 9 Number 5

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CLINICAL

Figure 6: Patient 1 — with 7 mm of overjet

Figure 5: Vektor Appliance illustrating its effect on the maxilla and the mandibular incisors

The vector solution to tipping side effects in Class II correctors

Figure 7: Patient 1 — vectors used for 5 months, and treatment completed in 24 months

Converting the use of moments that go through the center of rotation of the maxilla rather than the maxillary molar obviates tipping and intrusive forces against that tooth, while simultaneously placing an intrusive and forward vector against the overerupted and retruded mandibular incisors (Figure 5). This avoids correction of the overbite by extruding the molars, which autorotates the mandible down and back.

Patient treatments with the Vektor® Appliance Using the Vektor® Appliance (TP Orthodontics Inc.) requires banding of the maxillary and mandibular first molars. Bond all of the other teeth excepting the mandibular premolars. This prevents them from overerupting and also provides space for the sliding feature of the Vektor. Ordinarily, it takes 6 to 7 months to align the mandibular anterior teeth enough to accept a large arch wire (.022 brackets will require a .021 x .025 wire). Installation of the appliance seldom requires more than 5 minutes. Usually the overjet and overbite will correct within 4 to 6 months.

Figure 8: Patient 1 — cephalometric overlays. Little growth occurred with this patient, but note the profile improvement: almost no change in the maxillary arch, and a protrusion of the mandibular molar and incisors with no mandibular molar extrusion.

Equally important, the mandible has not autorotated down and back

Conclusion Some general principles have evolved over the past few years of experience with the Vektor Appliance: 1. When treating a patient with a retruded or normally positioned maxilla, don’t use retraction.

2. When treating a patient with a retruded mandible, use protraction to move its dentition mesially.

14 Orthodontic practice

Figure 9: Patient 2 — notice the upper lip protrusion and the lower lip retrusion

Figure 10: Patient 2 — note the changes with only 4 months of Vektor wear. 2/1/2011 Tx Plan U+L 2 x 4 (left).

4/4/2012 Vektor 4 months (right) Volume 9 Number 5

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CLINICAL

Figure 11: Patient 3 — note the apparent protrusion of the maxilla and the retrusion of the mandible

Figure 12: Patient 3 — note the massive overjet and the amount of time spent with the Vektor Appliance

3. When treating a patient with a steep mandibular plane, avoid extruding the posterior teeth.

4. When the posterior teeth have strong Class I interdigitation, patients seldom relapse after Vektor correction.

Clinicians can expect the following benefits from Vektor use: 1. Easy installation.

2. No lab fees with its use.

3. It clears the food zone.

4. Clinicians can expect occlusal corrections within 4-6 months.

5. Patients do not have to remember to employ the force.

6. It provides light, continuous forces.

7. Patients and parents can see fast improvements in the face and occlusion. OP

REFERENCES 1. Angle, EH. The latest and best in orthodontic mechanisms.

Dental Cosmos. 1928;70:1143-1158.

2. Coelho Filho, CM. Mandibular Protraction Appliance IV. J Clin Orthod. 2001;35(1):18-24.

3. Coelho Filho, CM, Coelho FO, White LW. Closing mandibular first molar spaces in adults. World J Orthod. 2006;7(1): 45-58.

4. Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO 3rd. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod. 1994;64(2):113-122.

5. Cacciatore G1, Ghislanzoni LT, Alvetro L, Giuntini V, Franchi L. Treatment and posttreatment effects induced by the Forsus appliance: A controlled clinical study. Angle Orthod.

2014;84(6):1010-1017.

6. McNamara, JA Jr. Components of Class II Malocclusion in Children 8–10 Years of Age. Angle Orthod.

1981;51(3):177-202.

7. Miethke RR, Lemke U. The Angle Class II division 1 is most often caused by mandibular retrognathism. Orthodontics.

2004;1:133-140.

8. Pancherz H, Hansen K. Occulsal changes during and after Herbst treatment: A cephalometric investigation.” Eur. J. Orthod. 1986;8(4):215-228.

9. Stromeyer EL, Caruso JM, DeVincenzo JP. A cephalometric study of the Class II correction effects of the Eureka Spring.

Angle Orthod. 2002;72(3):203-210.

Figure 13: Patient 3 — note not only the improvement in the patient’s appearance but also the impressive change in the overjet

16 Orthodontic practice

10. Valant JR, Sinclair PM. Treatment effects of Herbst appliance. Am J Orthod Dentofacial Orthop. 1989;95(2):138-147.

Volume 9 Number 5

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CASE STUDY

Class II and fast too Dr. Bella Shen Garnett discusses accelerating treatment for patients with Class II malocclusions

I

t’s been wonderful to see more adults than ever seeking orthodontics. With an increasingly competitive job market, increased use of social media and selfie postings, people are more aware of their smiles and want to look their best. Recently, Kelton Global conducted a national smile survey that found individuals with straight teeth are 57% more likely to be chosen for a first date. Harris Poll, another national survey, revealed nearly 1 in 5 adults attribute their straighter teeth to a promotion or career upgrade. These surveys prove the old adage, “putting your money where your mouth is,” can impact far more than oral health and one’s social life. Investing in a healthy smile can lead to advancements in one’s career, too.

Many challenges come parceled within this growing segment. The opportunity to guide skeletal growth is now far behind us.

Beyond clinical challenges, the formula is compounded with high or, at times, even unrealistic expectations. These busy adults are often well-educated and possess strong personalities. Many have recently re-entered the job market, or are aiming for a promotion. They may be getting married, or just got divorced and urgently desire to reinvent themselves. I can recall some of my best experiences and most rewarding finishes have come from taking on these challenging cases.

Class II malocclusions among adults whom elect only to be treated with Invisalign®, certainly qualify as one of those clinical challenges. I have fully embraced accelerated treatment partly because my Class II consults typically end with patients asking, “And how long did you say it will take?” in addition to various other market pressures. I tell them it doesn’t take that long just to align the front teeth. What takes time, and what the specialty of orthodontics is based on, is correcting their bite. How about correcting the bite and aligning teeth in half the time?

Bella Shen Garnett, DMD, MMSc, is a graduate of Stanford University, the Harvard School of Dental Medicine, and is a Board Certified Orthodontist and an Angle’s Society Affiliate member. She runs two private practices in San Francisco and is a Diamond Plus Invisalign® provider. She lectures for both Align Technology and Propel.

Disclosure: Propel® Orthodontics provided support to the author.

18 Orthodontic practice

Now that I’ve implemented both micro-osteoperforations (MOPs) and highfrequency vibration (HFV) from Propel® Orthodontics, I have become increasingly confident in quoting significantly abbreviated finish dates, using MOPs or HFV alone, or even in combination with each other. Bear in mind, anticipated treatment times must still account for patient participation. But patient compliance is another reason I have become quite fond of these two accelerated treatment options. Adhering to the prescribed orthodontic regimen is incredibly important for aligner patients, especially the Class II patient. Fortunately, my most impatient patients are among my most compliant with their regimen. They are highly motivated from the beginning, the finish is soon within sight, and burnout is a foreign concept. In my practice, these cases are without question delivering the highest revenue per visit despite any minimal adjunctive device costs.

Correcting a skeletal Class II in an adult is typically going to involve surgery or camouflage. The camouflage is typically achieved by extracting maxillary first premolars, or often a combination upper first premolars and mandibular first or second premolars. Extractions themselves can deliver a predictable form of accelerated treatment often referred to as the regional acceleration phenomenon (RAP).1 The RAP effect delivers quite remarkable speed at space closures or bringing a buccally displaced canine back into the arch.

Delaying the extraction until after level and align is completed is a successful way to fully harness its potential. However, for the Class II patient requiring maxillary distalization, premolar extractions will not help get any closer to the desired Class I molar relationship. I have learned a great deal from Dr. Sam Daher about Class II correction using clear aligners. Years ago, he taught me that a ½ cusp (≤4 mm) can be corrected with clear aligners without extraction, whereas if it is ¾ cusp or more (>4 mm), I should consider extractions or surgical correction.

Then I discovered how effectively Propel’s Excellerator drivers deliver microosteoperforations (MOPs). These drivers allow precise targeting of that powerful RAP effect and can be activated at my discretion. What I love about MOPs is, now I don’t always need to extract and can even

avoid surgery in many instances.2 I can truly distalize with MOPs and clear aligners. If patients have third molars, they will need to be extracted, but if they are at the oral surgeon getting thirds extracted, they can quickly, comfortably, and easily get the MOPs treatment at the same time. MOPs has been clinically proven in a university trial to increase bone remodeling markers and comfortably accelerate tooth movement by over 60%.3 I routinely provide the oral surgeon a sterile open tip with my original Excellerator RT manual driver for extraction cases such as Case 1. However, I prefer and now almost exclusively use the Excellerator PT motorized driver to easily deliver faster treatments in minutes myself.

Different cases can require different approaches. I have had tremendous success closing open bites with Invisalign® and highfrequency vibration from Propel®. I’ve tried other devices but prefer the 5-minute VPro based on my own willingness to tolerate almost anything for 5 minutes, while 20 minutes seems like an eternity. So I don’t subject my patients to something I wouldn’t want to do myself. I know Case 2 is going to require excellent aligner seating,4 and any discomfort could derail compliance. VPro 5-minute daily is non-negotiable for this case, or any case with moderate (blue), or advanced (black) movements staged. Additionally, with this implant placed 1 month prior, and no abutment or final restoration fabricated, the anabolic properties of highfrequency vibration in the absence of any orthodontic force can be utilized to improve bone density.5-7

Case 1: Class II Division II

Patient is a 27-year-old female presenting with almost a full-cusp Class II. Canines are definitely a full-cusp Class II on the left (Figure 1A). All third molars are present (Figure 1B).

Her chief complaint is, “I want to straighten my teeth and fix my bite.” Surgery would be required to advance the lower jaw, but she is satisfied with her profile. With no airway issues, we don’t require mandibular advancement. I can distalize this full-cusp Class II with with MOPs and aligners. Here’s how I set up my Invisalign® ClinCheck® for Class II correction: I used to put vertical attachments on the molars but tended to get posterior Volume 9 Number 5

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CASE STUDY open bites. As I distalized and expanded, the molars sometimes began to tip. To get the back teeth to land when I finish, I now request horizontal attachments on molars and always level the curve of Spee. What I love about Class II Division II patients and targeted MOPs is, I can torque the anterior and tip them out using equal and opposite force to procline as I’m distalizing, so really I’m multi-tasking. Two maxillary MOPs were performed per interradicular space mesial of

Table 1: Case 1 Duration

9 months

No. of aligners

37 aligners

1 refinement

17 aligners

Visits

8

MOPs proactively

1 Tx

Aligner interval

5 days

Profitability

$1,080/hr

Figure 1A: Initial composite 6-11-15

Figure 1B: Initial radiograph 6-11-15

Figure 1C: Final radiograph 5-26-17

the second molar around to the mesial of the second molar. MOPs were not required distal to the second molar due to extractions. My MOPs case finishes look just like my ClinChecks and that’s what I love about MOPs. It makes my ClinChecks work like they are programmed, even at an accelerated 5-day interval with advanced movements. This adult Class II case has a great finish (Figures 1C, 1D, and Table 1) in 9 months with no bicuspid extractions and the stubborn space closures that come with them.

Case 2: Class II open bite with recent dental implant The patient is a 64-year-old female presenting with lower right tooth No. 6 extracted and implant placed (Figures 2A and 2B). Her chief complaint is, “I would really love to fix my teeth because my crowding has made it really tough to keep my teeth clean, and I just had an implant put in.” She is full-cusp Class II on the right, ½ cusp Class II on the left, and Class II canines, with a constricted maxillary arch, mandibular crowding, and open bite. She has a mandibular plane angle of 51 degrees, 20 Orthodontic practice

Figure 1D: Final composite 5-26-17

Table 2: Case 2 Duration

11 months

No. of aligners

27 aligners

1 refinement

18 aligners

Visits

9

VPro proactively

5 min/day

Aligner interval

7 days

Profitability

$950/hr Figure 2A: Initial composite 1-27-16

Figure 2B: Initial radiograph 1-27-16 Volume 9 Number 5

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CASE STUDY

Figure 2C: Initial ceph tracing 1-27-16

Figure 2D: Progress composite 9-13-16

Figure 2E: Final radiograph 2-7-17

Wits of 8, and ANB of 9 (Figure 2C). This is a surgical case. When looking at the records on paper, many clinicians would be reluctant to treat this case, plus she has an implant.

Treatment planning with fixed appliances would have been rather complex, and likely would have resulted in several additional visits to my office. However, with aligners I could simply program no movement on that space, or into that space. Additionally, the space being maintained for the abutment and crown would not look or feel as noticeable with aligners on for 22+ hours per day as it would with fixed appliances. I felt this served as a great compliance driver for this complex case. With the implant already placed, this case definitely presents a challenge. At 5 months, we can see significant progress on closing the open bite (Figure 2D). Upper molars intruded, upper incisors were extruded via IPR and relative extrusion, lower incisors were proclined 6 degrees, and the mandible was auto-rotated counterclockwise. In addition, the lower molar came forward slightly, and the mandibular plane angle was improved by 2 degrees.

Peri-implant bone density posttreatment appears healthy. This advanced case was completed with 7-day aligner interval clear aligner therapy and high-frequency VPro in 11 months and nine visits (Figures 2E, 2F, and Table 2). Typically, a case like this would require a minimum of 18 months and surgery.

She is ecstatic and so happy that she can eat, smile, and keep her teeth clean. The patient said she has been waiting for this day for so many years and can’t believe there 22 Orthodontic practice

was almost no discomfort throughout her treatment. She attributes it to, and thanks me for, stressing the importance of her VPro device, which she maintains use of in retention,6-8 and to support the continued osseointegration of her dental implant.5-7 In summary, translational movements are difficult regardless of fixed or removable appliances but particularly for clear aligners. Excellerator® MOPs allow me to target the alveolar bone near the apex by making shallow perforations just above and below the mucogingival junction. The decreased bone density associated with the MOPs/RAP effect lasts for approximately 4 months1 and can be repeated if necessary.9 This simple tool provides me what I call “biological leverage” to truly distalize rather than just tip. High frequency VPro™ has clinically demonstrated faster, more predictable tooth movement, and the reduction of refinements.10 Dual, full-arch aligner seating, increased bone remodeling markers, and compliance driving immediate pain relief associated with orthodontic forces all come together to maximize treatment efficiency.4,6,10-11 High frequency was also recently shown to enhance and prolong the inflammatory response to orthodontic forces.7 This suggests their combined use may minimize the need to repeat the MOPs procedure, while supporting clinical control from crown to apex. The results of incorporating these simple and cost-effective treatment adjuncts have proven them to be invaluable skeleton keys. They are consistently unlocking some of my most

Figure 2F: Final composite 2-7-17

profitable finishes, while delivering patients non-surgical solutions to Class II’s and doing it fast too. OP

Acknowledgment The Excellerator® is the first and only device cleared by the US Food and Drug Administration (FDA) for micro-osteoperforation in orthodontic and dental operative procedures. Propel® Orthodontics markets the VPro™ series, the first and only high-frequency vibration aligner seater.

REFERENCES 1. Kantarci A, Will L, Yen S, eds. Tooth Movement. Front Oral Biol. Basel, Switzerland: Karger Publishers; 2016.

2. Raptis M. Micro-Osteoperforation as an Adjunct for the Correction of Negative Anterior Overjet in an Adolescent Patient with Missing Upper Lateral Incisors. J Clin Orthod.

2017;51(1)47-153.

3. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144:639-648.

4. Shipley T. VPro5™ —more efficient aligner seating with high-frequency vibration. Orthodontic Practice US. 2016;7:5.

5. Alikhani M, Khoo E, Alyami B, et al. Osteogenic effect of high-frequency acceleration on alveolar bone. J Dent Res. 2012;91(4):413-419.

6. Alikhani M, Sangsuwon C, Alansari S, Nervina JM, Teixeira CC. High Frequency Acceleration: A New Tool for Alveolar Bone Regeneration. JSM Dent Surg. 2017;2(4):1026.

7. Alikhani M, Alansari S, Hamidaddin MA, et al. Vibration paradox in orthodontics: Anabolic and catabolic effects.

PLoS One. 2018;13(5).

8. McFarlane B. Manual osteoperforation and high-frequency vibration. Orthodontic Practice US. 2017.

9. Nicozisis JL. Applications of controlled local inflammation in aligner treatment. Semin Orthod. 2017; 23:90-98.

10. Shipley TS. Effects of High Frequency Acceleration Device on Aligner Treatment—A Pilot Study. Dent J. 2018;6(3):32.

11. Brigham G. Accelerated treatment modalities in clear aligner treatment. Ortho. 2018;1:30-37

Volume 9 Number 5

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Specialty’s custom M.A.R.A. is a simple and predictable appliance for mandibular advancement on class II patients. The appliance is attached to the first molars, or the deciduous second molars, with crowns or Specialty’s ROC crowns. Adjustments are achieved by adding shims and/or bending the removable upper elbow. Expansion can be incorporated into each arch as needed.

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ORTHODONTIC INSIGHT

The optimized digital tool set Dr. Bruce Goldstein discusses how SureSmile® technology provides the practitioner with tools to treat patients with greater efficiency and accuracy

3D

imaging has become a very popular diagnostic aid in the orthodontic profession. This technology has allowed us to accurately visualize teeth and their relationship to the surrounding bone. Visualization is only part of the equation: The real benefit is to be able to use these diagnostic aids to help guide treatment.

SureSmile® is the only comprehensive system that blends the best diagnostics available with accurately prescribed therapeutics. SureSmile technology provides the practitioner with the tools needed to treat patients with greater efficiency and accuracy.

Patient KD will serve as an example of how 3D imaging, along with SureSmile technology, can improve treatment results for our patients.

More accurate diagnosis. Better treatment results.

Figure 1

Initial observations Patient KD, a 14-year-old male, presented with a Class I bimaxillary protrusive malocclusion (Figure 1). He had severe lower crowding, a maxillary cant, and lip incompetence. Third molars were impacted, and gingival tissue on the lower anteriors was very thin.

Treatment A discussion with the patient and parent regarding treatment options was performed at a consultation (Figure 2): • Option 1: Extract first bicuspids, eliminate crowding, and reduce dental protrusion.

• Option 2: Attempt non-extraction treatment and reevaluate after initial leveling and alignment were achieved.

Bruce Goldstein, DDS, MS, is a Diplomate, American Board of Orthodontics, who practices in Scottsdale, Arizona. Dr. Goldstein received his dental degree, Master’s degree, and Certificate in Orthodontics from the State University of New York at Buffalo. He was a clinical instructor, Department of Orthodontics at A.T. Still University. He is President Elect of the College of Diplomates of the American Board of Orthodontics.

He started offering SureSmile treatment in October 2006 and has completed more than 4,000 cases.

24 Orthodontic practice

Figure 2: Pretreatment records

A decision was made to attempt nonextraction treatment and reevaluate in 4 months. Extraction of third molars was recommended. The decision was made to wait until after active treatment was completed.

February 2011 Full fixed appliances were placed with bands on the upper second molars and the lower first molars. Bonded .022 MBT brackets (Unitek) were placed on all remaining Volume 9 Number 5

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“More than any other innovation in our careers, SureSmile makes it possible for orthodontists to achieve the highest quality patient care available, while supporting collaborative interdisciplinary treatment and greater efficiency in achieving planned outcomes.”

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ORTHODONTIC INSIGHT teeth. Also, .016 NiTi wires were placed to allow for initial leveling and alignment.

April 2011 Copper NiTi wires (17 x 25) were placed to allow for proper leveling.

June 2011 Progress records were taken. This included a new cephalometric radiograph along with new photographs. After tracing the lateral ceph, it was obvious that the upper and lower anteriors were proclined. After a discussion with the parent, a decision was made to extract the four first bicuspids. Our goal was to reduce lip strain and the dental protrusion.

Wires were removed, and a treatment request was sent to the oral surgeon (Figure 4).

Figure 3

July 2011 After extractions were performed, Patient KD presented. An .018 stainless steel wire, with stops mesial to the upper first molars, was inserted. A power chain was placed from the upper cuspids to the upper first molars to start retracting the cuspids. A round wire was used to allow for easier sliding mechanics, and a stop was placed for anchorage purposes. A 17 x 25 TMA lower archwire was inserted. We laced the lower 3-3 together with ligature wire. A power chain was placed from lower 3-5 to help protract lower posterior teeth.

September 2011 A 19 x 25 TMA closing loop archwire was inserted on the upper arch. A gable bend was placed distal to the upper lateral incisors. This was to be used to maintain torque control on the upper anterior teeth as space closure was completed. The closing loop archwire was activated, and power chain was placed from the upper cuspids to the upper molars.

The lower archwire stayed intact, but a new power chain from the lower cuspids to the lower molars were placed. Class II elastics (¼", 4 ½ oz.) were started. The elastics were used to help with anchorage.

Figure 4: Progress records taken after completing initial leveling and aligning

November 2011 The upper closing loop archwire was activated. Reverse curve of Spee was developed into the lower archwire. Power chain from lower cuspids to the lower molars were replaced. Class II elastics were continued at nighttime only.

January 2012 The upper closing loop archwire was activated. The lower wire was retied. Nighttime elastics were continued.

26 Orthodontic practice

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ORTHODONTIC INSIGHT March 2012 Treatment progressed as planned. New records, including photographs and a CBCT scan (SureSmile) were obtained. The photographs showed that the posterior occlusion was developing as planned. No signs of periodontal recession were noted. The CBCT scan data was electronically sent to Orametrix to convert the data into a virtual therapeutic model. The model revealed significant thinning of the bone around the maxillary cuspids and the lingual of the lower incisors. These issues would not have been exposed using traditional diagnostics.

A therapeutic setup was performed to position teeth in the most ideal functional and esthetic position possible. This included placing the roots of the upper cuspid and lower incisor teeth into the proper relation with the supporting alveolar bone. After obtaining the setup, robotically-bent archwires were displayed for my review. SureSmile provided us with the ability to “read the wire.” By superimposing the archwire over the brackets, we were able to evaluate how the wire will move teeth. After my approval, archwires were fabricated to align teeth into the prescribed position. Appropriate torque and angulation were built into the archwires to help achieve the desired results. The ability to visualize where the roots should be placed, and the ability to move them into the proper position enhanced our treatment results (Figure 7).

Figure 6

May 2012 SureSmile wire placement We placed, and fully engaged, upper and lower 19 x 25 copper NiTi SureSmile wires that were custom-bent using SureSmile’s robotic technology. These wires were based on our virtual plan and conformed perfectly to our prescription.

Figures 7A-7F: Records taken at SureSmile scan. E. Therapeutic model. F. Final treatment plan — setup complete

July 2012 Modification appointment We confirmed that the movement from the wires placed 8 weeks earlier had fully expressed. A clinical exam along with photographs were used to evaluate the need for any modifications required to finish treatment. Adjustments were made to the first set of SureSmile archwires, and new wires were fabricated. We re-tied the archwires and scheduled KD’s next visit (Figure 8).

August 2012 Modified wires placed New 19 x 25 SureSmile copper NiTi wires were placed.

28 Orthodontic practice

Figure 8: Progress photos taken for modification of the SureSmile archwires Volume 9 Number 5

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ORTHODONTIC INSIGHT October 2012 We performed a check for deband appointment and then retied the archwires.

November 2012 We removed patient KD’s appliances and placed a mandibular fixed retainer from bicuspid-to-bicuspid. A maxillary Essix retainer was delivered at the same appointment. Patient KD was asked to wear the upper Essix retainer for 12 hours per day (Figure 9).

Conclusion

Figure 9: Final records

Figure 10: Initial patient model

Figure 11: Initial patient model

Figure 12: Lower incisor bone-level therapeutic scan

Figure 13: Read the wire. Note the medial inclination of the second bicuspid

Treatment for patient KD took 21 months.

His cooperation was outstanding, which made our treatment progress as planned.

The first 5 months of treatment were used in attempting a non-extraction approach.

After extraction of the bicuspids, treatment became more efficient. Using SureSmile technology, it took us approximately 10 months to close spaces and 6 months to finish. Had we extracted initially, treatment would have been completed in approximately 16 months.

It is interesting to note that SureSmile treatment is often associated with faster treatment, but it would really be more accurately characterized as the most efficient orthodontic modality available to the profession. It is not just about speed; it’s about achieving the optimal result. SureSmile treatment helps me to “just do the right thing” for our patients.

The ability to use technology to help us achieve superior results for our patients is what SureSmile is all about. Being able to see potential problems and having a mechanism for dealing with these problems is what separates SureSmile from any other treatment modality. With patient KD, we saw how the thin bone around the upper cuspids and lower incisors would have gone unnoticed with conventional diagnostics. More importantly, we had the ability with SureSmile therapeutics to focus our mechanics on reducing these problems.

Summary benefits of SureSmile: 1. The ability to provide exceptional therapeutics based on 3D imaging.

2. Allows maximum control of individual tooth movement which significantly improves treatment efficiency.

3. Better Treatment = Better Health.

A concluding thought The question is: “How are you going to get teeth where you want them to be?”

The answer is SureSmile. OP Figure 14: Final patient right buccal — second bicuspid inclination corrected 30 Orthodontic practice

This article was originally published in SureSmile Clinical Report newsletter.

Volume 9 Number 5

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A CONVERSATION WITH ...

Conversation with Dr. David Sukoff Dr. David Sukoff discusses being a patient alongside his son What made you decide to go through orthodontic treatment with your son?

My son, Josh, had a very narrow maxillary arch form and required palatal expansion. He also had a tendency for a Class III malocclusion. I knew that he would require orthodontic treatment from an early age. I had always wanted to improve my smile as well, so I thought there would be no better time than to do it with my son. We could both motivate each other to keep up with the weekly aligner changes. I also thought it was a cool way to “connect” with my son on a different level. It was actually a really fun experience.

Did you have similar clinical issues?

We actually do have very similar issues.

We both have some overcrowding and a Class III tendency, which the Invisalign® treatment works fantastic with.

Were there any concerns that you had about the process?

I really had no concerns about my son and his treatment. He is a very responsible 14-year-old. He is also very much into technology so I knew he would be intrigued by the advanced technology that the Invisalign Dr. David Sukoff with his son, Josh

Stage 0

Stage 10 David Sukoff, DDS, attended New York University (NYU) College of Dentistry, graduating at the top of his class. Following NYU, he performed his clinical residency in general and hospital-based dentistry at North Shore University Hospital located in Manhasset, New York. He was proud to return to New York University where he was accepted into the coveted Orthodontic and Dentofacial Orthopedic Residency. Currently, he is a specialist in Orthodontics and Dentofacial Orthopedics practicing in Merrick, Long Island, New York. Dr. Sukoff can be reached at https://www.merrickortho.com/.

Disclosure: Dr. Sukoff has no financial interest in Invisalign.

34 Orthodontic practice

Volume 9 Number 5

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A CONVERSATION WITH ...

Stage 20

treatment offers. Josh is also the type of kid who always follows direction. I knew that he would be perfect for this type of treatment.

How did your son feel about it?

How does he feel at this point in the process?

Josh was excited to begin the process.

From the moment he was scanned for digital impressions with the Itero® Element, he was hooked! In my practice we’ve transitioned all our impressions to digital with the use of our scanner. It has completely changed our practice for the better. Our expenses have gone down (no more purchasing impression material), our Invisalign and orthodontic appliances have a much quicker turnaround time from the laboratory, and patient discomfort has been eliminated by no longer taking traditional impressions. Patients love the “wow” factor of using a digital camera to scan their teeth, and we portray the image of being a very technological advanced office compared to others.

He finds wearing the aligners to be an easy process and loves the fact that there are no food restrictions. He also goes to sleepaway camp during the summer and is gone for 7 weeks. His hygiene stays great since he removes the clear aligners to brush his teeth, and he rarely has to worry about having an

The Sukoff family 36 Orthodontic practice

Stage 29

I had always wanted to improve my smile, so I thought there would be no better time than to do it with my son.

We could both motivate each other to keep up with the weekly aligner changes. emergency while he’s away from home.

At this point in the process, he is almost finished. He actually wears his aligners longer than I even ask him to because I think he likes them too much! He is in no rush to finish, which is rare!

Is there anything you have done to improve the experience that you can pass on to our readers?

I have him wearing his aligners 20-22 hours a day and changing on a weekly basis.

By changing every week, his aligners always stay clear, fresh, and energized. I also think because we are doing it together, we are a good source of motivation for each other.

Do you want to offer tips for getting family members through orthodontics together or to help orthodontists navigate family treatment better?

I would suggest to family members looking to undergo orthodontic treatment together that it’s a great experience. It is always easier to be successful at something when you have someone who is counting on you. I use my son as motivation, and I know he looks to me for the same. It is a way to connect with someone on a different level. On days where I may want to stop

wearing my aligners, my son keeps me going and vice versa. Having a partner in my orthodontic treatment has made me much more successful in my outcome than if I had done it alone.

Has it helped with compliance for you two to be together on the process?

Absolutely! The two of us doing treatment together is a major bonus in the compliance department. I obviously want to set a good example, so I am forced to keep up with my end of the deal. It’s a win-win for both of us!

What did your son share with you about the experience? How did he feel before and during treatment with you?

He felt great during the entire treatment.

He never had any self-esteem concerns, and virtually no one knew he was even wearing the clear aligners. He is going into high school next month, and I know he has lots of concerns about starting a new school.

He is thrilled that by wearing Invisalign clear aligners, there will be one less thing that he will have to worry about. As an orthodontist, I see the stress and anxiety that kids have about going into high school with braces. If we have the ability to help these kids obtain a beautiful, healthy smile while not adding to the pressures and stress of high school, then everyone comes out a winner. OP Volume 9 Number 5

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CONTINUING EDUCATION

Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time Dr. David Alpan discusses how smart mechanics with accelerated orthodontics facilitates an improved clinical outcome in shorter time with less negative sequelae Abstract Reducing the pre-surgical orthodontic phase with accelerated orthodontics leads to a shorter overall treatment time.21,22,23,24 Planning orthognathic surgery with 3D virtual diagnostic setups can help predict the clinical challenges, which help reduce treatment time.39 A non-extraction treatment plan and elimination of NSAIDs statistically reduces the pre-surgical orthodontic phase.8,9,10,11 Prevention of orthognathic surgery can be accomplished with early detection and treatment of dentofacial irregularities.13 Smart mechanics with accelerated orthodontics facilitates an improved clinical outcome in shorter time with less negative sequelae, which justifies the need for combining accelerated orthodontics with orthognathic surgery patients' treatment plans.21,22,23,24

Introduction Surgical orthodontic treatment duration is based on the coordination between the patient, orthodontist, and oral surgeon. The treatment result is largely affected by how the patient responds or complies with the treatment plan.3 The length of treatment time is affected by the duration in pre- and post-surgical orthodontics. How well the presurgical orthodontics prepared the interarch relationships prior to surgery can dictate the length of time in the post-surgical orthodontic phase. The surgical osteotomies have a huge effect on how stable the occlusion will be post-surgery, which also can

Educational aims and objectives

This clinical article aims to examine how smart mechanics with accelerated orthodontics facilitates an improved clinical outcome in shorter time with less negative sequelae.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize some of the history and evolution of orthognathic surgery.

•

See some research on the duration of orthodontic treatment.

•

Recognize how incorporating the accelerated orthodontics method of using pulsatile forces helps reduce the pre-surgical orthodontic treatment time significantly.

•

Realize additional AO tangible benefits that reduce chances of unwanted sequelae of orthodontic treatment.

•

Realize how Incorporating skeletal anchorage utilizing temporary anchorage devices (TADs) or miniscrews can impact treatment outcomes, reducing the need for orthognathic surgery and, in some cases, facilitating orthognathic surgery.

influence post-surgical orthodontic treatment time.8,9,10,11 A limited amount of post-surgical orthodontic treatment time is the goal, as patients post-surgery are not as patient or cooperative.3,4 Successful outcomes can only be achieved with a detailed biomechanical orthodontic and orthognathic surgical plan to coordinate maxillary and mandibular arches, by leveling and aligning teeth, coordinating the sagittal, transverse, and vertical planes prior to orthognathic surgery.4 The goal of the orthodontist is to direct orthodontic forces to create the most ideal outcome in the shortest time pre- and post-surgically to minimize the unwanted psychological or iatrogenic effects of longer treatment time.3,4 I have been incorporating accelerated orthodontics (AO) with

David Alpan, DDS, MSD, received his Doctor of Dental Surgery degree from Arthur Dugoni School of Dentistry (UOP) and was licensed in California and Nevada in 1996. He earned an Orthodontic Specialty Certificate in 1998 and was awarded a Master’s in Science in Dentistry (MSD) for his research on a TMJ project. Dr. Alpan founded his private practices, Alpan Orthodontics, in Los Angeles, Beverly Hills, and Las Vegas in 1999. In 2015, Dr. Alpan transitioned out of the Las Vegas practice, and in 2016 added the Century City location, merging his Beverly Hills office. In 2018, he opened a Woodland Hills office. Dr. Alpan played an integral role for Align Technologies’ Clinical Education Department from 2002-2008, and participated as a consultant and a speaker for 6 years. He was a member of the Ormco® Insiders group for 10 years. He is one of the founding members of the Incognito Circle of Excellence and a part of 3M Unitek’s research panel. Dr. Alpan is a KOL for Propel® and AcceleDent® and has written several articles on accelerated orthodontics. He is an active member of ADA, CDA, LADS, PCSO, AAO, CAO, AO, OKU, TKO. His hobbies are racing cars as a member of Pirelli cup NASA, POC, PCA, CSM, and BMW CCA, and he spends his free time with his wife Mary, son Zephyr, and daughter Ambryn. Dr. Alpan can be reached at dalpan@aeortho.com.

38 Orthodontic practice

pulsatile forces, AcceleDent® (OrthoAccel®), to facilitate difficult tooth movements to reduce overall treatment time (Figures 1-8).

I find this combination increases predictability and reduces negative sequela.21,22,23,24

History The history of orthognathic surgery began with the sagittal split ramus osteotomy in 1957, which is considered the inception of the modern era in orthognathic surgery.1 This approach used an intraoral technique, which eliminated the necessity of a potentially disfiguring skin incision.1 The sagittal split design also offered a biologically sound method for lengthening or shortening the mandible with the same osteotomy, thus allowing treatment of a mandibular deficiency or excess.1 During the 1960s, American surgeons began to use and modify techniques for maxillary surgery that had been developed in Europe, and a decade of rapid progress in maxillary surgery culminated in the development of the Le Fort I downfracture technique that allowed repositioning of the maxilla in all three planes of space.2 By the 1980s, surgeons were repositioning either jaw or both jaws, moving the chin in Volume 9 Number 5

all three planes of space, and repositioning the dentoalveolar segments surgically as desired. In the 1990s, rigid internal fixation greatly improved patient comfort and experience by eliminating the need for immobilization of the jaws, and a better understanding of typical patterns of post-surgical changes made surgical outcomes more stable and predictable.2 With the introduction of facial distraction osteogenesis around the turn of the century and its rapid development since then, greater jaw movements and treatment at an earlier age became possible for patients with the most severe problems (usually related to syndromes).2 Traditional or conventional techniques begin with dental decompensation to ensure that adequate surgical movements are possible. This preparatory procedure assists in producing a precise, predictable final outcome. A key step in planning alignment is whether arch expansion, extraction, or interproximal reduction should be chosen to gain enough space.

Those decisions dictate the length of the pre-surgical orthodontic phase.4 Orthodontic movements during pre-surgical orthodontics can be difficult because of the adverse functional environment and can take 12-18

Figure 2: Initial pano normal anatomy with no dental irregularities

Figure 3: Initial with Class III dental relationships, crossbites, crowding, post-orthodontic relapse

Figure 5: Post-surgical dentition prior to case refinement No.1

Figure 7: Posttreatment ceph showing plates and AP correction of both jaws Volume 9 Number 5

CONTINUING EDUCATION

Figure 1: Initial ceph deficient maxillary growth or Class III skeletal

Figure 4: Progress pre-surgical 7 months into treatment

Figure 6: Final post-orthognathic results after 9 months or 16 months total non-extraction treatment time

Figure 8: Posttreatment pano showing stabilizing bone plates and screws Orthodontic practice 39

CONTINUING EDUCATION months or more. The patient’s occlusion becomes gradually worse as the dentition moves to a more optimal position in each jaw, but not occluding well with opposing arches (Figures 4 and 21).4 The patient may experience difficulty functionally as well as psychosocially during this phase of treatment.4 Most orthognathic patients, the maxillary arch form needs to be made compatible with the mandibular arch form prior to surgery (coordinated arches). Failure to do so leads to canine or incline plane interferences as the teeth are brought into occlusion during surgery, which will prolong the post-surgical orthodontic phase.4 Thus incorporating 3D

digital setups and AO helps shorten presurgical orthodontic treatment time, which in turn reduces overall treatment time.3,4,21,22,23,24 The patient’s function, facial harmony, self-esteem, and overall satisfaction improve instantly post-surgery.4 Profitt recommends the pre-surgical alignment of teeth to the point that post-surgical orthodontic treatment will be 6 months or less.4 Most orthodontists spend more time trying to perfect the occlusion pre-surgically as an attempt to reduce the amount of time in the post-surgical orthodontic phase, thus average pre-surgical orthodontic times are 18 months or longer.8,9,10,11 All patients will

need post-surgical orthodontic treatment, and the length will depend on the desire for ideal occlusion.4 Model surgery or feasibility mountings are recommended prior to surgery to verify the occlusion will be stable post-surgery to help reduce post-surgical treatment times. Alignment is the first step in pre-surgical treatment unless the teeth already are reasonably well aligned, as they sometimes are in patients who need jaw surgery. In that case, the pre-surgical treatment time can be quite short.4 Some key points in reducing overall surgical treatment time is to start with patients with a small incisor irregularity index, no need for extractions, and incorporate AO to the pre-surgical orthodontic phase (Figures 3, 9, 17).8

Research

Figure 9: Initial images are 10 years post-orthodontic relapse.

11/8/2014

Figure 11: Pre-orthognathic treatment dentition

Figure 12: Post 15 months orthognathic treatment. 2/25/16

Figure 13: Profile view before-and-after 15 months 40 Orthodontic practice

Figure 10: Post-orthognathic results in 15 months utilizing Insignia Damon® Clear™ and AcceleDent®, non-extraction

A European study comprised of 185 consecutive patients treated in the oral and maxillofacial department at Tampere University Hospital, Finland, in 2007-2014 showed an overall treatment duration (median) was 31.1 months, of which pre-surgical orthodontics took 24.4 months and post-surgical 6.4 months. Treatment duration (median) in bilateral sagittal split osteotomy (BSSO) was 32.1 months, LeFort I 30.1 months, and bimaxillary osteotomy 29.7 months.8 Orthodontic extractions were performed in 35 patients (19%).8 If the orthodontic treatment included tooth extraction, the duration of pre-surgical treatment was on average 10 months longer, which is a statistically highly significant difference (p < .001, linear regression).8 These are exactly the same results I find in my surgical patients without using acceleration.

In another study published in 2007, the median duration of postoperative treatment was shown to be 7.5 months (range, 5 to 11 months).9 Most of the research agrees that the post-surgical orthodontics is about 6 months, and I concur that my clinical results are the same. Another study was designed

Figure 14: Frontal view before-and-after 15 months Volume 9 Number 5

to analyze factors influencing the duration of treatment in a sample of patients treated by a combined orthodontic/orthognathic surgery approach.10 Pre-surgical and post-surgical treatment times were assessed for N = 315 patients over a 7-year period. The median total treatment duration for all patients was 21.9 months, the median pre-surgical duration was 15.4 months, and the median postsurgical duration was 5.9 months.10 Treatment involving extractions resulted in significantly increased pre-surgical and total treatment times, which is exactly what the more current studies have found as well.

This data also implies that extraction cases will statistically take longer than non-extraction orthognathic cases. A Swedish study published in 2010 showed the median value for preoperative orthodontic treatment time was 19.2 months (range 2.4-68.4); for postoperative orthodontic treatment 4.6 months (range 0-18.8), and for total orthodontic treatment 27.8 months (range 5.9-79.1).11

CONTINUING EDUCATION

Figure 15: Initial ceph deficient maxillary growth or Class III skeletal

Figure 16: Initial pano missing third molars

Figure 17: Initial pre-treatment skeletal and dental Class III relationships. 9/9/2017, post-orthodontic relapse

Figure 18: Progress InvisalignÂŽ, 12/16/2017

Figure 19: Progress Invisalign, 1/27/2018

Figure 20: Progress Invisalign, 3/10/2018

Clinical findings After careful evaluation of my clinical results treating orthognathic surgery patients with AO, I am finding that I can reliably complete the pre-surgical orthodontics in 7-9 months with compliance of 85% or higher.21,22,23,24,25

Figure 21: Progress Invisalign pre-surgery, 4/28/18 Volume 9 Number 5

Figure 22: Post-surgical elastics held in place with TAD, 6/1/2018 Orthodontic practice 41

CONTINUING EDUCATION

Figure 23: 4 weeks post-surgery, 7/2/2018

Figure 25: Post-surgery i-CATâ&#x201E;˘ ceph

Figure 26: Post-surgery i-CAT pano shows stabilizing bone plates and screws 42 Orthodontic practice

Figure 24: Post-surgery case refinement, #17/18/2018

This leads to finishing in 15-16 months for the overall treatment (Figures 1-16). Since, leveling and aligning is where acceleration shines, at a 85% compliance level or better,22 we can complete the pre-surgical phase sooner, ultimately reducing overall treatment time by 35% or more.

Incorporating AO helps reduce the presurgical orthodontic treatment time significantly, which reduces the overall treatment time. I have observed significant reduction in the pre-surgical orthodontics utilizing pulsatile forces with AcceleDent.21,22,23 Allowing the pre-surgical orthodontics to achieve the desired result faster is beneficial for the patient, orthodontist, and oral surgeon.38 My average 15-month orthognathic treatment time is actually half the average according to American and European studies.4,8,9,10 Fortunately, nonextraction is my primary goal, and in nonextraction cases, the overall average treatment time is already reduced.8,9,10 AO provides bone modulation affecting the biology of tooth movement on a cellular level.21,22,23 Incorporating AO with the use of bone modulation technologies, such as vibration, has shown reduction in treatment time and increased treatment predictability.16,17,18,19,20 AO tangible benefits are decreases in root resorption, decalcification, white spots, caries, gingivitis, periodontitis, loss of motivation, occlusal wear, and treatment time. These benefits are desired by the patients and practitioners alike.38 Early completion of treatment reduces chances of unwanted sequelae and creates a more pleasant experience for the patient and practitioner.17,38 AO Increases predictability and allows practitioners to treat more severe malocclusions in reasonable treatment times. Incorporating AO into practice requires alternative treatment planning, appointment intervals, and new practice management systems.21,22,23,26,27,29,30,36 Volume 9 Number 5

Given the recent advances in materials and research, the introduction of accelerated orthodontics is not only a possibility, but also a reality.16,17,18,21,22,23,24,26,35,36 The clinician’s daily dilemma is treating a wide variety of malocclusions, ethnicities, size of teeth, variable bone biology, and various levels of patient compliance. Research demonstrates that accelerating the biology of tooth movement is a modality to add to the orthodontist’s armamentarium.18,29,30,31,32 The practice of clinical orthodontics is managing the science of biomechanics, which inherently is harnessing or manipulating the biology of tooth movement.26,29 Treating orthognathic surgical patients is a challenge diagnostically and therapeutically; thus severe orthodontic malocclusions such as skeletal discrepancies are difficult case types to demonstrate the utilization of AO to accomplish a reduced overall treatment time (Figures 1-26).

In 1988-2010, multiple researchers found that the application of NSAIDs decreased the rate of tooth movement significantly, and cytokines played an important role in activating the bone remodeling machinery.26,29,30 Removing all NSAIDs in combination with AO via vibration is paramount. Previous studies that demonstrated that bone injury causes cytokine release, leads to an accelerated bone turnover and a decrease in regional bone density.14,15,16,17,20 I highly recommend any discomfort experienced by the patient be moderated with TYLENOL® only, no NSAIDs at all.18,29,31,32 Since OrthoAccel publicly launched AcceleDent Aura in early 2012 and now Optima in 2017, clinicians and patients are experiencing reduction in overall treatment time,34,35,36 increased treatment predictability, and a pleasant analgesic effect.37 Micropulse vibration, 20 minutes per day at a frequency of 30 Hz at a force of 0.25N (25g) in combination with orthodontic treatment is demonstrating reduced treatment time or acceleration of tooth movement. The clinical research states as high as 50% increase in the rate of tooth movement,18,34,35,36 but I have found this does not correlate to the same reduction in overall treatment time. Orthodontic acceleration is more efficient during leveling and aligning compared to sagital corrections,35 thus best suited for pre-surgical leveling and aligning.

With AO, I am observing an average of 35% reduction in overall treatment time dependent on the appliance choice, mechanics utilized, or compliance with acceleration devices. I am observing an average pre-surgical orthodontic treatment time of 9 months and Volume 9 Number 5

Smart mechanics with accelerated orthodontics facilitates an improved clinical outcome in shorter time with less negative sequelae, which justifies the need for combining accelerated orthodontics with orthognathic surgery patients' treatment plans. post-surgical orthodontic treatment time of 6 months.

Pulsatile forces offers an analgesic effect during the pre- and post-surgical orthodontic phase.37 I have observed a clinical analgesic effect with as little compliance as 50%, but I do not see any acceleration or reduction in overall treatment time at that level. Patients with 85% compliance are noticing reduction in treatment time in addition to the analgesia.

To be efficient, and make AO work, treating orthodontists would have to change patients’ appointment intervals. Patients who choose vibration need to be compliant daily: I check the compliance interface at each visit, which gives a chronologic history by day, month, time, and length of use. For fixed braces, we are activating treatment every 3 weeks, and for aligners we are changing aligners every 7 days.

Surgical prevention Ideal treatment for orthognathic surgery would be prevention with early treatment to help guide the erupting teeth into the correct position in the arch and to facilitate dentofacial orthopedics. Early adolescent expansion and early extraction of deciduous teeth have shown to prevent transposition of teeth, malocclusions, crossbites, skeletal discrepancies, etc.5

Orthognathic surgery with TADS TADs can be located transosteally, subperiosteally, or endosteally, and they can be fixed to bone either mechanically (cortically stabilized) or biochemically (osseointegrated).

Mini plates and mini screws have been utilized in oral and maxillofacial surgery procedures for short and long-term stability of bone fractures as well as orthognathic surgery for nearly 4 decades. Incorporating skeletal anchorage utilizing temporary anchorage devices (TADs) or mini-screws as Cope14 and Graham15 had introduced over a decade ago has impacted treatment outcomes, reducing the need for orthognathic surgery and in some cases facilitating orthognathic surgery. TADs were utilized for intermaxillary fixation during surgery

for placement of rigid fixation, eliminating the need to tie interarch brackets together (Figures 1-26). We incorporated TADs with our Invisalign® cases removing the need to place fixed appliances on the teeth prior to surgery (Figures 1-8 and 15-26), which also reduces concerns during surgery of any brackets or orthodontic appliances debonding during surgery.

Surgery-first technique To reduce the overall treatment time, some have promoted a surgery-first procedure in recent years.5 The obvious advantages are a short or no pre-surgical orthodontic preparation period and a subsequently shorter total treatment duration, psychosocial benefits, and rapid creation of a favorable functional environment for orthodontic movement (RAP effect).16,17,18,19,20 However, there are some disadvantages with this method. It is difficult to match the dentition without proper orthodontic decompensation pre-surgery, especially when dental alignments do not coordinate well between the maxillary and mandibular arches. It is also easy to underestimate the magnitude of surgery required for the best skeletal harmony because the teeth cannot be used as a reference. The position where the teeth fit the best, generally does not produce optimal jaw positions without orthodontic decompensation prior to surgery. Careful surgical planning for proper jaw positioning allowing for postoperative orthodontic decompensation is essential for quality outcomes. For patients requiring mild to moderate amounts of decompensation, this technique is favorable and has been shown to reduce overall treatment time significantly down to 6-8 months. On the other hand, those requiring major postoperative orthodontic movement probably should be treated with a traditional approach.6,7

Practice management considerations Informed consents for AO with orthognathic surgery patients is highly recommended. The prognosis can be questionable based on the treatment plan and experience of the surgeons. Use of CBCT 3D digital records is strongly recommended as viewing the entire Orthodontic practice 43

CONTINUING EDUCATION

Pulsatile forces or vibration technique

CONTINUING EDUCATION anatomy prior to planning any surgical cuts will help with proper treatment planning with the ideal mechanics needed.40 All pre- and post-surgical orthodontic treatments are recommended AO and no NSAIDs. Fee considerations play a role in the doctors’ and patients’ decision. Recently, our treatment coordinator incorporated the AO into the total treatment fee, which has increased our case acceptance. The AcceleDent pulsatile forces device requires no doctor chair time and is not invasive. Orthodontic fee agreements are either paid in full or spread over time. The majority of orthodontists require the full fee due by treatment finish. Patients appreciate the convenience of paying the treatment over time, as it lowers their monthly fee. Since AO has changed the original estimated treatment time, we have had to update existing contracts. This poses a new challenge with our new starts, since we don’t have as much time to amortize the fee. For some patients, we have extended the payment arrangements passed the finish date, but most patients we ask to complete payment by the end of their treatment. We have added this language to our contract to assist us with this issue: “If the active phase of treatment is completed before the agreed estimated time, the full fee is due and payable at that time.”

The commitment needs to be agreed upon before AO treatment is initiated.

Conclusion In conclusion, incorporating AO can facilitate reduced treatment times and improved outcomes with orthognathic surgery patients, especially those including bicuspid extractions.8,9,10,11,21,22,23,24 Preventing severe malocclusions, or skeletal discrepancies with early detection of dentofacial irregularities is the ideal goal.13 Utilizing appliances that can perform dentofacial orthopedics, such as early expansion treatment monitored with CBCT scans, can help to prevent skeletal malocclusions requiring orthognathic surgery.13,40 Treating orthognathic surgery patients can now be successfully managed with the use of CBCT imaging, progressive biomechanics harnessing 3D digital setups,39 and incorporating AO to reduce the pre- and post-surgical orthodontic phases.21,22,23,24 The benefits of decreased treatment time and increased predictability far outweigh any of the costs or additional work required by the patient or the practitioner utilizing AO techniques.39 TADs have proven to be an effective anchorage device to control intermaxillary fixation for patients who don’t have fixed orthodontic appliances or who have lingual appliances.12 Combining PSL smart 44 Orthodontic practice

Summary steps to reduce overall orthognathic surgery treatment length 1. No NSAIDs used during pre- and post-orthodontic phase17,18,20,21,26,27,28,29,30,31,32,33,37 2. Use of 3D digital setups to help coordinate arches — smart mechanics. Use of early IPR due to detailed pretreatment planning3,4,40 3. Accelerated orthodontics with MicroPulse technology, AcceleDent, 20 min daily for a compliance level of 85% or greater 21,22,23,24 4. Non-extraction treatment plans4,8,9,10,11 5. TADs to stabilize osteotomies eliminates the need for braces

mechanics, 3D digital setups, and AO has facilitated reduced pre- and post-surgical treatment times creating an average overall orthognathic treatment result for non-extraction patients at 15-18 months. OP REFERENCES 1. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg Oral Med Oral Pathol.

1957;10(7):677-689.

2. Epker BN,Wolford LM. Middle-third facial osteotomies: their use in the correction of acquired and developmental dentofacial and craniofacial deformities. J Oral Surg.

1975;33(7):491-514.

3. Liou EJ., Chen PH, Wang YC, Yu CC, Huang CS, Chen Y. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69(3):771-780.

4. Proffit WA, White RB Jr. Combined surgical-orthodontic treatment: How did it evolve and what are the best practices now? Am J Orthod Dentofacial Orthop. 2015 May;147(suppl 5).

5. Sharma VK, Yadav K, Tandon P. An overview of surgeryfirst approach: recent advances in orthognathic surgery. J Orthod Sci. 2015;4(1):9-12.

6. Hernández-Alfaro F, Guijarro-Martínez R, Peiró-Guijarro, MA. Surgery first in orthognathic surgery: what have we learned?

A comprehensive workflow based on 45 consecutive cases.

J Oral Maxillofac Surg. 2014;72:376-390.

7. Leelasinjaroen, P Godfrey K, Manosudprasit M, Wangsrimongkol T, Surakunprapha P, Pisek P. Surgery first orthognathic approach for skeletal Class III malocclusion corrections—a literature review. J Med Assoc Thai. 2012;95(suppl 1):S172-S80.

8. Paunonen J, Helminem M, Peltomaki T. Duration of orthognathic-surgical treatment. Acta Odontol Scand.

2017;75(5):372-375.

9. Luther F, Morris DO, Karmezi K. Orthodontic treatment following orthognathic surgery: how long does it take and why? A retrospective study. J Oral Maxillofac Surg.

2007;65(10):1969-1976.

10. Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A. Duration of orthodontic treatment involving orthognathic surgery. Int J Adult Orthodon Orthognath Surg.

1999;14(2):146-152.

11. Slavnic S, Marcusson A. Duration of orthodontic treatment in conjunction with orthognathic surgery. Swed Dent J. 2010;34(3):159-166.

12. Singh K, Kumar D, Jaiswal KR, Bansal A. temporary anchorage devices - Mini Implants. Natl J Maxillofac Surg.

2010;1(1):30-34.

13. Trivedi BD. Early diagnosis and prevention of complete transposition of mandibular lateral incisor during mixed dentition. Pediatric Dent Care. 2016;1:102.

14. Herman R, Cope J. Temporary anchorage devices in orthodontics: Mini implants. Semin Orthod. 2005;11:32-39.

15. Graham J, Cope J. Miniscrew troubleshooting. Orthodontic Products. April 1, 2006. http://www.orthodonticproductsonline.com/2006/04/miniscrew-troubleshooting-2006-04-04/.

Accessed August 21, 2018.

18. Başaran G, Ozer T, Kaya FA, Hamamci O. Interleukins 2, 6, and 8 levels in human gingival sulcus during orthodontic treatment. Am J Orthod Dentofacial Orthop. 2006;130(1):7.

19. Dale DC, Boxer L, Liles WC. The phagocytes: neutrophils and monocytes. Blood. 2008;112(4):935-945.

20. Davidovitch Z, Nicolay OF, Ngan PW, Shanfeld JL. Neurotransmitters, induces high numbers of cells expressing IFN-gamma at mRNA and protein levels. J Interferon Cytokine Res. 1988;20:7-12.

21. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Semin Orthod. 2015;21(3):187-194.

22. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014;48:11:678-688.

23. Ortan-Gibbs S, Kim NY. Clinical Experience with the use of pulsatile forces to accelerate treatment. J Clin Orthod.

2015;49(9):557-573.

24. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: A randomized clinical trial. Angle Orthod.

2016;86(4):625-630.

25. Daskalogiannakis J. Glossary of Orthodontic Terms. Leipzig, Deutschland: Quintessence Publishing. 2000.

26. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010; 89(10):1135-1141.

27. Frost HM. The regional acceleratory phenomenon: a review.

Henry Ford Hosp Med J. 1983;31(1):3-9.

28. Frost HM. (1989). The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. 1989;248:283-293.

29. Frost HM. The biology of fracture healing. An overview for clinicians. Part II. Clin Orthop Relat Res. 1989;248:294-309.

30. Arias OR, Marquez-Orozco MC. Aspirin, acetaminophen, and ibuprofen:their effects on orthodontic tooth movement.

Am J Orthod Dentofacial Orthop. 2006;130:364-370.

31. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery.

J Periodontol. 1994;65:79-83.

32. Adachi Y, Okazaki M, Ohno N, Yadomae T. Enhancement of cytokine production by macrophages stimulated with (1-->3)-beta-D-glucan, grifolan (GRN), isolated from Grifola frondosa. Biol Pharm Bull 1994; :1554-1560.

33. Alhashimi N, Frithiof L, Brudvik P, Bakhiet M. Orthodontic movement Arend WP, Palmer G, Gabay C (2008). IL-1, IL-18, and IL-33 families of cytokines. Immunol Rev. 2000;223:20-38.

34. Dienz O, Rincon M. The effects of IL-6 on CD4 T cell responses. Clin Immunol. 2009;130(1):27-33.

35. Henneman S, Von den Hoff JW, Maltha JC. Mechanobiology of tooth movement. Eur J Orthod. 2008;30(3):299-306.

36. Krishnan V, Davidovitch Z. On a path to unfolding the biological mechanisms of orthodontic tooth movement. J Dent Res. 2009;88:597-608.

37. Nicozisis JL Nicozisis Accelerated orthodontics through micro-osteoperforation. Orthodontic Practice US 2013;4(3):56-57. Accelerated orthodontics through microosteoperforation. Orthodontic Practice US 2013;4(3):56-57.

38. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007;115(5):355-362.

16. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages.

Bone. 1985;6(5):377-379.

39. Uribe F, Padala S, Allaredidy V, Nanda R. Patients’, parents’, and orthodontists’ perceptions of the need for and costs of additional procedures to reduce treatment time. Am J Orthod Dentofacial Orthop. 2014;145(suppl 2):S65-73.

17. Alikhani, Raptis, Zoldan, Chinapa Sangsuwon, Yoo B. Lee, Bandar Alyami, Corey Corpodian. Effect of the micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144:639-648.

40. Becker OE, Scolari N, Santos Melo MF, et al. Three-dimensional Planning in Orthognathic Surgery using Cone-beam Computed Tomography and Computer Software. J Comput Sci Syst Biol. 2013;6:311-316.

Volume 9 Number 5

REF: OP V9.5 ALPAN

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers.

Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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

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Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time ALPAN

1. The history of orthognathic surgery began with the _________ in 1957, which is considered the inception of the modern era in orthognathic surgery. a. sagittal split ramus osteotomy b. Le Fort I down fracture technique c. rigid internal fixation d. facial distraction osteogenesis 2. Orthodontic movements during pre-surgical orthodontics can be difficult because of the adverse functional environment and can take ________ or more. a. 2-3 weeks b. 1-4 months c. 6-8 months d. 12-18 months 3. The patient may experience difficulty __________ during this (pre-surgical orthodontic) phase of treatment. a. functionally b. psychosocially c. with compliance d. both a and b 4. Incorporating _______ and AO helps shorten pre-surgical orthodontic treatment time, which

Volume 9 Number 5

in turn reduces overall treatment time. a. 2D X-rays b. 3D digital setups c. digital photographs d. fluoride treatments 5. The patientâ&#x20AC;&#x2122;s ________, and overall satisfaction improve instantly post-surgery. a. function b. facial harmony c. self-esteem d. all of the above 6. Profitt recommends the pre-surgical alignment of teeth to the point that post-surgical orthodontic treatment will be ________ or less. a. 6 weeks b. 3 months c. 18 weeks d. 6 months 7. Treatment involving extractions resulted in ________ pre-surgical and total treatment times, which is exactly what the more current studies have found as well. a. significantly increased b. significantly decreased c. slightly decreased d. no effect on

8. AO tangible benefits are decreases in root resorption, ________, gingivitis, periodontitis, loss of motivation, occlusal wear, and treatment time. a. decalcification b. white spots c. caries d. all of the above 9. In 1988-2010, multiple researchers found that the application of ________ decreased the rate of tooth movement significantly, and cytokines played an important role in activating the bone remodeling machinery. a. acetaminophen b. COX-2 inhibitors c. NSAIDs d. vitamin D 10. ________ has/have shown to prevent transposition of teeth, malocclusions, crossbites, skeletal discrepancies, etc. a. Waiting for expansion to late teens or adulthood b. Early adolescent expansion c. Early extraction of deciduous teeth d. both b and c

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

New concepts in aligner therapy with the Orthocaps® system Dr. Wajeeh Khan discusses an alternative clear aligner technique Historical background Overlay appliances have been used in orthodontics for more than 90 years. In the early days, such appliances were shaped like positioners; that is, formed as single-unit appliances having tooth cavities to receive both upper and lower teeth.

For minor orthodontic tooth movement, Remensnyder in 1923, described a rubber gum-massaging appliance that he later patented as an “orthodontic appliance.”

In 1945, Dr. H.D. Kesling published a landmark article in the American Journal of Orthodontics and Dentofacial Orthodopedics entitled “The philosophy of the tooth positioning appliance.” Kesling described the making of a set-up model after teeth had been cut out from a plaster cast and repositioned in wax on the model base. The “Positioner” was thus formed as a negative of the model that had been created by repositioning teeth in wax. Kesling, who was granted a patent in 1945, mentioned the fact that if the extent of tooth movement was beyond the scope of a single appliance, more than one appliance could be used in sequence to move teeth.

Drs. McNamara, Ponitz, Nahoum, Sheridan, Rinchuse, and others also described the use of overlay appliances that took the form of modern-day aligners to achieve orthodontic tooth movement.

As the use of CAD/CAM became common in dentistry in the 1990s, the concept of using digital 3D scanners and rapid prototyping technology became apparent in the manufacturing of aligners.

Dr. Wajeeh Khan is the founder and owner of Ortho Caps GmbH, a company based in Germany dedicated to developing and improving invisible orthodontic treatment techniques using clear aligners. Prior to this position, Dr. Khan was in orthodontic private practice since 1996. He has given over 100 lectures in symposia and universities across Europe. Dr. Khan holds a Doctor of Dental Medicine from the University of Münster, Germany (1989), and has postgraduate training in orthodontics from University of Münster (1996). He is a Fellow of the World Federation of Orthodontics and is a Member of the American Association of Orthodontics.

46 Orthodontic practice

Educational aims and objectives

The aim of this article is to explore an alternative clear aligner technique.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 51 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some history of early overlay appliances.

•

Recognize some of the methodologies behind aligner mechanics.

•

Realize some of the necessary aspects of aligner design for effective tooth movement.

•

Realize that aligner materials need to have specific properties for efficient tooth movement.

•

Identify some characteristics of the Orthocaps® system that make it a viable alternative aligner system.

Dr. François Duret, a French innovator and dentist, used CAD/CAM techniques to construct dental prosthetic and restorative units as early as 1983.

In 1996, researchers like Alcañiz and Hemayed, separately described in detail the use of CAD/CAM techniques to create computerized set-ups and rapid prototyping (RP) models, for diagnostic and therapeutic purposes in orthodontics.

In 1998, Align Technology commercialized the production of aligners using such CAD/CAM techniques in the United States.

Although the Invisalign® system is the most widely used, some companies like Ortho Caps GmbH (Germany) and others, offer alternative aligner techniques, like the Orthocaps® system to Invisalign®.

Aligner mechanics The mechano-transduction (transmission of force) of orthodontic forces, triggers a tissue response that results in orthodontic tooth movement. Teeth and the surrounding tissues do not differentiate between force generated by aligners or any other type of appliances. The factors that determine the quality and quantity of orthodontic tooth movement depend greatly on the forcesystem that is used, including the amount of force, its duration, dynamics, and the underlying tissue response. It is therefore imperative that the design of the appliances, the material property of the thermoplastics, and the interface between the tooth and the

appliance are conducive to creating a force system that ensures a controlled, effective, and safe tooth movement.

Aligner design Aligners are removable appliances and are therefore inherently at a disadvantage when compared to fixed appliances. The aligner-tooth interface is mechanically less efficient in transmitting orthodontic force to the surrounding tissues as compared to systems based on brackets and wires.

To overcome this disadvantage, appliance design must incorporate features that enable the aligners to have a good grip on teeth and allow the aligners to have a maximum surface contact with teeth.

Material properties of thermoplastics A variety of thermoplastic materials are available that can be used for manufacturing aligners. These materials differ not only in their composition and thickness, but also in properties such as elasticity, which is essential for tooth movement. The choice of material depends on the type and amount of tooth movement, required force levels, and the condition and health of the underlying tissues.

The aligner-tooth interface As mentioned previously, to transmit force effectively, it is important to create an interface (contact area) that allows the Volume 9 Number 5

The Orthocaps® system The Orthocaps system is designed to address core problems that many aligner systems have — namely, the inability to transmit force to teeth without mechanical or directional loss, and the lack of adequate control while delivering forces that move teeth accurately in all 6 degrees of freedom (x, y, z — axes translation and x, y, z — axes rotation) in 3D space.

For this reason, the system emphasizes the use of elastic materials in the fabrication of aligners. The Orthocaps system also uses two different types of aligners (a day aligner and a night aligner) for each treatment step.

This technique ensures that optimal forces can be generated by selecting different thicknesses of elastic materials that are used for aligners that are worn at night or during daytime.

Aligner design In the Orthocaps® system, an exact “aligner-fit” is of paramount importance. Modifications to aligner design, like pressure points, dents, divots, or certain type of structures like power ridges, etc., that are used in some other systems to direct force to certain areas

Figure 1: Pressure points are counterproductive Volume 9 Number 5

on clinical tooth crowns, are thought to be counterproductive. These modifications result in spaces and voids (Figure 1) that are created between the teeth and aligners and therefore reduce the grip of the aligners on teeth.

The main design feature for the Orthocaps aligners is thus the ability to encapsulate the teeth completely. This allows the maximum surface of the teeth to be in contact with the soft inner aligner layer which is more elastic than the outer rigid aligner shell (layer).

High-pressure thermoforming techniques also facilitate the aligner material to flow into the interdental areas, thereby increasing the surface contact area with the aligners.

Thermoplastic materials Material elasticity is the foremost property that is needed in achieving controlled tooth movements. Elastic deformation of aligner material generates the force that is required to move teeth. Elastic material can be deflected or deformed without losing their shape or form. This deformation is generated due to the difference in the position of teeth between the set-up model on which the aligners are fabricated and the actual position of the patient’s teeth. If the aligner material is elastic, the aligner regains its original shape completely when it is removed from the mouth. This means that the aligner

remains active and continues to exert a force until it returns to its original form and thereby moves the teeth effectively. To the contrary, inelastic and rigid materials undergo a plastic deformation (Figure 2) even at lower deflection levels (strain) and thus lose their form and therefore are unable to move teeth. This explains why inelastic materials for aligners are not as effective as elastic materials.

In the diagram (Figure 2), the material stress is plotted along the Y-axis. The amount of stress is the force in Newtons (N) divided by area m2. The material strain or deformation is measured as a percentage of deflection from the original state of rest.

For linear deformation, this is calculated as the increase in length (∂l) divided by the initial length (L). The elasticity (modulus of elasticity E) of a material is shown by the gradient of the curve and is calculated by dividing stress by strain as shown in the equation below.

Bending, stretching or deforming a material beyond its elastic limit results in plastic deformation of the material.

E = (F/A) / (∂l/L) It is important to remember that elasticity is a material constant and does not depend upon the thickness or geometry of the material. The same degree (%) of deflection or strain would result in permanent deformation of a given material regardless of its thickness or shape.

Figure 2: Difference in elasticity in two materials Orthodontic practice 47

CONTINUING EDUCATION

transmission of force without a) loss of magnitude, or b) directional control, or both.

This requires an exact aligner-fit, as well as an accurate reproduction of the tooth surface and the interdental areas in models that are used to manufacture aligners. Aligners manufactured on such models, have the required “fit” on the teeth to achieve a good grip.

CONTINUING EDUCATION

Figure 3

Orthodontic movement is thus caused by the rebound force that makes the elastic material regain its original state or shape.

This force is directly proportional to the area, modulus of elasticity, and the deflection or strain the material undergoes, provided that the material is not strained beyond its elastic limit as shown in Figure 2.

F = AE(∂l/L) Attachments Many types of attachments can be used to increase the efficacy of tooth movement with Orthocaps. The use of soft and elastic materials also makes it easier for using attachment types that would be otherwise impossible to use with rigid or hard materials.

Some of the attachment types are shown in Figure 3.

Friction Pads Apart from normal attachments, a new type of “attachment” was developed at the

Figure 4

Figure 5 48 Orthodontic practice

Volume 9 Number 5

CONTINUING EDUCATION

Orthocaps Center in Germany. Called “Friction Pads,” these attachments consist of a flat textured surface that is bonded to the tooth to increase the friction between the inner aligner surface and the tooth. The advantage of using the “Friction Pads” is that these textured surfaces are only a fraction of a millimeter thick, making them almost invisible under normal circumstances and therefore more acceptable to patients. Figure 4 shows the CAD model of the friction pads on two teeth.

The attachments or friction pads are bonded to the teeth by indirect bonding techniques. Pre-formed attachment or friction pads are sent to the clinicians placed in the first aligners ready for indirect bonding.

Figure 5 shows the friction pads bonded to several teeth. As can be seen in the pictures, the friction pads are only visible at close inspection. This esthetic advantage of friction pads over regular attachments make these type of bonded retention aids much more acceptable to patients seeking an invisible treatment option.

Figure 6: Case 1

Clinical cases: before-and-after records Case 1 Treatment duration: 18 months Appliances used: Orthocaps aligners.

Comments: This young adult female patient was treated for upper and lower crowding and deep bite. Orthocaps Pro system was used without any auxiliaries.

Case 2 Treatment duration: 24 months Appliances used: Orthocaps aligners, BiteMaintainer.

Comments: This young female teenager was treated for Class II bite correction and deep bite. Orthocaps Pro system was used without any auxiliaries. Towards the end of the treatment, a BiteMaintainer was used as an active retainer.

Case 3 Treatment duration: 28 months Appliances used: Orthocaps aligners, TADs to distalize molars.

Comments: This 45-year-old female patient was treated with a distalizing apparatus based on TADs followed by Orthocaps aligners to correct the overjet and a midline deviation.

Volume 9 Number 5

Figure 7: Case 2

Figure 8: Case 3 Orthodontic practice 49

CONTINUING EDUCATION Case 4 Treatment duration: 30 months Appliances used: Orthocaps aligners Comments: The treatment for this 12-year-old was started in the mixed dentition and was completed with Orthocaps Pro. No auxiliaries were used in the entire treatment.

Case 5 Treatment duration: 28 months Appliances used: Orthocaps aligners, Hybrid Aligner Treatment (HAT) Comments: This 33-year-old female patient was treated for posterior crowding.

The upper right first molar was extracted and the space closed by moving the second molar into the extraction space with aligners.

At the end of the treatment, Orthocaps provided a lingual auxiliary, comprising four lingual brackets and a pre-ligated nickeltitanium wire within an indirect-bonding tray to bond the appliance. Subsequent aligners were designed to immobilize the two premolars, while allowing the second molar to upright. This design created the necessary anchorage in order to upright the second molar effectively.

Figure 9: Case 4

Conclusion The mechanical limitations of aligners can be overcome, and satisfactory orthodontic tooth movement, even in complex cases, can be achieved to a certain extent, provided the following conditions are met: 1. Knowledge of the limitations of aligner mechanics 2. Use of auxiliaries (mini-screws, expansion appliances, and partial fixed appliances) in conjunction with aligner treatments 3. Use of elastic thermoplastic materials to avoid plastic deformation of aligners during treatment and to optimize force levels (light forces) 4. Accurate reproduction of interdental areas in digital scans to allow maximum aligner-tooth contact 5. High-pressure thermoforming techniques to achieve better aligner adaptation 6. Sound planning (regulation of the amount of movement per stage) in the treatment-staging process 7. Use and placement of suitable attachments and friction pads to increase aligner grip 8. Clinicians' experience and ability to recognize problems during the treatment process 50 Orthodontic practice

Figure 10: Case 5

9. Dividing treatment in treatment phases and the evaluation of treatment progress (superimpositions and deviation analyses) at regular intervals during treatment 10. Patient motivation and cooperation As the demand and need for esthetic orthodontic treatment alternatives grows, aligners have secured a firm place in the orthodontic repertoire. However, the inherent disadvantages associated with the use of removable appliance, such as aligners for orthodontic tooth movement, pose great challenges in improving their efficacy.

The Orthocaps system is an effort in that direction. OP References 1. Remensnyder, Orrin: A gum-massaging appliance in the treatment of pyorrhea, Dent. Cosmos 48: 381-384, 1926.

2. Kesling, H. D.: The philosophy of the tooth positioning appliance, AMER. J. ORTHODONT. ORAL SURG. 31: 297-304, 1943.

3. Nahoum, H. I.: The vacuum-formed dental contour appliance, New York J. Dent. 30: 385-390, 1964.

4. Ponitz RJ. Invisible retainers. Am J Orthod 1971; 59:266-72.

5. McNamara JA Jr, Kramer KL, Juenker JP. Invisible retainers.

J Clin Orthod 1985;19:570-8.

6. Sheridan JJ, LeDoux W, McMinn R. Essix retainers: fabrication and supervision for permanent retention. J Clin Orthod 1993;27: 37-45.

7. Rinchuse DJ, Rinchuse DJ. Active tooth movement with Essix- based appliances. J Clin Orthod 1997;31:109-12.

8. Duret F., Blouin J. -L., and Duret B., “CAD-CAM in dentistry,” J. Amer. Dent. Assoc., vol. 117, pp. 715-720, Nov. 1988.

9. Alcañiz, M., Chinesta, F., Monserrat, C., Grau, V. and Ramón, A.(1996) An advanced system for the simulation and planning of orthodontic treatments. 4th Int. Conf. of Visualization in Biomedical Computing, Hamburg.

10. Hemayed E. E., Yamany S. M., and Farag A. A., “3D model building in computer vision with orthodontic applications,”Technical Report TR-CVIP 96, CVIP Lab., University of Louisville, Nov. 1996.

11. Khan W., Kieferorthopädische Behandlungen mit einem neuen Twin-Aligner-System (Orthocaps). Inf Orthod Kieferorthop, 2009 vol. 41 (03) pp. 175-182.

12. Krishnan V, Davidovitch Z. Cellular, molecular, and tissuelevel reactions to orthodontic force. Am J Orthod Dentofacial Orthop 2006; 129: 469e.1–460e.32.

13. Proffit WR. Contemporary orthodontics. 3rd ed. St. Louis: Mosby; 2000: 304.

Volume 9 Number 5

REF: OP V9.5 KHAN

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers.

Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

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

New concepts in aligner therapy with the Orthocaps® system KHAN

1. The factors that determine the quality and quantity of orthodontic tooth movement depend greatly on the force system that is used, including the ________, and the underlying tissue response. a. amount of force b. duration of force c. dynamics of force d. all of the above 2. Aligners are removable appliances and are therefore ________ when compared to fixed appliances. a. inherently at a disadvantage b. definitely are at an advantage c. would always have the same results d. usually much less expensive 3. The choice of material (for aligners) depends on ________. a. the type and amount of tooth movement b. required force levels c. the condition and health of the underlying tissues d. all of the above 4. To transmit force effectively, it is important to

Volume 9 Number 5

create an interface (contact area) that allows the transmission of force without ________. a. loss of magnitude b. loss of directional control c. thermoplastics d. both a and b 5. The main design feature for the Orthocaps aligners is the ability to _______. a. allow for space between the teeth and the aligner b. encapsulate the teeth completely c. loosen the grip d. decrease the surface contact area with the teeth 6. ______ is the foremost property that is needed in achieving controlled tooth movements. a. Material elasticity b. Material inelasticity c. Material rigidity d. Thickness 7. If the aligner material is _______, the aligner regains its original shape completely when it is removed from the mouth. a. inelastic

b. elastic c. rigid d. thicker 8. _______ a material beyond its elastic limit results in plastic deformation of the material. a. Bending b. Stretching c. Deforming d. all of the above 9. The advantage of using the “Friction Pads” is that these textured surfaces are _______, making them almost invisible under normal circumstances and therefore more acceptable to patients. a. only a fraction of a millimeter thick b. 1 millimeter thick c. 2 millimeters thick d. none of the above 10. As can be seen in the pictures, the friction pads are _______. a. available in different colors b. only visible at close inspection c. bonded by direct bonding d. not for those seeking an invisible treatment option

Orthodontic practice 51

CE CREDITS

ORTHODONTIC PRACTICE CE

GOING VIRAL

The four pillars of cybersecurity for the orthodontic practice Gary Salman, CEO of Black Talon Security, discusses the reasons for protecting against cyberattacks to your patient files

O

ver the past 20 years, an evolution in computer technology has taken place in the orthodontic practice. Computers were previously used only for basic recordkeeping and billing. Then came the progression from billing to appointment scheduling, digital radiography, charting, and now, to digital dentistry. As the amount of data stored in systems has increased, so have the frequency and sophistication of cyberattacks.

The days of simply relying on a firewall and antivirus software to protect the practice’s network and patient data are over. The reality is, if these devices were so effective at protecting networks from breaches, there would be no data breaches.

Cyberattacks have shifted dramatically in the past 12 to 18 months, and now, more than ever before, hackers are setting their sights on healthcare entities. The frequency and severity of these attacks have increased, and practices of all sizes are being impacted.

These ransomware and malware attacks can shut down and compromise networks, resulting in an inability to access patient records and loss of revenue.

Orthodontists must consider the scope of their data and understand that they have one of the highest risk databases in the dental community — children’s records. Many orthodontists may think that since they don’t

Gary Salman, is Chief Executive Officer, Black Talon Security, Katonah, New York (www.blacktalonsecurity.com). He has more than 26 years of dental technology and IT experience.

54 Orthodontic practice

store “medical records” in their system, they don’t have to worry about protecting patient records. In the eyes of Health and Human Services (or the parent of a child), it does not matter if you are a cardiologist, a dentist, or a laboratory. If you have any patient data in your system, everyone must follow the same rules to protect these records. In addition, if a practice were to have a data breach, the HIPAA Breach Notification Rule requires practices to notify every patient of record that a breach has occurred. Imagine the negative PR that a practice would encounter in its local community and the uncomfortable conversations with the parents of the minors whose data was compromised. In addition, Identity Theft Monitoring would need to be offered to all affected minors. Health and Human Services (HHS) and the Office of Civil Rights (OCR) are just two of the reporting agencies a practice will have to work with; 49 out of the 50 states now have equal or more stringent breach notification rules. Also, if a practice treats patients from multiple states, it may be required to report to all the states in which it treat patients. A data breach is about patient trust, and once it has been broken, it’s very difficult to regain that trust.

When we ask orthodontists what they do for cybersecurity, they often say, “My IT company handles that.” IT companies are not cybersecurity companies. IT organizations typically partner with a cybersecurity company to independently audit its work.

It is extremely critical to understand that IT companies cannot audit their own work.

It takes the expertise and knowledge of a cybersecurity company to help ensure the security of the network.

In speaking with numerous orthodontists, it is apparent that ransomware attacks have been impacting this community. The unfortunate mistake that practitioners make is that they have their IT company “clean it up and restore their data.” What if, as part of or prior to the attack, a practice’s data was stolen from their network and is being bought and sold on the Dark Web (the black market of hackers), and the practice did not report the breach to the Office of Civil Rights (OCR)?

The practice could be subject to massive fines for the lack of reporting. If an orthodontist’s office falls victim to a ransomware attack or other possible breach, there are steps that the practice and its IT company must follow to determine if electronic protected health information (ePHI) was compromised. This often involves hiring a forensics company and working with a cybersecurity company to harden the practice’s infrastructure. What we have typically seen is that if you were the victim of an attack once, you will mostly likely be a victim again because of vulnerabilities in your network that enabled the attack vector or payload to infiltrate your system. To recover from the attack, you cannot simply restore your data and hope for the best.

To secure your network and combat against these sophisticated attacks, an orthodontist needs to implement four key pillars of cybersecurity. These pillars are Cybersecurity Audit, Cybersecurity Volume 9 Number 5

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GOING VIRAL Awareness Training, Vulnerability Scanning, and Penetration Testing.

Cybersecurity Audit During this audit, a cybersecurity company works closely with the practice and its IT company to understand the complete landscape of the practice’s IT footprint. The cybersecurity company asks questions regarding where and how data is stored, what protocols are in place to protect the data, and how it is accessed. Are there remote team members? Does the practice contract with a billing company that “logs in” to the practice’s network? Do doctors leave the office with devices that store ePHI, leaving the practice exposed if the device is stolen or lost? Is ePHI transmitted and stored using encryption technologies to protect the data?

Cybersecurity Awareness Training As part of the HIPAA Security Rule, covered entities (i.e., your practice) are required to undergo cybersecurity awareness training to help mitigate the risk of human error and minimize the chances of being exposed to an attack. Recent data points to a 50%-75% reduction in cyberattacks against healthcare entities that properly train their staff.

Perhaps the most vulnerable components of a network are the people using it — the orthodontist and staff. Social engineering, often referred to as “hacking the human,” is the most prominent threat vector impacting practices and is often the least discussed. As advancements are made in security, hackers begin to rely increasingly on humans making mistakes. For example, most ransomware attacks are initiated via spear phishing, which is designed to fool an email recipient into opening an email that appears to be coming from someone he/she knows or trusts. An email may be sent to the staff, purporting to be from the orthodontist, asking them to open an attachment or click on a link to update or download something. Once they initiate the action, an executable file may run, which is a ransomware attack. The ransomware typically encrypts the current computer and then searches the network for other machines. Once it finds the server, depending on the complexity and lethality of the attack, the ransomware will encrypt most of, or all of, the files on the server. This results in the files becoming inaccessible to anyone unless the user pays the ransom to the hackers to have the data decrypted. This is typically done using a cryptocurrency such as Bitcoin or Monero. Often, however, the 56 Orthodontic practice

The days of simply relying on a firewall and antivirus software to protect the practice’s network and patient data are over.

files are not returned and, if they are returned, a time bomb attack may be set up that will impact the files again shortly thereafter. The hacking should be reported to law enforcement authorities.

Vulnerability Scanning For a ransomware or a network breach to occur, a network typically needs to have vulnerabilities. Examples of vulnerabilities include unpatched operating systems, outdated equipment, weak passwords, open ports on computers or firewalls, unsecure network protocols, and improperly configured firewalls. Cybersecurity firms deploy very sophisticated tools and technologies to search for “open doors and windows” on your network that hackers use to exploit.

These tools gather information on your network and run tests against the devices searching for vulnerabilities. This data is then turned over to the practice’s IT company for remediation purposes, and the IT company can effectively lock the “doors and windows.”

Cybersecurity companies invest heavily in best-in-class vulnerability scanning technologies that can detect thousands of vulnerabilities on a practice’s network. Testing should be performed quarterly or whenever network devices are upgraded, modified, or added.

Penetration Testing The final cybersecurity pillar is penetration testing, which utilizes a “white-hat hacker” (ethical hacker) who uses the same tools, techniques, and protocols that a cyber-criminal would use to try and “break into” your network. Unlike a vulnerability scanner, an ethical hacker has the capacity to problemsolve during the testing. For instance, a vulnerability scanner will get to a locked “window”

and not know how to progress. Essentially, it stops and moves on to something else. A hacker, based on his/her experience, will see that the “door” is locked but may run a certain script to pop the door open. Ethical hackers use their experience to exploit networks in a way an automated tool simply cannot. After ethical hackers finish their testing, they turn their findings over to your IT company so they can mitigate the risks.

The Cost of a Breach The U.S. Department of Health and Human Services has strict guidelines in place regarding what is required to protect patient records. In the event of a data breach, the Office of Civil Rights will be notified and will conduct an investigation into the breach.

They will want to see proof that the practice has complete HIPAA documentation in place and has provided HIPAA and cybersecurity training, and will ask what has been done to harden the practice’s network.

You have spent years to become an orthodontist, growing and building your practice, your reputation, and your patient’s trust. The risk of a data breach is real, and you should not be passive. You need to take a proactive approach to secure your network before this happens to you. Practitioners who have experienced data breaches all say the same thing: “This is one of the worst things that can happen to you.” The financial and social impact on your practice is debilitating.

The cost for mitigating a breach can run into the hundreds of thousands of dollars and may result in a significant loss of patient trust.

Fortunately, if a practice implements sound cybersecurity solutions, trains its staff, and puts a hyper focus on security, almost all attacks can be thwarted. OP Volume 9 Number 5

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PRODUCT PROFILE

Extend™ LTR Reliance introduces a new addition to its lingual retention line

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ne of the many difficult decisions you will face on a daily basis is how to achieve long-term retention when the patient is out of your control. Reliance has two excellent options (Retainium and Ortho FlexTech) when a case calls for a lingual retainer that is bonded on every tooth. These wires provide a proven retention method that is far better than relying on patient compliance with a removable retainer. However, they have one drawback — hygiene.

Dentists’ and dental hygienists’ biggest complaint about fixed retainers is neither they — nor the patient — can adequately cleanse around wires bonded to every tooth. They maintain, rightly so, that the wires bonded to every tooth are a catch-point for calculus and debris. The good news is not every case necessitates a retainer to be bonded on every tooth. In fact, a six bonding pad retainer would be overkill in many Class I “minor movement” cases.

Reliance is proud to introduce our newest addition to our lingual retention line — Extend™ LTR. We have improved a popular lab-generated retainer wire to allow for chairside wire selection and placement — no lab lead time and no lab costs. The ideal case where Extend will be utilized is a patient that had little anterior crowding and NO facial torquing. Neither of these issues can be stabilized with a cuspid-bonded lingual retention device.

Extend is fabricated from a nickel-free (.027) TMA wire. A bendable or shapable super-elastic wire, TMA has some give or flexibility without changing the formed/ shaped characteristics. This feature allows Extend a slight amount of flexion without

Extend arch measuring device 58 Orthodontic practice

Extend™ LTR

deforming under mastication forces. Ideal for holding cuspid width, Extend is not only flattened at the cuspid segment of the wire, but also incorporates 20° angulated bonding pads to allow the proper wire-lingual surface adaptation.

For the remaining anteriors, Extend must be adapted to the lingual sides of each tooth.

A bird-beak plier should be used for slight adaptation bends; while more extensive bends can be achieved with a three-prong plier without work hardening the wire. Available in five sizes: 18 mm, 20 mm, 22 mm, 24 mm, 26 mm.

The Extend arch measuring device makes chairside size selection accurate and simple. With the numbered side facing up, seat the contact point of the measuring device at the midline. The first number to fully

clear the distal edge of the cuspid will be the number to correspond with the designated wire size.

Chairside steps are as follows: 1. Adapt Extend on a study model.

2. Prophy the cuspids.

3. Sandblast the cuspids.

4. Etch the cuspids.

5. Apply one coat of Assure Plus, and air-dry.

6. Place a small amount of LCR paste in the middle of the cuspids; place wire plus light cure.

7. Apply the final coat of LCR to fabricate a custom pad of composite; smooth with a resin-saturated sponge pellet as needed plus light cure. OP This information was provided by Reliance Orthodontic Products, Inc.

Volume 9 Number 5

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Bonded only to cuspids, Extend™ resists permanent deformation and provides excellent long-term patient comfort!

Preformed Bonded Retainer Advantages • Dentist / Hygienist Friendly – Extend™ is bonded only to the cuspids - allowing fast and easy removal if needed • Eliminate Lab Costs – Measure, select, and bond chairside • Available In 5 Sizes – Includes measuring device • Sleek & Strong – Low profile yet durable (.027) nickel free TMA wire • One Piece Design –Eliminate solder failure and discoloration • LTR – Unique flattened 20 degree beveled cuspid pads ensure uniform fit and long term retention • Maintain Arch Form – Ideal for holding cuspid width

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PRODUCT PROFILE

3Shape OPEN orthodontics opens new opportunities

W

hether it’s a preferred clear aligner, bracket-maker, 3D printer, or more, it should be up to you to choose the way you work. 3Shape OPEN orthodontics opens the doors to your preferred treatment and manufacturing options.

At AAO 2018, 3Shape presented its brand-new software module, 3Shape Clear Aligner Studio.* The new module is created for labs and practices with in-house labs, wanting to produce their own clear aligners.

Depending on your expertise, design and production of the clear aligners can be done in-house using 3Shape Clear Aligner Studio or conducted by 3Shape design partners such as FullContour, which states a turnaround time for both its clear aligner and indirect bonding designs at 48 hours.

3Shape OPEN orthodontics opens the doors to your preferred treatment and manufacturing options.

3Shape Indirect Bonding Studio 3Shape Indirect Bonding Studio adjusts the patient’s malocclusion to create the setup based on a doctor’s preferences with just a click. The software virtually places the brackets and then enables the precise transfer of the bracket bonding positions to the patient using printed transfer trays. Any adjustments can be done easily onscreen prior to printing and transfer.

To support the solution, 3Shape openly integrates with over 350 original bracket libraries. Professionals can choose their preferred virtual bracket and wire library from within the software to use when creating the setup.

Connect with clear aligner and orthodontic treatment providers 3Shape makes it easy for doctors to work with their preferred clear aligner and

60 Orthodontic practice

orthodontic treatment providers. Doctors using the 3Shape TRIOS® intraoral scanner can connect to more than 45 integrated clear aligner and bracket solutions simply by choosing the brand from the TRIOS menu.

3Shape TRIOS digital impressions are cloudsent to the chosen partner-solution with just a click. The list of the 45-plus clear aligner makers and orthodontic solution providers openly integrated with 3Shape TRIOS orthodontics can be found at 3Shape.com

About 3Shape 3Shape is changing dentistry together with dental professionals across the world by developing innovations that provide superior dental care for patients. 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.

Two graduate students founded 3Shape in Denmark’s capital in the year 2000. Today, 3Shape has over 1,400 employees serving customers in over 100 countries from an ever-growing number of 3Shape offices around the world. 3Shape’s products and innovations continue to challenge traditional methods, enabling dental professionals to treat more patients more effectively. www.3shape.com. OP

*3Shape Ortho System™ clear aligner workflow and 3Shape Clear Aligner Studio workflow pending FDA clearance. For availability of 3Shape products in your country/region, please contact your reseller.

This information was provided by 3Shape.

Volume 9 Number 5

ORTHODONTIC PERSPECTIVE

In search of the etiology of malocclusions — a common discovery technique is proposed Dr. John Hayes discusses why finding the ideal treatment approach for any condition is identifying the cause Background — calls for action Consider the following three statements from eminent orthodontic educators as “calls for action” for more research into the etiology of malocclusions: 1. “I hate open bites! I don’t understand their etiology, I don’t understand why they don’t self-correct, I don’t seem to be able to be able to identify the diagnostic features that are really important, I really don’t know the best methods to treat them, and even worse, I don’t know how to successfully retain the correction.”1 2. “I predict you will be hesitant to promise long-term closure of the open bite, even if the patient agrees to follow through with any treatment approach you recommend.”2 3. “To this day, we pretend to be ‘scientific’… and have replaced extraction with a host of popular but largely ineffective substitutes, each with a labored, after-the-fact ‘scientific’ rationale. As long as nobody dies from anchorage loss and permanent retention, this clear violation of the tenets of science may seem to have little practical significance; however, it imposes a penalty that threatens the status of the specialty: It argues that there is little in the way of a market for evidence, the work product of ‘the schools.’ ”3 The causes of most malocclusions are generally understood by orthodontists to be unknown. The “calls for action” suggests a need for the discovery of

John L. Hayes, DMD, MBA, received his dental degree from the Boston University Henry 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.

62 Orthodontic practice

the etiology of malocclusion — in this instance, anterior open bite (AOB).

Consider the advantages if orthodontists were able to treat a patient’s malocclusion with confident knowledge in the efficacy that their treatment is based on science. There may be those who would argue that the effort to discover etiology is a waste of time — that things are well enough left alone. It may even be argued that there is no such thing as the etiology of a malocclusion — “AOB happens.” However, it should be reasonable to hold that every malady has a cause.

It should be evident that if the cause of any malady (medical or dental) were to be unknown — that the treatment “cure” for the malady would be at best palliative. We should also be aware that this malady is not a diagnosis — it is a symptom of something gone wrong.

The study of the etiology of malocclusions has on been on a back burner with a low flame. Through the years, those who deserve credit for keeping the flame going include the following notables: Drs. Kingsley, Lundstrom, Brodie, W. Price, Harvold, Vanarsdall, and Musich.

Orthodontics is not alone with unknowns — for example, in medicine, there are many

maladies that have unknown etiologies, and research may be ongoing. Medical patients may be acutely aware that their particular malady and their treatment is a question mark.

What to do?

This commentary is a call for action for a different approach to problem solving.

Commendable efforts have been undertaken in the past with the hope that AOB could be treated efficiently with lasting stability by way of a particular technique or regimen; we are unaware if this has proven fruitful.

We should follow Dr. Kim’s reasoning: “The ideal treatment approach for any disease [malady] is identifying the etiology, understanding the pathophysiology, and removing the etiology.”4

A corny story from the agricultural industry A major agricultural supplier of corn seed to farmers was attempting to invent a seed that would be more disease resistant. Their greenhouses grew thousands of cornstalks.

On the day the corn was to be harvested, one scientist happened to note that one plant yielded cobs 20% larger than the others.

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ORTHODONTIC PERSPECTIVE Size was not the purpose of the original research; however, the large cobs were noticed because the scientist’s mind was open to discovery. The larger cobs were an outlier. and they could eventually turn out to be a bonanza for the company and for farmers after further testing.

A true medical story

5

In 1929, a 47-year-old Scottish researcher presented a paper in front of his medical research club in London. A little over a year earlier, he had noticed something he had never seen before — the streptococcus culture was being liquefied by some fluffy white mold that had apparently settled in out of the air onto his culture dish.

Although he continued to believe in his discovery, there were many dead ends, and the project languished because it did not fit with universal belief at the time that disease was best cured by way of inoculation.

Nine years later — in 1938 — a couple of new researchers happened to come across his 1929 paper. Eventually, Alexander Fleming got his due respect in 1945 with a Nobel Prize along with the two researchers who followed up on his discovery. This discovery is another example of the recognition of an outlier.

Background information It should help to know that malocclusions were rare prior to the early 1800s. Our analysis of old and prehistoric museum skulls prior to the 1800s reveals universally wellformed arches, well-aligned teeth, Class I occlusions (tending with prehistoric skulls to become Class III subsequent to excessive occlusal wear), and slight-to-moderate curve of Spee with obvious lifelong dental stability.6,7,8 Those facts should also suggest that malocclusions are mostly caused by something environmental, something that apparently started to change beginning in the late 1700s to early 1800s. (To be clear, very old skulls of 10,000-plus years BP, for example, reveal space distal to the 12-year molars — and today, given several millenniums of natural selection, that space is no longer present — so we expect wisdom teeth to become impacted — that is a genetic change that leads to later crowding as the wisdom teeth attempt to erupt.)

Over the years, mixed inheritance has been proposed for crowding (Kingsley 1880, Case 1908, and others) — small jaws/large teeth; however, one would expect this to be equally offset by patients with large jaws and small teeth.

64 Orthodontic practice

Consider the advantages if orthodontists were able to treat a patient’s malocclusion with confident knowledge in the efficacy that their treatment is based on science.

Application of a discovery technique to malocclusions Lightman detailed the discovery process for what he considered the 23 high points of 20th-century discovery.5 “The urge to discover, to invent, to know the unknown, seems to be so deeply human that we cannot imagine history without it.” “In some cases, sheer brilliance leads to discovery.

In others, the required ingredients include circumstance and luck.”

A technique proposed for the discovery of etiology is not a new idea — it is what Lightman might call creating the circumstances for success along with some luck9: 1. Read every research manuscript with case studies on AOB that includes failed results: what was done and what was not done — draw some conclusions.

2. Read every study on AOB that purports successes: what was done and what was not done — draw some conclusions.

3. Consider the outliers in the treatment of one’s own AOB cases — those cases where treatment seemed easier and also those cases where treatment was intractable; consider posttreatment stability or instability; consider periodontal stability or instability; evaluate any “patterns” in cases that work and where it does not work.

4. “Cherry-pick” those patients from the cases that seem to work out.

5. Evaluate the “cherry-picked” results for their cephalometric similarities along with measured arch harmony or disharmony.8 6. Group those cases into a pilot study.9,10 7. The etiology of the malady can be proposed for further study.

(Incidentally, the etiology of Class II malocclusions might also benefit from this discovery technique (refer to Moyers, et.

al.’s, landmark paper that discusses the six horizontal types [symptoms] and five vertical types [symptoms] of Class II malocclusions.

The 11 possible etiologies were left for future discovery.)10

Time for an RCT? It is well accepted that a medical randomized controlled trial (RCT) is among research with the highest degree of validity. Medical RCTs can be accomplished most easily when a virus or bacteria is the etiology; when the double-blind requirement is feasible; when results can be evaluated over time spans that are also feasible among other strict requirements.11 RCTs are only real RCTs, when and if an etiology can be proposed and tested.

Unfortunately, the medical RCT design does not fit well with orthodontic treatment research for a several reasons: 1. The double-blind requirement is problematical.

2. The etiology of the malocclusion is not yet known.12-15 3. Malocclusions are not caused by a virus or bacteria.

4. Routine patient orthodontic care requires periodic adjustments at each visit.

A medical RCT requires that patients are not to receive additional treatment interventions while in the study. Accordingly, a medical RCT design and an orthodontic “RCT” are not the same thing.

If it is desired to proceed with the necessary compromises of an orthodontic “RCT,” the following is an outline: 1. Prospectively select 100 early AOB subjects (7 to 10 years old).

2. Stratify the subjects equally into two groups (treatment and controls) based on severity of AOB; age; sex; and most importantly, the proposed AOB etiology.

3. Treat the one cohort (as appropriately suggested from the pilot study).

4. Observe the control group and Volume 9 Number 5

$64,

900

ORTHODONTIC PERSPECTIVE treatment groups through age 18.

5. Accept the fact that the untreated controls have been left behind and likely cannot be caught up.

years old. That suggests that the discovery of etiology is feasible.

6. A medical randomized clinical trial (RCT) is among research with the highest degree of research validity.

For several reasons, the medical model RCT is not fully applicable to orthodontic etiology research.

7. Case studies and pilot studies should not be underestimated in their potential contribution to orthodontic knowledge when there is a need for discovery. OP

Conclusions 1. The causes of most malocclusions are generally understood by orthodontists to be unknown.

2. There is a need for the discovery of the etiology of malocclusions — in this instance, anterior open bite (AOB).

3. “The ideal treatment approach for any disease [malady] is identifying the etiology, understanding the pathophysiology and removing the etiology.”4 4. There is a technique that can be used for discovery that is not a new idea.

The technique starts with creating the circumstances for the recognition of outliers.

5. Much malocclusion is of relatively recent origin — a couple of hundred

5. Fleming A. Antibiotics. On the antibacterial action of cultures in penicillium. In: Lightman A. The Discoveries: Great Breakthroughs in 20th Century Science. New York, NY: Pantheon Books; 2005.

6. Hayes JL. March 8, 2003, PAO Meeting, Philadelphia, PA. Presentation: A Clinical Approach to Identify Transverse Discrepancies.

7. Hayes JL. Orthodontics. Smithsonian Institution. In: Owsley DW, Jantz RL, eds. Kennewick Man: The Scientific Investigation of an Ancient American Skeleton. Texas College Station, TX: A&M University Press; 2014.

8. Hayes JL. In search of improved skeletal transverse diagnosis. Part II: A new measurement technique used on 114 consecutive untreated patients. Orthodontic Practice US. 2010;1(4);34-39.

9. Hayes JL. A new regimen of phase I care applied to anterior open bite—10 case studies: an etiology proposed by the strategy of triangulation. Orthodontic Practice US. 2012;3(3):18-26.

10. Moyers RE, Riolo ML, Guire KE, Wainright RL, Bookstein FL. Differential diagnosis of class II malocclusions. Part 1.

Facial types associated with class II malocclusions. Am J Orthod. 1980;78(5):477-494.

14. Hayes JL. Design flaws in some randomized controlled trials.

Am J Orthod Dentofacial Orthop. 2008. 134(4):466-467.

15. Hayes JL. Problems with RCT designs. Am J Orthod Dentofacial Orthop. 2009;136(2):143-144.

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4. Kim KB. How has our interest in the airway changed over 100 years? Am J Orthod Dentofacial Orthop.

2015;148(5):740-747.

13. Hayes JL. Evidence-based orthodontics. Am J Orthod Dentofacial Orthop. 2008;133(5):637-638.

E CAS

3. Johnston LE Jr. Through a glass darkly: Orthodontics in the 21st century. Am J Orthod Dentofacial Orthop. 2015; 147(suppl 5):187-188.

12. Koletski D, Pandis N, Polychronopoulou A, Eliades T. What’s in a title? Assessment of whether randomized controlled trial in a title means that it is one. Am J Ortho Dentofacial Orthop. 2012;141(6): 679- 685.

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2. Turpin DL. Online only. Editor’s summary and Q&A: Zuroff JP. et. al., Orthodontic treatment of anterior open-bite malocclusion: Stability 10 years postretention. Am J Orthod Dentofacial Orthop. 2010; 137:302.e1-302.e8.

11. Wapner J. The Solid-Gold Wonder Drug. Scientific American.

2014;311(3)32-33.

PA

1. Berents RG. Editorial: New vistas in orthodontic research.

Am J Orthod Dentofacial Orthop. 2015; 148(5):701-702.

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REFERENCES

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TECHNIQUE

Accelerating orthodontic treatment with the D2 Appliance™ Dr. Todd Dickerson discusses a method to correct an anteroposterior discrepancy early in treatment

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hat once took weeks in our society now takes a fraction of that amount of time, thanks in great part to advances in technology. A simple example from the not-too-distant past would be how it was common to wait 6-8 weeks for an order via mail or over the phone to arrive. Now, with Amazon, we place an order online and have that same delivery in 2 days rather than 2 months. In some cases, that shipment can appear on our doorstep in a couple of hours. Most things that new technology has touched over the past 20 years have resulted in an expedited process. In fact, this is so much the case that we as consumers expect this expediency and look elsewhere if we don’t find it.

Take a simple example in orthodontics — digital photography. Gone are the days of waiting for the slides or photos to be developed. We now take digital photographs of our patients at their initial exams, and 10 minutes later are showing the cropped

images to those patients during their consultation. Those who have implemented digital technology could not imagine reverting to developing film again and waiting a week for the processed images.

Our society expects nearly everything to be faster and more efficient than in the past.

We live in a world of immediacy and instant gratification. Patients today expect treatment to be faster and more efficient than ever. That is one reason the average patient burns out at around 12 months. As orthodontists, we want to have as much of a patient’s treatment completed prior to this 12-month mark. After 12 months, breakage, and missed appointments increase while compliance and the quality of oral hygiene decreases.

It can be difficult to obtain anteroposterior (AP) correction at the end of treatment if that correction is dependent on cooperation from a burned-out patient. This is a convincing reason to be focused on establishing a good AP relationship early in

treatment. I have found that compliance is best at the beginning of treatment, so AP correction can be easier to achieve at that time and can save appointments and time at the end of treatment.

Following are three cases using one method, the D2Appliance™ (D2Appliance, Phoenix, Arizona), to more quickly correct an anteroposterior discrepancy early in treatment. This method can be used with brackets, aligners, or space maintainers. The D2Appliance™ is a patented product that uses a decrease in resistance to accelerate posterior Class II correction.

Case 1 This 13-year-old male had been in braces for 12 months of the projected 18-24 month treatment when he and his family moved out of state. The patient was admittedly burned out and hadn’t worn elastics in 6 months.

All third molars were present, but no root formation was evident (Figure1).

Figure 1

Figure 2 Todd Dickerson, DDS, is an orthodontist in private practice in the metropolitan Phoenix area. His primary orthodontic interest is efficient accelerated treatment and its application in private practice. Dr. Dickerson has served on clinical advisory boards for multiple orthodontic companies and lectures both in North America and abroad. For questions regarding this article, please contact Dr. Todd Dickerson at D2appliance.com.

Disclosure: Dr. Dickerson is the inventor the D2Appliance™, a patented and trademarked appliance for Class II correction.

68 Orthodontic practice

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TECHNIQUE

Figure 3

Figure 4

Figure 5

Treatment plan The patient agreed to re-engage and wear elastics if his braces were removed while anteroposterior was corrected.

Following removal of his current braces, a D2Appliance™ was placed on teeth Nos. 3-6 on the maxillary right side to correct the end-to-end molar and cuspid occlusion. A D2Appliance™ was also placed on teeth Nos. 4-7 on the maxillary left side. Molar and cuspid occlusion on the left was a full-step Class II. Buttons for elastics were placed on the mandibular 6’s, and an overlay was fabricated for fulltime wear along with the 1/4" 4 oz. elastics (Figure 2).

At the first return appointment at 7 weeks (Figure 3), the occlusion on the right was nearly corrected, and the left side improved to an end-to-end occlusion.

Patients today expect treatment to be faster and more efficient than ever.

The second appointment at 4.5 months (Figure 4) showed both sides had corrected to Class I molar. Space also opened distal

to the maxillary left first bicuspid. Note anterior bite opening as well as how the maxillary left cuspid has moved to the distal on its own, presumably from the transeptal fiber pull.

The final alignment following 9 months of treatment with braces is shown in Figure 5.

Case 2 — in combination with aligners One of the most difficult corrections to accomplish with aligners is concurrent AP improvement. Using a combined approach decreases the force and time needed to bring molars into Class I alignment while also reducing the number of required aligners. In this case, a 25-year-old female sought clear aligner therapy and also desired correction of her overjet (Figure 6).

Figure 6 70 Orthodontic practice

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Figure 7

Figure 8

Figure 9

Treatment plan Invisalign® (Align Technology, San Jose, California) treatment was combined with the D2Appliance™ to maxillary teeth Nos. 4-6 to maximize esthetics.

Figure 7 shows initial bonding and aligner delivery. Figure 8 shows first appointment back at 12 weeks.

At 6 months (Figure 9), the mandibular arch is level and ready for refinement, and the D2Appliance was removed in order to finish treatment with aligners alone.

Case 3 — Class III correction Note this is an off-label use since the appliance was originally intended for Class

II correction only. The patient is a 14-year-old male with significant Class III prominence.

Treatment plan Treatment included full braces with the D2Appliance™ on lower to improve cuspid and molar relations. Note that the third molars were present before and after

Figure 10

Figure 11 72 Orthodontic practice

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TECHNIQUE

Figure 12

treatment, although removal would normally be recommended (Figure 10).

At the 4.5 month appointment (Figure 11), note apparent overcorrection, which is partially due to compressive response in mandibular joint area. Without the apparent overcorrection, the bounce back will leave the bite incompletely corrected.

Final photos at 20 months are shown in Figure 12.

Discussion In all cases, the bite will tend to open in the anterior. This is beneficial in deep bite cases, but care needs to be taken in open bites such as the one above. End-to-end molar correction usually occurs in 8-12 weeks, while full Class II cusp cases often require 4-6 months.

D2Appliance™ The D2Appliance™ is a patented Class II orthodontic distalizing appliance that isolates the segment to be distalized, thus reducing the resistance to movement. This decreased resistance is more efficient use of elastic

Figure 13: D2Appliance™

force because once the posterior segment is in proper anteroposterior occlusion, the posterior teeth are used as anchorage to retract the remaining dentition. The D2 Appliance™ consists of two parts: a posterior component, which has a free-floating metal bar attached, and an anterior component to bond onto the cuspid or premolar. The posterior bar is cut to length chairside or in the lab to fit any size span. The posterior bar inserts into the anterior component post which has

a hole that penetrates partially through the anterior post. The appliance is universal, so each component fits both the right and left sides. Elastic wear maintains compression of the appliance.

Bonding: The posterior component is measured to length, cut, and bonded to the posterior tooth. The anterior component is then slid onto the bar and bonded to the anterior tooth. The bonding procedure takes 5 minutes or less chairside. OP

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74 Orthodontic practice

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MARKETING MOMENTUM

Millennial Moms: Why they should be an important audience of your marketing strategy Marketing consultant Julie Yeomans discusses how to reach this important niche in a social media environment

A

fter 20 years watching the trends in sales, education, and consulting in orthodontics, one thing is for certain — changes in the way practices market have been evolving quickly — and it has been a seismic shift. Unlike when sales teams helped launch Invisalign® or Damon® selfligation, for which the orthodontist could decide if he/she wanted to offer this option in his/her practice, this new marketing change is outside of the clinician’s control.

Increasingly, direct-to-consumer “Amazontype” retail options are delivered to willing patients’ mailboxes, catering, in part, to a huge consumer base, the “Millennial Moms.” For these consumers, those born between 1980 and 2000, it is important to have services literally at their doorstep.

The largest companies in the world are bringing in consultants to coach in methods of working with and managing Millennials.

This group is very diverse and affected by the technology evolution. There are “older” Millennials (pre-smartphone/iPad®), and “younger” Millennials. They shop, perceive value, convenience, and service completely differently from previous generations. Orthodontists probably have had plenty of experience already catering to the needs of this group of patients and parents.

At the 2018 AAO meeting in Washington DC, I had the sincere pleasure of meeting a successful orthodontist from Illinois. Talking about this exact topic, he said, “One of the best books I have read to understand an effective marketing strategy is Millennial Moms by Maria T. Bailey. It taught me that I have to change how I do my consults, my outreach, and my value to the patients.”

I was intrigued and bought the book on Amazon for $35. It was worth every penny.

Julie Yeomans is an orthodontic industry sales and marketing consultant. You can contact Julie at Julie@YeomansDesignGroup.com.

76 Orthodontic practice

Millennials shop, perceive value, convenience, and service completely differently than previous generations.

For this article, I reached out to author Maria T. Bailey, CEO of BSM Media.com (www.bsmmedia.com). She was kind enough to take my questions, and I will share some of her insights on how you can apply this to your orthodontic practice, and what marketing strategies are effective for moms like me.

Know your Millennial Mom: 2015 is the year that Millennials become the largest generation of consumers. According to the latest United States Census Bureau report, there are 83.1 million Millennials. There are currently an estimated 13 million Millennial Moms in the U.S., comprising only about one-third of the 42 million Millennial women in the U.S. The influence is real. Millennial Moms are expected to spend approximately $750 billion a year.

One question I asked Maria was, “As an orthodontic practice, what is the most effective way to reach this target base?” She offered the following advice: “I think the use of social media is certainly a good tactic for recruiting new business.”

Here are some useful tips that she suggested, and I have tweaked for orthodontists to consider: 1. Using images is more effective than word-based articles. For example, I could see an orthodontist holding an, “Off Day” in their community and have an Instagram® feed of their patients smiling on their off day — typically Fridays. I know with client/ patient privacy, orthodontists need to be careful to ask (and document) their patients’ permission to post their images and use their hashtag.

Seeing this fun content could interest prospective clients to their practice and keep existing patients interested.

In presenting your patient images on Facebook or Instagram, it would

serve your social media story well to share lots of before and afters, especially if you are accelerating cases. If you do a single image with the top two-thirds of the image a beautiful posed happy patient glowing with his/her new smile (the portrait feature on the iPhone® is incredible), and in the bottom one-third, a split before and after of the frontal shot-teeth only: this tells a great visual story.

In Figure 1, Dr. Kyle Fagala (Saddle Creek Orthodontics and Founder of The Digital Orthodontist) and Dr. Sheldon Salins (Salins Orthodontics) use the Instagram layout app effectively. It’s very easy to put together this image. They also use the iWatermark app on their portrait photo to maintain the integrity of the brand. The audience engagement at over 150 “likes” and followers comments is fantastic and easy for a client to scroll through quickly. You truly see the patient living with the successful treatment in a non-clinical setting. I see so many doctors’ pages who are standing with patients and congratulating them for completing the treatment. But as a prospective mom, I don’t know that patient, how many months treatment took, and what the patient’s teeth looked like before. For new patients, a picture and information that is too vague provides limited value, so really evaluate who your audience is and your specific goals.

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Figure 1

matter of minutes, easy-to-upload photos. Then drag, drop, and resize.

Share your good work, and share it proud. Differentiate your practice with the technology you offer, your team, your outreach in the community, your experience — It will make a difference and a connection with the patient.

2. Orthodontic practices could also focus on “smiles” and set up selfie stations at local events, high school football games, etc.

Many school carnivals, back to school nights, and graduations want to offer fun Instagram-worthy photo opportunities. I love this idea. Work with a local sign business to create a setup that can be reused. Here is one that my son’s school had on the first day (Figure 2), and there was a long line to snap a photo. “Sign Gypsies” made this display and have offices nationally (check out signgypsies. com for a location near you). Sponsoring this photo opportunity and tagging your practice for the chance to win a prize is a great marketing opportunity.

3. Boosting content on Facebook is also effective. I recommend fastform video (video clips at a higher speed) because right now Facebook and Instagram are rewarding videos, so it will appear more often in news feeds. They could do a fast-form video of putting on new colored bands or a fast-form video on some new technology.

4. I would think about the behavior of their clients, and how the doctor can insert himself into that behavior.

In the book, tip No. 24 notes that relationships are really important to Millennial Moms.

Do not outsource your social media posts.

The sterile nature of “tell us what you’re 78 Orthodontic practice

Figure 2

smiling about today” is obvious that it’s not from your practice. Also do not post the same thing on the three main social media platforms (Facebook, Twitter®, and Instagram). Change it up, and set up a monthly social media schedule (topics scheduled as well as dates) aiming to post three times a week if you can. This activity will get more traction in the scroll feeds. To develop that relationship, share the human side of your practice and your long-term relationships with your patients. Instead of two retainers included after treatment, maybe it’s a smile guarantee for a certain amount of time (a more feel good term) with the condition of annual retainer checks. Offer to your patients donations for school fundraisers to support their causes — maybe it’s a $50 Target gift certificate. You can also offer to help promote their events on your page; for example, an annual fall school carnival if appropriate. That patient will most likely share your post with their friends.

One of the biggest takeaways I got from this book is to revisit your social media strategy and re-evaluate your pages often. Millennials are on their phones all of the time. You want to be part of that landscape in the social

Figure 3

media space. Be engaging and interesting, otherwise people won’t follow your page.

It’s more than number of “likes” you have on Facebook — what so many people use to judge their success. Many SEO companies focus on this as a marker for success, but it’s a waste of money. What is beneficial to the orthodontic practice is responding to every comment on your page, shouting out to local businesses and patients, sharing live video, posting on youTube® (a very popular search engine for Millennial Moms), creating opportunities for patients to tag you in their posts, and communicating the personality of your practice. Always do this with the mindset of engaging and including your patients — just like you are at a dinner party, bring them into the conversation so they can learn more and enjoy your company.

This is the new age of marketing success in reaching the Millennial Moms.

Acknowledgment Many thanks to Maria T. Bailey for her advice, her excellent book, and contributions to this article. You can buy Millennial Moms — 202 Facts Marketers Need to Know to Build Brands and Drive Sales on Amazon. OP Volume 9 Number 5

RESEARCH STUDY

Does having had premolar extractions affect how orthodontists treat their patients? A pilot study Drs. Zubad Newaz and Laurance Jerrold investigate whether providers’ own experiences correlate with their own treatment philosophies regarding extraction orthodontics Abstract The issue of extraction therapy has been a historically contentious issue in orthodontics, but no study exists in the literature that investigates whether a provider’s own experience correlates with their own treatment philosophies regarding extraction orthodontics. A simple survey was distributed via various channels to orthodontists in North America. Seventy respondents completed the survey, of which 74% had orthodontic treatment. Among those treated, 24% had premolar extractions; 26% of providers who had extractions wished they did not have extractions, whereas only 6% of providers who did not have extractions wished that they did. Orthodontists who had extractions overall reported a greater number of perceived sequelae and were more skeptical about the role of extractions in temporomandibular disturbances and airway disturbances, although no statistically significant differences were found in any cross correlations between the extraction group and the others. A majority of both extraction and nonextraction groups reported no adverse sequelae.

Conclusions No significant differences were noted between providers who had extractions and other providers for the parameters studied, but some tendencies were noted that characterize prior extraction subjects to be more averse to extraction therapy.

Introduction Orthodontists have been historically divided on the issue of extractions, dating back to the early 20th century when the practices of the father of modern orthodontics, Dr. Edward Angle, who was known not to subscribe to extraction therapy, were Drs. Zubad Newaz, DDS, and Laurance Jerrold, DDS, JD, ABO, are both from NYU Langone Medical Center – Brooklyn, Department of Dentistry, Division of Orthodontics. Dr. Jerrold is the Chair and Program Director of the Orthodontic residency program.

80 Orthodontic practice

challenged by later leaders — namely, Dr. Charles Tweed, who retreated his allegedly failed nonextraction treatments with extractions and reported better outcomes.1 The wave of increase of extractions in the 1950s and 1960s that followed Tweed’s presentation in the 1940s represented the first shift of the “pendulum” we know today, with changes in thought regarding the appropriateness of extraction therapy in orthodontics, which many consider is currently back toward the nonextraction paradigm.

Some of the issues surrounding each pendulum shift include discussions about various topics, including stability, profile and facial esthetics, arch/smile width, periodontal health, TMJ disturbances, sleep disturbances and airway compromise, compatibility with holistic concepts (i.e., preservation of healthy tissues in the body), and changing perceptions of facial esthetics and beauty. Perhaps at the core of the debate is the nature versus nurture argument in jaw development. Some purport that we as a profession should adapt to the observational decrease in jaw size that has followed the evolution of mankind in modern history, and that accommodating to these discrepancies is possible by removing teeth. Others propose that reasonable interventions exist to guide jaw development that allow for even the modern human to be able to accommodate teeth predictably without extractions by emphasizing supportive therapies that better allow for this.

Brimm v. Malloy (1987) was a landmark legal case that precipitated a reawakening of the debate surrounding the appropriateness of extraction therapy, where the jury ruled against a Michigan orthodontist and awarded the plaintiff $850,000 who claimed she developed temporomandibular disorder (TMD) after upper premolar extraction and retraction, causing mandibular posteriorization and entrapment.2 Some authors have described the outcome of this ruling to be unfortunate and unfounded in scientific principles.2,3 Much of said scientific knowledge base stemmed from efforts from the orthodontic

View the complete survey on pages 88 and 90

community following this ruling to prove that extraction orthodontics does not categorically cause TMD (nor has a detrimental effect on facial form). The publishing of many articles ensued, which contained a plethora of data and theories that essentially debunked the incidence of any detrimental effects of extraction orthodontics.4-12 These articles, which suggest that negativities in arch width, facial form, and temporomandibular balance do not occur following extraction therapy, are currently regarded as classical literature and required reading for every orthodontic resident in the United States, and are testable material for the American Board of Orthodontics’ certifying examination.

As modern trends toward nonextraction therapy progress in today’s orthodontic landscape, some providers continue to question the body of evidence that exists about the harmlessness of extraction therapy.

Perhaps the most prominent limitation for these studies, and almost all clinical orthodontic literature, is that it is very difficult to design high-quality controlled studies that Volume 9 Number 5

RESEARCH STUDY follow the patients for decades after their orthodontic treatment, especially when some of the alleged undesirable effects of extraction treatment typically arise at a much later age than the treatment.

It can also be contended that the effects of extraction can be classified based on their anticipated effects on the dentoalveolar complex, in that some extractions are not intended to result in any change in jaw size and morphology, and the teeth simply play “musical chairs” within the jaw in order to align, whereas other extractions are performed with the direct effect of reducing jaw size or dentoalveolar procumbency. It is likely that the effects of these treatments are fundamentally different from one another.

This is not to say that the classical literature completely ignored this potential difference (by including headgear and maxillary incisor retraction groups in their studies), but the discrimination of these groups is considered by some to be inadequately addressed in a longitudinal period of sufficient duration to make conclusions.

This also leads to an area of recent heightened interest with airway and sleepdisordered breathing concerns, which was not an area of peak focus in the era of influx of extraction-supporting literature. As such, a lack of attention to airway resistance issues and effects of underdeveloped jaws with time is a limitation to many empirical demonstrations of the benign nature of extraction orthodontics. Understanding about this topic is evolving and is a work in progress, with conflicting reports in the literature demonstrating a mix of detrimental versus nondetrimental effects on the airway.13-23 The advent of CBCT has allowed for a better assessment tool to comprehensively evaluate some of the issues that relate to bone support, TMJ morphology and position, and airway characteristics in three dimensions. This serves to overcome limitations in the two-dimensional cephalometric support found in the extraction-supporting literature.

It is empirically demonstrated that different orthognathic surgical movements and modifications to the jaws carry significant, predictable effects on airway morphology.24-29 This is regarded as support for those who suggest that changes from nonsurgical orthodontics may mimic such patterns as clearly demonstrated for corresponding surgical movements, albeit more minutely, but regarded as insignificant by others who deem these effects too minor to draw conclusions of clinical significance.

The need for longitudinal support to demonstrate adverse or non-adverse effects 82 Orthodontic practice

The advent of CBCT has allowed for a better assessment tool to comprehensively evaluate some of the issues that relate to bone support, TMJ morphology and position, and airway characteristics in three dimensions. brings about another conundrum. If an extraction subject does develop problems later in life, the multifactorial etiologic possibilities of such conditions, known to have complex etiologies, will preclude identification of a primary etiology. This is a built-in obstacle to any provider or investigator who attempts to demonstrate that extractions have any detrimental effects and are challenged by the empiricists to produce proof that this is indeed what contributed to the rise of adverse effects after extraction treatment. This obstacle will, by its nature, be very difficult to ever overcome (empirically, that is).

The purpose of the preceding commentary is not to be, in itself, any support or detraction for either side of the argument.

Rather, it serves to reinforce that great minds in our profession have failed to reach consensus about this topic after over 100 years of existence. The nature of the orthodontic profession is that a series of anecdotes and innovations have led to treatment modalities, and their effectiveness or ineffectiveness is eventually demonstrated through a combination of widespread provider experience and literature support. However, this process typically occurs significantly later than the time point where these principles are found to be effective by one or few individuals in practice and thereabout presented or proposed to the orthodontic community.

In other words, one might argue that the orthodontic profession is largely founded and dependent on anecdotes as building blocks to regarding therapies as reliable and responsible. As such, the orthodontic professionals who ponder into the validity of anecdotal evidence and thereby defer to their colleagues to investigate how they perceive such issues, in order to build a case for or against a treatment modality, are valuable assets to the profession. This process has given rise to many proven therapies we rely on today to practice our profession.

With this, we sought to investigate how orthodontists’ own experiences with orthodontic treatment on themselves shape their views about the extraction issue. We were unable to locate any study in the accessible

literature relating to this topic. Anecdotal reports on non-orthodontist patients are plentiful in support or opposition to extraction therapy, but those of orthodontists themselves may help qualify and validate some viewpoints given their own unique combination of expertise along with their experiences as orthodontic patients. Hence, our study serves as a pilot investigation via a simple survey that inquires about the provider’s own type of treatment and perception of it, how it might have influenced them, and whether certain thought processes regarding extractions might apply to them. We hope that this study will help precipitate more valuable investigations into this topic, so as to provide an alternate, supplemental dimension for the orthodontic practitioner to ponder over their treatment philosophies in addition to the clinical experience and body of evidence to which we conventionally refer.

Methods An 11-item survey on pages 88 to 90 was sent to program directors or chair-persons of orthodontic residency programs in the United States and Canada with a request to distribute to all faculty and residents within their departments, as well as to other orthodontists for which the principal investigator had contact information.

The recruitment of subjects was made through an email welcome letter with a brief explanation of the topic being investigated, including an anonymous link to the survey supported by Qualtrics (Provo, Utah).

Complete responses were recorded.

Incomplete surveys were excluded. Tallies were made and readily retrievable using the Qualtrics survey reporting tools. Proportions of respondents answering the questions were extracted. In addition to basic tallies and descriptive statistics, a cross-reference tool was utilized to weigh the responses of Questions No. 8 (about treatment sequelae) and No. 11 (about modes of thinking) against the provider’s extraction history, and a Chi-square analysis was used to determine significance of differences between responses of these categorical variables (alpha set to 0.05).

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RESEARCH STUDY Results Seventy respondents completed the survey. The experience level of respondents was effectively bimodal, with 50.7% of respondents having 20-plus years of experience and 34.8% having 0-5 years; 74% of respondents underwent orthodontic treatment.

The following proportions are of those who had orthodontic treatment. A vast majority (72.6%) of the treated respondents had orthodontic treatment started early in life (childhood/adolescence), while 23.5% started later in life before practicing orthodontics and 11.8% during their practicing careers. The sum of these numbers exceeds 100% due to several respondents having undergone treatment more than once in their lifetime. A minority, 18%, had noteworthy dental anomalies of tooth size or number.

Nineteen respondents reported having extractions of some type. Twelve respondents (23.5 %) of treated respondents had premolar extractions without a major skeletal component, while one respondent reported having a skeletal component. Six (11.8%) reported having extractions of a different protocol, and 62.8% of respondents had no extractions. Of those who had extractions, five respondents (23%) replied that they wish they did not have them done, and seven (37%) responded that they are content with having had them done. Of those who did not have extractions, two respondents (6%) wish they had them done, while nine (28%) reported that they would not have wished to have them done. The remainder responded that their responses would depend on a review of their initial records or that the question did not apply to them.

A greater proportion of the extraction group reported narrow archforms, lack of smile fullness, flat profile, TMJ disturbances, premature anterior contact with posterior functional shift, and snoring/sleep apnea than nonextraction subjects. No respondent in any group indicated that their smile was either too broad or that their profile was too full. A greater proportion of the nonextraction group (77.4%) reported no negatives with treatment than the extraction groups (50% premolar group and 16.7% other extraction group). Cross tabulation showed that no significant differences were found between any of the answer choices and extraction history (p = 0.16).

A small majority of treated respondents (57%) replied that their own treatment experience has influenced the way they treat their patients. Among the extraction group 84 Orthodontic practice

As modern trends toward nonextraction therapy progress in todayâ&#x20AC;&#x2122;s orthodontic landscape, some providers continue to question the body of evidence that exists about the harmlessness of extraction therapy. respondents who were influenced by their treatment, five respondents reported that they recommend less extractions and four recommend more, showing almost equal distribution. Among the nonextraction group respondents who were influenced by their treatment, 13 reported that they recommend less extractions, and two recommend more, showing a noteworthy predilection toward nonextraction subjects recommending less extractions.

For Question No. 11, a greater proportion of premolar extraction subjects reported more skepticism about extractions correlating to TMJ disturbances (25%, versus 17% no tx and 9% non-extraction), and sleep/ breathing disturbances (41%, versus 22% no tx and 16% non-extraction), and that anterior tooth retraction could have detrimental effects on the airway (25%, versus 5% no tx and 3% non-extraction). Cross tabulation showed that no significant differences were found between any of the answer choices and extraction history (p = 0.69).

Discussion Our study did not show any significant differences between provider treatment type and the items for questions No. 8 (sequelae) and No. 11 (attitudes). Despite this, the results of our pilot study suggest a tendency for orthodontists who have had extractions to a) be more wishful of the alternative (nonextraction) treatment, b) recommend proportionally less extractions than the converse of their nonextraction counterparts, c) be more skeptical of the role of extractions in temporomandibular disorder, sleepdisordered breathing, and anterior retraction effects on the airway, and d) report more adverse sequelae that they attribute to their treatment. It was interesting to note that no respondent thought that their smile was too broad or full, indicating, perhaps, a lesser risk of patient displeasure when employing such an approach in a borderline case.

This study had significant limitations. The sample was not at all random, having been distributed primarily to academic personnel

(faculty, residents, etc.), and other orthodontists otherwise known or locally available to the investigators. With the cohort being mostly academic, it may have differed from general orthodontic populous if the survey was more far-reaching and did not grossly under-represent important sectors of orthodontic professionals (private practice, public service, internationals, etc.). The sample size was small, given the target population of at least 13,500 (and many more if distributed worldwide, as there was no reason to limit this survey to North Americans based on the objective).

There was substantial bias in survey distribution, which depended on many recipients of the email invitation to forward the survey to others, instead of acquiring proper lists of all personnel and sending the survey to individuals directly. There was bias built into question No. 11, which contained only statements of belief of those with a particular line of thought.

Another problem with this question was that the choice was simply to select or not select, whereas a better positioning of this question would be to offer a continuum or 5-point scale response. An example of such a modification would read â&#x20AC;&#x153;Extractions contribute to TMJ disturbances,â&#x20AC;? giving the respondent the ability to select on a scale of strongly disagree to strongly agree. Respondents might have answered the questions differently if presented in this way, and there may have been fewer empty data points as orthodontists harbor beliefs on a continuum.

A comments section was unavailable for the respondents to deliver feedback or personalized pertinent information, which, for a pilot study, would have been very useful in the shaping of future studies and to include as discussion points. Furthermore, this would have better captured the primary intent of this study, which was to collect thoughts about how providers truly feel about this issue given their experiences. There might have also been respondent-fatigue from question display, as questions No. 8 and 11 each had 12 answer choices, making for a Volume 9 Number 5

RESEARCH STUDY less-than-ideal visual survey flow. It may have been better to pose these questions separately, and this may have further facilitated targeted statistical analysis.

This survey was potentially too inclusive of different variables and attitudes, as more meaningful data might have been acquired with a more selective focus of topic (e.g., extraction history effect on airway beliefs).

However, it was chosen to include all variables as this pilot study sought to identify ways to refine future studies, and this, we believe, was better achieved by broadening the scope of this study.

Inadequate statistical testing and application of exclusion criteria are other potential criticisms of this study, as more extensive statistical comparisons could have been made, as well as cross references between variables other than extraction history.

Lastly, technical glitches seemed to contribute to some respondents not being displayed questions that should have otherwise been displayed, which reduced collectible data, and may have confused some respondents as to why the apparent objective of the study’s title was not at all explored, especially for those respondents who did not undergo orthodontic treatment and did not see the full spectrum of questions. Perhaps a medium where all questions are visible on a scroll-down page, so that respondents are more acquainted with the study, would be a better mode of visualization.

In addition to the immediately foreseeable improvements in this investigation as highlighted above, another potential supplement to the exploration of this topic in the future might include the formulation of an issue or collection of orthodontists’ detailed commentary on their own treatment and effects, with photographic and radiographic support. A chronicle or repository of sorts of orthodontists providing detailed documentation of their records, along with any supporting data such as health assessments, sleep studies, occlusal analyses, and other adjuncts could be a valuable resource for the profession.

Given the abundance of limitations and limited conclusiveness of this study, this body of work does not seek to be recognized as science and is absolutely not intended to guide clinical decision-making in any way for the target audiences. Rather, this study and its existence in the literature is intended to provoke thought among orthodontic professionals to consider personal experience in the professional milieu, and to gently challenge staunch views of evidence-based dogmatism in orthodontics — a field where 86 Orthodontic practice

the science is universally understood to be somewhat “soft” and very subjective in nature. This study proposes the orthodontist to value that anecdotal evidence that is akin to the essential professional act of listening to one’s own patient and considering all of their reported complaints and problems with an open ear, so as to deliver personalized, individualized care and understand the limits of a profession, especially of orthodontics, to produce hard evidence and then further apply it to the momentary clinical situation, especially when it involves an irreversible procedure.

This study also seeks to assign a different degree of anecdotal evidence — that which is observed by the practitioner in his/her own body in conjunction with his/her own expertise. Anecdotal evidence may take a new meaning when a person is himself/herself the anecdote in question. Additionally, it does not take much of a venture for the orthodontist to find reports in his/her own practice or on message blogs and websites to hear the valid concerns of patients and parents regarding this controversial aspect of our profession. There are few, if any, instances of a large percentage of professional practice in other disciplines of medicine and dentistry involving the removal of healthy organs to achieve a standard that the profession exclusively holds to be golden, with the exception of plastic surgery, perhaps.

Conclusions No significant differences were noted between providers who had extractions and other providers for the parameters studied, but some tendencies were noted that characterize prior extraction subjects to be more averse to extraction therapy. Although both extraction and nonextraction treatment served many of the subjects well without problems, more perceived problems were reported by extraction subjects. Stronger, more focused studies are needed to build on the takeaways of this pilot study. OP

6. Gianelly AA, Petras JC, Boffa J. Condylar position and Class II deep bite, no-overjet malocclusion. Am J Orthod Dentofacial Orthop. 1989;96(5):428-432.

7. Gianelly AA, Cozzani M, Boffa J. Condylar position and maxillary first premolar extraction. Am J Orthod Dentofacial Orthop. 1991;99:473-476.

8. Gianelly, AA, Anderson CK, Boffa J. Longitudinal evaluation of condylar position in extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop.

1991;100(5):416-420.

9. Luppanapornlap S, Johnston LE Jr. The effects of premolar extraction: A long-term comparison of outcomes in “clearcut” extraction and nonextraction Class II patients. Angle Orthod. 1993(4);63:257-272.

10. Stephens CK, Boley JC, Behrents RG, Alexander RG, Buschang PH. Long-term profile changes in extraction and nonextraction patients. Am J Orthod Dentofacial Orthop.

2005;128(4):450-457.

11. Erdinc AE, Nanda RS, Dandajena TC. Profile changes of patients treated with and without premolar extraction. Am J Orthod Dentofacial Orthop. 2007;132(3):324-331.

12. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial and soft tissue changes in Class II Division 1 cases treated with and without extractions. Am J Orthod Dentofacial Orthop. 1995;107(1):28-37.

13. Haddad S, Kerbrat JB, Schouman T, Goudot P. [Effect of dental arch length decrease during orthodontic treatment in the upper airway development. A review]. Orthod Fr. 2017;88(1):25-33.

14. Bhatia S, Jayan B, Chopra SS. Effect of retraction of anterior teeth on pharyngeal airway and hyoid bone position in Class I bimaxillary dentoalveolar protrusion. Med J Armed Forces India. 2016;72(suppl 1):S17-S23.

15. Pliska BT, Tam IT, Lowe AA, Madson AM, Almeida FR. Effect of orthodontic treatment on the upper airway volume in adults. Am J Orthod Dentofacial Orthop.

2016;150(6):937-944.

16. Guilleminault C, Abad VC, Chiu HY, Peters B, Quo S. Missing teeth and pediatric obstructive sleep apnea. Sleep Breath.

2016;20(2):561-568.

17. Hu Z, Yin X, Liao J, Zhou C, Yang Z, Zou S. The effect of teeth extraction for orthodontic treatment on the upper airway: a systematic review. Sleep Breath. 2015;19(2):441-451.

18. Stefanovic N, El H, Chenin DL, Glisic B, Palomo JM. Threedimensional pharyngeal airway changes in orthodontic patients treated with and without extractions. Orthod Craniofac Res. 2013;16(2):87-96.

19. Zheng Z, Liu H, Xu Q, Wu W, Du L, Chen H, Zhang Y, Liu D. Computational fluid dynamics simulation of the upper airway response to large incisor retraction in adult class I bimaxillary protrusion patients. Sci Rep. 2017; 7;7:45706.

20. Hang WM, Gelb M. Airway Centric® TMJ philosophy/Airway Centric® orthodontics ushers in the post-retraction world of orthodontics. Cranio. 2017;35(2):68-78.

21. Buck LM, Dalci O, Darendeliler MA, Papageorgiou SN, Papadopoulou AK. Volumetric upper airway changes after rapid maxillary expansion: a systematic review and meta-analysis.

Eur J Orthod. 2017; 1;39(5):463-473.

22. Chen Y, Hong L, Wang CL, Zhang SJ, Cao C, Wei F, Lv T, Zhang F, Liu DX. Effect of large incisor retraction on upper airway morphology in adult bimaxillary protrusion patients.

Angle Orthod. 2012;82(6):964-970.

23. He J, Wang Y, Hu H, Liao Q, Zhang W, Xiang X, Fan X. Impact on the upper airway space of different types of orthognathic surgery for the correction of skeletal class III malocclusion: A systematic review and meta-analysis. Int J Surg. 2017;38:31-40.

24. Gottsauner-Wolf S, Laimer J, Bruckmoser E. Posterior Airway Changes Following Orthognathic Surgery in Obstructive Sleep Apnea. J Oral Maxillofac Surg. 2018;76(5):1093. e1-1093.e21.

REFERENCES 1. Rinchuse DJ, Busch LS, DiBagno D, Cozzani M. Extraction treatment, part 1: the extraction vs. nonextraction debate.

J Clin Orthod. 2014;48(12):753-760.

2. Williams P, Roberts-Harry D, Sandy J. Orthodontics.

Part 7: Fact and fantasy in orthodontics. Br Dent J. 2004;196(3):143-148.

3. Rinchuse DJ, Kandasamy S. Temporomandibular Dysfunction: Controversies and Orthodontics (Chapter 24) in Integrated Clinical Orthodontics, 2012 - Wiley Online Library.

4.

Gianelly AA. Orthodontics, condylar position, and TMJ status.

Am J Orthod Dentofacial Orthop. 1989;95(60:521-523.

5. Gianelly AA, Hughes HM. Wohlgemuth P, Gildea C. Condylar position and extraction treatment. Am J Orthod Dentofacial Orthop. 1988;93(3):201-205.

25. Christovam IO, Lisboa CO, Ferreira DM, Cury-Saramago AA, Mattos CT. Upper airway dimensions in patients undergoing orthognathic surgery: a systematic review and metaanalysis. Int J Oral Maxillofac Surg. 2016;45(4):460-471.

26. Al-Moraissi EA, Al-Magaleh SM, Iskandar RA, Al-Hendi EA. Impact on the pharyngeal airway space of different orthognathic procedures for the prognathic mandible. Int J Oral Maxillofac Surg. 2015;44(9):1110-1118.

27. Marcussen L, Stokbro K, Aagaard E, Torkov P, Thygesen T. Changes in Upper Airway Volume Following Orthognathic Surgery. J Craniofac Surg. 2017;28(1):66-70.

28. Jiang C, Yi Y, Jiang C, Fang S, Wang J. Pharyngeal Airway Space and Hyoid Bone Positioning After Different Orthognathic Surgeries in Skeletal Class II Patients. J Oral Maxillofac Surg. 2017;75(7):1482-1490.

Volume 9 Number 5

RESEARCH STUDY

Orthodontic provider treatment experience and effects on treatment approaches and experience regarding extraction therapy 1.

How long have you been practicing orthodontics? q 0-5 yrs q 15-20 yrs q 5-10 yrs q more than 20 yrs q 10-15 yrs

2. Have you ever undergone orthodontic treatment? q Yes (continue to Question #3) q No (skip to Question #11) 3.

When did you have the treatment started? (Select all that apply.) q Early in life, childhood/adolescence q Later in life, young adulthood or adulthood, but before my practicing career q During my practicing career

4. Do/did you have any dental anomalies regarding tooth number (supernumerary/missing) or gross tooth size discrepancies? q Yes q No 5.

Have you had extraction treatment performed? q Yes, 4 premolars or 2 premolars in one jaw, and I do not remember having orthognathic surgery or a major skeletal discrepancy q Yes, 4 premolars or 2 premolars in one jaw, and I know that I had orthognathic surgery or a major skeletal discrepancy q Yes, some other protocol (lower incisor, substitution, atypical, second molars, etc.) q No

6. Having learned and practiced the profession as you have, do you wish that you did not have premolars extracted if you were treated with extraction mechanics? q Yes q No q Not sure, it would depend on a comprehensive review of my initial records q Does not apply to me 7. Having learned and practiced the profession as you have, do you wish that you did have premolars extracted if you were treated with expansion mechanics (which does not necessarily include all nonextraction cases, as spacing is not typically treated with expansion mechanics)? q Yes q No q Not sure, it would depend on a comprehensive review of my initial records q Does not apply to me 8. From a qualitative perspective (this question does not depend on whether you have had a definitive knowledge of your orthodontic workup or diagnoses), do you consider yourself to have any of the following characteristics, which you either know or question if they were related to your orthodontic treatment? [check all that apply] q Narrow archform/excessive buccal corridors q Smile too wide/arch too broad q Lack of smile fullness/anterior teeth inclined too upright or far back q Overly flat profile or other associated soft tissue characteristics such as inadequate lip support q Unsightly dental protrusion in any arch q Too much smile or profile fullness q Gingival recession or periodontal compromise q TMJ disturbances, not requiring intervention or impacting quality of life q TMD or other orofacial pain that would benefit from intervention or that has adversely impacted quality of life q Premature anterior occlusal contact with a posterior functional shift into centric occlusion q Snoring/obstructive sleep apnea/airway resistance q No perceived negatives secondary to my orthodontic treatment

88 Orthodontic practice

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RESEARCH STUDY

9. Do you feel that your own treatment experience has influenced the way you treat your patients? q Yes (continue to Question #10) q No (skip to Question #11) 10. If yes, how so? q I had extraction treatment, and it leads me to recommend fewer extractions than I otherwise would had I not been treated. q I had extraction treatment, and it leads me to recommend more extractions than I otherwise would had I not been treated. q I had nonextraction treatment, and it leads me to recommend fewer extractions than I otherwise would had I not been treated. q I had nonextraction treatment, and it leads me to recommend more extractions than I otherwise would had I not been treated.

11. If any of the following thought processes apply to you, please select all that apply: q A. “Despite a lack of evidence for extractions causing sleep/breathing disturbances, I am not convinced that there is no correlation.” q B. “Despite a lack of evidence for extractions causing temporomandibular disturbances, I am not convinced that there is no correlation.” q C. “I think there is some merit to archform broadening with slow, gentle mechanics as a means of creating space to accommodate all the teeth most or all of the time without compromising bone support”. q D. “I do not believe that incisors get pushed off of the bone support when they are advanced or proclined as long as appropriate mechanics are used”. q E. “I avoid retraction of the anterior teeth whenever possible because I am concerned about the effects on the airway, and/ or I am not convinced that the tongue will necessarily adapt favorably to a smaller oral cavity.” q F. “I am not so bothered with the bimaxillary protrusive profile and question (or refute) whether it is a condition that should be treated by removing otherwise healthy body parts (teeth).” q G. “I do not believe that nonextraction treatment categorically increases the vertical dimension; i.e., there are non-cumbersome ways to offset adverse vertical effects of nonextraction treatment.” q H. “I do not believe that nonextraction treatment increases the incidence of late incisor crowding.” q I. “Proper myofunctional training and correct oral posture is essential to jaw development, treatment effectiveness, and for creating an environment for posttreatment stability.” q J. “I do not think that mainstream orthodontic thought promotes the development of jaws to their full genetic capacity at a young age.” q K. “I believe that full development of the jaws promotes health and good facial form and am willing to accept certain minor dental/orthodontic compromises to achieve such development.” q L. “The airway is at least equally or more important to me than the dento-skeletal features of a malocclusion itself in the diagnostic process and is one of the most major considerations when determining appropriateness of a treatment plan

90 Orthodontic practice

Volume 9 Number 5

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SMALL TALK

Rules for giving and receiving feedback Dr. Joel Small discusses methods for providing positive and generative feedback

F

eedback, both positive and remedial, can be a powerful tool for developing people and enhancing the performance of organizational teams. However, when used improperly, feedback can become a demoralizing and dehumanizing weapon that destroys teams. Given this distinction, it would be wise for all leaders to learn the basic principles for providing feedback that is both positive and generative.

It is important to realize that even remedial feedback need not be negative. Somehow, today’s society has made the terms “remedial” or “corrective” synonymous with terms like “negative” or “punishing,” when in fact, corrective feedback can be both rewarding and positive. As an example, large organizations are beginning to embrace the concept of a coaching culture in which leaders are trained in facilitating positive behavioral change by leading team members to a place of positive empowerment through increased personal awareness and positive corrective feedback. If done properly, those trained in this technique are reporting both immediate and sustainable behavioral change in their organizations.

Before we discuss the rules for providing feedback, it is important to acknowledge the critical role of purposeful leadership as the stabilizing factor in any organizational culture. More often than not, I find that offices suffering from default leadership are the ones that experience the most severe, and often irreversible, staff problems. Without the guidance and clarity provided by purposeful leadership, an organization is more likely to descend into anarchy as everyone is left to create his/her own set rules within the workplace. When an organization descends to this level, feedback is at best meaningless.

So here are my rules for giving and receiving feedback:

1. Behavior should manifest organizational values This is critical. Once mutually accepted, organizational values become the benchmark for what is acceptable behavior within the organization. When giving feedback, either positive or corrective, we should always use organizational values as the background for our comments.

2. Direct communication Triangulation occurs when complaints are made to a third party rather than directly to the offending party. This is a very common scenario in organizations and is one of the reasons ill feelings exist and tend to linger.

Triangulation should be banned from our

Joel C. Small, DDS, MBA, ACC, FICD, is an endodontist, author, and board certified executive leadership coach. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. **To receive a free copy of Dr. Small’s “Core Values Exercise,” please contact the author at joel@joelsmall.com.

He is also available for a complimentary coaching session to discuss your practice-related issues.

92 Orthodontic practice

organizations. Leaders must avoid the tendency to become part of the triangle by insisting that all feedback take place directly between the involved parties.

3. Positive focus All corrective feedback should be given with the intention of creating new and positive behaviors that align with the organizational values. To be an agent for change, the one providing the feedback must highlight the positive consequences of the new desirable behavior. We are most effective when we paint a positive vision of a brighter future for the feedback recipient.

4. Provide feedback for the good and not so good Corrective, or remedial feedback, is much more effective when the leader is also willing to provide positive feedback that highlights a job well done. The recipient of corrective feedback is more likely to take the comments to heart when the leader has historically praised them for the good things they have done. Many of us are guilty of forgetting to offer positive feedback when we should. Even worse, we often try to soften the corrective feedback by including praise for past positive behavior Volume 9 Number 5

SMALL TALK that went unmentioned when it occurred.

The recipient of this feedback can easily see through this duplicity, and the net intended effect of the feedback is seriously diminished.

5. Feedback should be given often

Again, it is always wise to recognize how these desired changes are consistent with the mutually accepted practice values.

7. Follow-up

Waiting for a yearly performance review to offer feedback is the worst possible method for facilitating sustainable change in our team members. If we were to ask our staff, I feel certain that they would overwhelming agree that they benefit more from ongoing performance feedback as opposed to a yearly feedback session.

If corrective feedback is to be effective, we must acknowledge when positive change occurs. Nothing is more disheartening than an earnest effort to change that goes unrecognized. This is the time to offer positive feedback on a job well done. Without this follow-up feedback, change becomes unsustainable, and future corrective feedback becomes ineffective.

6. Remain future focused

8. If you give, be willing to receive

Nothing is gained by dwelling on past negative behaviors. Instead we should facilitate change by creating a vision of a brighter future based on the desired positive changes.

The very best organizations have leaders that encourage feedback from their team regarding their effectiveness as leaders. By asking for feedback regarding

our leadership, we create an openness that promotes a healthy feedback loop.

Furthermore, research has shown that our staff is the best prognosticator of our future success as leaders. Their assessment of our leadership capabilities has proven to be more accurate than a host of professionally designed and administered leadership assessments. Given this finding, it would be wise if we listened closely to what our staff has to say.

In summary, feedback is important. It is our means for facilitating individual change as well as organizational stability. Learning to give and receive both positive and remedial feedback is one of the most important steps in becoming the leader of an exceptional organization. Utilizing these rules for effective feedback will enable us to bring out the best in the people we serve. OP

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94 Orthodontic practice

Volume 9 Number 5

BOOK REVIEW

Stability, Retention and Relapse in Orthodontics

by Drs. Christos Katsaros and Theodore Eliades Quintessence Publishing, Surrey, UK www.quintpub.co.uk

D

rs. Katsaros and Eliades have assembled a group of 30 dental professionals with unusual experience in the study of the myriad features of orthodontic retention to produce the most thorough publication to date regarding this elusive and frustrating aspect of the orthodontic process. This book has all of the expected characteristics of a Quintessence book with excellent fidelity in photographs, easily deciphered charts and tables, thick durable pages, and clear, well-edited narratives.

Drs. Katsaros and Eliades have divided the book into three sections, the first of which begins with a history of retention, the biological basis for orthodontic relapse, and a review and assessment of the clinical evidence. The second section begins with an interesting chapter on the change in irregularity of teeth with and without orthodontic treatment, followed by chapters on transverse stability, stability and relapse of Class II malocclusions, stability and relapse of Class III malocclusions, stability of open bite therapies, and the stability of orthognathic surgery patients. The final section provides chapters on acrylic removable retainers, fixed retention, biomaterials for fixed retainers, and a final chapter on the long-term effectiveness of fixed retainers.

One could only hope that this remarkable book might offer some final conclusions about the best, most reliable, and durable retention protocols. Unfortunately, no such regimen exists because clinicians use so many differing techniques. They have discovered that a majority now prefers fixed retention, at least in the mandibular arch, whereas Hawley retainers and Essix retainers remain the favorites for the maxillary arch. Interestingly, with removable retainers, their use in only the evening hours seems adequate to retain the orthodontic correction.

Orthodontic clinicians need to realize they deal with a dynamic, chaotic system where posttreatment changes are not all due to relapses, and that the only way of 96 Orthodontic practice

maintaining the result is to rely on lifetime retention. My late friend, Dr. Jack Sheridan, may have come up the best advice orthodontic clinicians can give patients at the conclusion of their therapies. â&#x20AC;&#x153;I am the creator of your smile, I am not the guarantor

of your smile. That is your responsibility.â&#x20AC;?

At some point, orthodontists need to give patients the responsibility they should have assumed throughout treatment. OP Review by Dr. Larry White

Volume 9 Number 5

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Presented by Great Lakes Dental Technologies Cancellations within month of the course dates are subject to a cancellation fee gaining procedures, optimize aligner treatment, and how to inspire teamwork through leadership to improve the patient experience. Dr. Learnbeauty more and register at Unloc Grummons will also discuss how facial harmony and smile or call Paula Molfese at

are optimized when the transverse maxillary occlusal plane, midline, Learn more and register at UnlockAligners.com chin location, and smile or call Paula Molfese at

esthetics are emphasized.

Great Lakes Orthodontics is now Great Lakes D Here are the Great Lakes Orthodontics is now Great Lakes Dental Technologies dates, times, and locations for the courses: September 21 in San Diego, California; October 26 in Orlando, Florida, and November 16 in Las Vegas, Nevada, from 7:30 a.m. – 5 p.m. Attendees will receive 8 CE Credits PACE AGD (Subject Code 370) for the course, which is open to dentists and their non-dentist staff. These courses are presented with commercial support by GLO006 Grummons_PrintAd_TBD_9x117_v6.indd 1 Great Lakes Dental Technologies.

To register, visit unlockaligners.com, or call Great Lakes Dental Technologies at 800-828-7626.

SMPT650REV081718

October 4-6, 2018

Volume 9 Number 5

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INDUSTRY NEWS With more than 20,000 units shipped, Carestream Dental’s CS 8100 family continues to surpass significant milestones

DynaFlex® awarded patent for DynaFlex Accu-Fit Dorsal® DynaFlex®, a certified-medical device manufacturer, has been awarded the patent for the DynaFlex Accu-Fit Dorsal®. The AccuFit design is used for the treatment of patients who have been diagnosed with mild to moderate sleep apnea. The unique thermal acrylic liner (Accu-Fit) provides a custom fit that fits first time, every time. This sleep device is simple and easy for the dentist to deliver at chairside. There are no adjustments of acrylic or wires at the time of delivery. In addition, the Accu-Fit liner can be re-formed in the event a patient requires future dental work that might otherwise render the original sleep device obsolete. This eliminates the cost of a new device.

For more information, visit www.dynaflex.com, or call 1-800-489-4020.

Carestream Dental’s most popular imaging system shipped the 20,000th unit of the CS 8100 family in July 2018, in less than 2 years since exceeding the 10,000-units-sold mark. Within those 2 years, the compact, award-winning family of imaging systems, which includes the CS 8100, the CS 8100 3D, and the CS 8100SC, grew to include a fourth system, the CS 8100SC 3D. The CS 8100SC 3D was honored with an Edison Award in the spring of 2018 for its innovation.

All four systems are known for their imaging quality, speed, and compact size. In fact, the CS 8100, first launched in 2012, earned six international clinical and design awards within its first year on the market. As for speed, the CS 8100SC and CS 8100SC 3D can capture cephalometric images in just 3 seconds (for 18 x 24 cm image in fast scan mode), making them one of the fastest scanning cephalometric imaging systems available. Additionally, Flash Scan mode, a feature of the 3D units, captures images in seconds to reduce dose and risk of blurred images. The small footprint of CS 8100 family units — even with the addition of a cephalometric arm — makes the systems compatible with practices of all sizes, so doctors can provide exceptional imaging and diagnoses no matter what their office’s square footage.

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

Stop Letting New Patients

OrthoChats continues rapid growth Leave — Yourannounces Website physical expansion Without a Conversation.

OrthoChats announced that the company has expanded and is continuing to grow by a monthly increase of 15%. OrthoChats, a HIPAA-compliant live website chat service exclusively for orthodontists, is now servicing more Professionally Managed Online Chat than 1,200 clients and has offi-Customized for Your Orthodontic Practice cially surpassed 500,000 individual online chat sessions managed.

200,000+ Chats Completed for Leading Orthodontists Worldwide The expansion into another structure will add 10,000 square feet to their previous 7,500 square foot location and will allow them to continue recruiting professionally trained chat specialists to meet 816-282-0429 – info@OrthoChats.com - OrthoChats.com growing demands.

OrthoChats highly trained chat specialists are spelling- and grammar-certified and utilize the industry’s best customized scripting to dramatically improve the online experience. Their services seamlessly merge with its patient service experience to help them generate more leads and amplify the overall brand of their practice. OrthoChats requires no contract, and no training or new software for employees.

For more information, visit https://orthochats.com, or call 816-282-0429.

G&H Orthodontics® partners with Premier Dental G&H Orthodontics® — a full-line manufacturer of orthodontic products that has supplied orthodontists worldwide with the best products on the market for over 40 years — has announced its collaboration with Premier Dental, to offer customers even more outstanding treatment options. Made in the USA, G&H Orthodontics’ product line includes brackets, bands, tubes, wires, springs, elastomerics, and other orthodontic supplies. Premier Dental is a global privately held developer and manufacturer of dental products with sales in over 75 countries.

To learn about G&H Orthodontics, visit GHOrthodontics.com, To schedule an in-office product demonstration, call 888-670-6100. Order through your dealer. and to learn moreVisitabout Premier Dental, visit www.premusa.com. www.premusa.com for current special offers.

Please contact your dealer concerning product availability in your country.

premusa.com/promise

Premier® Dental Products Company • 1710 Romano Drive, Plymouth Meeting, PA 19462, USA Phone 888-670-6100 • 610-239-6000 • Fax 610-239-6171 • www.premusa.com • E-mail: dentalinfo@premusa.com MDSS GmbH Schiffgraben 41 30175 Hannover, Germany

100 Orthodontic practice

MDSS GmbH Schiffgraben 41 30175 Hannover, Germany

MDSS GmbH Schiffgraben 41 30175 Hannover, Germany

8610402 0118035 Rev34 NKP10M

Volume 9 Number 5

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

Hu-Friedy launches new powder for AIR-FLOW® Therapy system

CHERRY reveals a new color for EZClean™ KC 1000 wipeable keyboards CHERRY, computer input devices company, is pleased to announce that EZClean™ KC 1000 is now available in white. The new bright color of the silicone flat covered keyboard is specifically designed to provide keyboard buyers with a clean-look option. The new color EZClean™ keyboard will help clinicians meet the industry regulations and ensure infection control where you need it most.

EZClean™ KC 1000 solves two problems. Unsealed keyboards can be difficult to clean and, in specific environments, are vulnerable to germs and bacterial growth, especially in the hard-to-clean areas between keys. Meanwhile, entirely sealed keyboards are more accessible to cleaning but aren’t as comfortable to type with on a daily basis. CHERRY’s latest EZClean™ KC 1000 solves both problems, delivering the comfort of a non-sealed keyboard that is easily cleaned.

For more information, visit http://cherryamericas.com/.

Hu-Friedy announced the release of a revolutionary new product as a part of its strategic alliance with Electro Medical Systems (EMS).

AIR-FLOW® Plus powder, designed for use with the AIR-FLOW® Therapy system, is the first air polishing powder in dentistry that can gently and effectively remove biofilm from delicate surfaces while also efficiently eliminating light to moderate stains. The release of AIR-FLOW Plus powder gives the AIR-FLOW Therapy system an even broader range of applications for dental professionals to provide better care to their patients. This is because of the unique makeup of the powder. Made from erythritol, a harder material that ensures more efficient stain removal, AIR-FLOW Plus is the first high-tech powder in the market that removes biofilm in a minimally invasive way. The small 14-micron particle size also makes it suitable for all types of surfaces, including enamel, dentin, soft tissue, restorations, orthodontic appliances, and implant surfaces. The new AIR-FLOW Plus powder is a significant advancement that allows dentists to provide fast and efficient care to patients. This delivers a more pleasant experience, which helps with patient retention.

To learn more, visit www.hu-friedy.com/BIOFILM.

J. MORITA USA announces availability of Veraview X800 in Canada Structo’s dental 3D printers empowers ClearCaps to deliver superior clear aligners ClearCaps is one of Europe’s leading clear aligner brands, founded in Berlin, Germany, in 2016 by now Chief Unbrace Officer, Jesse Bartels. When Bartels was looking to expand ClearCaps’ fleet of 3D printers, there were two criteria more important than any others: ease of maintenance and the scalability of the technology. Today, Structo’s Mask Stereolithography (MSLA)-powered 3D printers forms an integral part of the Berlin company’s cuttingedge manufacturing facilities. With a large build platform, Structo’s latest dental 3D printer, the DentaForm, is capable of printing up to 10 clear aligner molds in 30 minutes, a throughput rate that is ideal for large volume clear aligner manufacturing. Structo is a Singaporebased dental 3D printing solutions provider that designs, develops, and builds 3D printers tailored for dental applications using its unique proprietary MSLA technology.

For more information, visit www.structo3d.com.

102 Orthodontic practice

J. MORITA USA announced the availability of Veraview X800 in the Canadian market. Released earlier this year in the United States, Veraview X800 is a new multifunctional X-ray unit with 3D, panoramic, and cephalometric capabilities. Completely redesigned, this unit is loaded with practical, unique, and refined features that produce stunning images for a thorough evaluation. Veraview X800 offers progressive technology that automatically sets the optimal X-ray beam angle, horizontal for 3D, or raised 5° for 2D panoramic images. This slight upward projection for panoramic imaging enhances image quality by eliminating potential superimposition of anatomical structures, including the shadow from the base of the skull and hard palate over the maxillary teeth. For 3D imaging, a horizontal beam minimizes distortion and reduces metal artifacts.

CBCT imaging clarity has also been improved with a reduced voxel size of 80 μm and a resolution of 2.5 LP/mm. This model also offers Morita’s completely exclusive 3D Reuleaux Full Arch FOV. For more information, call 877-JMORITA (566-7482), or visit www.morita.com/usa.

Volume 9 Number 5

TIME FOR CHANGE Explore NEW Symetri Clear, made of polycrystalline-alumina and featuring the proprietary laser-etched bonding base that provides consistent, easy, one-piece removal.

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Š 2018 Ormco Corporation

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