SAO News - April 2021

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SAO LEADERSHIP President Dr Sims Tompkins Columbia, SC


President-Elect Dr Mark W. Dusek Savannah, GA Secretary-Treasurer Dr Preston Miller Jackson, TN

President’s Corner – Sims Tompkins ............ Page 2 SAO Trustee Update – Richard Williams ............ Page 3

First Senior Director Dr Debbie Sema Birmingham, AL

Meet Dr Preston Miller ............ Page 4

Second Senior Director Dr Beth Faber Tappahannock, VA

Let’s All Take a Shot or Two... – Jeri Stull ............ Page 4

Third Senior Director Dr Eric Nease Spartanburg, SC

The American Board of Orthodontics 2020 Interim Constituency Report – December 2020 (2.9.21) ............ Page 5-6

Immediate Past President Dr Jeri Stull Fort Thomas, KY

Joy in the Time of COVID ............ Page 6-7

AAO Trustee Dr Richard Williams Southaven, MS AAO Trustee at Large Dr Alexandra Thomas Spartanburg, SC Speaker, AAO House of Delegates Dr Jeff Rickabaugh Winston-Salem, NC Director, The American Board of Orthodontics Dr Tim Trulove Montgomery, AL

You Are the Bright Light of DOS! – Chelsey Banaskavich, Program Coordinator, Donated Orthodontic Services ............ Page 7-8 Research Project: Perceived Efficacy of Extrusion with Invisalign of Maxillary Lateral Incisors – Mason Bates, Second-year Resident, Virginia Commonwealth University ........... Page 8-9 Developing and evaluating 3D Printed Resorbable PLLA Scaffold for Bone Regeneration – Divakar Karanth, David Puleo, Dolph Dawson, Lina Sharab ........... Page 9-10 Counter Clockwise Rotation of the Maxilla: An effective treatment option for Sleep Apnea with preservation of facial characteristics. ........... Page 10-14

SAO CONTACT INFORMATION 32 Lenox Pointe Atlanta, GA 30324 Phone: (404) 261-5528 Fax: (844) 214-1224 1

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President’s Corner Sims Tompkins

First, I would like thank you for allowing me to serve as President of the SAO. It is truly an honor and privilege to represent this great group of orthodontists and I appreciate your support. I am a second-generation orthodontist and have been practicing in Columbia, South Carolina for more than thirty years. I am proud to say that I am a Diplomate of both the American Board of Orthodontics and the American Board of Dental Sleep Medicine, and have served in leadership at the local and state levels during the decades.

I am a graduate of Clemson University and am a huge Tiger fan. I have a wonderful wife (Libby) of thirty-six years and three grown boys (Sims, Jr.; Rush; and Griff). I also have a wonderful daughter-in-law (Pamela) and a grandson (Cannon). Of course Cannon is the “only kid in the world” and he has brought great joy and perspective to this old guy. Our profession of orthodontics has evolved and changed since the SAO was founded 100 years ago and we need to stay ahead of the change and be at the forefront. Winston Churchill once said, “We make a living by what we get. We make a life by what we give.” So I encourage everyone to be involved at the local and state level – especially with the issues such as DIY orthodontics or the changes to the Teledentistry laws in your state. I would also encourage you to participate in the SAO’s Leadership Program in 2022, which is a great way to learn more about the SAO and interact with those involved with its leadership.


Lastly, I want to invite everyone to SAO’s Annual Meeting in Charlotte, North Carolina from October 7th – 9th, 2021.

It is the SAO’s 100th Anniversary and we are looking forward to seeing one another in person. The host hotels are Le Meridian and Sheraton hotels in Uptown Charlotte. We will offer ample CE opportunities. Our Southern Celebration will be held on Friday night at the NASCAR Hall of Fame. I hope to see you there and thank you again for the opportunity to serve the SAO as president.

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SAO Trustee Update

Richard Williams

Greetings from the AAO! Just as we in our practices and in our everyday lives have experienced change in our routines and the need for an accelerated pace of adaptation has been greatly magnified, it is no different for the AAO. Lynne and the wonderful staff in St. Louis have been remarkable in “virtually” moving AAO to hear and act upon members’ needs and concerns. Technology and remote contact have unfortunately become standard operating procedure in the COVID world and we have seen it play out at all levels in how we function. Meetings have lost some of the personal interaction that we all crave as we are anxious to physically be in the presence of our colleagues and friends. The virtual world removes a portion of the conversation and limits us to the cold and sterile environment of the internet. We have all been forced to be better at technology than we ever dreamed we would need to be. The Board of Trustees last functioned as a face-to-face Board (albeit not everyone could attend) last August. Our meeting in December was a virtual meeting with a lot of business to address. The decision to

April 2021 move Winter Conference to an all-virtual event was one of the items. That decision was a wise choice. Some of you likely participated in the conference. There were over 900+ doctors registered from all over the world, the largest number of orthodontists who ever attended a Winter Conference. The positive that we have found from our new normal is that there is an audience that we can reach in the virtual format that might not normally be a part of these events due to travel, time away from the office, or family commitments. AAO 2021 in Boston, originally scheduled for late April, has become another casualty of the current climate. The opportunity was presented to move the dates to June 25-27 and change the format to a three-day (Friday, Saturday, and Sunday) event. With the sense that there is a great appetite for an in person meeting and with the likelihood that the vaccine will be more widely administered, the BOT took advantage of the opportunity and for the first time ever, maybe we will have two annual meetings in one fiscal year. The challenge of the business of the Association and the need to set budget and dues, created urgency for separation of the House of Delegates from the annual session. For those who can remember, it hasn’t been that long ago that the discussion of “killing the virtual House” was a very real conversation. Thank goodness we have had the mechanism in place and some of the challenges worked out prior to our need. We can be very proud of our own Jeff Rickabaugh as he has demonstrated great wisdom in perfecting the operation of a virtual House. We will hold the virtual HOD April 23-25 with a more robust battery of resolutions. The business of the Association must go on! I have had the pleasure of enjoying the opportunity to work with Alex Thomas (Spartanburg, SC), one of the two new At-Large Trustees (ALTs), on a couple of assignments. I can testify that the addition of a New and Younger voice on the BOT has added immense value. Her engagement on the two assignments has been as if she was a seasoned member. Her insights added GREAT value to the issues studied. Dale Ann Featheringham, the other ALT, has stepped in with another perspective that I believe is strengthening our Board. We will add a third ALT at some future date, just not this year. It was determined that with the need to clarify roles and assignments in


order to best use ALT talents, and with the uncertainty COVID has created, a one year delay would be appropriate. A pair of normal events for the FebruaryMarch timeline has also converted to a virtual format. The Leadership Development Conference is typically held immediately prior to the Winter Conference. It became a multi-night event that began with keynote addresses from Vernice “Flygirl” Armour and Chris Bentsen. There were break out events on February 25 and March 25 that engaged and delighted our future leaders. The annual Advocacy day, February 23, in Washington DC was also virtual with presentations and speakers on the evening of the 22nd and “virtual Hill visits” on Tuesday, February 23 between the hours of 11:00am and 2:00pm. Even with a condensed schedule and no travel, we had effective engagement with Congressmen and Senators. I am sure we have all gained a heightened awareness of the need to “get along” with our fellow man in light of recent events. The AAO is no exception. In order to take a deeper dive into barriers and obstacles that hinder our members, a new Task Force on Inclusion and Engagement has been created. Chris Roberts just recently announced the membership of the Task Force and Southern has two individuals, Christian Johnson and Nick Kim as participants. I look forward to their engagement in this important task. Membership numbers have recovered to levels slightly ahead of where we were at a similar time point in 2020. This is a testament to the perceived value the Association has and will continue to strive to provide for our members. I am currently reading materials for our next BOT meeting, one item of which is a futurist study similar to the one SAO commissioned around 2006. The discussion to move this study forward included a review of the history of how SAO conducted its study. SAO’s efforts greatly influenced the decision. We can be proud to be a part of a culture that is trying to carry all of us ahead. As has been said, “a rising tide lifts all boats!” As always, thank you for allowing me the privilege to represent you on the national stage! It is truly a humbling honor.

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Meet Dr Preston Miller Dr Preston Miller is a native of Memphis. He has been practicing with FMY Orthodontics in Jackson, TN since 2003. He attended Washington and Lee University where he played on the baseball team and was President of the Senior Class. He received both his dental and orthodontic training at the University of Tennessee and continues to be involved with the University of Tennessee Department of Orthodontics as a parttime Assistant Professor.

Board of Trustees and Executive Committee of the University School of Jackson where he also chairs the Athletics Committee. He has also served as Chairman of both the Church Council as well as the Finance Committee at his church. Dr Miller’s wife Allison, an Optometrist, grew up in Monroe, LA. They have three children Madeline (16), Preston IV (15), and William (10). Madeline plays on the high school soccer and tennis teams, Preston IV plays on the high school golf, basketball, and tennis teams, while William plays baseball, basketball, and golf.

Dr Miller is a third generation dentist and believes in organized dentistry. He has served in several leadership positions. These include: Chairman of the AAO Council on New and Younger Members, President of the Tennessee Association of Orthodontists, President of the University of Tennessee Orthodontic Alumni Association, AAO Delegate, and now Secretary-Treasurer of the SAO. Locally, he serves on the Board of Directors of the Jackson Soccer Club as well as the

Let’s All Take a Shot or Two... Jeri Stull

I am writing this article a few hours after my second shot of the Moderna Vaccine. No symptoms yet, just a sore arm.

When not busy coaching or watching his kids’ activities, Dr Miller enjoys playing golf, playing the piano, and reading. He and Allison love to travel when they can find the time.

I feel excited and blessed to have received this vaccination. It is a personal choice that we all have to make, but personally, I was running to the Church / Vaccination site to receive this “get out of jail card.” The SAO 2020 Virtual Meeting was a huge success thanks to our Volunteer Leadership, SAO Team, Polaris by OrthoScience, Vendors, and Platinum Sponsors – Sesame and Smile Doctors! We had 24 hours of Continuing Education from the comfort of our homes – no travel, no wardrobe selections, no TSA, and no baggage. We also had the opportunity to have live question and answer sessions with the speakers. I personally enjoyed hosting Luis Carrière from my home in Kentucky as he sat in his home in Barcelona Spain! We received so many positive responses that we are planning to add a virtual component to the 2021 meeting. We believe that members want choices for their future CE opportunities. During the four month planning for the virtual meeting, my greatest fear was that the SAO would lose hundreds of thousands of dollars during “my” meeting year due to hotel and event contracts. A global pandemic was not an excuse that I wanted to use… but I would have! I am elated to report that the meeting made a small profit for the SAO. This was due to the hard


work of our Leadership, our Professional Partnerships and our Executive Director, Heather Hunt. We had 1,050 registrations for the SAO Virtual Meeting. All of the registrants interacted with the content. The Sponsors / Exhibitors / Speakers experienced the SAO attendee members’ unique logins over 15,000 times. SAO meeting spaces, including the virtual booths, had over 50,000 total views. Users have engaged with the content in these spaces 25,000 times. There were over 2,000 private messages sent between attendees at the event; these include the exhibitor interaction. A final, heartfelt thank you for allowing me to serve as your 2019-2020 SAO President. It was an honor that I will always cherish. I have made friendships that will last a lifetime. Being involved during this time gave me the opportunity to be involved with meetings with our component leadership. It was amazing to see the resourcefulness of our orthodontic community. We supported each other and we figured out how to reopen safely and efficiently for our patients, our teams and our sanity. I am very excited for our live 100th Anniversary of the SAO in Charlotte, North Carolina this fall. I hope that we can all get together and raise a shot or two… for the amazing future of orthodontics!

The American Board of Orthodontics 2020 Interim Constituency Report December 2020 (2.9.21) The mission of The American Board of Orthodontics is to elevate the quality of orthodontic care for the public by promoting excellence through certification, education and professional collaboration. ABO Vision: The American Board of Orthodontics is the global leader in orthodontic board certification and sets the standards of care for excellence in orthodontics and dentofacial orthopedics. ABO Yearly Update: • Clinical Exam Update: The ABO conducted Clinical Examinations in February and November 2020. A total of 706 examinees were certified or re-certified between January 1, 2020 and February 1, 2021. A complete listing of names by constituency is located on the ABO website. The ABO currently represents 49 percent of AAO membership. The February 2020 Clinical Examination was held in St. Louis in the Scenariobased Oral Clinical Examination format. However, in response to safety requirements recommended by the CDC due to COVID-19, an alternative testing option for the Clinical Examination was identified and announced in July 2020. The July 2020 Clinical Examination was canceled, with examinees having the opportunity to reschedule to a future examination. Beginning with the November 2020 Clinical Examination and for 2021 Clinical Exams scheduled in February, July and November, the examinations will take place at Scantron testing centers worldwide. Travel to St. Louis will not be required. The examination will continue to be administered in a scenario-based format with the same exam components and testing criteria. The validity of the exam will be maintained with changes only made to accommodate how answers are submitted. Exams will continue to be scored by multiple ABO examiners to ensure accuracy and consistency for each exam section. To-date, all future examinations are full with wait-lists, with the exception of the November 2021 date which is currently open. Complete details regarding the

Clinical Examination, study materials and how to prepare can be found on the ABO website. • Certification Renewal: Certification renewal is an important component of the board certification process. It requires ongoing proficiency in orthodontics and a commitment to life-long learning. In order to maintain an active board certification status, certification renewal is required every 10 years. Individuals may register for this exam up to two years prior to their expiration date. Please view a Motion Graphic Video created to outline the certification renewal process. Additional details and requirements for completing this examination are located on the ABO website. • Written Examination Update: Examination eligibility requirements and exam resources can be found on the ABO website. The ABO Written Examination was administered to 409 examines throughout the United States and Canada on June 5 and 6, 2020. The reliability of the exam was 87% with a 99% pass rate. Due to COVID-19 restrictions, the original April 7, 2020 testing date was rescheduled and the exam format conducted through a live onlineproctored test administered through Scantron/Examity. This change allowed examinees to complete the exam from their personal computer with strict security measures in place. Registration for the April 2021 Written Examination closed on January 22, 2021. The exam is scheduled for April 6, 2021 at Scantron Testing Centers throughout the United States and Canada. An important reminder that once the Written Examination is successfully completed, it never expires and does not need to be retaken. • The College: Due to COVID-19, the College canceled in-person prep courses for the ABO Scenario-based


Clinical Exams. Virtual presentations are being considered with the next in-person prep course being offered during the 2021 AAO Annual Session in Boston, MA, pending COVID-19 restrictions. The ABO and College continue to collaborate to ensure all CODA accredited orthodontic programs in the United States and Canada have at least one assigned volunteer advocate to promote board certification. • GORP: GORP 2020 was canceled due to COVID-19. Plans are underway for ABO’s participation during the 2021 event. • WFO: ABO directors were invited to be present at the 2020 9th International Orthodontic Congress scheduled in Yokohama, Japan. However, the physical meeting was canceled and held virtually. In response, the ABO directors participated in the virtual meeting and presented information on board certification. Additionally, the ABO directors submitted an article for inclusion in the Journal of the WFO entitled “Introduction to the American Board of Orthodontics Scenario-based Clinical Examination”. Educational Update: The ABO continues to develop study materials that assist the candidate to prepare for the Scenario-based Clinical Examination. These materials include a study guide, sample cases, and videos. Additionally, the ABO is working closely with examiners and orthodontic program educators by requesting feedback and assistance with the new exam format and item writing process. ABO advocates continue to be appointed for each orthodontic program as a resource to residents interested in additional information on board certification. To add value to board certified orthodontists, the ABO is proud to introduce an orthodontic specialty video on the importance of using a specialist. This professionally created video was developed specifically for board certified orthodontists to use in lobby or patient waiting areas, on websites and social channels and during patient consultations. The ABO continues to offer online educational materials to allow board certified orthodontists to speak in a unified voice. These materials include an Educational Toolkit, Brand Standards Guide, sample website wording, press release, pathway graphic, window clings, and consumer brochure. Board certified orthodontists also have access to a personal online dashboard where enhanced software includes an Continued on next page...

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orthodontist locator with the ability to list multiple offices and user-specific dashboard notifications. The ABO’s April 2020 Educators Symposium, “The Change is Here – Are You on Board?”, honoring Dr Katherine Vig, was canceled due to COVID-19. In lieu of the physical meeting in St. Louis, a PowerPoint presentation with important examination information and updates was distributed to Department Chairs and Program Directors of CODA accredited orthodontic programs in the United States and Canada. The ABO will announce plans to reschedule the symposium in the fall of 2021. Complimentary ABO measuring gauges were distributed to first year residents from requesting CODA accredited orthodontic programs. In preparation for the AAO’s 2021 Annual Session, the ABO plans to again host an Educator/Advocate Workshop and an ABO Open House/Info Session to share updates, answer questions and provide educational information on the Written and Clinical Examinations. In addition, the ABO will have an informational booth located in the

Dr Randy Rigsby

Joy in the Time of COVID We all know 2020 was a challenging year for us. As we plan for better things in 2021, we thought it would be a good time to touch base with our recent SAO Past Presidents for some insight!

Convention Center to provide information on the board certification process. ABO Award Recognition: Due to the cancellation of the 2020 AAO Annual Session meeting, the award ceremonies honoring the 2020 recipients could not take place. Therefore, these individuals will be recognized during the 2021 Annual Session in Boston, MA during a newly established ABO Awards Night. No additional award recipients will be identified for 2021. The following 2020 ABO award recipients who will be recognized in 2021 include: • Albert H. Ketcham Memorial Award: Dr Rolf G. Behrents • Dale B. Wade Award of Excellence in Orthodontics: Dr Carla Evans • Earl E. and Wilma S. Shepard Distinguished Service Award: Dr Perry Opin

The ABO Directors for 2020-21 are: Dr Valmy Kulbersh, President, Great Lakes Association of Orthodontists Dr David Sabott, President-Elect, Rocky Mountain Society of Orthodontists Dr Patrick Foley, Secretary/Treasurer, Midwestern Society of Orthodontists Dr Timothy Trulove, Director, Southern Association of Orthodontists Dr Jae H. Park, Director, Pacific Coast Society of Orthodontists Dr Roberto Hernandez-Orsini, Director, Middle Atlantic Society of Orthodontists Dr Stephen McCullough, Director, Southwestern Society of Orthodontists Dr Nicholas Barone, Immediate Past President, Northeastern Society of Orthodontists

• O.B. Vaughan Special Recognition Award: Dr John Kanyusik

The AAO House of Delegates confirmed Dr Emile Rossouw as the new ABO Director. He will represent the Northeastern Society of Orthodontists.

Please visit the ABO website for information on all award honorees.

Congratulations to Dr Valmy Kulbersh who serves as the first female ABO President.

Dr Anthony Savage

Dr Jeri Stull

What was your biggest source of stress when COVID-19 Started?

Dr Greg Inman

Rigsby: I stayed connected to colleagues and realized that we are all in it together. I think COVID made all of us realize how Dr Randy Rigsby (2017-2018): For me, it important organized orthodontics is to was how to maintain staff with no production. our practices and the value of friendships Also, trying to sift through a copious amount during difficult times. of information for nuggets that could help us survive as well as make sure our patients Who were you with during quarantine? were not neglected. Dr Greg Inman (2016-2017): Our section Dr Anthony Savage (2018-2019): I had too of the Inman family suddenly didn’t go in all many webinars to attend. I waited until they different directions. Our children studied were recorded and watched them at 1.75 from home. Probably 50 soccer games speed in a quiet room. were canceled. Amy’s (wife) job became ultra-essential when our City Hall changed How did you survive in 2020? to a small skeleton crew who ran the daily operations of our city. Dr Jeri Stull (2019-2020): I networked with other orthodontists who Stull: I spent time with my two children, helped me to develop strategies and find my office manager Sherree, my best friend, resources for ordering supplies. The AAO a general dentist (and my neighbor), her and ADA also provided greatly needed family, and my dogs. information and guidance.


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What did you take for granted that are now priorities?

followed by online mandolin lessons.

Inman: High quality WiFi service is a priority. Savage: I learned to prioritize spending time with family and good friends. I also miss hanging out with the SAO Executive Committee.

Inman: I am staying in the routine of working Monday through Thursday and enjoying family time Friday, Saturday, and Sunday. I am concentrating on worrying only about the things that I can affect.

I took online ukulele lessons,

As a pilot, I took simulator courses

for citation Jet and also for Twin. We

enjoyed lots of hot tub time as well as time on boats spent safely distancing

with family. Lastly, time spent with our grandchild, shooting at the gun range,

and most important - Bourbon.

– Dr Anthony Savage

Do you have any funny COVID stories to share?

What do you miss the most from the pre-COVID world?

Stull: During shutdown, prior to laying off my team, the only thing that made me happy was clearing the woods around my house. Using my chainsaw (only bushes, vines, and small trees were at risk) and burning the results. I had some massive fires and became the talk of my neighborhood. I don’t think it takes a therapist to interpret how I feel about loss of control. Rigsby: Gloria (wife) became my backporch barber. She kept telling me to trust her. When I was able to see my bona fide barber, he related that Gloria is good at many things, but cutting hair is not one of them. How are you coping since the outbreak? Stull: The chainsaw is in retirement and I am coping well with my new normal. However, I hope we can get back to the pre-COVID normal one day!

Savage: I miss flying off on 4-day weekends with family and friends as well as Flying Dentists flights 4-5 times per year when COVID numbers did not have to be checked. I really miss traveling. Rigsby: I miss being able to visit with colleagues in person, especially our SAO friends.

Did COVID-19 change how you foresee your career? Inman: COVID revitalized my love for treating patients and for running a successful, growing practice. Stull: COVID made me realize that I was tired of being a single doctor practice. So, I decided to affiliate with Smile Doctors! It has been a very positive change due to the HR support, systems support, and patient care. What good life lessons did COVID teach you? Savage: Don’t let others around you define the situation for you. Develop your own view. Never ever give up, always captain the ship, fly the plane into the weeds if you have to, but land softly to be able to go on for another day and another and another... Rigsby: I think above all, the COVID shutdown taught us all to be patient. No matter what happens, it is good to stop and count our blessings and be thankful for our profession.

What is the most important advice you can give to orthodontists struggling with the pandemic?

I miss live concerts, parties,

Stull: Get online and do continuing education! Learn about new technologies like Dental Monitoring. This has been a great tool to offer patients that do not want to come into the office as often. Inman: Reach out to your friends and colleagues if only to commiserate. We are all in this together.

face-to-face meetings, hugs, and handshakes. Most of all I miss

‘normal’ for our children! I ache for their loss of a normal school


– Dr Jeri Stull

You Are the Bright Light of DOS! Chelsey Banaskavich

Program Coordinator, Donated Orthodontic Services

Good news spreads like a morning light across a landscape. When one family finds something good, word spreads far and wide. And when the good news is the life-changing

Our American Association of Orthodontists (AAO) members across the country that are volunteering with DOS are currently changing the lives of 225 children who are receiving Orthodontic treatment. We celebrate all the work being done nationwide, with a special spotlight on one of our most prolific regions. Of our country’s eight regions, members of the Southern Association of Orthodontists (SAO) are providing care for 49 of the country’s children in active treatment (22 percent).

work of our specialist volunteers through Donated Orthodontic Services (DOS), the light is especially bright!


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April 2021 In related good news - the American Association of Orthodontists Foundation (AAOF) is happy to announce that it has welcomed DOS under its philanthropic umbrella and guidance in January 2021.

These cases are in 9 of SAO’s 11 states. Word of our volunteers is spreading; waitlists are growing across the SAO, and 27 percent of all applicants nationwide are from SAO states. As much as our spotlight on SAO shines brightly on the work of these southern volunteers, it also illuminates what is possible in all of our regions. When you volunteer with DOS, you change the life of children who might otherwise have had to go without care. To that end, we invite you to join us in meeting an admittedly ambitious goal. In 2021, we want to light up each state with active DOS cases. Will you help us do that? Signing on to provide care will strengthen our volunteer network and spread big, bright smiles from coast to coast!

We are now offering more ways to serve AAO members, by assisting in charitable giving through direct service volunteerism. Not able to host a DOS patient in your office? Support our shared mission through a donation to the AAOF. American Association of Orthodontists Foundation The mission of the AAO Foundation is to advance the orthodontic specialty by supporting quality education and research that leads to excellence in patient care, and by promoting orthodontic charitable giving.

Accomplishing this big goal starts with one small step - contact the DOS office to sign up. We will explore your interest in and capacity to volunteer your services to children who need your help. We might even have a child on the waitlist in your community who is ready and waiting for the gift you can give. Give us a call today 800.424.2841 x582 or send a message to

To learn more, please visit:

My name is Mason Bates. The title of my research project is

I am a second-year resident at Virginia Commonwealth University. Thank you so much to Drs. Stull, Sarver, Sema, and everyone else at the SAO who judged my research presentation worthy of an award. It was an honor to be able to contribute.

Perceived Efficacy of Extrusion with Invisalign of Maxillary Lateral Incisors

Even in my limited experience of using Invisalign to treat patients, I have on numerous occasions experienced tracking issues with maxillary lateral incisors (of normal size/shape) that I am attempting to extrude. This problem has been great for my learning, as I’ve been able to set up cases with different mechanics and/or attachments in an attempt to prevent tracking issues. I have also learned different ways to intervene when necessary. After a literature review, it became apparent to me that no real consensus existed as to when to consider a maxillary lateral not to be tracking, how to intervene, or how to best set up a case to avoid tracking issues. Though the answers to some of these questions may be somewhat case-dependent, I felt it worthwhile to survey the perceptions and experiences of other clinicians.

The purpose of my study was to assess the perceived efficacy of Invisalign to perform extrusive movements for maxillary lateral incisors and to determine a general threshold of when a maxillary lateral incisor is not extruding as predicted. If intervention is required, the frequency and methods of mid-course intervention to achieve the predicted extrusion needed to be evaluated. Additionally, a goal was to evaluate any differences between orthodontists and general dentists as well as between clinicians who have treated differing numbers of Invisalign patients during the past 12 months. An original 18-question survey was sent by mail to a randomized and geographically proportionate selection of orthodontic specialists (N = 400) and general dentists (N = 400) who are listed as Invisalign providers on the Invisalign website.


• 126 providers responded to the survey (a 15.8% response rate) • 36 general dentists (28.6%) and 90 orthodontists (71.4%) responded • The average perceived efficacy of extrusion of maxillary lateral incisors with Invisalign was 4.71 out of 10 • Perceived efficacy was significantly associated with number of Invisalign patients treated in the past 12 months (p-value=0.0195) and the percentage of orthodontic patients treated with Invisalign (p-value=0.0380), but not with provider type or number of years in practice. 54% of respondents reported 0.5mm as the threshold for considering a maxillary lateral incisor to not be extruding as predicted and requiring intervention. Continued on next page...

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• This selection was significantly associated with provider type, with orthodontists using 0.5mm as their threshold at a higher rate than general dentists (67% vs 39%, p-value=0.0305), as well as with the number of Invisalign patients treated in the past 12 months (p-value=0.0316). • Those who reported having treated greater than 100 patients considered 0.5 mm as their threshold more often than those who had treated 100 or fewer patients.

attachment (p-value=0.0001), whereas orthodontists were significantly more likely to select a gingivally beveled horizontal rectangular attachment (p-value<0.0001). There was no clear agreement between clinicians on the percentage of patients for whom they experienced tracking issues when extruding maxillary lateral incisors. • 63% of respondents indicated intervention by taking a refinement scan • 19% indicated intervention via the bootstrap technique.

• When planning for this movement, general dentists were significantly more likely to select an optimized

When asked about the timing of taking a refinement scan, orthodontists were more likely to indicate waiting until the end of the series while general dentists tended towards immediate refinement. Thank you, SAO for honoring my work. It is truly a blessing to be able to join this amazing specialty, and I am excited to work alongside you as we strive to love, serve, empower, mentor, and impact our patients, colleagues, and others in our communities. Mason

Developing and evaluating 3D Printed Resorbable PLLA Scaffold for Bone Regeneration. Divakar Karanth1

Dolph Dawson3

David Puleo2

Lina Sharab4

1, 4 Department of Oral Health Science, University of Kentucky, Division of Orthodontics, Lexington, United States 2 Department of Biomedical Engineering, University of Mississippi, Oxford, United States 3 Department of Oral Health Practice, University of Kentucky, Division of Periodontics, Lexington,

The primary objectives of this research was to develop a 3D-printed scaffold for bone regeneration with poly (L-lactic acid) (PLLA), a biodegradable polymer that has piezoelectric properties and to evaluate critical characteristics essential for biologic use, such as the architecture of the 3D-printed scaffolds and their effects on cellular infiltration, attachment, and proliferation. The research was funded by an NIH pilot study grant. PLLA scaffolds can be 3D printed using fused deposition modeling technology with an interconnected, porous microstructure. The surface morphology and microarchitecture were analyzed with scanning electron microscopy (SEM) and microCT, respectively. Crystallographic characterization was done by X-ray diffraction. Compressive modulus was determined with an electromechanical testing system. The piezoelectric potential generated upon mechanical distortion was characterized with the use of an oscilloscope. Hydrolytic degradation was measured as weight loss at 4, 8, and 12 weeks. MG63 osteoblastic cell proliferation

on the scaffold was quantified with Cell Counting Kit-8 assay (CCK8) at 3, 7, 10, and 14 days. The cell coverage on the scaffolds was qualitatively evaluated with SEM and multiphoton microscopy (MPM). The morphology of the MG63 cells and their cytoskeletal architecture was assessed from the images obtained from the MPM. The porosity of the scaffolds was 73%, with an average pore size of 450 µm and an average scaffold fiber thickness of 130 µm. The average compressive modulus was 244 MPa. The scaffolds generated an electric potential of 25 mV upon cyclic/repeated loading. X-ray diffraction revealed that during the 3D printing process the crystallinity of the as-supplied PLLA fiber was reduced from 27.5% to 13.9% by melting and extrusion. The PLLA scaffolds showed minimal hydrolytic degradation during the 3-month study period. The CCK8 assay revealed that the number of MG63 cells proliferating on the scaffolds increased rapidly until day 10. SEM and MPM images showed cell attachment and proliferation on and in the scaffolds with complete coverage by day 14.


The PLLA scaffolds were successfully designed and printed. These successes validate the feasibility of using PLLA as a scaffold material and 3D printing as a method of fabricating scaffolds. The mechanical and piezoelectric properties of these PLLA scaffolds were satisfactory. The elastic modulus was comparable to that of trabecular bone, and the piezoelectric properties of the PLLA were retained after 3D printing. These scaffolds showed a very slow rate of degradation. The scaffolds were cyto-compatible; the osteoblastic cells adhered to the scaffolds and proliferated to form multiple layers. 3D-printed PLLA scaffolds showed promising properties akin to natural bone. The technique is worth investigating further for bone regeneration capabilities. Additional experiments are necessary in order to answer all questions thoroughly, such as in vivo animal experiments to study the host response to PLLA scaffold, the scaffold’s ability to regenerate bone, and biodegradability. See photos on following page...

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Developing and evaluating 3D Printed Resorbable PLLA Scaffold for Bone Regeneration. Continued from previous page.

3D printed PLAA scaffolds

SEM images showing osteoblast attachments to scaffold fibers

Counter Clockwise Rotation of the Maxilla: An effective treatment option for Sleep Apnea with preservation of facial characteristics. Modern day ailments have seen an increase in Obstructive Sleep Apnea (OSA) which is defined as a pause in breathing during sleep, with subsequent arousal or oxygen desaturation. The incidence of OSA is 2-4 % in men, 2 % in women and 5-10 % in adults(1). Good sleep has been shown to play a huge role in recovery from everyday stresses and is therefore fundamental for the health of an individual. The common and gold standard for treatment of OSA is continuous positive airway pressure with a medical device pump assembly (CPAP) (2). Patients often require lifelong treatment (3) but 25-50% of patients have difficulty accepting this treatment due to a variety of reasons(4). The most important deterrent is the cumbersome equipment that is involved and the inconvenience that comes with it. It has been reported that

OSA may be improved by surgical forward movement of the maxilla and mandible, with subsequent improvement of airway volumes, thereby eliminating the need for CPAP(5). However, this may compromise the facial esthetics of patients who receive no benefit from a more protrusive profile. OSA may be treated with counter clockwise rotation of the mandible (CCW) (6) ,combined with maxillo-mandibular advancement or by conventional advancement of the jaws as a first choice(7). In the grand scheme of things this may be an excellent option for patients who want to stop the CPAP and find a permanent solution that does not involve wearing a mask tightly fitted to the face while sleeping, an activity that is so essential to human body survival.

Everyday we come across patients who have been diagnosed with OSA and who have been given the options of treatment, some of which are not applicable to every facial type. More and more research is now being directed towards finding the most non invasive option. Although CPAP is the gold standard, mandibular advancement devices and even myofunctional therapy(8) have been shown to be effective. If a patient has already tried the gold standard and is intolerant of it, what are some of the parameters that can be used to access the option of maxillofacial surgery? Will the patient’s profile allow the drastic change needed for surgical correction? Please observe the records of the following patient. Continued on next page...


Quarter 1 The 57 year old female patient was referred to an oral surgeon by her sleep physician for an evaluation. Her main concern was the ‘Inability to tolerate the CPAP’ prescribed for sleep apnea. She was in search of an alternative because she felt claustrophobic with the mask of the CPAP and would often wake up feeling like she was ‘drowning’. The patient denied difficulty staying awake driving or watching movies but was unable to stay awake when reading. She reported fatigue and daytime sleepiness, trouble falling asleep with the mask on and waking up tired most mornings. The patient had a history of adenoidectomy, uvulopalatopharyngoplasty as well as a sleep endoscopy which demonstrated anterior posterior collapse at the level of the palate and circumferential collapse at the level of the base of the tongue. She also had undergone a turbinoplasty procedure and currently had a Mallampatti score of III(9). An initial sleep test confirmed the sleep quality relationship to her AHI, but no other clinical questionnaires or tests were performed at her sleep physician’s office. Clinical examination revealed a convex facial profile, partially retrognathic and normo- divergent mandible and a retrusive chin on a skeletal class II base. Orthodontically, she had a stable class 1 molar and canine bilaterally with an over-jet of 3mm, an over-bite of 4 mm and mild crowding in both arches. The maxillary midline was co-incident with the facial midline and mandibular midline was shifted 3 mm to the right. Records consisted of photographs, panoramic and cephalogram radiographs as well as a CBCT scan. Lateral cephalometric analysis confirmed the occlusal class II deformity with an SNB of 74.6 degrees. The CBCT showed no abnormalities other than those described above. Surgical management options included a combined orthodontic and orthognathic approach to help with resolution of the sleep apnea symptoms. Goals included improving AHI, while maintaining an esthetically acceptable profile and attaining a stable functional occlusion. Time management was an important factor because the patient was intolerant of the CPAP and the quality of her sleep was being adversely affected. She was too tired to carry out day to day function. Surgery with minimum pre surgical orthodontics was therefore planned.

April 2021 Orthodontically, the dental, skeletal and soft tissue objectives for this patient were to assist the OMFS surgeon in preparing the patient for surgery in an expedited treatment time. This treatment included; 1. Placement of self ligation brackets (American Orthodontics Empower Clear) in the maxillary dentition only 2. A short 2 visit orthodontic treatment that included creation of space distal to the maxillary laterals to create an over-jet 3. Placement of mandibular brackets the day before surgery 4. Post-surgery overbite correction and elimination of crowding 5. Inter-arch mechanics after Bilateral Sagittal Split Osteotomy (BSSO) and counter clockwise rotation of the maxilla 6. Maintenance of the anterior-posterior (A-P) relationship with the use of inter arch mechanics after surgery 7. Detailing and finishing orthodontics 8. Retention The final treatment plan consisted of non-extraction in the maxillary and mandibular arches and fixed appliances. There would be a short interval of presurgical fixed orthodontic appliances, followed by Lefort 1 down fracture of the maxilla, counter clockwise (CCW) rotation of the maxilla, BSSO with septoplasty and post-surgical orthodontic treatment to correct minor discrepancies. The surgical goals included increase in the airway parameter due to CCW of the maxilla and as well as mandibular advancement. These procedures would result in advancement of the soft palate and projection of the chin anteriorly(10). Careful assessment of the pre-operative airway volume was done using the DICOM file and a thorough cephalometric analysis was completed. Airway assessment was recorded at the narrowest cross-sectional point (in the sagittal plane) at two levels. The retropalatal level (RP) was found to be 20.5 mm and the retro lingual level (RL) was found to be 5.3mm. These measurement areas were defined by Boyd(11). The total volume of the airway between (RL) and (RP) was measured to be 3746-millimetre square. Pre-operative virtual surgical planning (VSP) was performed and measurements of the end


results after surgery predetermined. The advent of virtual surgical planning (VSP) through computer-aided design (CAD) and computer-aided manufacturing (CAM) techniques has offered an alternative workflow(12) for more precise preoperative planning and a decreased likelihood for intraoperative trial and error. This was an important step for a number of reasons which included: 1. A clearly discussed plan to maximize the patient’s facial esthetics and goals for the OSA 2. A definitive occlusal plan since minimal orthodontics was carried out prior to surgery 3. A discussion of the smile esthetics after treatment As a result of the on-line VSP conference, a CCW rotation of the maxillary plane of 6 degrees was anticipated. The occlusal plane was treatment planned to be flattened and the AP position of the maxilla maintained with no change to the alar base, therefore no compromise to facial esthetics was anticipated. A Class I occlusion with normal overbite and over jet was achieved with coincident dental midlines to the mid-sagittal plane. A straight soft tissue profile with competent lips and an esthetically pleasing smile arc with an adequate gingival display was accomplished. The airway cross sectional area at the narrowest point in the sagittal plane at the level of retropalatal (RP) increased to 22 mm from 20.5 mm and retro lingual (RL) area increased to 11.3mm from 5.3 mm with a total increase in airway volume to 10667 millimeter cube from 3746 millimeter cube. VSP planned changes were confirmed in the frontal plane, the occlusal plane and in the orientation of proximal and distal segments(14). The counter clockwise rotation of the maxilla was achieved with differential anterior impaction of the maxilla, followed by maxillary advancement with rotation centers at the buttresses in order to maintain the profile. Mandibular advancement, which is the key to changes in airway, was therefore possible with minimum change to the profile. The patient reported improvement in sleep patterns and commented on how she was much more rested upon awakening. She also reported satisfaction with her facial esthetics and with the improvement of her profile. See photos on following page...

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