Clinical articles © management advice *® practice profiles ¢ technology reviews
Orthodontic PRACTICE*US
PROMOTING EXCELLENCE
Using lingual appliances for optimal esthetics and minimal compliance issues Drs John R “Bob” Smith and Mario Paz Corporate profile OrthoAccel® Reframing orthodontics: part 3 Dr Rohit C.L Sachdeva PAYING SUBSCRIBERS EARN 2 CONTINUING EDUCATION
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Trang 2INTRODUCTION
Considering a dual pediatric-
orthodontic practice?
Ai, dual-trained pediatric dentist and orthodontist, it was ays my goal to “quarterback” a team of pediatric dentists and orthodontists under one roof | now operate two such practices, which has become a distinct trend over the last several years For tenured orthodontists, it seems an effective means of practice growth; and for newly graduated orthodontists with appreciable debt, it is a way to jump-start their careers without more debt; and for the “retiring” orthodontist, it is a means to practice without an owner's responsibility
Now with an orthodontic partner and three associate pediatric
dentists practicing in two towns, my personal goals have been Mike Mayhew, DDS, MS achieved Coordinating our shared patients and responsibilities of
care, however, is an ongoing endeavor If you are an orthodontist considering the idea of a dual-specialty practice, | offer a few thoughts
First to consider is the difference in patient cultures Young patients are often apprehensive about going to the dentist and are intensely vocal about their fears They're also understand- ably more dependent on their parents, who also, understandably, are often anxious and inclined to attend to their fretful child chairside The open-bay concept in orthodontic offices may not lend itself to these circumstances To any practitioner considering a dual-specialty practice, | suggest physical separation of the two sides of the practice
Another big question is whether other GPs/pedodontists will refer to you lest they lose a patient to your pedodontist | have very carefully nurtured relationships with our referring
general dental and pedodontic practices to be certain they trust our commitment to them
We pledge always to send referred patients back to their general dentist/pedodontist for routine care We even include a reward for patients who have their teeth cleaned with them To ensure the dentist/pedodontist is aware of our efforts, we have the dentist return a signed card to us for verification
If you're considering forming a dual-specialty practice, there's no better way to explore issues you'll likely encounter than through connecting with fellow professionals at meetings — regional society meetings, study club groups, and seminars offered by companies such as Ormco | have enjoyed networking and sharing my knowledge with as well as learning from colleagues at these conferences, including The Ormco Forum The social and engaging atmosphere at these conferences makes them a perfect place to chat face-to-face with people who've already been down this road and can help guide your way
My own journey to a dual-specialty practice took a circuitous route As a new pediatric dentist having just graduated from UNC-Chapel Hill, | took over the practice of a pediatric dentist who was leaving for an orthodontic residency, planning later for us to work together under one roof That dream vanished when the new orthodontist decided not to return It took several years to finalize my decision, hire another pediatric dentist to maintain the practice, then pursue my own dual training and build that practice dream myself I'm now pleased to have combined the two specialties that share young dental patients in providing comprehensive care
ul
Dr Mike Mayhew
Mike Mayhew, DDS, MS, received his dental education at the University of North Carolina with specialty degrees in
pediatric dentistry and orthodontics He is board certified in both specialties and operates a dual-specialty practice in
Boone and North Wilkesboro, North Carolina Dr Mayhew has lectured nationally and internationally on the Damon™ System, CAD-CAM digital orthodontics, indirect bonding, and office utilization of CBCT He is on the Sports Medicine Team at Appalachian State University, is an adjunctive clinical professor at the UNC School of Dentistry, has held leadership positions in organized dentistry, and serves as the director of the North Carolina/South Carolina Damon Study Club He was inducted into the American College of Dentists in 2010 and the International College of Dentists in 2013 2 Orthodontic practice Orthodontic PRACTICE+US November/December 2016 - Volume 7 Number 6 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E Binder, DMD S Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P Brigham, DDS, MSD George J Cisneros, DMD, MMSc Jason B Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N Edgren, DDS, MS, FACD Eric R Gheewalla, DMD, BS 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 Robert L Vanarsdall, Jr, DDS 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-in- chief 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
expressed herein are those of the author(s) and not necessarty the opinion of
either Orthodontic Practice US or the publisher
Trang 3TABLE OF CONTENTS
Financial focus
Are high 401(k) fees putting
your retirement at risk? Tom Zgainer discusses how hidden fees can drain money from your
COE ân guiccnotoeceiiaoscbuaoiakcasvses 18
Case study
Maintaining clearly defined treatment objectives: part 2 Drs Domingo Martin and Jorge Ayala illustrate treatment using the FACE
concept of orthodontic treatment
h
Practice profile sas sia
Gcaper Calaway, BIS MS A Herbst® journey Orthodontic insights
Striving to be successful and significant Dr Bill Dischinger discusses how his personal Herbst experience led to
development of a comfortable and efficient appliance - 26 Orthodontic concepts Reframing orthodontics: Designing accelerated
orthodontics by managing error — the BioDigital way: part 3 Dr Rohit C.L Sachdeva discusses
the journey of error management in
Clinical praGlce sissies ee: 30
Corporate profile 14
OrthoAccel®
Innovating accelerated orthodontic treatment and practice integration
inset photo on cover courtesy of Drs Domingo Martin and Jorge Ayala Article begins on page 20
Trang 4
TABLE OF CONTENTS Continuing education Treating cleft palate with presurgical nasoalveolar molding (PNAM)
Dr Thomas Wilson discusses an effective technique that can minimize
the extent of surgery to repair cleft
palate in newborns 42
Laboratory link
3D printing in orthodontics
James Bonham and Arlen Hurt review innovations in 3D-printing technologies
Practice development
What you need to know about online reviews for your practice lan McNickle, MBA, discusses the importance of a strong online
Dresence .- S 49
6 Orthodontic practice
Continuing education
Using lingual appliances for optimal esthetics
and minimal compliance issues
Drs John R “Bob” Smith and Mario Paz discuss the development and use of a square-siot, passive self-ligating, straight-wire lingual appliance
Practice management
Designing a dynamic digital team: part 1
Dr William E Crutchfield discusses how to design a dynamic digital
orthodontic team that is primed IV SIMKGĐS9:4 210010 ElStgttoottza 50 Product profile Air-Free 90° by Medidenta Product profile Prophy Magic Book review
Global Diagnosis: A New
Vision of Dental Diagnosis
and Treatment Planning
J William Robbins, DDS, MA,
and Jeffrey S Rouse, DDS 4W MeciMark, lic PUBLISHER | Lisa Moler Email: imoler@medmarkaz.com GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com
Trang 5CASE STUDY
Maintaining clearly defined treatment objectives:
part 2
Drs Domingo Martin and Jorge Ayala illustrate treatment using the FACE concept of orthodontic treatment
l the September/October 2016 issue of Orthodontic Practice US, we intro- duced the FACE (Functional and Cosmetic Excellence) concept of orthodontic treat- ment and its importance in achieving func- tion and esthetics We also explained the treatment goals and the key factors that make up the goals
After the introduction to the FACE treat- ment philosophy, we explained that the FACE Evolution bracket* was developed by some of the key members of the FACE group This bracket was developed by clini- cians for clinicians In the article, we gave the many reasons for the development of a new bracket system In retrospect, the main reason was the need for a bracket system that took function into account, and this is the first of its kind
In the second part of the article, we will further explain the necessity for changing the original Roth prescription The rationale for the many changes in the prescription makes sense to experienced clinicians We also introduce the concept of “working tube,” something that many clinicians will like, and more importantly, the need for this type of bracket in our toolboxes We also announced the “working bracket” and its multiples uses, and why we need this in many instances to obtain our functional and esthetic occlusal goals
Prescription for work and pre- scription for finish
FACE Evolution incorporates a new concept into orthodontic biomechanics:
& Member
Figures 12A-12C: Three vertical guides enable the placement of the tube more mesially, more distally, and a central framework to achieve three different anchorages (14°, standard, and -6° of rotation) with the same tube
working prescription and finishing prescrip- tion The work prescription consists of using specific tubes and brackets for their tempo- rary use in certain situations with the purpose of attaining certain aims (Figure 11A)
The prescription for finish is obtained with the use of the standard FACE Evolu- tion prescription — a good finish in a high percentage of cases — without needing to bend the arches In some situations, because of minor anatomic variations, the necessary adjustments should be performed (Figure 11C)
Working tubes
By varying the mesiodistal position of the tubes, we can modify the rotation values and the anchorage values to tackle
Dr Domingo Martin has a BA from the University of Souther California and an MD and DDS from the University of the Basque Country in Spain He also earned a Master in Orthodontics from the University of Valencia in Spain He has a diploma in orthodontics by the FACE/Roth Williams Center for Functional Occlusion and has postgraduate work in Bioesthetic Dentistry from the OBI Foundation for Bioesthetic Dentistry Dr Martin gives courses and conferences all over the world, and he has a private practice limited to orthodontics in San Sebastian, Spain He is also a FACE
cases of minimum, medium, and maximum anchorage Therefore, the tube will have three vertical guides (Figure 12) that enable us to locate the tube more mesially for cases of maximum anchorage, or more distally, for cases of minimum anchorage, and a central framework for cases of medium anchorage and finishing stage These guidelines will coincide with the main vestibular sulcus as indicated Tubes with markings became available in 2016 (Figures 12A-12C)
With the same tube, we can therefore attain three different anchorages (standard, +4°, and —4°), simply and efficiently; the necessary inventory is also simplified, so this is like having three different prescriptions in the same tube
As its name indicates, the prescription for work is the one with which we can perform specific actions — for example, distalization or retrusion of the six anterosuperior teeth or mesialization of the posterior segments — by increasing or reducing the anchorage
Once the required aim is obtained, in this case closure of the spaces, we will switch to the prescription for finish by positioning the tubes in the usual way
Dr Jorge Ayala has a medical degree from the University of Chile with a specialty in Orthodontics and Maxillar Orthopedics from the University of Chile He is Director of the FACE/Roth Williams Center for Functional Occlusion from Latinoamĩrica and a professor of the FACE/Roth Williams Center for Functional Occlusion in California He runs a private practice limited to orthodontics in Santiago
de Chile He is the author of numerous articles and publications and speaker at national and international courses and conferences 3
Working brackets
For cuspids, the working bracket with 20° positive torque will enable us to place
Disclosure: Drs Martin and Ayala are consultants for Forestadent
Trang 6these teeth in the required position to be subsequently replaced with the standard torque bracket or bracket with the final prescription
For the mandible, the molar torque of -—30° operates efficiently in most cases, although at times not in the case of second molars Indeed, in a lower percentage of cases, the second lower molar “tips” toward the lingual region, especially in those cases with an accentuated curve of Spee
The explanation appears to reside in the fact that when attempting to access these molars and given that the apices are in rela- tion to the compact bone of the external oblique line, this undesired effect would occur, which is difficult to resolve Therefore, FACE Evolution proposes a working tube with O° of torque, which once the molar torque has been corrected, should be replaced with the prescription’s standard finishing tube
Active system and hybrid system
It is difficult to come to an agreement in regard to which self-ligating system has more advantages and less disadvantages UK cu Zaha Torque Angvlation In/Out Rotation 3 tcrmrn +20 8 0 7 2 Mot or o 0 %0 _ Slot.018 Slot 022”
Order No Order No Rechts Lieks Rechts Ueks
739-0323 738-0323 739-0321 738-0321 748-831! 748-821! 748-832! 748-872!
Table: Working brackets and working tubes for FACE Evolution system
Various papers conclude that sliding mechanics are favored for the use of
passive self-ligating brackets, but control of the root position could be comprised
They also confirm that the sliding resistance (SR) is necessary when we have to produce torque and correctly position the root for correct finishing
The wish to minimize resistance to fric- tion should be moderated because of the need to control movement of the teeth In the new FACE Evolution, we have opted to take the advantages of both parts by means of two versions: the active system and the hybrid system
The active system gives us more control: During subsequent treatment stages, sliding resistance (SR) increases along with the size of the arch This provides better three- dimensional control and fills the sulcus to
produce a torque force that correctly posi- tions the root and the crown
The hybrid system provides the clinician with the best combination of low friction and control, especially in cases with extractions A recent study performed by Dr Douglas Knight on 400 finished patients concluded that the duration of treatment and number of appointments of 200 patients treated with the hybrid system reduced by 15% Clinical cases
A 13-year-old female presented with severe space deficiency, and with her skeletal anatomy, we decided to extract four bicus- pids and close spaces, maintaining her upper teeth forward, not retruding the upper lips, and obtaining a good functional occlusion
Figures 13A-13B: 13A Before and 138 after correction with
working bracket; the apex is seen inside the bone Volume 7 Number 6
Trang 7CASE STUDY y > =
Figures 17A-17C: We start the aligning and leveling phase in the upper arch with a 020" Figures 18A-18C:
x 020" BioTorque® archwire with a 019" x 025" BioTorque® in the upper and lower arch.We are closing spaces in the upper
and lower arch preparing for the working phase We place a transpalatal bar for vertical control
The rationale for the
many changes in
=—
Figures 19A-19B: We are now in the working phase in the upper and lower arch with a 019" x 025" TMA T-LOOP Double
keyhole loop archwire that gives us torque control, creates a moment for incisor control, helps us loose anchorage, controls
m akes S Đ nse to the canine in the three dimensions, and will correct the curve of Spee — all with one archwire
the prescription experienced clinicians
» — —-_ 5 “ `_ LỆ _ on
Figures 20A-20C: We are now in the finishing stage with the curve of Spee aligned, spaces almost completely closed, torque of the upper anteriors achieved, and good arch form in the lower and upper arch We can resort to Class Il elastics in this phase if necessary
Figures 22A-22F: Posttreatment intraoral pictures
Trang 10A Herbst® journey
Dr Bill Dischinger discusses how his personal Herbst experience led to development of a comfortable and efficient appliance
had a Herbst® as a teenager How are my
memories of that time in my life? Well not exactly great Although as an adult, | look at the results it gave me compared to the upper bi extraction cases that were the norm back then, and | know it was worth it But
The second Dischinger to have a Herbst was none other than Terry Dischinger himself We treated him when he was in his late 50s He had always been a Class II open bite that would have required surgery Eventu- ally, he developed a modified Herbst appli- ance that intruded the maxillary molars while the Herbst was correcting the Class Il The results are similar to what we see in today’s technology using TADs to intrude the maxil- lary molars and autorotate the mandible He claims his experience was an easy process, but my dad is kind of that way It sure beat surgery though, but in watching from the other side, it didn’t look all that comfortable Shortly after finishing his treatment, we decided to see if we could make a smaller Herbst appliance Our purpose in attempting this design change was to improve the comfort of orthopedic Class II treatment for our patients | was two boys into my now current four-boy family, and it was obvious they were following the Dischinger growth pattern and would require Class II correction Selfishly speaking, | wanted my kids’ experi- ence to be better than mine, my dad’s, and all my previous and current patients So we set off on a journey, and let me tell you, it was
ORTHODONTIC INSIGHTS
a journey much harder and more frustrating than we had dreamed When | was in my residency, | had a classmate that sat down at the bar with me one night, grabbed a napkin and pen, and said, “Let’s invent an appli- ance.” Well, it isn't quite that easy We had the design idea, but making that work from an engineering perspective is a little harder than most people would think Thanks to the hard work of some amazing engineers at Ormco, we slowly started putting out some prototypes We worked with these proto- types for a few years until we felt we had a design that worked consistently with great results
AdvanSync™ was launched shortly thereafter Early on, it was widely adopted by many based on the features that other doctors also recognized were beneficial to their practices and patients Like many initial concepts, once the product was
Bill Dischinger, DMD, of Lake Oswego, Oregon, received his dental degree from Oregon Health and Science University School of Dentistry in 1997 and his certificate in orthodontics at Tufts University in Boston in 1999 His B.S degree is from Oregon State University In private practice with his father, Dr Terry Dischinger, Dr Bill Dischinger has taught at their in-office comprehensive courses and used the Damon® System for over 15 years He is an Adjunct Professor in the Orthodontics Department at the University of the Pacific in San Francisco and one of 12 certified Damon instructors who has taught and lectured extensively on passive self-ligation with the Damon System He has also lectured nationally and internationally on a variety of subjects, including functional jaw orthopedics, indirect
mass-produced, we began to see several flaws surface We then went to work on the second generation with manufacturing and design changes that would resolve the issues Thus came AdvanSync 2 with modi- fied enhancements, and this is the product we are still using today and have been for nearly 5 years
As stated, our goal was to improve the comfort of orthopedic Class II treatment for our patients AdvanSync™ 2 is almost half the size of the miniscope appliance that we had been using and half of the size of the flip-lock design we used prior to that It is well over half the size of what | had as a kid, which | can assure you Because of the smaller size, it fits more in the posterior of the mouth Most of the sores we saw patients experiencing were in the lower premolar area from the screw housings This has been minimized with the enhancements of AdvanSync 2 The appliance also does not show in the mouth like previous Herbst designs, so patients are more accepting to wear it
A bonus that came out of the smaller design was the ability to bracket every tooth forward of the appliance In the past, we were unable to bracket the lower premolars, and at times, we would not bond the maxil-
bonding, and practice management from a team approach
Dr Dischinger has written articles published in Orthodontic Products, Orthotown, and Ormco’s Clinical Impressions and is actively involved in national study clubs that address the latest treatment techniques He is also a member of the American Association of Orthodontists, Pacific Coast Society of Orthodontists, the American Dental Association, and orthodontic professional associations that enable him to actively participate in continual education and remain current on advances in orthodontic treatment Dr Dischinger has been married to his wife, Kari Lynn, for over 20 years, and together they have four sons
lary premolars either With this new design,
we bond all the teeth, and sometimes the
mandibular second molars as well When we are finished with the Class II correction and the appliance is removed, most of the Class | orthodontics has been accomplished
Trang 11
ORTHODONTIC INSIGHTS
as well, which allows us to quickly move to the end of treatment making our orthopedic Class Il cases much more efficient Since moving to the AdvanSync 2 appliance, we have dropped our average treatment time by over 6 months
Over the years of using the AdvanSync, | have modified my treatment protocols on most of my patients | used to place the crowns, place the braces, and hook up the AdvanSync arms on every new patient the = first day of his/her treatment Today, with ie most of our current patients, | am waiting
C- 4 - 4 | , > = 2 to 4 months before hooking up the arms
For younger patients, this helps them ease ae into treatment with less to adjust to For
ss = x some patients, | like to get the lower arch
Taylor Dischinger initial phase 1 leveled, particularly in Class Il, division 2 patients Although this postpones the Class ll correction by 2 to 4 months, the end result is that less orthodontics needs to be done after removal of the appliance Because of this, the Class II correction occurs smoothly without vertical issues, and thus, the overall treatment time is lessened
Since starting my Herbst journey over 35 years ago, | have seen a great progression in the comfort and efficiency of treating skeletal Class || patients It has been rewarding to see my patients, especially my own children, go
through a better experience than | did [13
«2 +
Taylor Dischinger initial phase 1 occlusal upper Taylor Dischinger final occlusal upper
Herbst® is a registered trademark of Dentaurum, Inc., and AdvanSync™ is a trademark of Ormco Corporation
wu ai
Taylor Dischinger final
Trang 12ORTHODONTIC CONCEPTS
Reframing orthodontics:
Designing accelerated orthodontics by
managing error — the BioDigital way: part 3 Dr Rohit C.L Sachdeva discusses the journey of error management in clinical practice
The road to wisdom?
Well, It's plain and simple to express: “Err Err And err again but less and less and less” — Piet Hein from Grooks “The Road to Wisdom” Introduction
The key dimensions of quality care that drive the philosophy and practice of Bio- Digital Orthodontics are patient centered- ness, patient safety, and clinical effective- ness.'* Errors committed during the delivery of care have the highest potential of negatively
impacting these quality measures and, as a result, treatment time Strategic approaches
to error management in clinical practice have been substantially neglected by the orth-
odontic professionals in their pursuit of the
holy grail of accelerated orthodontic care A culture of patient safety cannot be practiced without confronting the causes
of orthodontic errors and their appropriate
management
This journey of error management in clin- ical practice can only begin by recognizing
Rohit C.L Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva
Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use He also works
with the dental industry in product design and
development He is the co-founder of the Institute of Orthodontic Care Improvement Dr Sachdeva is the co-founder and former Chief Clinical Officer at OraMetrix, Inc He received
his dental degree from the University of Nairobi, Kenya, in 1978
He earned his Certificate in Orthodontics and Masters in Dental
Science at the University of Connecticut in 1983 Dr Sachdeva
is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics In the past, he has held faculty positions at the University of
Connecticut, Manitoba, and the Baylor College of Dentistry, Texas
A&M Dr Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit Visit Dr Sachdeva's blog
on http://drsachdeva-conference.blogspot.com Please contact
improveortho@gmail.com to access information
30 Orthodontic practice
the various types and sources of errors and then finding ways to prevent them or, at a
minimum, to develop appropriate barriers
to arrest their propagation | have found that errors in clinical practice commonly manifest
around what | term the 7 M's: 1 Miscommunication Misdiagnosis Misplanning Misprescription Mismanagement Misadministration Misaction
The root cause of these is grounded in
deficits of knowledge, inadequate skills, and
the violation of rules
The objective of this paper is to famil- iarize the reader with the principles, the tools,
and the clinical practices that | use and have
NOAP
WN
developed in the service of error-proofing the
care of my patients with a focus on managing the 7 M's These practices have resulted in
shorter treatment times and, more impor-
tantly, enhanced patient safety
Principles and practice of error
proofing
“We can’t solve problems by using the
same kind of thinking we used when we created them.” — Albert Einstein
The strategic and tactical practices to
error-proofing patient care against the 7
M's that | present are based on a bedrock of sound biomechanical principles and,
when appropriate, are enabled with the
use of 3D-imaging technologies such as CBCT, OraScan (Figure 1), and CAD/CAM technologies offered by the suresmile® total
Figure 1: Various types of images used for care design and planning Note the CBCT provides information regarding bone, crown, and roots The OraScan is limited to the crowns and gingival tissue suresmile® offers the service of merging the CBCT image with the OraScan and 2D extraoral frontal images
Trang 13patient care management platform® (Figure 2) These approaches are discussed below
A) Error-proofing against Misdiagnosis
A major thrust of orthodontic diagnosis involves the understanding and delineation of the complex spatial interrelationships
between the various anatomical components
of the craniofacial complex Misdiagnosis in
orthodontics commonly occurs as a result
of perceptual, measurement, and judgment errors By using 3D images and 3D virtual
models of a patient for simulations, such
errors may be minimized Clinical examples of the use of these tools follow
High-fidelity 3D diagnostic imaging
2D images of patients, such as photo- graphs or the panorex, are commonly used as aids in diagnosis Unfortunately, such
images lack depth and are also prone to
projection errors.’ This limits the doctor’s ability to perform a thorough diagnosis for his/ her patient Misdiagnosis leads to incorrect treatment decisions and, as a result, treat- ment time is negatively impacted 3D imaging
helps overcome these issues Examples of
both the clinical “misses” resulting from 2D images and the benefit of using 3D images
in these situations are shown in (Figure 3) Autoanalytics
Many of our diagnostic decisions rely
upon accurate and precise measurements of the dentition We are often hampered
both by the limitations of the tools we use and our perceptual biases This is primarily
due to a lack of operational definitions for
the region of interest and having no common plane of reference to measure against This
leads to inaccurate, unreliable (inter- and intra-operator) measures that result in
the incorrect diagnostic assessment of a patient Autoanalytic tools overcome such limitations and allow for more reliable diag- nosis.° (Figure 4)
Interactive diagnosis with simdiagnostics
Currently, we measure the degree of severity of a malocclusion by measuring against a normative age/sex/ethnic-based
sample However, it is equally important to
measure the degree of severity of a mal-
occlusion based upon the amount and
nature of tooth displacement required to achieve the treatment objective (Figure 5) Assessing this measure with conventional tools is difficult For instance, the assessment of the severity of crowding is affected by a Volume 7 Number 6 Robotics Printing "` Ũ Ss aes a s4 |
Figure 2: suresmile cloud-based total patient management system Note: suresmile provides 3D printing services Also STL files of models are available for remote printing at the practice or a laboratory
Figures 3A-3C: 3A Note the CBCT image detects the bone fenestrations around the canines but not the gingival recession that can be seen on both the intraoral or OraScan image 3B 3D images can be navigated to allow the viewer to see multiple perspectives of the image and gauge depth As a result, the “hidden” can be seen Note that the second bicuspid is extruded This is not seen on the intraoral visible in the intraoral images or from the occlusal perspective of the 3D OraScan It is clearly
visible from the lingual perspective of the OraScan 3C The panorex image does not show the dilaceration at the apex of the
lower left central incisor This is seen with the CBCT image S|=ỏăồ ở o/>=00 oO 0 © © ae SA %xexếc 2 ota »
Trang 14ORTHODONTIC
multiplicity of boundary conditions such as
arch form, nature of tooth movement, midline,
and anatomical constraints Accounting for all these variables is beyond the capacity of the clinician The ability to run multiple simulations on a patient’s virtual models and impose upon these models varying boundary conditions provides an elegant solution to this problem (Figure 6) | term this practice simdiagnostics It is performed
quickly and, most importantly, does not put
the patient at risk as all the simulations are done virtually An accurate assessment of the
nature and type of planned orthodontic tooth
movement allows the operator to design the appropriate appliance system that delivers
Figure 5: Simdiagnosis This patient demonstrates a significant shift (asymmetry) of the mandible to the left The severity of
CONCEPTS
the appropriate force system to move the teeth This minimizes “round tripping,” which
invariably adds to treatment time
-proofing against Mis- -
85 ) m Erre
lannin
Misplanning is commonly a result of misdiagnosis and a misguided under- standing of the impact of a doctor's treat- ment measures on the course and outcome of care | use two approaches to overcome these limitations
)
Oo ©
ĩ
Prior to beginning active treatment on a patient, | run simulations that model different
the dentoalveolar compensation in the lower left buccal segment is difficult to assess with conventional intraoral images The
nature of compensation can be the CBCT when compared to the right side Quantifying its extent and the nature of the tooth movement to correct it require the ability to both simulate and measure the movement of the tooth to the desired state In
this situation, the lower right first molar was controlled tipped 15° with a center of rotation at the left of the crown tip This is a difficult movement to accomplish and will take time to correct and require the creative design of a force-driven appliance
Recognition of this patient need can only be done with the aid of simdiagnosis ERRATA RIZAL RIZE ELELE IJXY111
Figure 6: Simdiagnostics Simulations allow a quick way to understand the impact of various boundary conditions on the resolution of crowding In this situation, the impact of choosing the natural arch form (Figure 6A) versus the Damon arch form (Figure 6B) is being considered Note the amount of intersections, a measure of crowding when using both arch forms,
is similar However, more tooth movement will be required to achieve the desired Damon arch form especially in the molar
areas The use of the Damon versus a natural arch form may well be driven by the esthetic needs of the patient but not by efficiency or stability of treatment
32 Orthodontic practice
treatment scenarios to critically evaluate and validate the best “care flight plan” for the
patient This avoids wayfaring or midcourse
retractions during the patient's care journey, allowing for the promotion of patient safety and less wasteful practices As a result, treat-
ment time is compressed (Figure 7)
Avery important aspect of care planning resides in a doctor's ability to determine the
prognosis of treatment This requires that the
Clinician be skilled in forecasting the poten-
tial “fault lines” or risks associated with the
treatment measures and the likelihood of a successful treatment outcome Simulations provide a very useful method to assess
Figures 7A-7E: Simplanning 7A.This patient would have benefited from simplanning prior to the start of treatment 7B
Note the simulation depicting the non-extraction approach to
care clearly demonstrates that such a treatment would result in an bimaxillary protrusion with an anterior open bite This treatment strategy would not be in the best interest of the patient 7C Note the similarity between the non-extraction simulation and the clinical result 7D.An extraction approach
to treatment would have been a better approach to treatment
7E Mid-treatment the four first bicuspids were extracted
Although the bimaxillary protrusion is resolved, itis apparent that space closure has not been well controlled, resulting in
forward tipping of the buccal segments and, especially, the lower right buccal segment Practicing orthodontic care by a
“fly of the wheel” approach is not right patient care and adds
to treatment time as well
Trang 15_ " hod 11/11 ee
not the case
the prognosis of treatment (Figures 8-10) Accurate prognostics again saves treatment time since it allows the doctor to proactively recognize the impact of his/her treatment
regiments and design appropriate solutions
to better manage patient care and therefore shorten the care cycle
C) Error-proofing against Mis- communication
It is not uncommon to observe a dis- connect between the voice of the patient and that of the doctor in terms of treat- ment needs Furthermore, this disconnect commonly extends into the larger concentric circle of the care team and interprofessional care collaborators This leads to conflicting treatment goals and measures, placing the
patient at risk, compromising the patient's
care experience, delaying treatment, and potentially hindering the quality of treatment outcomes One common source of this angst lies in the high signal-to-noise of information shared orally or in the form of abbreviated text in the patient’s notes Visual communi- cation with simulations, complemented with both the oral and textual mediums, provides a realistic solution to overcome miscommu-
nication.® A brief description of the approach
| use to better communicate among all the stakeholders is provided below
To break the walls of miscommunication
between the patient and the care team, a
shared “blue space” for all the stakeholders is created Real-time simulations are used to both design and explain treatment to the patient This draws the patient into a “show and share” versus “show and tell” mode of
34 Orthodontic practice
© ef Ẹ ` €
CT
Figure 8: High-fidelity diagnosis 2D OraScan and the panorex images are inadequate in demonstrating the exact position of the roots Note the upper right mesiolingual resides between the distobuccal and lingual root of the upper first molar root On the panorex, the lower first bicuspid appears to show a root
proximity problem with respect to the lower second bicuspid However, when
seen from multiple perspectives of the CBCT image, it is apparent that this is
eo @&
safe patient care
Figure 9: Simplanning and simprognostics Correction of the rotation of upper second right molar at the crown level appears to be innocuous However at the root level, one can clearly see that root collision will be a consequence of the derotation of the molar and put the patient at risk Patient A.Z clearly demonstrates that correct diagnosis, planning, and prognostics needed to be integrated in a sequential manner to serve
Figure 10: Simprognostics Alignment of the lower incisors leading to the appearance of black triangles was forecast prior
to the start of treatment and discussed with the patient She declined any more interproximal reduction than that which was required to correct the crowding between the incisors and accepted the black triangles However, she was very satisfied with the results as she was made aware of this occurrence using simulations at the beginning of treatment and made a personal
choice to accept the black triangles
Figure 11: Simcomm Creating a shared interactive environment around the “blue space” gives the doctor the ability to actively input the patient’s preferences in the design of his/her occlusion Additional tools for planning the surgical and restorative
needs of a patient are used This facilitates interprofessional communication | often perform these consult sessions with
webinars over the Internet
communication with the doctor(s) Thinking out loud encourages both the patient's “buy- in” in terms of his/her care needs and adher- ence to future requests made by the doctor, such as the wearing of elastics (real time)
The virtual visual treatment plan established for the patient is accessible to all members of the care team, bringing concurrence in under- standing the goals of care to all stakeholders involved in the care process (Figure 11)
Trang 16Orthodontic literacy with patient decision aids
Communication with patients is further facilitated by ensuring they have access to current disease-specific literature that is context-sensitive and caters to cultural diversity
D) Error-proofing against Mis-
management and Misaction
Continuous active participatory care man-
agement with checklists, clinical pathway guidelines and patient care navigation maps with simtracking
A common challenge in managing patient care through the care cycle is that the care team loses sight of treatment goals, leading to clinical inertia or thematic vagabonding’ (Figure 12) This is commonly seen in practices that are busy, where work stress and intensity are high, and where the environment encourages safety violations® (Table 1) As a result, treatment is delayed, and greater opportunities for failure emerge Such unwanted practices are contained with the use of checklists and clinical pathway guidelines (Figure 13) Checklists are also
Table 1: Practice violations
High levels of diagnostic uncertainty High decision density High cognitive load Narrow time windows Multiple transitions of care Multiple interruptions/distractions Low signal-to-noise ratio Surge phenomena Circadian dysynchronicity Fatigue Novel
Table1: Some factors that can enhance safety violations in an orthodontic practice (Adapted from Croskerry and Wears, 2002) Croskerry P, Wears RL Safety errors in emergency
medicine In: Markovchick VJ and Pons PT (eds.) Emergency
Medicine Secrets, 3rd Edn ; Hanley and Belfus: Philadelphia, PA, 2002:29-37 Safety violations in practice
Volume 7 Number 6
Figure 12: Thematic vagabonding Patient has been in treatment for 16 months and shows little progress in treatment over
this period
These practices have resulted in shorter treatment times and, more importantly, enhanced patient safety
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Class I non-Extraction “Fast-Track”© Protocol A CPG, 6 Months Treatment (Sachdeva) APPT 1 * nd consultation (Week 0) *+ Take supplementary impressions for auxiliary appliances such as quad helix if needed * Bond teeth * Place posterior molar turbos check for height and balance * Perform IPR prn
* Insert Initial archwire
crowding or torque control and deep bite correction
* Diagnopeutic scan (OraScan /or CBCT scan taken post bonding)
~ 016" preformed SE NiTi A, 35°C or 017" x 025" SE NiTi A, 35°C if minimal
needed
~ Place auxiliary appliances e.g Tipback springs, ART springs ete
* Perform IPR prn
APPT 2 * Place auxiliary devices such as quad-helix if needed
(Week 4) posterior molar turbo height, as needed
SureSmile * SureSmile Precision Archwire (SSPA) (full expression or partial expression) Therapeutic Note: For 018"/.022" bracket either 016" x 022” or 017" x 025”
Phase SE NiTi A, 35°C are crossection of choice
APPT 3 * Review progress against the Virtual Therapeutic Simulation (VTS)
(Week 12) + Review expression of SSPA against bracket archwire image * Perform selective IPR prn
* Check turbo for height/balance
Replace current archwire with:
~ 100 % staged SureSmile precision archwire
- For 018" bracket step up to pre-ordered SureSmile 017" x 025" if needed
~ For 022” bracket a up to pre-ordered SureSmile 019” x 025" arch
Wea + onum On Gebonding l sa schedule allows
Trang 17used to minimize errors of omission and
commission? (Figure 14)
Another solution to care inertia involves the creation of patient care navigation maps
(PCNMs) These visual simulations show a temporal sequence of the milestone-driven goals of the patient's care journey The care team and patient can use PCNMs to track treatment progress (Figure 15) | term this approach to care management simtrack | also use simtracking to manage patient visits Patients are provided their PCNMs and asked to self-monitor and assess their care prog- ress against the map Patients then schedule their care visits based upon the attainment of the planned milestones, allowing for just-in- time care scheduling Simtracking results in fewer unnecessary patient visits, opening the doctor's schedule up, decreasing the “busy- ness” in the clinic, and, in turn, minimizing the risk of operator-induced errors due to a decline in workload intensity
Patients are also encouraged to use PCNMs to detect any untoward or spurious tooth movement and may schedule
an appointment immediately to
rectify the presenting problem Such care management prac-
tices help contain errors and,
most importantly, encourage the patient’s enthusiastic and WEEKO-1 WEEK 3-4 WEEKS-7 WEEK8-10 WEEK 11-1: ORTHODONTIC CONCEPTS
active participation in his/her own care
Indeed, patient cooperation is vital to achieve a successful outcome
Conclusions
Orthodontic Misdiagnosis, Misplanning, Miscommunication, and Misaction impact the care cycle and, more importantly, put the patient at risk Unfortunately, as a profes- sion we have neglected to understand the influence of these care processes on the duration of orthodontic care and develop approaches to mitigate these “misses”
consistently Instead, the current orthodontic
marketplace has addressed the problem of reducing the care cycle by inundating the
profession with promises of transforma-
tional technologies that claim to accelerate orthodontic tooth movement Many of these technologies are sold on the basis of having a “biological” foundation to explain
Sunday, March 7, 2010
Patient JL Activity Log (10-27-09 to 2-16-10)Finish! About me
their superior performance Furthermore, in my opinion, these claims are accentuated by marketing tactics that create an echo chamber populated by “the believers” whose ammunition consists of a few isolated clinical patient histories with insufficient documenta- tion Added justification comes from quoting research whose strength is justified by the fact that it was published by “independent” researchers from an academic center rather than on what really matters — the design of the study and cross validation of the results from multiple centers
On the other hand, the “nonbelievers” also need to be held to the same standards as the “believers” and subject to the rigors of scientific scrutiny It is not enough for the nonbelievers just to dismiss the other side without holding themselves accountable It is my hope that the profession of orthodontics imposes upon itself the habit of self-reflection and recognizes that
Figure 14: Forgetting to engage an archwire is an error of omission Not engaging an archwire properly is an error of commission Checklists are used to engage such errors
| would consider myself to be most comfortable in the outdoors as | love to hunt, fish and camp | also enjoy sports | will be running my 3rd marathon this December | am blessed with a wonderful wife and three beautiful children ages 5, 3 and 1
My educational background is in engineering and | also have an MBA degree | am currently employed with OraMetrix since Aug 2006
Week 9 (12/29/09 ~ 1/6/10)
A noticeable difference can be seen after 2 months of treatment in the straight wire to both the lower and upper arches The leveling of my teeth on the upper arch is very apparent while the crowding in the lower arch is substantially less due to IPR and realignment
Figure 15: Simtracking A patient-care navigational map is shown Patients are encouraged to self-monitor their treatment progress by taking images of their own teeth during the course of treatment and matching it against the map Care team members also have access to these maps to monitor treatment progress Such practices create a flat-bed structure, allow for open
communication between all stakeholders, and minimize errors
Trang 18its sustainability will be driven by focusing on finding the problem first and then the solution rather than trying to fit a solution to a problem This will also require that the opposing camps refrain from debating each other with the sole
purpose of proving the other faction wrong
and engage in meaningful conversation that seeks the truth supported by the bedrock of scientific evidence Only then will we able to
practice what | call authentic orthodontics
where the interests of the patient supersede personal opinion
In my next article, | will discuss how | manage errors related to orthodontic
therapeutics (J
REFERENCES
1 Sachdeva R Novus ordo seclorum: a manifesto for prac-
ticing quality care - part 1 EJCO 2014;2(3):71-76
2 Sachdeva R Novus ordo seclorum: a manifesto for prac-
ticing quality care - part 2 EJCO 2015;3(1):2-14
3 Sachdeva R Integrating digital and robotic technologies:
diagnosis, treatment planning, and therapeutics, In: Graber ML, Vanarsdall RL, Vig KWL, eds Orthodontics: Current Principles and Techniques 5th ed Philadelphia, PA:Elsevier/ Mosby; 2012
4 Bouwens DG, Cevidanes L, Ludiow JB, Phillips C
Comparison of mesiodistal root angulation with posttreat- ment panoramic radiographs and cone-beam computed tomography Am J Orthod and Dentofacial Orthop 201 1;139(1):126=132
5 Grũnheid T, Patel N, De Felippe NL, Wey A, Gaillard PR,
Larson BE Accuracy, reproducibility, and time efficiency of dental measurements using different technologies Am J Orthod and Dentofacial Orthop 2014;145{2):157=164
6 Almog D, Sanchez Marin C, Proskin HM, Cohen MJ,
Kyrkanides S, Malmstrom H The effect of esthetic consulta- tion methods on acceptance of diastema-closure treatment plan: a pilot study J Am Dent Assoc 2004;135(7):875-881
7 Aujoula |, Jacquemin P, RietzscheE, et al Factors associated
with clinical inertia: an integrative review Adv Med Educ Pract 2014;5:141-147
8 Croskerry P, Cosby K, Schenkel SM, Wears R, eds Patient
Safety in Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2008
9 Gawande A The Checklist Manifesto: How to Get Things
Right.London: Profile Books; 2010
10 Cash AC, Good SA, Curtis RV, McDonald F An evaluation of slot size in orthodontic brackets — are standards as expected? Angle Orthod 2004; 74(4):450-453 11 Balut N, Klapper L, Sandrik J, Bowman D Variations in
bracket placement in the preadjusted orthodontic appliance Am J Orthod Dentofacial Orthop 1992:102(1):62-67 12 Eerkens JW Practice makes within 5% of perfect: visual
perception, motor skilis, and memory in artifact variation Current Anthropology 2000;4 1(4):663-668
13 Sachdeva R, Bantleon H Cantilever based orthodontic— biomechanical and clinical considerations In: Sachdeva RCL, ed Orthodontics for the Next Millennium Glendora, CA: Ormco Publishing; 1997
14 Fontenelle A Challenging the boundaries of orthodontic tooth movement In: Sachdeva RCL, ed 14 Root Cause Analysis Patient Safety World Health Organization doc:1.10.A http://www.who.int/patientsafety/educatior/ curriculum/course5a_handout_paf
15 Vaughan D The Challenger Launch Decision: Risky Tech-
nology, Culture, and Deviance at NASA London: The Univer-
sity of Chicago Press; 1996 Volume 7 Number 6 1) «RSE DS) NO RC) ARN OLE(@) SAR: Quality
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Trang 19CONTINUING EDUCATION
Using lingual appliances for optimal esthetics and
minimal compliance issues
Drs John R “Bob” Smith and Mario Paz discuss the development and use of a square-slot, passive self- ligating, straight-wire lingual appliance
onsidering the evolution of lingual orthodontics, it is worth noting that the lingual technique gained limited popularity in the United States and Canada during the early 1980s In the intervening years — partly due to the clinical difficulties associated with it during its early development and the success of esthetic alternatives — lingual therapy has languished in North America Educated later with improved techniques, Clinicians in Europe and Asia had greater success with lingual therapy where its use has become much more common
An October 2013 AAO survey, entitled “The Economics of Orthodontics,” found that the number of orthodontic starts in the U.S and Canada increased 20% between 2010 and 2012 with a 14% increase in the number of adult patients over the age of 18 during that same period.' Certainly, the tremen- dous growth of Invisalign® is testament to the demand for esthetic appliances and is what adults and even teens come into offices asking for While aligners enable us to perform suitable corrections for many patients, there are times when fixed appliances are a better choice And the conversation moves consid- erably in favor of fixed appliance treatment when we introduce lingual therapy
Lingual offers a high level of care with optimal esthetics and minimal compliance issues It can serve as an important strategy for sustained practice growth since it’s a
Educational aims and objectives
This article aims to discuss the use of the Alias™ lingual appliance passive self-ligating, square-slot linqgual bracket system
Expected outcomes
Orthodontic Practice US subscribers can answer the CE questions on page 45 to øarn 2 hours of CE from reading this article Correctly answering the questions will demonstrate the reader can
Identify instances for which fixed appliance treatment would be a more appropriate choice than removable appliances
Identify instances where lingual systems would be more appropriate than labial systems Identify some characteristics of the Alias™ lingual appliance
Recognize some benefits of using this system for certain patients
Figures 1D-1F: The patient switched to lingual appliances with the final result achieved in approximately 2 years
specialist's treatment modality, not some-
John R “Bob” Smith, DDS, MSD, received his dental degree from Emory University He earned a MSD in Dental Science at the University of Washington, winning the coveted Milo Hellman International Research Award for research which established that implants could be used for stable anchorage Such research was the precursor for the development of TADs, so important to today's orthodontic treatment modalities
Dr Mario Paz, DDS, MS, completed his General Dental Residency at Eastman Dental Center, Rochester, New York, eaming an MS in Dental Science from the University of Rochester and a certificate of proficiency in orthodontics with special training in lingual treatment
Both Drs Smith and Paz have published on the lingual technique and have trained orthodontists on the methodology throughout the world for many years Over the past 9 years, Dr Smith has been involved in the development of Insignia™ Advanced Smile Design™, part of the Ormco™ Custom digital suite of products Since 1990, Dr Paz has focused on lingual therapy, having established one of the largest lingual orthodontic practices in the U.S He is known internationally for his expertise and is the Past President of the American Lingual Association of Orthodontists (ALOA)
Disclosure: Drs Smith and Paz served on the international evaluation team that participated in the development of the Alias™ appliance system Both Drs Paz and Smith have treated patients with the Alias bracket
38 Orthodontic practice
thing a GP would likely adopt Moreover, the adult segment of the market offers tremen- dous growth opportunity since the penetra- tion of it currently stands at a mere 5%
While Invisalign has driven a demand for esthetic orthodontic treatment in the adult and teen population, in some circumstances, a removable appliance is not able to achieve the level of care as reliably as a fixed treat- ment alternative (Figures 1A-1C) In such cases, if metal or clear labial braces will not satisfy the patient esthetically, lingual treat- ment is a powerful tool to have at the clini- cian's disposal (Figures 1D-1F)
Trang 20Additionally, patients who originally come in seeking clear removable therapy, when apprised of its compliance aspect, will often opt for lingual treatment instead If a fixed appliance is more appropriate for their partic- ular case, their decision for lingual is rein- forced Friends, co-workers, and spouses of our lingual patients who had clear removable treatment and struggled with compliance or learned later that fixed appliance treatment would likely have given them a superior result admit that they wish they had been given the option of lingual treatment Being able to propose lingual treatment — the ultimate esthetic option — gives clinicians a needed and now efficient tool to fulfill these patients’ expectations cosmetically without compro- mising the finish
The new Alias™ lingual appliance (Ormco) is the profession’s first passive self- ligating, square-slot lingual bracket system Specifically, if we were to take a look at the patented 018 x 018 square slot of the Alias PSL lingual appliance, there are a number of benefits for doctors With passive labial self- ligation, the standard 022 x 028 rectangular slot does not facilitate rotational control until placing 014 x 025 Cu Ni-Ti wires Given the greater inter-bracket width and the 018
x 018 square slot — exclusive to the Alias
PSL lingual appliance — clinicians can realize the benefits of early rotational and torque control with smaller diameter, more flexible arch wires Because of the tight wire-bracket interface tolerances, there is less wire spin and play The 016 x 016 Cu Ni-Ti wire is an excellent wire to gain both rotational and the first stage of torque control
The slot provides improved torque control when reaching full-sized wires It's always been difficult to insert a 018 x 025 stainless steel wire in a standard lingual slot without the risk of debonding the bracket — even when the case is fully aligned and ready for this size wire The full-size wire for the appliance is the much smaller 018 square wire, which makes insertion easier yet main- tains vertical root control during final torque refinements near the end of treatment
Moreover, the solid fourth wall of the bracket maintains torque control when retracting posterior teeth and closing spaces with a power chain The wire can’t pull out of the slot as it can with a conventionally ligated bracket In part, it is the way the wires insert in the posterior — going in vertically Plus the snug fit of the 018 square wire in the 018 slot (when the self-ligating door is closed) maintains axial inclination, fostering tooth translation rather than tipping Volume 7 Number 6 Spare et ON X0 OTT OI wee 01790x OTTS wee x 2o het 098" x O18" shot OV + 098* ?-#' gay >4' gay 1-2" play ` x
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(1 demande) 2 py bl ad Or my l j Rotation comtrot square shot supertor to ` a rectanguiar stot Table 1: Lingual straight-wire facilitates easier sliding 018 x 018 Archwire Slot for Enhanced Rotational and Torque Control? Figures 2A-2C: The small size and low profile of Alias lingual brackets means less interference with speech and greater comfort Figures 3A-3C: Notice the alleviation of crowding and increase in arch width in 1 and 4 months A Pretreatment B 1 month C 4 months
In terms of additional advantages, vertical wire insertion improves visualization of the wire-slot interface and simplifies wire place- ment The small bracket dimensions provide more comfort with less occlusal and speech interference compared with numerous options on the market Self-ligation appre- ciably reduces clinical chair time compared with steel ligation or double over-tie elasto- mers There are also the inherent advantages of “straight wire"— simplified protocols with no or fewer wire bends to disrupt sliding mechanics, and easier archwire coordina- tion and finishing
While in some cases the wire may not be a “perfectly straight wire in appearance,” it will not have sharp bends like the typical lingual mushroom archwire that greatly inhibits sliding mechanics The goal is to maintain the straight-wire shape Addition- ally, the square slot offers important advan- tages over the typical rectangular lingual slot — better tip control and appreciably better rotational control
Patients have reported the considerable comfort of Alias, which boasts rounded edges, a small shape and noticeably low profile (Figures 2A-2C) The passive aspect of
this self-ligating bracket also means clinicians will see many of the same benefits associated with passive self-ligating labial appliances — better sliding mechanics with less friction for faster arch unraveling and transverse width development (Figures 3A-3C) Effective tooth
translation with better mesial-distal root tip
control has also been reported
Trang 21to secure the wire properly This standardizes archwire progression, which they appreciate because it takes the guesswork out of it and keeps treatment on track
When patients are happy, staff is happy, and we have noticed fewer patient complaints about soreness and speech interferences with the smaller size bracket Our staff also reports that there is a huge improvement in ease and time savings for wire changes with it because of the way the brackets open
Long-tenured staff members, especially those who have suffered from (or even have had surgery for) carpal tunnel syndrome appreciate the ease of self-ligation Tying steel ties or attaching elastics onto conven- tional lingual brackets is even more straining than it is with labial brackets
The biggest surprise with this system was the velocity of tooth movement both in nonextraction and extraction cases — even though I’ve had considerable expe- rience with the Damon™ System passive self-ligating labial bracket with similar results (Figures 4A-4B) We're sure to cinch back the early archwires or leave them shorter, so they have room to move distally without irritating tissue Clinicians unfamiliar with passive self-ligation will need to be careful to use Ormco-supplied lingual archwires and follow the prescribed wire progression in order not to overpower the system and thus over-expand arches
Because it’s a straight-wire system, we're also able to use packaged lingual wires and shape them ourselves to duplicate a wire, if needed While we seldom need to resort to this option, it’s a real timesaver when we do There is considerable added expense and potential treatment delay to order and receive a replacement wire with appliance systems that provide technique-sensitive, robotically shaped wires
For case presentations, as profes- sionals, we educate our patients about the best approaches to solve their orthodontic challenges Our case presentation schools patients about their condition and its degree of treatment difficulty Through the discus- sion phase of the presentation, we come to agreement about the best appliance, timeline
for treatment, and cost If the patient has
very high esthetic demands and rejects labial clear brackets, the choices are either clear aligners or lingual braces The difficulty and odds of success with clear aligners steers the conversation from that point If | feel | need a fixed appliance, then the lingual appliance is my recommendation
40 Orthodontic practice
CONTINUING EDUCATION
Figures 5A-5G: Using Alias in the upper arch and Damon Clear in the lower arch satisfies fee-sensitive patients A-B Pretreat- ment C-D Bonding E-G 9 months
Lingual therapy gives us the full capability of a fixed appliance that avoids the possible compromises
with removable appliance therapy
We offer lingual treatment as an option in all teen and adult case presentations — even for selected Phase | treatment Lingual therapy gives us the full capability of a fixed appliance that avoids the possible compro- mises with removable appliance therapy With lingual treatment, we have the same force capabilities and treatment contro! as labial therapy, so we never have to settle for a compromised treatment result
To increase patient comfort and lessen speech interferences in patients with restricted lower arches and/or considerable lower arch crowding, we sometimes recommend lingual appliances for the upper arch and esthetic labial brackets (Damon™ Clear) on the lower arch (Figures 5A-5G) We price this option more affordably than full lingual; so if the fee is a major consideration for particular patients, this combination can be quite satisfactory
Conclusion
Being able to offer efficient lingual treat- ment in lieu of an esthetic labial option is vital to competing in today’s competitive
market that has become extremely insis- tent on esthetic treatment While patients in Southern California are certainly demanding of esthetic solutions, we don’t feel that they're appreciably more demanding than most people across the U.S In fact, even years ago, Dr Jack Gorman had more lingual patients in Marion, Indiana, than doctors in larger metropolitan areas
With the recent modifications made to the Alias appliance, we are continuing to notice the speed and reliability of move- ment Archwire sequence used on the case described below has been as follows: 014CN, 016CN as initial wires 16x 16 CN 18x 18CN 016 TMA to be used for finishing stage
We noticed decreased speech interfer- ence due to small bracket design and dimin- ished initial discomfort from initial light forces Excellent torque control is due to precise fit of the square archwire in the square bracket slot Also, know the efficiency of self-ligating
Trang 22Figures 6A-6B: A Class Ill patient being treated nonsurgically with UL Alias using Cl 3 mechanics B Fifteen months into treatment and approaching completion of treatment a J Ấ M “
Figure 7: Teen sisters and patients The patient on the left is wearing STb, an earlier lingual appliance from Ormco The patient on the right had previously worn clear removable appliances but switched to Alias when it became available Patients interested in esthetics will rarely choose a labial option over lingual when given the opportunity
Volume 7 Number 6
mechanics with its resulting freedom of
movement
With this bracket system, there’s no need to settle for a non-fixed treatment alternative in cases where doing so could compromise treatment Because we make this option readily available, it is rare that an esthetically demanding teen or adult patient will choose a labial option over lingual Combine the indirect bonding setup and an efficient reliable bracket, there is no better time than now to incorporate lingual therapy into your practice J
REFERENCES
1 AAO study finds adults are seeking orthodontic treatment in record numbers Orthodontic Products Published October 30, 2013 http://www.orthodonticproductson- line.com/2013/10/aao-study-finds-adults-are-seeking-
orthodontic-treatment-in-record-numbers/ Accessed
October 17, 2016
2 Scuzzo G, Takemoto K, Takemoto Y, Scuzzo G, Lombardo L A new self-ligating lingual bracket with square slots J
Clin Orthod 2011;45{12):682-690
3 Turnbull NR, Birnie DJ Treatment efficiency of conventional
rial Am J Orthod Dentofacial Orthop 2007;131(3):395-399 4 Chen SS, Greenlee GM, Kim JE, Smith CL, Huang
GJ.Systematic review of self-ligating brackets Am J Orthod
Trang 23CONTINUING EDUCATION Treating cleft palate with presurgical nasoalveolar molding (PNAM) Dr Thomas Wilson discusses an effective technique that can minimize the extent of surgery to repair cleft palate in newborns
Ox of the most challenging conditions confronting the craniofacial healthcare team is treatment of cleft lip and palate The many functional, esthetic, psychological, and sociological issues resulting from clefts
and related craniofacial anomalies require
a team approach using the expertise of
professionals in many healthcare disciplines
A successful treatment result will depend on a combination of surgical, orthodontic/
orthopedic, and restorative care, as well as
speech therapy and ongoing maintenance of the dentition
Treatment approaches and timing for cleft conditions remain a matter of debate
even in our current era of advanced tech-
nology and knowledge The basic goal of any approach to cleft lip, alveolus, and palate repair is to restore normal anatomy Ideally, deficient tissues should be expanded, and malpositioned structures should be repo- sitioned prior to surgical correction This provides the foundation for a less invasive surgical repair Historically, the use of pre- surgical infant orthopedic (PSIO) appliances or molding plate therapy has helped reduce the size of clefts of the alveolus and hard palate prior to surgery Since its introduction by McNeil (McNeil, 1950), various techniques have been described for bringing the intra- oral alveolar segments closer together in uni- lateral and bilateral cleft patients (Mylin 1969; Latham 1980)
In 1997, Drs Barry H Grayson and Court B Cutting at the Institute of Reconstructive Plastic Surgery at New York University Medical
Thomas Wilson, DDS, is a gradu-
ate of the University of lowa
College of Dentistry He completed his residency in pediatric dentistry
at the University of Florida and his residency in orthodontics at Emory University Dr Wilson is board cer-
tified in both pediatric dentistry
and orthodontics He maintains a
private practice in pediatric dentistry and orthodontics
in Des Moines, lowa Dr Wilson also holds an adjunct position at the University of lowa College of Dentistry
42 Orthodontic practice
Educational aims and objectives
This article aims to discuss presurgical nasoalveolar molding for treatment of cleft palate in newborns
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
e Discuss some accepted treatment approaches for cleft conditions identify the technique using presurgical nasoalveolar molding (PNAM) Recognize some appliances needed for the PNAM procedure
Recognize some clinical procedures for correction of the unilateral cleft using the NAM appliance Identify some physical reactions to look for during treatment to ensure that the infant is reacting well to the technique
Center developed a new approach of pre-
surgical nasoalveolar molding (PNAM) PNAM includes not only reduction of the size of the intraoral alveolar cleft through the molding of the bony segments, but also the active molding and positioning of the surrounding
Figure 1A: 2.5 weeks old
raat" wht
Figure 1B: NAM in place Figure 1C: 10 days before with taping surgery
soft tissues affected by the cleft, including the deformed soft tissue and cartilage in the cleft nose This is accomplished through the use of a nasal stent that is based on the labial flange of a conventional oral molding plate and enters the nasal aperture
The stent provides support and gives shape to the nasal dome and alar carti-
lages Presurgical nasoalveolar molding may be successfully employed in the early
management of both the unilateral and bi-
lateral cleft anomalies in newborns These
Figure 1D: 4 years posttreatment
Trang 24new techniques greatly improve upon the results usually achieved through traditional cleft palate appliances The result is an overall improvement in the esthetics of the nasolabial complex, while minimizing the extent of surgery and the overall number of surgical procedures
Clinical procedures for correction of the unilateral cleft using the NAM appliance
As soon as possible after birth, the infant is scheduled for an exam, and an impression of the cleft is made using a polyvinylsiloxane material The impression is obtained with the infant awake and without any anesthesia Care is taken to ensure that the material has reproduced the borders as well as the cleft area The infant should be able to cry during the impression procedure If no crying is heard, the airway is blocked
The impression is then poured in stone and trimmed The cleft region of the palate and the alveolus can be filled with wax or
silly putty to approximate the contour of an
intact arch prior to fabrication of the molding appliance The appliance is then made using clear orthodontic resin with a thickness of 3 mm to 4 mm
The appliance is mainly retained through extraoral facial tape and elastics Also, no acrylic material should project into the cleft areas, as this will block the intended move- ment of the alveolar segments into their desired presurgical positions The infant must be able to easily feed without gagging or struggling If gagging is noted, the posterior extent of the appliance should be reduced At the second appointment, if the infant is doing well, the appliance is modified to begin molding the alveolar cleft segments This is accomplished through selective removal of acrylic from the area where the alveolar bone is to move At the same time, a soft denture reline material is added to the area where bone is to be moved These minor adijust- ments are made weekly The ultimate goal of this sequential addition and selective grinding away of material is to reduce the size of the cleft gap and to have the two segments of alveolus contact with proper maxillary form At this same appointment, an external reten- tive button is added at the site of the cleft This retentive button helps seat the appliance and secure the retentive lip tapes and elastic bands (Figure 3) The taping of the cleft lip segments also serves to improve the align- ment of the nasal base region by bringing the columella toward the midsagittal plane and improving the symmetry of the nose
Volume 7 Number 6
Figure 2A: Pre NAM 4 weeks old Figure 2B: Nasoalveolar molding (NAM) appliance with stent
Figure 2C: NAM in place with taping Figure 2D: After 3 months treatment with NAM, pre-surgery
Trang 25Figure 4A: Pre NAM, 1 week old
The infant is checked, and the appliance is modified every 7 to 10 days When the cleft gap has been reduced to approximately 6 mm or less, a nasal stent is added, and active nasal cartilage molding begins The nasal stent is a wire and acrylic projection that is placed inside the nasal dome on the cleft side of the nose When properly placed and taped, blanching of the tissue overlying the tip of the nasal stent can be observed The nasal stent also exerts a reciprocal intraoral molding force against the alveolar segments The goal of the intraoral molding has the gingival tissues contact on either side of the alveolar ridge Successful surgery can result even when a small cleft remains between the alveolar ridges
At the conclusion of intraoral molding and nasal stenting, the alveolar segments should be aligned and the nasal cartilages, columella, and philtrum should be properly repositioned to facilitate the first surgical procedure This first surgery is usually performed between 3 and 4 months of age The infant wears the appliance continuously up to the time of surgery Following surgical repair of the lip, the lip is taped, and no intra- oral appliance is used The palate repair, if
44 Orthodontic practice
CONTINUING EDUCATION
(ss
Figures 4C-4D: 3 months treatment with NAM
indicated, is usually performed at approxi- mately 11 to 13 months of age
Cleft lip and palate patients pose special challenges for the treating dentist and require a team that involves several healthcare disci- plines An early coordinated team provides an accurate diagnosis, preventative and treatment regimens, ongoing evaluation and
maintenance and can produce results that
vastly improve the function, esthetics, and
overall quality of life for patients [J Acknowledgment
Dr Wilson appreciates the skill and expertise of cranio-
facial and children's reconstructive surgeons, Samuel Maurice, MD, and W Dale Franks, DDS, MD These individuals are dedicated to the health and well-being
of children with craniofacial anomalies and seek to promote an optimal surgical outcome for these children
REFERENCES
1 McNeil CK Orthodontic procedures in the treatment of
congenital cleft palate Dent Rec 1950;70(5):126-132
2 Mylin WK, Hagerty RF, Hess DA Modern concepts in the
treatment of unilateral cleft lip and palate South Med J
1969 Feb;62(2):171-174
3 Latham R Orthodontic advancement of the cleft maxil-
lary segment: a preliminary report Cleft Palate J
1980; 17(3):227-233
4 Grayson BH, Santiago PE, Brecht LE, Cutting CB Presur-
gical nasoalveolar moiding in infants with cleft lip and palate
Cleft Palate Craniofac J 1999;36(6):486-498
kí: su nan xv , *
Figure 4E: 2 years post surgery
Trang 26LABORATORY LINK
3D printing in orthodontics James Bonham and Arlen Hurt review
innovations in 3D-printing technologies
D printing continues to march forward on what many experts call the next industrial revolution Also known as ad-
ditive manufacturing, 3D printing is the
process for making a physical object from a three-dimensional digital model file by laying down successive thin layers of a material 3D-printing technology is chang-
ing the way products and prototypes are
produced in every industry, including ad- vancements in the dental industry The purpose of this article is to review several common 3D-printing technologies used in today’s dental market
3D printers rely on 3D scanners and CAD software to create and manipulate print- able data files 3D scanners can be direct or indirect Direct scanners are in contact with the object, while indirect scanners gather information with the scanner away from the object Most dental scanners use
the indirect capture technique All scanners
are prone to missing data and rely on CAD software to fill the voids of missing data It is always important to carefully review your dental scans for accuracy prior to starting the printing process
After the scan data has been captured, the 3D model files need to be sealed and identified before it can be sent to the 3D printer A third-party additive printing soft- ware such as Netfabb® is used for printer preparation The 3D printer's software then slices the model file into very small layers These thin layers are then reconstructed during the printing process Printers vary in their resolution capabilities High-resolution printers will lay thinner layers and produce
James Bonham is a partner at Specialty Appliances and manages sales and marketing He has spent
the past 12 years in orthodontics with a strong focus on the integration of digital technology into
orthodontic practices
As Vice President and partner at Specialty
Appliances, Arlen Hurt, CDT, has dedicated the past 30 years to orthodontic appliance innovation Mr Hurt is recognized as an award-winning inventor, published author, and national orthodontic speaker
He is best known as one of the most dependable resources for orthodontists everywhere
46 Orthodontic practice
a surface that is smoother than low-reso- lution printers
There are multiple additive printing technologies available, including Vat Photo- polymerization (light polymerization), Material Jetting, Binder Jetting, Material Extrusion, Powder Bed Fusion, Sheet Lamination, and Directed Energy Deposition At Specialty Appliances laboratory, we currently use three different 3D-printing technologies to fabricate dental models Each technology has strengths and weaknesses that we will discuss
VAT Polymerization
The first type of light polymerization that we use is stereolithography (SLA or SL) Stereolithography is an additive manufac- turing process that works by focusing an ultraviolet (UV) laser on to a vat of photo- polymer resin This process creates parts when a laser passes over the resin, using photo polymerization to cure each layer SLA advantages include a relatively fast print
SLA is the most common form of VAT Polymerization printing speed Printed models are strong and make great master molds Disadvantages of SLA printing include a higher cost of ownership, and post-processing requires a chemical bath before being placed in a UV curing oven
Another VAT Polymerization technology is Digital Light Projection (DLP) DLP tech- nology is used in cinemas, classrooms, and
a
DLP has the fastest print speeds and a low cost of ownership for in-office use
Trang 27in rear projection televisions In 3D printing,
this energy source is projected onto a
photo polymer to create 3D models DLP
technology exposes one complete layer in a single shot, creating much faster print times compared to point-by-point technol-
ogies The layer thickness is adjustable to
sub-50 um resolution on the image plane
DLP printing shares the same advantages as SLA printing, but it is faster and offers a lower cost of ownership Disadvantages of DLP technology include the same chemical
bath and UV curing for post-processing as
with SLA technology
Material Jetting
This process is very similar to an inkjet printer, but the print head drops photopoly- mers instead of ink Two materials are used in this process A build material is accompa-
nied by a filler material to help create difficult geometries A UV light cures both materials
as their layers are dropped Post- processing
involves soaking the model, then using a high-powered water jet station to remove the
fill material Material jetting has advantages such as consistent accuracy, and no chem- icals are necessary for post-processing Multiple materials can also be incorporated
in a single print job Disadvantages include
a noisy and technique sensitive pressure washer for post-processing The material
cost is higher than any other 3D-printing technologies covered in this article
Material Extrusion
Material Extrusion is also referred to as
FFF (Fused Filament Fabrication) Parts are
produced by extruding small beads of melted
material, which harden immediately to form
object layers A spool of hermoplastic fila-
ment is unreeled to supply material to an
extrusion nozzle head The nozzle head
heats the material and turns the flow on and off Typically stepper motors are used to move the extrusion head and adjust the flow of material as the layers are placed Advantages include a wide range of mate-
rials and the lowest cost of ownership There is also no post-processing required for FFF printers Disadvantages include visible layer lines and longer build times compared to other printing technologies Temperature
fluctuations during production can cause
issues like delamination
To learn more about 3D printing for
your orthodontic office, contact Specialty Appliances (J 48 Orthodontic practice q _—
Material Jetting is a reliable form of 3D printing and is great for high volume print jobs