Tạp chí chỉnh nha OPUS tháng 01+02/2014 Vol 5 No.1

Tạp chí chỉnh nha OPUS tháng 01 02 2014 vol 5 no 1

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CONTINUING EDUCATION CREDITS

to Interproximal Reduction (IPR)

Dr Randol Womack

New study may

change the face

of orthodontics

Dr Juan-Carlos Quintero

Corporate profile

suresmile/OraMetrix

© 2014 Ormco Corporation

See it live or to hear from Dr Alpan

my offi ce It lets my patients and referring dentists

know how interested I am in technology and in the

January/February 2014 - Volume 5 Number 1

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,

Shalin R Shah, DMD (Abstract Editor)

Lou Shuman, DMD, CAGS

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

PUBLISHER | Lisa Moler

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MANAGING EDITOR | Mali Schantz-Feld

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ASSISTANT EDITOR | Elizabeth Romanek

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EDITORIAL ASSISTANT | Mandi Gross

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© FMC 2014 All rights reserved FMC

is part of the specialist publishing group Springer Science+Business Media The publisher’s written consent must be obtained before any part

of this publication may be reproduced in any form whatsoever, including

photocopies and information retrieval systems While every care has been

taken in the preparation of this magazine, the publisher cannot be held

responsible for the accuracy of the information printed herein, or in any

consequence arising from it The views expressed herein are those of the

author(s) and not necessarily the opinion of either Orthodontic Practice US or

the publisher.

As I have transitioned my life to dental education, I have observed that my students (graduate and undergraduate) want simple solutions to diagnosis and treatment as graduates starting private practice They are looking for a “cookbook” approach

As you read through this journal in 2014, as well as others, I will give you the same message as I give my students Avoid the cookbook concept Use critical thinking every day in your practice, adapt to change, and understand that the way you practice today will not be the way you practice in the future

So, as you evaluate the articles not only in this journal, but also in others, the following New Year’s resolutions might apply to you

• All patients are not the same Don’t treat them as though they are For example, children should be treated differently than adults orthodontically As Dr Vince Kokich, who was a transcendent orthodontic and dental educator (and who is sorely missed), said, “Orthodontic treatment in children should be ideal … in adults realistic.” He meant simply that in children having no history, all considerations should be addressed, but in adults with a longer dental history, don’t fix what isn’t broken by forcing “ideal” treatment on them All patients are individual and special Don’t pigeonhole them

• Don’t forget that you are a dentist first As Dr Kokich also said, “My treatment (adult orthodontics) has been influenced greatly by my association with restorative dentistry and periodontics.” Don’t assume that referring general dentists have performed a complete examination Do your own Also, form an interdisciplinary team in your community that will provide the synergy and increased scope of treatment that will not only expand your practice horizons but also be beneficial to your patients

• Don’t be the first on your block to adopt new technology in your practice, but certainly don’t

be the last! In my 35 years of practice, I have filled my “dental museum” with technology costing thousands of dollars, now collecting dust Be critical; is the technology evidence-based? Will the technology improve your diagnosis or treatment outcomes? Will the expense add to your bottom line? Will the technology help promote your practice? Most importantly, does it have a track record? On the other hand, patients expect their doctors to be up-to-date For example, make sure your imaging is current (to address radiation concerns) Utilize new anchorage techniques and approaches that can decrease treatment time safely

• Constantly educate yourself Dr William Osler, a trailblazer in medical education and author

of the renowned textbook, The Principles and Practice of Medicine, once said, “The greater

the ignorance, the greater the dogmatism.” Learn to question and be critical of all information presented no matter what the source You will be surprised at how this also helps you better educate your patients and increases treatment acceptance As an educational exercise, I purposely give my graduate students articles that completely contradict each other so that they can discern what is scientifically valid

• You don’t have to do everything! But do what you like, and do it well Today’s economy and patient expectations often push practitioners into doing treatment they are uncomfortable with For example, I teach diagnosis and management of temporomandibular disorder (TMD) and orofacial pain to my students, but I emphasize that many orthodontists prefer not to deal with these patients Some orthodontists love treating just children and have successful practices without getting overly involved with adult orthodontics In other words, be yourself; but at the same time, if you aren’t getting the results you want, further education is the key to improvement However, don’t ignore new trends and procedures that can be easily and productively introduced into your practice For instance, it is my opinion that every orthodontist should include making sleep appliances for their patients (as long as risks and benefits are explained)

In conclusion, as you browse journals, be critical, especially of dentists and manufacturers that offer cookbook, quick-fix, “turnkey” systems Make sure that the journal is peer reviewed (as the clinical and CE articles in this one are) Make sure that any new changes in your practice have withstood the test of time

But just as importantly, be willing to change and adapt, evaluate the individual needs of your patients, and finally — enjoy your practice! My best wishes to all for success and a happy new year!

Dr Harold Menchel

Harold Menchel, DMD, is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep-disordered breathing Dr Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Fort Lauderdale, Florida He is the director of orofacial pain at Larkin Community Hospital, one of Florida’s 12 statutory teaching hospitals, in Miami and lectures both nationally and internationally He is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.

New Year’s resolution: throw away the cookbook!

TABLE OF CONTENTS

Orthodontic concepts

BioDigital Orthodontics:

Management of space closure in Class I extraction patients with SureSmile: part 7

Dr Rohit C.L Sachdeva, and Drs Takao Kubota and Kazuo Hayashi discuss management of space closure in patients requiring extraction therapy 14

Research

A survey of orthodontic practitioners regarding the routine use of lateral cephalometric radiographs in orthodontic treatment

Drs Matthew McCabe and Donald

J Rinchuse uncover the latest trend

in the use of lateral cepahlometric radiographs . 24

Dr Jerry R Clark: Reflections on faith, hope, and orthodontics

Inspired by faith, Dr Clark strives to work hard, provide the finest care for his

patients, and have some fun along the way.

OraMetrix

Now cloud-based, new suresmile 7.0 eliminates the need for in-office servers

while providing orthodontists powerful and coordinated tools for diagnosis,

treatment planning, archwire design and reduced treatment times.

ON THE COVER

Cover photo courtesy of Dr Juan-Carlos Quintero Article begins on page 41

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4 Orthodontic practice Volume 5 Number 1

Industry news 30

Continuing

education

Efficiency by design

Dr Mark McDonough discusses

increasing efficiency through proper

treatment decisions 32

The biology of orthodontic tooth

movement part 2: modulating

tooth movement via nitric oxide

and prostaglandin production

Dr Michael S Stosich reviews the

markers of bone cell activity that are

intrinsic to the complex process of

bone modeling and remodeling 38

Book review

The Master’s Guide to

Interproximal Reduction (IPR)

Stability, longevity, and predictability in your practice management technology

Drs Shalin R Shah and Ryan K

Tamburrino discuss the benefits of

a high-quality practice management system 44

Product profile

Great Lakes offers a complete 3D orthodontic solution for orthodontists and their labs 50

Practice development

Automated patient appointment reminders — the data is in

Diana P Friedman shows the significant impact on no-shows, practice efficiency, and production 52

Practice management

Life happens, and big screen TVs

go on sale: a look at based selling

solution-Justin Harding reminds practitioners

to address patients’ wants and needs 54

Diary 56

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What can you tell us about your

background?

I grew up in Philadelphia, Pennsylvania, and

after high school attended the University of

North Carolina for 8 years, completing my

undergraduate work and receiving a BS

degree and then obtaining my DDS from

the UNC School of Dentistry After dental

school, I entered the U.S Navy as a dentist

and served a 2-year tour of duty at Naval

Air Station (NAS) Oceana in Virginia Beach,

Virginia After that, I became an associate

in a dental practice in Greensboro, North

Carolina, for 2 years practicing general

dentistry In 1973, I entered orthodontic

school at St Louis University, and in 1975,

received my Masters in Orthodontics In

1975, I returned to Greensboro and opened

my own private orthodontic practice, and

since then I have been actively practicing

orthodontics in Greensboro

Why did you decide to focus on

orthodontics?

While growing up, I was fortunate enough to

have my orthodontic treatment performed

by Dr Paul Reid, former chairman of

the Department of Orthodontics at the

University of Pennsylvania Dr Reid also

served a term as president of the American

Association of Orthodontists (AAO) Dr

Reid really enjoyed orthodontics, and it

showed I had never seen anyone enjoy

his or her profession more than Dr Reid

While undergoing treatment, we discussed

orthodontics as a career, and he strongly

encouraged me to consider being an

orthodontist

How long have you been

prac-ticing, and what systems do you

use?

I began my orthodontic practice in 1975

Over the years, it has been our privilege

to create thousands of beautiful smiles

With new techniques and technology, it is

always a challenge to keep up and ensure

that we are providing the very finest care

for all of our patients Today our practice

utilizes virtually all the technical advances

at our disposal We use 3D imaging,

aligners, TADs, the fantastic and

easy-to-use Picasso™ Lite soft tissue laser

(AMD Lasers), Dentsply GAC’s Sentalloy®

and BioForce® heat-activated archwires, and most importantly, we use Dentsply GAC’s In-Ovation® (Dentsply GAC) self-ligating brackets and the Complete Clinical Orthodontics (CCO) system of treatment

Over the past few years I have been actively involved with Dr Antonino Secchi and a group of leading orthodontists from all over the world in developing and promoting the Complete Clinical Orthodontics treatment system CCO is the intelligent integration of the best concepts provided

to us by our predecessors: Tweed, Andrews, Roth, and Damon, to name a few, combined with the most efficient and effective technologies available today

This group is open to every orthodontist interested in improving his or her clinical skills, and we invite all orthodontists to join

us at any of our future CCO meetings

These advances have allowed us

to reduce patient discomfort, decrease treatment time, decrease chair time, and decrease the number of patient visits necessary to complete treatment while at the same time improving the consistency and quality of our treatment results

What training have you en?

undertak-Every year, I attend the AAO meeting which

affords me the opportunity to continually monitor what is new in our profession

I also usually attend at least four or five courses that will allow me to obtain a more in-depth knowledge of topics of interest

to me and my patients I regularly attend state, local, and alumni meetings, and have attended the meetings of the Damon Forum, the Gorman Institute, and took the Post-Graduate Week Residency Program

at the University of Washington For over

20 years, I have subscribed to the great

series, Practical Reviews in Orthodontics,

which monthly gives me a critical review

of the literature and the important topics involving the orthodontic practitioner

Who inspired you?

My faith inspires me I have a profound belief that we have been placed here to help others and leave this place better for those who come after us Our practice is committed to providing the very finest care for each and every patient we have the privilege to treat My family inspires me also

to be the best that I can be at everything I

do My parents insisted that I get the best education possible When I was a teen,

my orthodontic treatment was performed

by Dr Paul Reid, former chairman of the Department of Orthodontics at the University of Pennsylvania and former

PRACTICE PROFILE

president of the AAO His love for

orthodontics was contagious, and I thought

as a teen that orthodontics would be a

great profession In orthodontic school at

St Louis University, Dr Leo Mastorakos

inspired me to carefully examine every

detail in my approach to treatment and

to accept nothing but the finest treatment

results

What is the most satisfying aspect

of your practice?

What a privilege it is to daily work with our

patients to provide them with beautiful

smiles and a dental occlusion that will last

them a lifetime Every day, patients are

excited about getting their braces on, and

other patients are excited about getting

their braces off During their treatment,

we have the opportunity to change our

patients’ lives, not only with the way their

teeth and smiles look, but also to be

involved in their lives hopefully always in a

positive fashion Our patients become our

I am also very proud of the company

I started over 20 years ago to provide practice valuation and transition services

to the orthodontic profession Today, Bentson Clark & Copple is regarded

as the premier orthodontic practice transition company exclusively serving the orthodontic profession

What do you think is unique about your practice?

We love providing Ritz Carlton-type service for each and every individual who enters our practice We do everything we can to

make every patient comfortable and feel well cared for in our office We are not only providing orthodontic care; we are provid-ing care for the entire individual We try to not just be the patient’s orthodontist; we want to create a comfortable atmosphere

of fun and excitement centered on the tient’s treatment

pa-What has been your biggest challenge?

Time management has probably been my biggest challenge Having four children and

a wonderful wife, I find it is sometimes very difficult balancing family time along with the demands of managing and running a busy orthodontic practice, in addition to being actively involved in the community and with

Dr Clark’s team Bentson Clark and Copple Principals

Hope Academy

8 Orthodontic practice Volume 5 Number 1

PRACTICE PROFILE

wanted to be an architect; I really enjoyed

mechanical drawing and design work

When I entered college, I enrolled as a

business major and thought about working

in the public relations part of the business

world However, after three semesters

in the business school, I decided that

dentistry was the career that I wanted to

pursue

What is the future of orthodontics

and dentistry?

I see a bright future for our profession The

orthodontic supply companies continuously

come out with newer and better technology

and appliances to make the treatment

of our patients quicker, easier, and more

comfortable for them I feel privileged to be

a Key Opinion Leader for Dentsply GAC and

having the opportunity to work closely with

their Research and Development team in

developing the next generation of products

to improve the quality of orthodontic care

for our patients I see significant changes

in bracket design, treatment techniques,

archwires, and aligners; and most of all,

I believe the new digital technology along

with 3D imaging will help to revolutionize

the way we provide orthodontic care

However, the key to great orthodontic care

will continue to be the proper diagnosis

and treatment planning of cases

What are your top tips for

main-taining a successful practice?

Continuous continuing education is

necessary, not only in the technical field

of orthodontics, but also with the practice

management side of the practice “Raving

Fans” customer service (from the book

of the same name by Ken Blanchard and

Sheldon Bowles) is essential to maintaining

a successful practice Keeping up with referral patterns is critical, and today the proper use of “social media” is essential

in maintaining an active practice A strong marketing program within the practice

is important to maintaining contact with referring doctors and our patients It is very important to be involved in civic activities

in order to give back to the community

Twenty-eight years ago I founded the A-Wish Foundation of North Carolina, and

Make-to date the organization has granted over 5,000 wishes to children under the age of

18 suffering from life-threatening illnesses

What advice would you give to budding orthodontists?

Be a constant student and keep up with all the changes that are occurring in our profession Work hard, and provide the finest care for your patients — but most of all, have fun Orthodontics is a wonderful profession that is highly gratifying and fulfilling Enjoy your patients and staff, and take pride in the quality of care you provide

What are your hobbies, and what

do you do in your spare time?

I really enjoy reading and learning My favorite hobby is golf, which allows me

to spend hours outside and enjoy nature

My wife, Regina, and I love to travel and experience the wonderful adventures that travel provides I am also a big sports fan and enjoy almost every sport both as a fan

in the stands and as a spectator watching

on television

Make-A-Wish wizard

Dr Clark and wife, Regina, at Pebble BeachUNC football with family

Top Ten Favorites

1 Reading — every kind of reading — scientific, mystery, suspense, historical, and most of all, my Bible.

2 Golf — this is my relaxation I have had the privilege of playing some of the world’s finest courses.

3 Travel — my wife, Regina, and I love to travel and experience new adventures We have visited most of the U.S national parks and traveled all over the world — our bucket list now includes a trip to New Zealand Anyone from New Zealand reading this, we would love to come visit you.

4 University of North Carolina athletics — our family has season tickets for the North Carolina football and basketball teams, and we also go to some of the other UNC sporting events

5 My practice — after all these years, it is still a wonderful privilege to go to the office every day and have the opportunity to create beautiful smiles and impact the lives of our patients in a positive fashion.

6 New technology — it is so much fun to learn about and utilize most of the new technology that continues to allow us to provide better and better care for our patients: TADs, the laser, 3D imaging, new brackets and archwires, and so on.

7 Volunteering for the Make-A-Wish ® Central and Western North Carolina — I have been involved with Make-A-Wish Foundation since I helped found the organization over

28 years ago It is a constant source of inspiration and strength to me to be able to work with the children and families who are going through such difficult times.

8 Involvement with my church — for over

15 years, I have been volunteering every Wednesday night at our church to help feed and work with the homeless people of the Greensboro community I volunteer every Monday and Tuesday during the school year

to tutor children in our church’s after-school tutoring program I also drive the church van to take the children home after tutoring

I also have a handicapped friend whom I mentor and take to church on Sundays

9 Nat Greene Kiwanis Club — I have been a member of this civic organization for over

30 years and have made many close and lasting friendships as we help to better serve and care for the children of our community.

10 Hope Academy — a faith-based, private school for inter-city middle school children

of Greensboro My wife, Regina, started this school in 2012 to help provide a first-class education to children living in the inter-city who had few education options I have had the privilege of watching, and helping in some small ways, as this school has grown from a dream to a reality.

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The smiles that dreams are made of

suresmile 7.0 from OraMetrix is designed

to help clinicians achieve that goal more

predictably and efficiently than ever before

Not only has treating patients digitally

gotten dramatically more sophisticated,

it’s also more cost-effective Now

cloud-based, new suresmile 7.0 eliminates the

need for in-office servers while providing

orthodontists powerful and coordinated

tools for diagnosis, treatment planning,

archwire design and reduced treatment

times suresmile doctors use advanced

3-D imaging, virtual simulations and

robotically-bent archwires customized for

each treatment plan — all while continuing

to use their bracket system of choice

Chuck Abraham, CEO, suresmile/

OraMetrix, said, “suresmile 7.0 was

designed by our team to advance the

digital revolution within our specialty

Taking it to the cloud was essential and the

result of comprehensive re-engineering,

but the design goal for 7.0 was simple and

focused: to build an even better way for

our users to realize their treatment plans

for each and every patient.”

“There is a technology convergence

in orthodontics now Advances in CAD/

CAM technology, 3D scanning, advanced

robotics, 3D printing, and the cloud have

all helped us to take suresmile 7.0 to new

levels of performance and efficiency,”

Abraham continued “We’ve developed

the suresmile system to become a true

treatment management platform, enabling

our doctors to meet the esthetic demands

of a growing adult patient population by

offering lingual, lingual/labial, and even a

hybrid treatment of braces and aligners

with the same treatment efficiency and

excellent results our doctors have always

achieved.”

The move to the cloud makes 7.0

easier to integrate into the practice “The

cloud acts as your ‘server in the sky,’

meaning that digital file storage is much more convenient, and the system is easily accessible, regardless of the user’s location,” commented Phillip Getto, Chief Technology Officer, suresmile/OraMetrix

“You don’t have to be in the office to access a case via internet connectivity — you can be at home or a Starbucks All patient-identifying information is encrypted, including photos, X-rays, and patient names All communication between your browser and the servers is also encrypted,

as are the servers, which, by the way, are Amazon servers, amongst the most secure

in the world.”

Since 1998, when OraMetrix developed the suresmile system, this revolutionary digital technology has empowered orthodontists with a powerful diagnostic, treatment, and monitoring tool to deliver the most precise, customized orthodontic care available In fact, suresmile has been shown to reduce treatment time by an average 30%, based on a February 2011 comparison of more than 40,000 patients

Since 2004, suresmile has been used for over 125,000 patients by orthodontists in

the United States, Australia, New Zealand,the European Union, Canada, and Japan suresmile 7.0 was developed to enhance the system’s efficiency while achieving new levels of precision planning With the ability to view both bone and roots, it now makes case planning more predictable in achieving roots in the bone The simplified user interface is more intuitive for the user, reducing the time required to set-up cases.The single-most significant advance in technology that empowers suresmile from its inception is robotic wire production Patient-specific wire sequences are calculated by computer and optimized by the orthodontist to achieve the desired treatment goal There is 100% control, tooth-by-tooth or by shape, at any point during treatment suresmile currently

Cloud-based suresmile 7.0 from

OraMetrix takes digital orthodontics

to an entirely new level

CORPORATE PROFILE

suresmile/OraMetrix Executive Management Team from left to right: Phil Getto, Chief Technology Officer; Glenn Lyon, Vice President, New Business Development; Jerry Metz, Vice President, Operations; Rohit Sachdeva, Chief Clinical Officer; Chuck Abraham, Chief Executive Officer; Jay Widdig, Chief Financial Officer; Bob Davis, Director, Marketing

suresmile’s new interface is designed to be more intuitive

CORPORATE PROFILE

produces over 18,000 wires per month,

each one of them optimized to achieve a

specific treatment goal for that patient,

making it truly the only system for fixed

appliances that can provide proactive

management of treatment objectives and

appliance design A suresmile archwire

can be refined at any time, and suresmile

software provides tools for analysis of

results and decision-making support

throughout the course of treatment

“There is a misperception in our

profession that suresmile is just a

finishing archwire,” commented Dr Rohit

Sachdeva, Co-Founder and Chief Clinical

Officer, suresmile/OraMetrix “In fact, the

strength of the software is the ability to

treatment plan cases in advance, which

allows the doctor to anticipate and avoid

common clinical problems that arise during

treatment The ability to visualize patients’

roots and bone is a profound advance for

us in putting roots in their proper position

Even with this advanced planning, we

know that patient compliance and biology

can impact our best-made plans One of

the true strengths of the suresmile system

is that the doctor can modify the original

plan at any time, order modified archwires,

and still achieve an excellent result.”

suresmile empowers the orthodontist

to see tooth anatomy in ways never before

possible, while providing the ability to

visualize and simulate multiple diagnostic set-ups and design archwires accurate

to 1 mm Clinical decisions and their interdependencies are calculated across all teeth simultaneously, calculating archwire designs needed to accomplish your objectives, precisely and predictably

Several independent university studies have confirmed reduced treatment times of

up to 30% over conventional and improved quality treatment scores

Real-time treatment simulations make it possible for the treating clinician

to know, precisely, where each case is going, and serve as a dynamic patient communication tool Writing in a recent

issue of Orthodontic Practice US, Dr

Randall Moles commented on this aspect

University Studies

Recent studies show thatsuresmile achieves better

or equal quality finishes in

30 percent less time while effectively achieving desired tooth movements Information available upon request

12 Orthodontic practice Volume 5 Number 1

CORPORATE PROFILE

of suresmile: “The digital systems facilitate

information transfer so much more easily

and effectively Treatment proceeds

quicker (there is no need to reposition

brackets) and more easily for both them

and us Along the way, they can see our

proposed targets and even be involved in

their development Finally, after appliance

removal, we can create digitally-formed

retainers, which are also aligners, to make

any post-treatment adjustments.”1

In his article, “The Optimized Digital

Practice,” Dr Bruce Goldstein puts it like

this: “suresmile is the only comprehensive

system that blends the best diagnostics

available with accurately prescribed

therapeutics suresmile technology

provides the practitioner with the tools

needed to treat patients with greater

efficiency and accuracy.” (suresmile clinical

report No 1).”2

Dr Jeff Johnson, concludes his article,

“Treating an Asymmetric Class II Case with

suresmile,” with this summary:

“1 Have confidence that dramatically

reduced treatment times are possible and

not for isolated patients, but for all patients

in general…We must be willing to step

outside our orthodontic boxes while still

trying to adhere to timeworn orthodontic

principles

2 The confidence that can be conveyed

to patients is most often our greatest

motivating factor We basically discuss

with them that we all have our jobs to do…

and are able to backup these claims by

telling them that 65-70% of all our patients

complete their treatment in 15 months or

less

3 Our planning becomes very transparent

and allows the patients to be an integral

part of their treatment to the degree they

desire…

4 We are able to create a target that, for all

intents and purposes, has been optimized

during the mid-treatment planning process

This allows us to monitor treatment more

efficiently and not try to achieve what likely

is not possible with the given conditions.”

(suresmile clinical report No 2).3

There is more to come

“2014 will be an exciting year for the

suresmile team,” commented Bob

Davis, suresmile/OraMetrix’s Director

of Marketing “We have entered into a

joint marketing agreement with Specialty

Appliances to offer labial indirect bonding

service and lingual case design exclusively

powered by suresmile software Indirect

bonding setups are digitally designed using suresmile software, which enables greater accuracy of bracket placement and case design, as they will have access to our library of over 20,000 brackets and buccal tubes Specialty Appliances will also offer lingual case planning and setups, including suresmile wires for lingual treatment.”

With over 125,000 patients already benefitting from suresmile treatment globally, suresmile 7.0 is now delivering advanced functionality, more intuitive and easy-to-use features, and greater

Treatment plan based on root-and-bone positionInitial CBCT scan (optional)

operational efficiency To put it simply, suresmile 7.0 was designed and engineered

to help orthodontists achieve their clinical goals more precisely than ever before

This information was provided by OraMetrix.

ReFeRenceS

1 Moles, R Treating digitally and the new

orthodontic practice Orthodontic Practice

— Chuck Abraham, CEO, suresmile/OraMetrix

suresmile digital images provided by Dr Bruce Goldstein2

suresmile case by Dr Jeff Johnson3

January 2009

Actual result (Final)

The purpose of this article is to discuss

the application of SureSmile© technology1-6

in managing space closure in patients

requiring extraction therapy Strategies to

optimize the use of SureSmile prescription

archwires and various Clinical Pathway

Guidelines (CPG) developed by the first

author (Sachdeva) to manage space closure

are discussed These are highlighted with

patient histories where possible

Space closure with SureSmile

Efficient and effective management of

patients requiring extraction therapy

requires proactive care planning, the

appropriate choice and design of

appliances driven by sound biomechanical

principles, and the vigilant follow-up of the

patient during treatment based upon a

well-designed clinical protocol

When using SureSmile, two clinical

strategies are generally considered in

closing the extraction space, namely:

Type 1- Space Closure with SureSmile

The first involves achieving sufficient

alignment and overbite correction with

conventional mechanics followed by

closing the majority of the residual space

with sliding mechanics on a SureSmile

archwire (Type 1) An example of this is shown in the treatment of patient A.S

(Figures 1-6) With proper consideration to the design of the slideline* in a SureSmile archwire, one can plan to move teeth over

a long span with no collision between an archwire bend and bracket (Figure 4)

Type 2- Space Closure with SureSmile

The second strategy (Type 2) involves using conventional mechanics to close the majority of the space followed by using SureSmile wire The choice of the space-closure device is driven by the nature of malocclusion and the anchorage

requirements The appliance types that

a clinician may use to achieve space closure are numerous However, a prime consideration in their use is driven by anchorage considerations, the desired nature of tooth movement, i.e., controlled tipping or translation (Table 1), and patient cooperation The relative effectiveness of various space closure devices used by the first author (Sachdeva) in controlling tooth movement during orthodontic space closure is provided in Table 2

Furthermore, it must be appreciated that timely and effective care of a patient with SureSmile technology warrants

Dr Rohit C.L Sachdeva, and Drs Takao Kubota and Kazuo Hayashi discuss management of space closure

in patients requiring extraction therapy

Rohit C.L Sachdeva, BDS, M Dent Sc, is

the co-founder and 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 He is a clinical

professor at the University of Connecticut, Temple

University, and the Hokkaido Health Sciences Center,

Japan In the past, he held faculty positions at the

University of Connecticut, Manitoba and the Baylor

College of Dentistry, Texas A&M Dr Sachdeva has over

80 patents, is the recipient of the Japanese Society for

Promotion of Science Award, and has over 160 papers

and abstracts to his credit

Table 1: Anchorage classification scheme developed by Burstone7 is used by the first author (Sachdeva) in designing his strategy for space closure mechanics

Table 2: Guideline developed by Sachdeva to assess the relative degree of control offered by various space closure appliances

Volume 5 Number 1 Orthodontic practice 15

avoiding any reactive care processes One

approach to keeping the patient “on-track”

is to establish and follow clinical protocols

The first author (Sachdeva) has developed

a number of guidelines to clinically manage

extraction patients with SureSmile (Tables

3-5) These protocols are driven by the

nature of the presenting malocclusion

and anchorage requirements It must

be recognized that these CPGs provide

a general framework for managing the

course of patient care, and a clinician may

need to deviate from the pathway at times

to cater to the prevailing circumstances

and the patient’s response

Patient I- A.S (Space Closure Protocol

A CPG- Sachdeva )

Patient A.S presented with a Class II

canine and Class I molar respectively with

a deep bite and minor upper and lower

crowding with retained upper E’s, missing

upper right 5, and ectopic erupting

upper-left first bicuspid Based upon the treatment

plan, it was decided to extract the retained

E’s and upper left second bicispid and

treat to a Class I canine and Class II molar

relationship respectively

The treatment pathway for patient A.S

followed Protocol A CPG closely (Table 3)

Details of patient management are shown

with the Figures 1-6

Figures 1A-1B: Patient I- A.S 1A Initial Diagnostic records Class II canine and Class I molar respectively with a deep bite and minor upper and lower crowding 1B Initial lateral ceph and panorex radiographs

Figures 2A-2B: Patient I- A.S 2A Upper E’s were extracted and initial alignment and leveling accomplished with 016” NiTi and 016” x 022” NiTi archwire in both the upper and lower arches Therapeutic scan was taken at this stage of treatment 2B Mid-treatment ceph and panoramic view was taken at time of therapeutic scan

Figures 3A-3C: Patient I- A.S 3A Virtual Therapeutic Model (VTM) 3B Virtual Therapeutic Simulation (VTS) with upper space closed and prescription archwire designed 3C Prescrip-tion sliding archwire viewed against VTS Since the upper anteriors are being retracted, the archwire appears lingual to the teeth

16 Orthodontic practice Volume 5 Number 1

ORTHODONTIC CONCEPTS

Figure 5: Patient I- A.S Shows simulated staged events against the archwire (A-I) Note: mesial slide planned in front of the upper right molar and the distal slide behind the upper cuspid and bicuspid This slide refers to the straight length of the segment between the brackets that allows for uninterrupted movement of teeth

Figure 6: Patient I- A.S Entire space was closed with 019” x 025” NiTi SureSmile sliding precision archwire with power chain Note: No collisions are seen between the archwire bends and the brackets

Figures 4A-4C: Patient I- A.S 4A Shows the straight archwire at the time of the therapeutic scan 4B Shows the Virtual Therapeutic Model and the design of the sliding SureSmile precision archwire 4C Shows the SureSmile sliding prescriptive precision archwire design The areas in green are the slide planned in the archwire This is the straight length of the archwire that allows unimpeded slide of the teeth during space closure

Table 3: Clinical Pathway Guideline for managing space closure in patient presenting with minimal crowding

Table 4: Clinical Pathway Guideline for managing patients with moderate crowding

Table 5: Clinical Pathway Guideline for patients requiring maximum anchorage Note:

“C” Anchorage situations may also represent clinical situations requiring maximum chorage In such situations, the anterior teeth A-P position may need to be maintained, and depending upon which arch is being treated, Class I or Class III elastic wear may be required to enable a differential force system

18 Orthodontic practice Volume 5 Number 1

Figure 9: Patient II- T.Y The initial phase of treatment involved separate canine retraction in both the upper arch and lower arch with sliding mechanics The current image, 7 months from the start of treatment, is the time at which the therapeutic scan was taken Most of the space has been closed, and the space among the upper anteriors is being consolidated en masse with 017” x 025” stainless steel teardrop loops in a continuous archwire Note that the buccal segments in both arches are slightly dumped because of the lack of control of the couple-to-force ratio

Patient II- T.Y (Space Closure Protocol

C CPG- Sachdeva )

Patient T.Y presented with a Class I

malocclusion with severe upper and lower

arch crowding Based upon the treatment

plan (Figures 7B and 8B1), it was decided

to extract the upper and lower first

premolars and treat the patient to a Class I

with “A” anchorage

The treatment protocol for patient

T.Y was very closely adhered to as shown

in the Protocol C CPG (Table 5), and the

duration of treatment for this patient was

11 months

Figures 10A-10C Patient II-T.Y A Virtual Therapeutic Model (VTM) Note the arch widths are reasonably controlled; however, it is apparent that the buccal segments are “dumped.” 10B Shows the Virtual Target Setup with the accompanying SureSmile archwire design

10C Shows the Suresmile archwire design against the virtual therapeutic model (VTM) A full expression 017” x 025” SureSmile prescription archwire was designed Also, note the brackets used in this patient have a 018” prescription

Figures 11A-11E: Patient II-T.Y Treatment re-evaluation of space closure was done at the Therapeutic stage VTM model is in white and the “best fit” superimposed on the VDM in green to evaluate the nature of anchorage loss Note that most of the anchorage was lost in the maxillary buccal segments Also, note that about 4 months into treatment, dumping of the buccal segments becomes obvious, and at this stage of treatment, about 50% of the space has been closed

Figures 12A-12H: Patient II- TY Re-evaluation of the VTM against the VDM in both the upper and lower arch The VTS is in white and the VDS in green Note some buccal lingual dumping of the lower buccal segments is noted However, the arch widths at the molar level were controlled The anchorage in the upper right buccal segment was better controlled than that in the upper left Maximum anchorage control was achieved in the lower arch Also, note as the upper right canine was retracted distally, the palatally blocked upper right lateral first moved laterally, probably as a result of the transseptal fibers, and once it was engaged with the archwire, it was tipped labially into the arch

ORTHODONTIC CONCEPTS

Figures 13A-13B: Patient II- T.Y 13A Shows the comparison between the initial plan (VDS) in white and the initial model (VDM) which is blue 13B Shows the

comparison between the initial diagnostic model plan (VDS) in white and the Virtual Therapeutic Model (VTM) in green Note the similarity in the plan movement

versus the executed

Figure 14: Patient II- T.Y SureSmile archwires were inserted 7 weeks post Therapeutic scan Note Check elastics are worn along with the SureSmile 017” x

025” NiTi precision archwires

Figure 15: Patient II-T.Y Recall visit 8 weeks post

SureSmile archwires insertion Note the Class I buccal

segments relationship and the substantial correction of

the dumped segments achieved

• One system with superior 3D scans with multiple fields

of view, 2D panoramic imaging and optional one-shot cephalometric imaging

• Optimize your image quality and dosimetry

• Cut treatment time by 30% with SureSmile* certification

• Experience seamless integration

To learn more about what a great image can do for your practice, visit carestreamdental.com/cs9300 or call 800.944.6365 today

© Carestream Health, Inc 2013 10243 OR DI AD 0114

The CS 9300C Select is ready to work hard for your practice.

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* SureSmile is a trademark of OraMetrix.

8765_Bundle ad-Ortho-3.8x10.7_02.indd 2 1/2/14 2:39 PM

Figures 18A-18B: Patient II-TY 18A Note the development of black triangles was predicted in the lower anterior region using the Virtual Diagnostic Simulation (VDS) 18B These are also seen in the frontal intraoral image at the end of treatment

Figure 17: Patient II- T.Y Shows a comparison of the initial simulation (VDS) in green versus the final model (VFM) Note the initial plan was closely adhered to

ORTHODONTIC CONCEPTS

Figures 16A-16C: Patient II- TY 16A Debonded 4 weeks later 16B Final X-rays cephalogram and pano 16C Virtual final records achieved

1 Sachdeva R BioDigital orthodontics: Designing

customized therapeutics and managing patient

treatment with SureSmile technology: part 2

Orthodontic Practice US 2013;4(2):18-26.

2 Sachdeva R BioDigital orthodontics:

Diagnopeutics with SureSmile technology: part 3

Orthodontic Practice US 2013;4(3) 2013;4(3):22-30.

3 Sachdeva R BioDigital orthodontics: Outcome

evaluation with SureSmile technology: Part 4

Orthodontic Practice US 2013;4(4):28-33.

4 Sachdeva R BioDigital orthodontics: Planning

care with SureSmile Technology: Part 1 Orthodontic

Practice US 2013;4(1):18-23

5 Sachdeva R BioDigital orthodontics: Management

of Class 1 non–extraction patient with “Fast–Track” © –

six month protocol: Part 5 Orthodontic Practice US

2013;4(5):18-27.

6 Sachdeva R, Kubota T, Hayashi K BioDigital

orthodontics: Management of Class 1 non–extraction

patient “Standard–Track” © – nine month protocol:

Part 6 Orthodontic Practice US 2013;4(6):16-26.

7 Burstone CJ The segmented arch approach to

space closure Am J Orthod 1982;82(5):361-378.

8 Fontenelle A Challenging the boundaries of

orthodontic tooth movement In: Sachdeva RCL, ed

Orthodontics for the Next Millennium Glendora, CA:

Ormco Publishing; 1997: 248.

9 Sachdeva R, Bantleon H Cantilever based

orthodontics—biomechanical and clinical

considerations In: Sachdeva RCL, ed Orthodontics

for the Next Millennium Glendora, CA: Ormco

Publishing; 1997.

Conclusions

SureSmile technology, when used

appropriately within the framework of the

clinical pathway guidelines developed

by Sachdeva, offer a unique approach

to providing both efficient and effective

treatment of Class I patients requiring

extraction therapy

Future articles will provide more

clinical patient histories to demonstrate the

benefits of using SureSmile technology in

improving patient outcomes, providing it is

driven by a skilled clinician who is willing

to follow a proactive care approach to

managing patients

*Slideline is the length of the straight segment between

the teeth in a SureSmile archwire along which a tooth

may slide uninterruptedly.

Acknowledgments

The authors are most grateful to Con

Vanco, BDS, D Clin Dent, M Orth RCSEd,

MRACDS (Ortho), FRACDS, from Adelaide,

Australia, for sharing records of Patient

A.S for this paper

The authors also wish to thank Sharan

Aranha, BDS, MPA, for the invaluable

assistance she continues to provide in the

preparation of this series of articles

CS ORTHOTRAC CLOUD

Count on us for INNOVATIVE design

to keep your practice in the forefront

INTEGRATED software for seamless workflow, office to operatory

And INTERACTIVE products that promote better patient relationships

© Carestream Health, Inc 2013 OrthoTrac is a trademark

Introduction: The purpose of this study

was to survey orthodontists in North

America to assess the routine use of lateral

cephalometric radiographs in orthodontics

Methods: A 20-item survey questionnaire

was e-mailed to 2,215 randomly selected

active members of the American

Association of Orthodontists for 2013 The

questionnaire assessed the percentage of

patients on whom lateral cephalometric

radiographs were taken and to what extent

these records were being evaluated

Results: Of the 2,215 orthodontists

contacted, 232 completed the survey for a

response rate of 10.47%

• 60.34% reported always taking

“pre-treatment” lateral cephalometric

radio-graphs, and 38.53% reported always

performing a cephalometric “analysis” on

pretreatment cephalograms

• 30.30% reported always taking

“post-treatment” lateral cephalometric

radiographs, and 6.49% reported always

performing a cephalometric “analysis” on

post-treatment cephalograms

• 75.11% reported using centric occlusion

(maximum intercuspation), and 18.34%

reported using centric relation for patient

positioning in lateral cephalograms

• 37.95% reported at least inspecting

the lateral cephalogram for diagnosis

when a cephalometric “analysis” was

not performed, and 81.94% reported

using clinical findings over the lateral

cephalometric analysis when a disparity

existed between the two

• 68.47% reported using a digital-tracing software program, while 31.53% still utilize hand tracing

• 52.16% report having diagnosed pathology from a lateral cephalometric radiograph at some time in the past

Conclusion: This study demonstrated

the varying opinions of orthodontic practitioners on the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning There

is a current trend toward the utilization

of digital software and a decrease in the amount of practitioners routinely tracing lateral cephalometric radiographs

Introduction

Orthodontic diagnosis and treatment planning can be accomplished through the use of a multitude of orthodontic records

These records generally include a clinical exam, diagnostic study models, extraoral and intraoral photographs, a panoramic radiograph, and a lateral cephalometric radiograph.1 When considering all of the diagnostic information gained from these records, one may begin to wonder if all of this information is overlapping or does each piece individually lead us to a better and more thorough diagnosis of the patient

The cephalometric radiograph has been around for nearly a century since it was introduced by Broadbent in 1931.2

Since then, multiple cephalometric analyses have been developed to evaluate patients’

skeletal and dental patterns In practice, most orthodontists in the United States routinely obtain a lateral cephalometric radiograph with orthodontic records to use

in diagnosis and treatment planning

As with any medical radiograph, dental radiographs expose patients to ionizing radiation.3,4 Because of this, any unnecessary exposure should be avoided due to the cumulative effects

of radiation exposure The As Low

As Reasonably Achievable (ALARA) principle is a concept that recommends reducing ionizing radiation exposure to levels as low as reasonably achievable for minimization of potential risks and adverse consequences.5,6,7 As healthcare providers, orthodontists have the ethical obligation to do no harm to patients under the Hippocratic Oath With this in mind, orthodontists should always consider the amount of additional information that is gained by taking radiographs

A major problem that orthodontists sometimes face is conflicting data obtained from the various analyses of orthodontic records The soft tissue may present the clinician with one picture, the dental evaluation with yet another, and the skeletal evaluation with a third Not only can there be potential for variability in findings from different sources, but there can also be errors with each source For example, from one cephalometric analysis

it may be concluded that the patient is of

a certain dental or skeletal classification, whereas with another the exact opposite may be decided This can cause confusion when trying to properly diagnose and treatment plan a case, particularly for a new orthodontist So how does the clinician know how to prioritize information? If there is ambiguity, should the soft tissue dictate the treatment decisions? Should the cephalometric analysis? The answer is probably neither and both

Studies questioning the usefulness,

or validity, of different orthodontic records are not a new topic by any means It has been shown that variability exists on the intraexaminer8 (agreement among a single examiner) level and on the interexaminer9,10

(agreement among examiners) level when treatment planning Proffit11 attributes the difference in treatment opinions to the lack

of scientific data to support what works best under which conditions It has also

A survey of orthodontic practitioners regarding the

routine use of lateral cephalometric radiographs in

Matthew McCabe, DMD, MS, MBA, is in private practice

of Orthodontics and Dentofacial Orthopedics in Gautier,

Mississippi

Donald J Rinchuse, DMD, MS, MDS, PhD, is a Professor

and Graduate Orthodontic Program Director, Seton

Hill University Center for Orthodontics, Greensburg,

Pennsylvania.

26 Orthodontic practice Volume 5 Number 1

RESEARCH

been suggested that the cephalometric

radiograph is not essential for making

treatment planning decisions.12 In a

study by Han, et al.,8, it was found that

in 55 percent of patients, study models

alone provided adequate information for

treatment planning, and the incremental

addition of other diagnostic records

made minimal difference Nonetheless,

orthodontic clinicians continue to routinely

take cephalometric radiographs

Orthodontists are taught to gather

a plethora of information from the initial

records This is especially important for

new orthodontists with less experience

Once this clinical experience is gained, the

orthodontists’ judgment may be perceived

to be as accurate as the cephalometric

analyses.13 Therefore, rightfully or wrongly

so, an experienced orthodontist may

feel there is no need to collect all of the

Table 1: Respondents’ demographics

Age

14.66 % - 34 years or less 24.57 % - 35-44 years 25.86 % - 45-54 years 32.33 % - 55-64 years 2.59 % - 65 years or more

Years in practice

15.58 % - 4 years or less 14.29 % - 5-9 years 22.08 % - 10-19 years 48.05 % - 20 years or more

ABO certified

30.74 % - yes 48.48 % - no 20.78 % - in the process of becoming certified

Region of

residency training

25.65 % - Northeast 19.13 % - Southeast 33.04 % - Midwest 13.91 % - Northwest 7.83 % - Southwest 0.43 % - Canada

Region of practice

21.12 % - Northeast 22.84 % - Southeast 26.29 % - Midwest 18.97 % - Northwest 10.34 % - Southwest 0.43 % - other

records or to trace lateral cephalometric radiographs

According to the American Board

of Orthodontics (ABO), a fundamental component of orthodontic records includes the lateral cephalometric radiograph and tracing.14 However, in a recent study

published in the American Journal of

Orthodontics and Dentofacial Orthopedics,

it was suggested that the availability of a lateral cephalometric radiograph and its tracing did not make a significant difference

in treatment-planning decisions.15 Due to the tremendous confusion concerning what records are “necessary” from a medical/

legal standpoint verses a clinical one for diagnosis and treatment planning, a study

is needed to determine what orthodontic practitioners are doing in practice

Therefore, the primary goal of this study was to survey a representative sample of orthodontists in North America regarding the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning The aim of the study was not to determine whether it is good

or bad to use or not use cephalometric radiographs and tracings, but simply to determine what is being done in practice

Materials and methods

The research protocol was approved by the Seton Hill University Institutional Review Board Upon permission from the American Association of Orthodontists (AAO), a 20-item survey consisting of multiple-choice, Likert scale, and narrative questions was e-mailed to 2,215 randomly selected active members of the American Association

of Orthodontists The questionnaire was developed to assess in what percentage of patients’ lateral cephalometric radiographs are taken in practice and to what extent these records are being used for evaluation

In the survey, the first 14 items included questions regarding lateral cephalometric use in clinical practice The remaining six questions consisted of demographic information, such as age, years in practice, board certification, gender, area of residency, and area of practice

The survey was pretested with residents, full-time faculty, and part-time faculty at Seton Hill University Center for Orthodontics Minor changes and corrections were then made, and the survey was finalized The survey and supporting materials were then sent to a random sample of practicing orthodontists

in North America

The initial e-mail, containing a description and the actual survey, was sent out on February 26, 2013, and a reminder e-mail was sent approximately two weeks later on March 11, 2013 The survey was closed on April 10, 2013, and the responses were collected SurveyMonkey®

was used as the survey instrument and for data collection and analysis Descriptive statistics were used to analyze the data

Results

Of the 2,215 who were sent the survey, 232 responded for a response rate of 10.47% Table 1 summarizes the respondents’ demographic information, and important findings from the survey are listed in Table 2 The six demographic questions addressed gender, age, time in practice, ABO certification, region of orthodontic education, and region of practice

The results indicated the majority

of practitioners almost always took pretreatment lateral cephalometric radiographs 60.34% reported always doing so, and 34.05% reported doing

so in 66%–99% of patients The amount

of clinicians who traced pretreatment lateral cephalometric radiographs varied 38.53% reported always tracing them, 19.05% did so in 66%–99% of patients, and 25.97% reported doing so in 1%–32%

of patients The amount of clinicians who took post-treatment lateral cephalometric radiographs also varied 30.30% reported always doing so, 24.68% did so in 66%-99% of patients, 23.38% did so in 1%-32% of patients, and 14.29% never took post-treatment lateral cephalometric radiographs The majority of clinicians did not trace post-treatment lateral cephalometric radiographs, as 29.87% never did and 48.48% only did so in 1%-32% of patients The number of clinicians who used a cephalometric radiograph for diagnosis when no cephalometric analysis was performed varied greatly 37.95% reported always doing so, 16.07% did

in 66%–99% of patients, 17.41% did in 1%–32% of patients, and 20.09% never did Very few practitioners reported utilizing cone beam computed technology (CBCT)

to make lateral cephalometric radiographs 71.55% never did and 22.84% did in only 1%–32% of patients The majority of respondents selected all of the available choices when asked about reasons for taking lateral cephalometric radiographs 90.09% selected for better diagnostics, 81.90% selected to monitor growth,

and 75.86% selected for legal reasons (multiple answers were allowed here) The majority (75.11%) of practitioners reported using centric occlusion (maximum intercuspation) for patient positioning in lateral cephalometric radiographs Most (81.94%) reported going with clinical findings over the lateral cephalometric findings when a disparity existed between the two More clinicians (68.47%) reported utilizing digital tracing software programs over hand tracing In most offices (76.13%), the orthodontist completes the tracing instead of the staff Multiple reasons were selected for using a particular analysis 54.87% selected they use the analysis that works best based on their practice, 47.79% selected they use the analysis they learned in residency, and 18.14% selected they use the analysis the literature states is the most valid or reliable (multiple answers were allowed here) 52.16% reported diagnosing pathology on a lateral cephalometric radiograph at some time in their career Lastly, the majority of clinicians strongly agree (32.03%) or somewhat agree (36.80%) that cephalometric tracing

is important in making treatment decisions

di-The results of this study demonstrate that the majority of orthodontic practitioners are routinely taking “pretreatment” lateral cephalometric radiographs A total of 60.34% of respondents reported taking them on all patients, and 34.05% reported taking them on at least 66%-99% of patients This finding was in line with what was expected It was also found that 38.53% of the respondents routinely performed a cephalometric analysis on all pretreatment lateral cephalometric

Table 2: Cephalometic radiograph data summary

% of patients in which a pretreatment lateral

cephalometric radiograph is taken

0.86% – in 0% of patients 3.02% – in 1%-32% of patients 1.72% – in 33%-65% of patients 34.05% – in 66%-99% of patients 60.34% – in 100% of patients

% of patients in which a pretreatment

cephalometric analysis is performed

7.79% – in 0% of patients 25.97% – in 1%-32% of patients 8.66% – in 33%-65% of patients 19.05% – in 66%-99% of patients 38.53% – in 100% of patients

% of patients in which a post-treatment lateral

cephalometric radiograph is taken

14.29% – in 0% of patients 23.38% – in 1%-32% of patients 7.36% – in 33%-65% of patients 24.68% – in 66%-99% of patients 30.30% – in 100% of patients

% of patients in which a post-treatment

cephalometric analysis is performed

29.87% – in 0% of patients 48.48% – in 1%-32% of patients 9.09% – in 33%-65% of patients 6.06% – in 66%-99% of patients 6.49% – in 100% of patients

% of patients in which a cephalometric

radiograph is used for diagnosis when no

analysis performed

20.09% – in 0% of patients 17.41% – in 1%-32% of patients 8.48% – in 33%-65% of patients 16.07% – in 66%-99% of patients 37.95 % – in 100% of patients

% of patients in which a CBCT is used to make a

lateral cephalometric radiograph

71.55% – in 0% of patients 22.84% – in 1%-32% of patients 0.86% – in 33%-65% of patients 2.16% – in 66%-99% of patients 2.59% – in 100% of patients

Reasons for taking lateral cephalometric

radiograph (multiple answers allowed)

90.09% - for better diagnostics 81.90% - to monitor growth 75.86% - for legal reasons 11.21% - other

Patient positioning for lateral cephalometric

radiograph

75.11% - centric occlusion (maximum intercuspation) 18.34% - centric relation

6.55% - other

Reason for using an analysis (multiple answers

allowed)

54.87% - use analyses that work best based on their practice 47.79% - use analyses they learned in residency 18.14% - use analyses that literature states is most valid/reliable 11.06% - other

Diagnosed pathology from a lateral

Agree or disagree that cephalometric tracing is

important in making treatment decisions

9.96% - strongly disagree 9.09% - somewhat disagree 12.12% - neutral 36.80% - somewhat agree 32.03% - strongly agree

28 Orthodontic practice Volume 5 Number 1

RESEARCH

radiographs; 19.05% on 66%-99% of

patients; 8.66% on 33%-65% of patients;

25.97% on 1%-32% of patients; and

7.79% on none at all According to a

similar study performed by the Journal

of Clinical Orthodontics (JCO) in 200818,

74.2% reported routinely performing a

cephalometric analysis on pretreatment

cephalometric radiographs This was

down from 82.2% in 2002 and 89.9%

in 1996 These findings demonstrate

that although clinicians are still routinely

taking pretreatment lateral cephalometric

radiographs, they are selectively choosing

on which patients to perform a pretreatment

cephalometric analysis

According to Silling, et al.,13, the

priority given to cephalometric analysis

in treatment planning seems to vary

considerably Some practitioners feel that

it is indispensable in every case Others

are of the opinion that it is useful to them

only in specific instances or in particular

types of malocclusion Obviously, many

factors influence the extent to which

an orthodontist relies on cephalometric

analysis in arriving at a treatment plan

The most important of these are probably

educational background and degree of

experience

In today’s age of technology,

digital radiographic systems and digital

tracing software programs are rapidly

replacing traditional hand tracing of lateral

cephalometric radiographs These digital

images offer several advantages over

conventional film-based radiography: faster

data processing; elimination of chemicals

and associated environmental hazards;

and the ability to alter and improve the

image and correct for exposure errors,

thus virtually eliminating the need for a

second exposure.19,20,21 Digital radiographic

images are easy to store and facilitate

communication between healthcare

providers Additionally, depending on the

system used, they can require lower levels

of radiation.22

The findings of this study illustrate the

trend away from hand tracing of lateral

cephalometric radiographs Of those who

traced, 68.47% reported doing so utilizing

a digital software tracing program, and

only 31.53% reported still hand tracing

These findings illustrate the increased use

of digital technology in practice today and

are in agreement with the results obtained

in the 2008 JCO study.18 They found the

percentage of orthodontists still hand

tracing cephalograms to be 28.7%, which was down from 48.0% in 2002 and 61.2%

in 1996

The increased use of digital radiography and digital software tracing programs has elicited some clinicians to critically examine the reliability of this new technology For example, Santoro, et al.,21

assessed the accuracy of digital and analog cephalometric measurements Although digital imaging introduces new errors, such as resolution, pixel size, shades

of gray, and so forth, the differences noted between cephalometric measures identified on digital images compared to manual tracing of conventional films were clinically insignificant It was concluded that both methods could be safely regarded as reliable

It seems logical that if radiographic records are taken, we are examining them at a minimum A total of 52.16%

of the respondents in this study reported diagnosing pathology from a lateral cephalometric radiograph at some point

in their career This value was higher than originally expected but illustrates one of the additional values of the lateral cephalometric radiograph In addition, potential legal implications may be involved

in the event of missing a diagnosis that was present on records taken but not examined

Nijkamp, et al.,12 goes as far to suggest that cephalometric radiography is only justified if it directly influences information

on non-radiographic records used for orthodontic treatment planning With the

This study demonstrated the varying opinions of orthodontic practitioners on the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning There

is a current trend toward the utilization

of digital software and a decrease in the amount of practitioners routinely tracing lateral cephalometric radiographs.

multiple treatment records available for orthodontic evaluation, it is important to ensure that orthodontists are using all of the records they have decided to take in diagnosis and treatment planning Also, we are in a time when more attention is given

to ionizing radiation than ever before, so orthodontists should be judicious in their use of cephalometric radiographs and ensure they benefit treatment decisions

If these records are being taken but not evaluated, orthodontists must decide the worth of putting patients through the additional radiation exposure created when taking lateral cephalometric radiographs

If these records are being evaluated and used in diagnosis and treatment planning, the justification for their routine use is warranted

As 51.52% of the respondents reported being board certified or in the process of becoming certified, lateral cephalometrics will continue to be an important piece of the “gold standard” for orthodontic records, as per the AAO Clinical Guidelines.14 As a requirement for case submission for board certification with the American Board of Orthodontics, pretreatment and post-treatment lateral cephalograms will most likely continue to