Orthodontic practice US

Orthodontic practice US 10 2013 vol4 No 5 Tạp Chí Chỉnh Hình Răng Miệng 10-2013

PAYING SUBSCRIBERS EARN 24

CONTINUING EDUCATION CREDITS

for dentists: dental

sleep medicine: part I

Dr Bradford Edgren

Treating digitally and the new orthodontic practice

Dr Randall Moles

Twins Digital Auxiliaries Practice Development Education

Twins Digital Auxiliaries Practice Development Education

Self Ligation Aligners Tubes/Bands Archwires Lab Products ormco.com

Damon® Clear™ is the self-ligating bracket whose

beauty is more than skin deep Validated by

multi-site in vivo studies and third-party research*,

Damon Clear combines the look image-conscious

patients demand with the strength discriminating

clinicians need Its crystal-clear design is resistant

to staining, while its robust construction facilitates

effective torque expression and rotation control for

meticulous fi nishing And now, with Ormco Lifetime

Rewards, self ligation is more attractive than ever

Earn points to redeem for free products and seminars.

Advanced Aesthetics – Uppers and Lowers

Crystal-clear appliance with innovative SpinTek™ slide for effi cient wire changes

On Both Arches

*Clinical research and performance data available at ormco.com/damonclear

January 15–18, 2014 Phoenix, Arizona

Register at damonforum.com

Twins Digital Auxiliaries

Practic

e Development Educa

tion

Self Ligat ion

Aligners Tubes/

Bands Archw

ires Lab Product

s

Year after year, thousands of orthodontic professionals have attended the

through 30 plus interactive sessions for clinicians, treatment coordinators,

front office staff and chairside assistants.

Register your practice today and learn new treatment modalities, progressive

technologies and practice differentiation strategies.

Register Today damonforum.com

ormco.com

October 2013 - Volume 4 Number 5

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

Email: lmoler@medmarkaz.com Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell Fernández

Email: kay@medmarkaz.com Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross

Email: mandi@medmarkaz.com Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning

Email: michelle@medmarkaz.com Tel: (480) 621-8955

NATIONAL SALES/MARKETING MANAGER

Drew Thornley

Email: drew@medmarkaz.com Tel: (619) 459-9595

PRODUCTION MANAGER/CLIENT RELATIONS

Adrienne Good

Email: agood@medmarkaz.com Tel: (623) 340-4373

PRODUCTION ASST./SUBSCRIPTION COORD

© FMC 2013 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.

I’ve been practicing orthodontics for more than 40 years, and one of the most important things I’ve discovered is that your practice and the patients whose lives you change are your legacy The ability to provide patients with enhanced self-esteem, build lifelong relationships, and create an environment that nurtures a “practice family,” is a gift that we have the opportunity to take advantage of

I run a high-tech practice where we treat with Ormco’s Damon® System, Insignia™Advanced Smile Design™, and Lythos™ Digital Impression System The progressive technology helps us deliver patients the best possible care with comfort and speed, but, our treatment philosophy extends far beyond straightening teeth Our mindset is whole-health treatment I encourage all to consider this approach From breathing habits to sleep concerns and tongue thrust, we’re looking to improve each patient’s quality of life.Yes, we all need to make a living (there is no denying that!), but not all decisions can be driven by the bottom line I’m an advocate for treating patients and team members like family, which requires investing time At our office, we start every day with a morning huddle and end it with a prayer Our objective is to keep the truth that we are here to serve our patients and our community top-of-mind Our motto is “Enriching lives and smiles.” It’s all about investing in the people around you As my team says, “We’re not saving lives here, but we are changing them!”

The profit/loss numbers cannot be ignored, but what stays with you is how you’re able to change lives in a profoundly positive way My advice: take the time to be involved in your community, be a mentor, and care deeply about your team and your patients — it will be your legacy

Dr Jim Lyles

Dr Jim Lyles has been practicing orthodontics for more than 40 years and treats patients at Smiles by Lyles Orthodontics in Spring, Texas Dr Lyles assembled a group of exceptional restorative dentists and dental specialists with the purpose of continued growth and education in the field

of dentistry He served with the Air Force Reserve and spent 4 years with a MASH unit, completing military service with the rank of Major

Dr Lyles began college at the age of 17 with two scholarships and majored in dental medicine at the University of Texas After completing undergraduate studies at University of Texas, Dr Lyles continued with 4 years of dental school at the University of Texas Dental Branch in Houston He is an active member of the American Association of Orthodontists and a past-president of the Houston Regional Society of Orthodontists.You can visit Dr Lyles’s website at: http://www.smilesbylyles.com

pre-Investing in your legacy INTRODUCTION

To learn more about NEW suresmile 7.0 or request

Clinical Report No 2, call 877.787.7645

Dr Melisa Rathburn

Atlanta, GA

BioDigital Orthodontics:

Management of Class I non extraction patient with “Fast– Track”© – 6-month protocol: part 5

Dr Rohit C.L Sachdeva discusses a treatment for Class I non-extraction

Drs Shalin Shah and Ryan Tamburrino: Center for Orthodontic

Excellence

These analytical, intellectual, and business-savvy clinicians have found their

purpose in serving their patients and their community.

• One system with superior 3D exams 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

• Make accurate assessments and diagnoses

• Experience seamless integration

To learn more about what a great image can do for your orthodontic

practice, visit carestreamdental.com/3DOP or call 800.944.6365 today

© Carestream Health, Inc 2013 9438 OR 93 AD 0713

The CS 9300C Select is ready to work hard

for your practice.

This technologically-advanced system will finally give you clarity, flexibility

and, most importantly, complete control of your image quality and dosimetry

It will also show your patients how dedicated you are to their dental health.

It’s amazing what a great image can

do for your practice.

Continuing

education

The frontal cephalometric analysis

– the forgotten perspective

Dr Bradford Edgren delves into the

A golden opportunity for dentists:

dental sleep medicine: part I

Dr Harold F Menchel offers a

wake-up call to clinicians to explore an

Research

TMD/orofacial pain survey of

orthodontic residents in the U.S

and Canada

Drs Amanda Guess, Mark Causey,

John Stockstill, Donald Rinchuse,

and Eladio DeLeon explore dental

students’ education regarding

occlusion, TMD, and orofacial pain

Treating digitally and the new orthodontic practice

The art of orthodontic efficiency

Dr Neil Warshawsky discusses the

Product profile

Reliance Orthodontic Products addresses today’s problems with effective solutions 56

H4™ Self-Ligating Bracket System

Book review

Orthodontics, Volumes I, II and III

By Dr Chris Chang and Dr W

Apply current tax laws to improve patient care

Bob Creamer explains Section 179

Practice management

New office or major renovation?

Andrew Greene offers some tips to take the stress out of planning a new

Materials &

Touch the Future with the New DENTSPLY GAC

Insider Knowledge

Outside-the-Box Thinking.

You already know how the DENTSPLY GAC legacy has shaped the practice of orthodontics Now discover how our visionary thinking will shape the future of orthodontics We’re developing new products that will help you practice more efficiently and effectively We’re generating practice building programs to help you foster new business relationships and create new revenue streams And we’re pursuing educational ideas that will inspire new ways to approach each case Stay in contact with what matters and touch the future with DENTSPLY GAC

800.645.5530 newdentsplygac.com

Trusted Products Powering Practice Growth

Advancing the Art of Orthodontics

13-DGAC-117 Visionary Male Ad - Oct OP FA HR.pdf 1 9/18/13 9:50 AM

What can you tell us about your

background?

Shalin Shah (SS): Although my wife

brought me to settle down in New Jersey,

I am a true Philadelphian at heart Having

grown up in the suburbs of Philadelphia

and gone to the University of Pennsylvania

for all my education (where I also met my

future wife), I am a die-hard fan of all things

Philadelphia, especially the sports teams

Ryan Tamburrino (RT): I am a Pittsburgh

boy who still holds a strong allegiance for

my Pittsburgh sports teams, even though

my wife brought me to the eastern part of

Pennsylvania I traveled out of the state for a

brief period to complete my undergraduate

training at Duke University, but I eventually

returned to the Keystone State for my

dental and orthodontic education at the

University of Pennsylvania

Remarkably, we both agree on almost

everything that we jointly undertake, but

neither of us is willing to give in that the

other’s city has the best sports fans!

Why did you decide to focus on

orthodontics?

Our love of orthodontics stems from a

variety of passions The most important to

us is giving each person the ability to love

his smile The profession as a whole has

many opportunities and challenges, which

allows us to draw upon our non-traditional

backgrounds and interests while keeping

us excited at the same time Orthodontics

is unique in that every case allows us to

continue to hone our analytical skills,

develop our intellectual curiosities, and

fine-tune our business skills from marketing

to IT to negotiations Every day is a true joy!

How long have you been

practicing, and what systems do

you use?

The Center for Orthodontic Excellence

looks to bring patient service, peer

education, and orthodontic solutions

together to provide patients with the best

possible care utilizing the latest technology

All three areas are interests of ours, and we

view the merger of the three as synergistic

We also look to effectively integrate Shalin’s

focus in the basic sciences with Ryan’s passion for clinical application to develop novel methods and products

The practice has been operational out

of two major locations for the last 2 years

The systems we use include the In-Ovation®bracket system (Dentsply GAC), i-CAT®FLX (Imaging Sciences International), topsOrtho™, AD2 articulators, Quick Ceph® (Quick Ceph Systems, Inc.), and Anatomage, among many other products and systems We remind ourselves, as well

as our students, that it is not the system that makes a great orthodontist Rather, it

is a comprehensive understanding of how

to use what you have (strengths and limits)

to meet the needs of your diagnoses and treatment plan

What training have you undertaken?

We bring a unique educational background

to the Center for Orthodontic Excellence

Both of us completed our dental school and orthodontic training at the University

of Pennsylvania While in orthodontic residency, we also both pursued additional training in functional occlusion through

a 2-year program in Detroit, Michigan

(Advanced Education in Orthodontics),

as well as completing both Andrews’ Six Elements of Orofacial Harmony and Tim Tremont’s Four Faces of Orthognathic Surgery courses

Ryan attended Duke University for his undergraduate education His extensive background in Biomedical Engineering and Mechanical Engineering/Material Science has led him to new innovations and research in the field of orthodontics Additionally, he has leveraged this extensive education to develop two patent pending devices to date and author several manuals and articles, as well as a textbook chapter

Shalin attended University of Pennsylvania for his undergraduate education His passion for basic science research led him to pursue a Masters of Science in Oral Biology while completing his orthodontic residency Additionally, while

at Penn, he achieved his board certification from the American Board of Orthodontics, which made him the second person in the history of the department to complete such

a feat Shalin’s interest in research led him

to accept a position as Abstracts Editor for

a peer-reviewed orthodontic journal

Drs Shalin Shah and Ryan Tamburrino

PRACTICE PROFILE

Center for Orthodontic Excellence

Dr Tamburrino (left) and Dr Shah (right) took their friendship and mutual aspirations to the next level by partnering to provide the highest quality of orthodontic care at the Center for Orthodontic Excellence

PRACTICE PROFILE

Between Ryan and Shalin, they have

earned 12 additional certifications in pursuit

of excellence in diagnosis, treatment

planning, and care for their patients

Who has inspired you?

We are very fortunate to come from loving

and supportive families They are the base

of our success and everyday happiness

They challenge us to be better people

and practitioners while accepting our long

workdays dedicated to orthodontics and

our patients

We both are also very fortunate to

have been the students of Dr Robert L

Vanarsdall, the Penn Faculty, the Advanced

Education in Orthodontics faculty, Drs

Lawrence and Will Andrews, and Dr

Timothy Tremont Each milestone reached,

each concept learned, and each novel

thought/product developed is a result of

the unparalleled dedication and interest

these people have had in our personal and

professional growth Henry Brooks Adams

once said, “A teacher affects eternity; he

never knows where his influence stops.”

We can say that what they have taught us

will continue to influence throughout our

careers

What is the most satisfying aspect

of your practice?

Coming to work every day knowing we

are making a real and tangible difference

in our patients’ lives and doing something

we love to do, which doesn’t feel at all like work We have found our purpose to serve our patients and the communities within which they operate, and nothing can be more professionally satisfying

Professionally, what are you most proud of?

Although we are honored to be orthodontists serving the community and profession, we are most proud of being

on the Penn Orthodontic faculty and lecturing/growing to/with their peers We are Clinical Associates in the Department

The exterior of the office is in harmony with the heritage of the building’s rich history

The doctors blended the rustic feel of the old barn with modern decor for a warm, unique feel The private treatment area still offers spacious comfort

and views of the barn’s old stone walls

of Orthodontics teaching alternate weeks (one day/week) Our primary responsibilities include overseeing orthodontic cases treated by residents, lecturing to orthodontic residents, lecturing to dental students, and mentoring orthodontic resident research

We view teaching as a privilege and a way to be involved with the future of the orthodontic and dental professions It is truly a humbling experience

What do you think is unique about your practice?

Although, we have two practices (Philadelphia and Princeton Junction), our

PRACTICE PROFILE

Princeton Junction office is a practice that

was truly built from scratch Below are a

few facts about our Princeton Junction

office that make it unique:

1) Green technology, including a floor

made of 30% recycled material that

possesses antibacterial and antiviral

properties

2) Built in a building pre-dating 1929 It

was initially a potato barn and then sold/

leased to an exotic car photo shoot

studio In fact, the garage door that

served as the entrance into the building

was present until November 2011

Thereafter, it was leased to a hard rock

entertainment label company We like

to say that is now inhabited by the two

most exciting guys, the orthodontists!

3) The office includes a lecture area with

future plans to have live video feed and

TVs at each chair for teaching purposes

4) Music is customizable in different areas

of the office per patients’ requests

5) The entrance area features a life-size

wine barrel from the Napa Valley (empty

of course)

6) Patients experience an audiovisual

experience during their consults via

a 52-inch LED TV that also has 3D capabilities

8) The main treatment bay includes a wave architectural piece that is almost 30 feet in length and suspended from the high ceilings The wave is comprised of the three horizontal lines representing the company’s three lines of business – lines also seen in the Center for Orthodontic Excellence logo

What has been your biggest challenge?

As mentioned above, we love what we do every day The biggest challenge is for us

to remember to maintain balance with all

of the things we have going on in our lives both personally and professionally There has been many a time that our spouses (who are equally career-oriented) have reminded us to come home for dinner!

What is the future of orthodontics and dentistry?

The future of orthodontics and dentistry

is rooted in innovation, and being lifelong

learners and critical thinkers Innovation extends to the way we diagnose and treatment plan to actual treatment modalities Our efforts should lead to reduced treatment time while providing longevity, stability, and predictability in the smiles we create Collecting long-term data points will help better understand effective treatment It is also remiss of us not to look

to history for answers to future questions Being lifelong learners and critical thinkers enables us to draw upon successful thoughts and techniques to better what we

do and can deliver to our patients

What are your top tips for taining a successful practice?

main-In today’s ever busy and hectic world, our patients and their caregivers are busier than ever We are figuring out ways to give patients an amazing and convenient experience while still giving them the right solution It is a difficult balancing act but

a very important one nonetheless Also,

in today’s “all things digital and mobile age,” there are so many ways to reach your patients and prospective patients,

At the Princeton Junction train station, the office’s signature orange color and striking ads from 7Group signify a different and wonderful experience awaiting future patients

3) Hanging out with our families and friends

4) Music – listening to it, dancing to it, and making it

5) RT: Cookies – if it’s a good tasting

cookie, it must be eaten Although,

I love the traditional chocolate chip, there is no cookie I won’t try (and enjoy)!

SS: Jimmy Johns’ sandwiches – a

new location opened near our Princeton Junction office, and I cannot get enough

6) Sharing our learning with our professional peers throughout the world

7) Kids! Our patients as well as our own!

8) Pizza - especially fresh made Brooklyn pies! Come visit, and we will make sure you get to enjoy as well!

9) Talking about orthodontics all the time!

10) Hearing young people say they want

to be orthodontists!

Dr Shah and his wife, Neha, along with their two boys, Aidyn and Kaayan

Dr Tamburrino and his wife, Shazia

so embrace technology in your marketing

efforts, patient experience, etc

Our vision statement sums up our

goals for the future of the practice:

Excellence defines us!

Our vision is to always exceed expectations

and the standard of care by passionately

delivering orthodontic treatment with

outstanding service and a personalized

touch It is our goal to get to know our

patients and make them feel excited about

the benefits of orthodontics

Through advanced training and

technology, we strive to provide

individualized care and achieve functional

and esthetic goals for each patient We

diagnose the entire orofacial system we

go beyond simply straightening teeth

Orthodontics is a team effort With our

support and through our best efforts, both

adults and children will actively participate

in their care, maintain a lifelong interest in

their long-term health, and enthusiastically

refer friends and family

We work in concert with a community

of professionals who mutually seek out and

demand the highest caliber of treatment,

service, and results for their patients and

loved ones

Everything that we do makes a

difference.

In this recovering economy, what

are you doing to grow the business

side of your clinical practice?

In a time of challenging economics, it’s

been important for to us to grow our visibility

by creating a strong brand identity, which

differentiates us from our competitors As

others decrease their marketing budgets,

it opens opportunities for us to expand our

market share Being creative and innovative

in terms of our messaging and use of new marketing channels was a very high priority for us We wanted to think outside the box

to add the element of surprise So far, the feedback from the community has been very positive

What advice would you give to budding orthodontists?

Always invest in your knowledge and skills to remain at the cutting edge of the profession, and most importantly, to allow yourself to give the best solution to your patients We don’t believe in cutting corners and always think about the long-term consequences of our actions

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

RT: Professional golfer Shalin describes

my drives as sounding like a shotgun blast

You can ask me to play golf in any weather and any temperature, and my answer is always a resounding “Yes!” (Comment from SS): It should also be noted that at

a recent team-building event, Ryan did demonstrate amazing bowling skills! He was a varsity letter recipient for bowling and golf all 4 years in high school, but when asked he undeniably says golf is his true passion!

What are your hobbies, and what

do you do in your spare time?

RT: I love to golf, cook, and spend time

with my wife and two cats I am also an expectant father so I am getting in my extra sleep right now!

SS: I love to snowboard and play most

sports (the more extreme the better) as well

as spending quality time with my wife and two young boys (ages 3 and 1) I also enjoy being an amateur DJ, a hobby I started during my college days at UPENN OP

You could Find the waY on Your own

but we’ll get You there Faster.

How do you plan on reaching your practice destination? are you taking a confident and proactive route, or do you find yourself constantly reacting to unforeseen detours?

the challenge is you can only do so much at one time You’re lacking time in some areas and expertise in others You want to keep control without getting bogged down in the details

orthosynetics is the company you’ve been looking for we assist orthodontic and pediatric dental practices with business, marketing and administrative functions

bring orthosynetics on board, and we’ll help you accelerate towards your goals.

OrthoSynetics and You Together We Can Make It Happen.

877-OSI-1111 www.OrthoSynetics.com

With roots that can be traced back to

the 19th century, Carestream Dental

certainly has a long history of innovation

when it comes to dental specialties —

including orthodontics This legacy still

carries on, as the company continues to

develop imaging systems and software

and enter new markets It’s because of this

proud tradition that more than 800 million

images are captured each year on products

from the company’s imaging portfolio

Today, Carestream Dental is focused on

providing orthodontists with the products

they need to facilitate treatment planning

and improve patient care

History of Carestream Dental

The Carestream Dental of today was

built on the shoulders of major industry

leaders of the past — starting in 1896

when Eastman Kodak introduced the first

photographic paper designed specifically

for dental X-rays As technology improved

and became more digitalized, Trophy

Radiologie filed a patent for the world’s

first digital intraoral sensor in 1983 Already

known for producing intraoral X-ray

generators, the digital intraoral sensor

earned Trophy a reputation as the world’s

leader in dental digital radiography On the

practice management front, OrthoTrac

became the first practice management

software developed specifically for

orthodontists in 1982

In 2000, PracticeWorks emerged as a

dominant dental software company when it

acquired several other software companies

PracticeWorks went on to acquire Trophy

Radiologie in 2002 and was purchased the

next year by Eastman Kodak to expand

their presence in the dental business With

the integration of PracticeWorks/Trophy,

Eastman Kodak built the industry’s leading

portfolio of film, digital imaging systems,

and practice management software Then,

in 2007, Onex Corporation purchased

Kodak’s Health Group, and Carestream

Dental was born

The Carestream Dental Factor

“We exist to make your practice better,”

said Marc Gordon, Carestream Dental’s General Manager, U.S Equipment and Software “Our number one goal is to make user-friendly, yet sophisticated, technology

to put our customers’ practices at the forefront.”

Carestream Dental’s dedication to advancing orthodontics can be summed

up by the Carestream Dental Factor; three pillars on which the company bases all of its products and services Incorporating the key elements at the heart of Carestream Dental’s philosophy, the company’s main focus is on delivering workflow integration, humanized technology, and diagnostic excellence

Workflow integration: Administrative

tasks cut into time that can be better spent communicating with and treating patients

For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy orthodontic practices Ensuring that every link in the chain fits and contributes to the workflow as a whole allows orthodontists

to increase productivity and efficiency

Intuitive technology and software are the hallmarks of Carestream Dental By developing imaging systems that can be

quickly utilized by practitioners — and are even compatible with third-party products

— users can eliminate time that would have been spent troubleshooting problems and instead focus on patients

Humanized technology: Patients are an

integral part of every orthodontic practice,

so Carestream Dental is committed

to providing solutions that facilitate communication between the orthodontist and patient When communication is optimized, patients are happier and healthier — allowing them to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance

Diagnostic excellence: Details are

everything when it comes to planning orthodontic treatments To facilitate faster, more reliable treatment planning,

CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

CS 9300C panoramic image

CS 9300C Autotracing image

CORPORATE PROFILE

Carestream Dental has created a number

of cutting-edge diagnostic tools that enable

orthodontists to capture sharp, high-quality

images quickly From industry-leading

3D imaging systems to comprehensive

imaging software, Carestream Dental

offers a range of solutions that allows

orthodontists to identify areas of concern

and determine the best course of action

Technology developed for

clini-cians, by clinicians

The Carestream Dental Factor isn’t the only

thing driving user-focused and innovative

products and services — the clinicians at

the heart of the company also play a large

role Through meetings and forums with

doctors in the field, Carestream Dental

is better able to understand the needs of

orthodontists in order to develop — and

modify — products In fact, the voice of the

customer (VOC) is critical throughout the

development process

To ensure quality, Carestream Dental

also manages every aspect of the products

they develop “We are the only company that

is designing its own practice management

software and imaging equipment,” said

Mr Gordon “By controlling every step in

the process — from development and

manufacturing all the way to support — we

make it easier for orthodontists to deliver

better patient outcomes.”

Innovative products to facilitate

orthodontic treatment planning

Orthodontists require high-resolution

images to evaluate the trajectory of

the teeth and identify any unexpected

pathologies during treatment planning —

something that Carestream Dental certainly

delivers The following is just a sample of

the imaging products Carestream Dental

has designed to meet the specific needs of

orthodontic practices:

CS 9300C: As a three-in-one unit, the

CS 9300C allows users to select from

panoramic, cone beam computed

tomography (CBCT), and true

cephalometric imaging Users can also

choose from seven selectable fields of view

(ranging from 5 cm x 5 cm to 17 cm x 13.5

cm), or four selectable fields of view for the

Select model (5 x 5 cm to 10 x 10 cm),

to tailor their image based on the specific

clinical application And, the system

features Intelligent Dose Management for

greater control over patient exposure

The CS 9300C’s one-shot

cephalometric imaging technology provides orthodontists with an exclusive full cranial option as well as addresses all orthodontic diagnostic and tracing needs through auto-landmark detection The system is also certified for use with SureSmile technology

to proactively develop effective treatment plans

CS 3D Imaging software: Included

with Carestream Dental’s CBCT imaging units, CS 3D Imaging software allows practitioners to view images slice by slice

in axial, coronal, sagittal, cross-sectional, and oblique views to enhance diagnostic interpretation In addition, the images can

be saved to a CD/DVD or USB drive with

a complimentary copy of the software to share with the referring doctor — improving the colleague collaboration process

CS OrthoTrac Cloud: For over 30 years,

OrthoTrac has helped orthodontists build and maintain productive and efficient practices Now, with the Cloud version

of this practice management software, orthodontists gain 24/7 access to their patient files and 2D images from any web-connected location or device

— including PCs, Macs®, iPads® and tablets—while eliminating many of the costs associated with IT infrastructure and server maintenance In addition, all patient information storage is HIPAA compliant and backed by Carestream Dental, ensuring that the data is protected

Comprehensive educationWhen orthodontists understand how to fully maximize their imaging capabilities, they are better able to get the most out of their equipment For this reason, Carestream Dental is committed to providing thorough training and education to ensure their customers have the skill and knowledge necessary to use their imaging products and software

In addition to providing web-based and in-person training, Carestream Dental

holds a dedicated Orthodontic Users conference each year featuring a number

of hands-on classes as well as a 3D Symposium, where practitioners can learn how to use 3D imaging equipment in their daily practice This event features leaders

in the industry who share advice and insights, as well as information on the latest industry trends in 3D to make participants’ practices more efficient and successful

Next stepsWith the launch of CS Solutions, a one-appointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market — and it certainly will not be the last As an integrated, open-architecture system, practitioners can scan

an impression with a CBCT unit, design the crown, using the CS Restore software, and mill the crown in-office with the CS 3000 milling machine

CS Solutions also features an intraoral scanner — the CS 3500 Handheld and truly portable, the CS 3500 requires no trolley, external heater, or powder to capture true-color 2D and 3D image scans In addition, the scanner’s light guidance system lets practitioners know when scanning is successful, so they can focus more on their patient and less on the monitor

As always, Carestream Dental will continue to focus on customer service

“Our number one goal is to provide superior customer experience through best-in-class products and best-in-class support,” said

Mr Gordon

To learn more about Carestream Dental’s portfolio of imaging products and software for orthodontic practices, please call 800-944-6365 or visit carestreamdental.com

This information was provided by Carestream Dental.

OP

The use of “bite turbos” to help

maintain bite opening during aspects

of orthodontics has become a relatively

routine aspect of treatment Bite turbos

can have some orthodontic biomechanical

advantages when using elastic wear during

Class II or Class III correction In addition,

there are some claims that by “unlocking”

the occlusion, teeth move more freely

and this, thereby, shortens treatment

time From a practical viewpoint, they can

facilitate bonding both the upper and lower

arches, and help prevent the patient from

shearing off brackets

Bite turbos can be placed on the

lingual surface of the upper incisors, or they

can be placed on the posterior teeth Using

the posterior teeth to open the bite can be

achieved by using stainless steel crowns or

by bonding resin material to the occlusal

surface

While posterior “bonded resin” bite

turbos have become very common among

orthodontists, there are a few side effects

and cautions that one needs to be aware

of First, discluding the posterior teeth

will make chewing very difficult In rare

instances, this can create a choking hazard

for younger patients as well as potential

digestive problems Second, when

placed on posterior teeth, bite turbos can

cause fremitus and pain due to traumatic

occlusion Third, it may be a contributing

factor to exacerbation of TMD in a patient

who may be sensitive in the TMJ Fourth,

they can cause unwanted tooth intrusion,

and depending on where the bite turbo

is placed on the posterior tooth surface,

unwanted root movement can occur

The following cases demonstrate that

placing bite turbos can cause unwanted

tooth movement In case No 1, bite turbos

were placed on the mesial aspect of the lower first molars and caused unwanted

distal root movement into the mesial root

of the lower second molar The taller the bite turbo, the more adverse movement one can expect

Case No 2 shows an intrusive movement of a posterior single-rooted tooth Generally, bite turbos should be reserved for posterior molars, but in this case, they were placed on the second

bicuspids due to missing posterior molars

on the lower left side While this movement can be corrected, we question the added stress placed on the root or roots of the affected teeth

Ultimately, bite turbos do have many positive effects and are an important tool for orthodontists, but clinicians must be aware of the adversities that may present when using posterior bite turbos

Bite turbos

CASE STUDY

Drs Nathan Yetter and Donald J Rinchuse discuss the pros and cons of bite turbos

Nathan Yetter, DDS, is senior orthodontic resident at

Seton Hill University, Greensburg, Pennsylvania.

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

and Graduate Orthodontic Program Director, Seton Hill

University, Greensburg, Pennsylvania.

Case No 1 (Figures 1A and 1B)

Case No 2 (Figures 2A-2E)

Missing Teeth? Want Aesthetics and Simplicity?

Beautiful aesthetics for missing teeth is now Easy, Fast, Perfect!

For more information, contact…

(800) 323-4348 • (630) 773-4009 • Fax (630) 250-7704

www.relianceorthodontics.com

Perfect A Smile™

• Missing or lost teeth during clear aligner therapy.

• Temporary teeth during bone graft healing.

• Implant restorations after placing posts.

• Congenitally missing teeth.

• Developed by Orthodontist Dr Laurel Martin, Perfect A Smile™ is the

easy fast solution for pontic replacement of missing teeth

• Perfect A Smile™ bonds directly to clear thermoplastic aligners – no

conditioner or plastic preparation is needed Simply paint the inside

of the aligner tooth socket and light cure

• Perfect A Smile™ flexes with the plastic and will not fail due to stress

or flex

• Available in 3 shades; Light, Medium and Dark You can mix paint for custom shades if required

Temporary anterior teeth for implant patient

In previous articles, the science, the

philosophy, and principles of BioDigital

Orthodontics developed by the author

have been discussed.1-7

It is defined by a systematic,

process-driven approach for planning and providing

care within a framework of a personalized,

empathic, and safe care environment,

more aptly described by Berwick as

“a practice of one.”8 In addition, the

application of SureSmile technology in

enabling reliable and “high touch” care has

been discussed.9-14

Clinical Practice Guidelines

(CPGs) developed by the author for the

management of orthodontic patients are

described When followed, these guidelines

provide both efficient and effective

pathways to provide quality care.15-19

It should be noted that these

guidelines are constantly reevaluated in

order to continuously improve clinical

performance and outcomes It must also

be emphasized that the application of these

guidelines, although very useful, should be

complemented with professional judgment

to suit the individual care needs and

preferences of the patient Furthermore,

successful outcomes require that the

practice is committed to a proactive approach to care delivery

In this article and the next, the treatment of Class I non-extraction patients will be discussed Patient and Practice characteristics (Table 1) and Clinical Practice Guidelines developed by the

BioDigital Orthodontics:

Management of Class I non–extraction patient with

“Fast–Track” © – 6-month protocol: part 5

ORTHODONTIC CONCEPTS

Dr Rohit C.L Sachdeva discusses a treatment for Class I non-extraction patients

author for completing treatment of Class

I non-extraction patients with a “Fast–Track”© – 6-month protocol (Table 2), and the “Standard-Track”© 9-month protocol are described with the aid of patient histories

Table 1: Patient and practice characteristics that encourage the successful implementation of “Fast-Track” care are defined by the author

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

the cofounder 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

and 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.

PATIENT PRACTICEPatient Doctor and Team

• High orthodontic IQ, very cooperative, receptive to shared decision making, and participates in care

• Dedicated to tenets of high performance and learning organizations, and obsessed about delivering on time care and personalized care

• Oral hygiene excellent, high threshold to discomfort

• Care and treatment schedule is proactively planned and followed with rigor with the aid of CPGs

• Values timely care and is motivated to have a short treatment time

• Practice is well designed to prevent or minimize both active and latent errors

• Desires few visits and is open to extended visits • Zero tolerance policy for bracket failure, misplacement of archwires

• Adaptive scheduling to accommodate the patients’ needs

ORTHODONTIC CONCEPTS

Table 2: Clinical pathway guidelines developed by the author for “Fast-Track” care Protocol A for both users of 018” and 022” brackets systems

Class I non-extraction “Fast Track” © Protocol A CPG

6 months treatment (Sachdeva)

• Diagnopeutic scan (OraScan or CBCT scan taken post bonding)

• Place posterior molar turbos, check for height and balance

• Perform IPR prn

• Insert initial archwire

- 016” preformed SE NiTi Af 35ºC or 017” x 025” SE NiTi Af 35ºC if minimal crowding or torque control and deep bite correction needed

- Place auxiliary appliances, e.g., tipback springs, ART springs, etc

APPT 2 (Week 4)

SureSmile

Therapeutic Phase

• Perform IPR prn

• Place auxiliary devices such as quad helix if needed

• Adjust posterior molar turbo height, as needed

• Insert SureSmile Precision Archwire (SSPA) (full expression or partial expression)

Note: For 018”/.022” bracket either 016” x 022” or 017” x 025” SE NiTi Af 35ºC are crossections of choice

• Check archwire placement against bracket archwire image

APPT 3 (Week 12)

• Review progress against the Virtual Therapeutic Simulations (VTS)

• 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 step up to pre-ordered SureSmile 019” x 025” arch

APPT 4 (Week 18) • Review progress against VTS.• On-demand debonding, if schedule allows.

APPT 5 (Week 24) • Debond.• Take final records for outcome evaluation.

Patient 1: “Fast-Track” Protocol A (6 months)

Figures 1A and 1B: Patient 1 1A “Fast-Track” presents with a Class I occlusion with minimal upper crowding and moderate lower arch crowding A non-extraction approach to treatment was chosen IPR was planned among the lower anteriors to relieve crowding 1B Initial cephalometric and panoramic radiographs

ORTHODONTIC CONCEPTS

Figure 2: Patient 1 Initial visit 7-7 upper and lower arch bonded with 0I8” bracket system Upper 017”x.025” SE CuNiTi

Af 35°C engaged Lower posterior first molar turbos placed to disengage anterior occlusion Lower IPR 3-3 initiated and 016” SE CuNiTi Af 35°C wire inserted Power chain placed

Figures 3A-3D: Patient 1 3A Diagnopeutic scan This scan was taken immediately post bonding and post IPR at the first visit with an in-vivo OraScan 3B Virtual Diagnostic Model (VDM) derived from the Diagnopeutic model by turning off the bracket objects The advantage of the Diagnopeutic scan is that it provides for both the Virtual Diagnostic and Therapeutic models 3C Virtual Diagnostic Simulation (VDS) non-extraction 3D VDS superimposed on VDM

Figure 4: Patient 1 The therapeutic scan has also been derived from the diagnopeutic scan The bracket and archwires are shown The Virtual Therapeutic Model (VTM) derived from this scan may be used to plan definitive care for the patient as well as the SureSmile Precision Archwire (SSPA)

opalorthodontics.com | 888.863.5883

© 2013 Ultradent Products, Inc All rights reserved.

TM

Comfortable mesial hook is easy to install and remove Enclosed spring prevents

painful pinching

Smooth CNC-machined body for patient comfort and durability

Innovative clip design

allows easy placement

Laser-welded components hold

up to the toughest conditions

When we asked doctors what they wanted in a Class II corrector, the response was clear: More comfort More durability Easier placement.

So we developed Esprit The breakthrough appliance that offers everything your Class II corrector is missing.

to learn more about Esprit.

Comfortable machined mesial hook enables smooth gliding, prevents rolling, and reduces the need for push-rod bends

Photos courtesy of Dr Robert Miller

Class II to Class I in 4.5 months

Now Aligned

Figure 5: Patient 1 SureSmile Virtual Prescription Form completed with the Treatment Objectives These are defined

by “MACROS.” For this patient, the following objectives were selected Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane, IPR of 2.5 mm in the lower 3-3, and esthetic contouring of the upper central incisors

Figure 6: Patient 1 Virtual Therapeutic Simulation (VTS)

Figures 7A and 7B: Patient 1 7A Initial 7B Note the planned recontouring of the upper central incisors

Figure 8: Patient 1 SureSmile Precision Archwire (SSPA) Design evaluated against the

Virtual Therapeutic Model (VTM) Figure 9: Patient 1 SSPA engaged 4 weeks from start, upper and lower archwires SE 0.17” x 0.25” CuNiTi Selective IPR performed around the mesial distal surfaces of the lower left

lateral incisor

ORTHODONTIC CONCEPTS

ORTHODONTIC CONCEPTS

Figure 10: Patient 1 Progress 8 weeks post SureSmile precision archwire insertion and 12

weeks from start of treatment Figure 11: Patient 1 12 weeks post SSPA insertion and 16 weeks from the start of treatment

Figures 12A-12C: Patient 1 12A “Fast–Track” debonded 5 months from the start of treatment 12B Final cephalometric and panoramic radiographs 12C Virtual Final Models (VFM)

Figures 13A-13B: Patient 2 13A “Fast-Track” presents with a Class I occlusion with minimal upper crowding and moderate lower arch crowding Patient has a deep bite with retroclined upper incisors, peg lateral incisors, and a midline diastema; a non-extraction approach to treatment was chosen IPR was planned among the lower anteriors to relieve crowding 13B

Initial cephalometric and panoramic radiographs

Patient 2: “Fast-Track” Protocol A (6 months)

ORTHODONTIC CONCEPTS

Figure 14: Patient 2 Initial visit 7-7 upper and lower arch bonded with 022” DAMON® bracket system Upper 017” x.025” SE CuNiTi Af 35°C engaged Lower posterior first molar turbos placed to disengage anterior occlusion Lower IPR 3-3 initiated and 017”x.025” CuNiTi Af 35°C wire inserted .017”x.025” TMA tipback springs placed in upper and lower arch to facilitate deep bite correction Patient was scanned (Diagnopeutic scan) intraorally post bonding with the OraScan prior to placing the turbos and tip-back springs

Figures 15A-15C: Patient 2 15A.Virtual diagnostic model derived From the Diagnopeutic model by turning off the bracket objects The advantage of the Diagnopeutic scan is that

it provides for both the Virtual Diagnostic and Therapeutic models 15B Virtual Diagnostic Simulation (VDS) for anterior space closure 15C VDS superimposed on Diagnopeutic model

Figure 16: Patient 2 The therapeutic scan has been derived from the Diagnopeutic scan

The brackets and archwires are shown This Virtual Therapeutic Model (VTM) may be used

to plan Virtual Therapeutic Simulation (VTS) for definitive care of the patient as well as the

SureSmile Precision Archwire (SSPA)

Figure 17: Patient 2 SureSmile Virtual Prescription form completed with the Treatment Objectives These are defined by “MACROS.” For this patient, the following objectives were selected Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane, IPR of 1.5 mm in the lower 3-3 and selective spacing among the upper anteriors with veneers planned for upper 2-2

Figure 18: Patient 2 Virtual Therapeutic Simulation (VTS)

TWO MAJOR WAYS TO BENEFIT YOUR ORTHODONTIC PRACTICE

Receive Payments On-Time, Each Month

Decrease Staff Work Load

THREE ELEMENTS TO SUCCESS

Credit Recommendations

Automatic ACH and Credit Card Draft ing

Complete Account Management

OrthoBanc has the

lowest credit card rates

you will fi nd for recurring monthly drafts.

ORTHODONTIC CONCEPTS

Figure 19A-19B: Patient 2 19A Virtual Therapeutic Simulation

(VTS) without brackets and wire 19B Note the planned veneers

for the upper anteriors

Figure 20: Patient 2 SureSmile Precision Archwire (SSPA) Design evaluated against the Virtual Therapeutic Model (VTM)

Figure 21: Patient 2 SSPA engaged 4 weeks from start, upper and lower archwires SE 0.17” x 0.25” CuNiTi Note upper ART spring placed to provide additional torque control on the upper anteriors

Figure 22: Patient 2 Progress 8 weeks post SureSmile precision archwire insertion and 12

weeks from start of treatment Figure 23: Patient 2 12-weeks post SSPA insertion and 16 weeks from the start of treatment

Figures 24A-24B: Patient 2 24A.“Fast-Track” debonded 5 months from the start of treatment 24B Final cephalometric and panoramic radiographs

ORTHODONTIC CONCEPTS

Figures 25A-25B: Patient 2 25A Final veneers 2 months post debonding 25B Virtual Final Models (VFM)-post veneer placement

Conclusions

The “Fast–Track”© – 6-month protocol

(Table 2), enabled with the use of SureSmile

technology developed by the author, offers

the practitioner both an effective and

efficient approach to providing patient

care.15-19 Many of these efficiencies reside

in effective management proper selection

of the patient as shown in Table 1 and using

sound principles developed by Sachdeva

such as Condition Based Scheduling, Timely Constraint Management, and Concurrent Mechanics

Future articles in this series will discuss an alternative pathway to manage the treatment of a Class I non–extraction patient

Acknowledgements

It is with the deepest sense of gratitude

that the author wishes to thank Drs Takao Kubota (Yame City, Japan), Kazuo Hayashi (Sapporo, Japan), Jeff Johnson (Dallas, Texas), and Sharan Aranha (Richardson, Texas) for their unconditional and enthusiastic support in the preparation

of this manuscript Without their effort, it would be impossible to write and prepare this paper in a timely fashion OP

RefeRences

1 White L, Sachdeva R Transforming

orthodontics-Part 1 of a conversation with Dr Rohit Sachdeva,

Co-founder and Chief Clinical Officer of Orametrix Inc by

Dr Larry White Orthodontic Practice US

2012;3(1):10-14.

2 White L, Sachdeva R Transforming

orthodontics-Part 2 of a conversation with Dr Rohit Sachdeva,

Co-founder and Chief Clinical Officer of Orametrix Inc by

Dr Larry White Orthodontic Practice US

2012;3(2):6-10.

3 White L, Sachdeva R Transforming

orthodontics-Part 3 of a conversation with Dr Rohit Sachdeva,

Co-founder and Chief Clinical Officer of Orametrix Inc by

Dr Larry White Orthodontic Practice US 2012;3(3):6-9.

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: Designing

customized therapeutics and managing patient

treatment with SureSmile technology: Part 2

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

6 Sachdeva R BioDigital orthodontics:

Diagnopeutics with SureSmile technology: Part 3

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

7 Sachdeva R BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4

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

8 Berwick DM What ‘patient-centered’ should mean:

confessions of an extremist Health Aff (Millwood)

2009;28(4):w555-565.

9 Sachdeva RCL, Feinberg MP Reframing clinical

patient management with SureSmile technology PSCO

11 Sachdeva RCL Digital Care Solutions for the

Orthodontic Industry The Orthodontic CYBER Journal

Available at: solutions-for-the-orthodontic-industry/ Accessibility verified August 23, 2013.

http://orthocj.com/2001/06/digital-care-12 Sachdeva RCL SureSmile Technology in a

Patient-Centered Orthodontic Practice J Clin Orthod

2001;35(4):245-53.

13 Sachdeva R, White L Dr Rohit C.L Sachdeva

on A Total Orthodontic Care Solution Enabled

by Breakthrough Technology J Clin Orthod

2000;34(4):223-232.

14 Mah J, Sachdeva R Computer-assisted

orthodontic treatment: the SureSmile process Am J

Orthod Dentofacial Orthop 2001;120(1):85-87.

15 Alford TJ, Roberts WE, Hartsfield JK Jr, Eckert

GJ, Snyder RJ Clinical outcomes for patients finished with the SureSmile™ method compared with

conventional fixed orthodontic therapy Angle Orthod

2011;81(3):383-388.

16 Saxe AK, Louie LJ, Mah J Efficiency and

effectiveness of SureSmile World J Orthod

2010;11(1):16-22.

17 Sachdeva R, Aranha S, Egan ME, Gross HT, Sachdeva NS, Currier GF, Kadioglu O Treatment time:

SureSmile vs conventional Orthodontics: The Art and

Practice of Dentofacial Enhancement 2012;13:72-85.

18 Groth C Compare the Quality of Occlusal Finish Between SureSmile and Conventional [thesis] Ann Arobor, MI: University of Michigan; 2012.

19 Rangwala T Treatment Outcome Assessment of SureSmile Compared to Conventional Orthodontic Treatment Using the American Board of Orthodontics Grading System [thesis] Bonx, NY: Albert Einstein College of Medicine, Department of Dentistry; 2012.

When greeting a person for the first

time, we are supposed to make

direct eye contact and smile But how often

when you meet a person for the first time

do you greet them towards the side of the

face? Nonetheless, this is generally the only

perspective by which orthodontists routinely

evaluate their patients radiographically

and cephalometrically Rarely is a frontal

radiograph and cephalometric analysis

made, even though our first impression of

that new patient is from the front, when we

greet him/her for the first time

A patient’s own smile assessment

is made in the mirror, from the facial

perspective It is also the same perspective

by which he/she will ultimately decide

if orthodontic treatment is a success

or a failure So why don’t orthodontists

utilize the frontal analysis more? B Holly

Broadbent is credited with developing

the cephalometric procedure in 1931

when he simultaneously took frontal and

lateral radiographs on his patients to

evaluate the craniofacial skeleton in all

three dimensions, including the

posterior-anterior dimension Interestingly, even

though Broadbent took both frontal

and lateral radiographs simultaneously,

orthodontists are generally trained to use

the lateral cephalometric analysis on all

patients, but only encouraged to use the

frontal analysis when an asymmetry is

suspected or a dental crossbite is clinically

observed Accordingly, many orthodontists

rarely assess a patient with a frontal

cephalometric analysis

Since all orthodontic patients are dimensional, they should be evaluated three-dimensionally, and the frontal analysis provides valuable information that should be part of the diagnostic process1 Additionally, with the increasing use of Cone Beam Computed Tomography (CBCT) scans in orthodontics, a frontal analysis should be made for all patients receiving a CBCT scan; making use of the volume of information obtained CBCT scans provide the opportunity for adjusting the orientation

three-of the patient’s head, improving the reliability

of the cephalometric measurements, and simulating Broadbent’s cephalometric procedure

Skeletal facial asymmetries are more the rule than the exception, and the frontal analysis is an excellent instrument to use for their evaluation However, skeletal asymmetries are not always readily visible clinically nor do skeletal lingual crossbite patterns reveal themselves with obvious posterior dental crossbites It can be challenging to determine the presence

of a skeletal lingual crossbite pattern when it appears that there is a normal transverse relationship between the upper and lower jaws without a frontal analysis

Many patients who appear to have normal transverse skeletal relationships have skeletal lingual crossbite patterns2 that can negatively affect orthodontic treatment

outcomes Furthermore, skeletal lingual crossbite patterns are not just limited to

a narrow maxilla Posterior skeletal lingual crossbites can also be the result of wide mandibles, which are further exacerbated

by future, excessive lower jaw growth1 True dental asymmetries can be treated by orthodontics alone However, prior to the initiation of treatment, the etiology of the dental asymmetry should

be determined If that dental asymmetry is the result of a skeletal issue, an orthopedic

or surgical approach will be necessary because orthodontic treatment alone would likely result in an unfavorable outcome

So, what about those skeletal asymmetries? It’s not uncommon for the orthodontist to miss a skeletal asymmetry

in a severely crowded and maligned malocclusion that only becomes obvious after the leveling and alignment phase

of treatment3 At this stage in treatment,

it may be more difficult to address the skeletal asymmetry and, therefore, more difficult to salvage But, diagnosing the skeletal asymmetry initially, prior to the start

of treatment, provides informed consent to the patient and reduces the unintended consequences of poor treatment planning.Perfectly symmetrical faces are largely theoretical concepts that seldom exist in living organisms4 Minor facial asymmetries are relatively common In a study by Severt and Proffit of 1,460 patients, 34% had a

The frontal cephalometric analysis – the

forgotten perspective

CONTINUING EDUCATION

Dr Bradford Edgren delves into the benefits of the frontal analysis

Educational aims and objectives

This article aims to discuss the frontal cephalometric analysis and its advantages in diagnosis.

Expected outcomes

Correctly answering the questions on page 34, worth 2 hours of CE, will demonstrate the reader can:

• Understand the value of the frontal analysis in orthodontic diagnosis.

• Recognize how the certain skeletal facial relationships can

be detrimental to skeletal patterns that can affect orthodontic treatment

• Realize how frontal analysis is helpful for evaluation of skeletal facial asymmetries

• Identify the importance of properly diagnosing transverse discrepancies in all patients; especially the growing patient.

• Realize the necessity to take appropriate, updated records on all transfer patients.

Bradford Edgren, DDS, MS, earned both his

Doctorate of Dental Surgery, as Valedictorian,

and his Master of Science in Orthodontics

from University of Iowa, College of Dentistry

He is a Diplomate, American Board of

Orthodontics and an affiliate member of the SW Angle

Society Dr Edgren has presented to numerous groups

on the importance of cephalometrics, CBCT, and

upper airway obstruction He has been published in

AJODO, American Journal of Dentistry, as well as other

orthodontic publications Dr Edgren currently has a

private practice in Greeley, Colorado.

CONTINUING EDUCATION

clinically apparent facial asymmetry Of

the facial asymmetries that were present,

the upper face was only affected in 5%,

the middle third (primarily the nose) in

36%, and the lower third in 74% of cases

Vertical asymmetries were present in 41%

of cases5 Moreover, facial asymmetries

are more frequently associated with Class II

and Class III malocclusions than with Class

I malocclusions4

The frontal cephalometric analysis is

useful in diagnosing skeletal asymmetries

and skeletal crossbite patterns for both

jaws It also aids in the evaluation of:

occlusal cants, nasal widths, turbinate

enlargements, dental arch widths,

bucco-lingual angulation of first molars, angulation

and position of impacted canines, location

of the maxillary incisors to the skeletal

midline, location of the mandibular incisors

to the mandibular midline and skeletal

midline, and the morphology of the maxilla

and mandible The frontal analysis can also

aid in determining if an off-centered dental

midline is due to a tooth-size discrepancy,

a mandibular functional shift, or skeletal

dysplasia

Significant skeletal asymmetries

can be congenital, developmental, or

acquired Hemifacial microsomia is a

congenital birth defect where the lower half

of the face is typically unilaterally, or rarely

bilaterally, underdeveloped This common

facial birth defect, second only to clefts,

most frequently affects the ears, mouth,

and lower jaw6 In this case, the patient

has a significant unilateral dentofacial

asymmetry to the right Complete

diagnostic records were taken, including a

CBCT scan, followed by lateral and frontal

cephalometric analyses The frontal image

and the corresponding cephalometric

analysis demonstrate the effects of the

hemifacial microsomia on the right side of

the patient’s face (Figures 1 and 2) The

lateral radiographic image alone does not display the degree of the lateral and vertical asymmetries that could easily be passed off as poor patient positioning (Figure 3)

The panoramic radiograph demonstrated a hypoplastic right ramus and condyle (Figure 4) The maxillary canines and lateral incisors were ectopically erupting due to an anterior maxillary constriction

Early interceptive treatment included rapid maxillary expansion followed by upper and lower fixed appliances Following the removal of the fixed appliances at the end

of early interceptive treatment, a CBCT scan was taken The scan revealed an improvement in the facial asymmetry and significantly improved permanent tooth eruption and root parallelism (Figures

Figure 1: Posterior-anterior image demonstrating

right-sided lateral and vertical facial asymmetries

(CBCT images taken with i-CAT [Imaging Sciences

International])

Figure 2: Frontal cephalometric analysis demonstrating significant dentofacial asymmetry

to the right and occlusal cant

Figure 3: Lateral CBCT image

CONTINUING EDUCATION

5 and 6) This patient will be monitored

until the eruption of the permanent

dentition is complete Second phase

treatment will include full fixed appliances

and orthognathic surgery to correct the

remaining asymmetries

Condylar hypoplasia is the unilateral

or bilateral underdevelopment of

the mandibular condyle(s) Condylar

hypoplasia can be either congenital or

acquired, and is often associated with head

and neck syndromes as in the previous

case7 Bilateral condylar hypoplasia is

considerably less common than unilateral

involvement, even though both can lead

to significant facial deformities In acquired

cases, the extent of the facial deformity is

dependent upon the severity of the injury

that caused the disruption in condylar

growth, the duration of that injury, and the

age that it occurred.8

This case of acquired condylar hypoplasia was a transfer into my office

She had had previous Phase I treatment, including the extraction of the maxillary first premolars At her clinical exam, a right- sided facial asymmetry was noted After taking progress records, which included a CBCT scan (Figures 7 and 8), both lateral and frontal cephalometric analyses were made A frontal analysis revealed a severe mandibular asymmetry to the right, a right vertical asymmetry, as well as a skeletal lingual crossbite pattern due to both jaws (Figure 9) The mandibular asymmetry amounted to a total of 8 mm to the patient’s right The source of the asymmetry was a hypoplastic right condyle The patient’s right ramus was also significantly shorter and comparatively broader when compared

to the left Since this patient still has several years left to grow, the facial asymmetry will

most likely become more pronounced The best solution for this patient is maxillary expansion, leveling and aligning, and eventually orthognathic surgery to correct the facial asymmetry Note, this is a case where the significant facial asymmetry and the skeletal lingual crossbite were not documented until a frontal analysis was made Consequently, this case is a perfect example of where a facial asymmetry

Figure 4: Panoramic image demonstrating a hypoplastic right condyle and ramus, and ectopic maxillary canines Figure 5: Posterior-anterior image following early

inter-ceptive treatment

Figure 6: Panoramic image following early interceptive treatment The anterior maxillary constriction has been resolved,

and the maxillary canines have erupted nicely

Figure 7: Note, in the lateral radiographic image, the difference in the borders of the left and right sides of the mandible When the borders of the mandible present this large of a difference, and the orbits are aligned, a facial asymmetry should be suspected

Figure 8: Posterior-anterior image revealing the significant right-sided vertical and lateral asymmetries

went undiagnosed until the frontal analysis

was made, after irreversible orthodontic

treatment had been already initiated,

including extractions of permanent

teeth It only disputes the myth that the

frontal analysis should only be made if

an asymmetry is suspected Obviously,

significant facial asymmetries do exist

and can be missed without a

posterior-anterior radiograph and subsequent

analysis Routinely taking a

posterior-anterior radiograph reduces the chances of

missing an asymmetry Even this patient’s

panoramic image illustrates the extent of

the right condylar hypoplasia, shortened

ramus, and noticeable asymmetry (Figure

10)

This case also illustrates why it is

necessary to take appropriate, updated

records on all transfer patients I have

found previously undiagnosed tumors,

severe facial asymmetries, cysts,

supernumeraries, and other pathologies

Figure 9: Posterior-anterior image revealing the significant right-sided

vertical and lateral asymmetries

that required attention before continuing orthodontic treatment in patients already in orthodontic appliances

Like facial asymmetries, skeletal lingual crossbites due to either the maxilla and/or mandible are more the norm than the exception Transverse maxillary constrictions frequently result in significant crowding and impacted teeth This 7.3-year-old Caucasian female presented with loss of arch length in both arches due to premature loss of the deciduous lateral incisors The left maxillary molar was ectopically erupting and had resorbed the distal root of the left maxillary second deciduous molar, blocking out the eruption path of the second premolar (Figure 11) But, it was the patient’s overall pre-existing maxillary deficiency, including the transverse constriction, that was the original source for the loss of maxillary arch length, severe crowding, disruption

of the eruption of the maxillary laterals,

and subsequent impaction of the maxillary canines

A posterior-anterior image taken from the diagnostic CBCT scan of the patient demonstrates the significant rotation of the maxillary lateral incisors and severe maxillary anterior crowding (Figure 12) The frontal cephalometric analysis not only illustrated a dental lingual crossbite pattern

Figure 10: Panoramic image exhibiting condylar hypoplasia of the right condyle and subsequent widening

of the ramus The patient’s maxillary first premolars were extracted to aid in the eruption of the maxillary canines If expansion had been performed on this patient initially, it may have been unnecessary to extract the maxillary first premolars to make room for the eruption of the canines

Figure 11: Initial panoramic image exhibiting severe crowding and multiple impacted teeth

Figure 12: Initial posterior-anterior image Note the significant rotation of the right maxillary incisor

CONTINUING EDUCATION

due to both arches but also a skeletal

lingual crossbite pattern due to the maxilla

and mandible (Figure 13) After distalization

of the maxillary left first molar, the patient

was expanded with a bonded expansion

appliance to correct the dental and skeletal

lingual crossbite patterns

After 29 months of Phase I treatment,

the maxillary and mandibular lateral incisors

have erupted into proper position, and the

maxillary canines are erupting appropriately

(Figures 14 and 15) Early extraction of

the maxillary deciduous canines was not

necessary, nor was it indicated Studies

have suggested that impacted canines

are a result of maxillary constriction, and

rapid maxillary expansion can aid in the

proper eruption on maxillary canines.9,10,11

Orthodontic treatment without expansion, when a transverse maxillary constriction exists, does not address the root of the problem Extraction of permanent teeth

in a growing patient, to promote eruption

of the maxillary canines, may result in future crossbite patterns when the patient becomes an adult and dentofacial growth

is complete A case that appears to be treated to proper balance may indeed become a significant malocclusion years later because future growth and the skeletal lingual crossbite patterns were never addressed, nor treated.8

This adult case exemplifies the importance of properly diagnosing transverse discrepancies in all patients and especially in the growing patient

Figure 14: Progress panoramic image exhibiting improved eruption of the maxillary canines and the erupted lateral

inci-sors with complete root formation Also, note maxillary right third molar blocking the eruption of the maxillary right second

molar

Figure 15: Progress posterior-anterior image Note the significantly improved angulation of the maxillary canines and lateral incisors

This 30-year-old Caucasian female patient presented with a chief complaint

of myofascial pain disorder (MPD) and

an anterior open bite Her maxillary first premolars were extracted as a child as part

of her orthodontic treatment However, what may have been a well-treated case

at the finish as an adolescent became a significant problem as an adult Because her skeletal lingual crossbite pattern was never initially diagnosed, extraction of the first permanent premolars negatively enhanced her transverse discrepancy Additional facial growth only intensified her transverse discrepancies Over time, this patient developed an anterior open bite and crossbite, bilateral posterior crossbites, gingival recession, and MPD (Figures 16 Figure 13: Initial frontal cephalometric analysis