Tạp chí chỉnh hình OPUS tháng 5 6 2013 vol 4 no3
Trang 1for lower dose
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P R O M O T I N G E X C E L L E N C E I N O R T H O D O N T I C S
Incorporating
TAD-supported Haas expansion
into everyday practice
Drs Ryan K Tamburrino and
Shalin R Shah
Corporate profile
Ormco
A new regimen of Phase I
care applied to potential
maxillary canine impactions
Trang 2Volume 4 Number 3 Orthodontic practice 1
May/June 2013 - Volume 4 Number 3
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
Mali Schantz-Feld Email: mali@medmarkaz.com
Tel: (727) 515-5118 ASSISTANT EDITOR
Kay Harwell Fernández Email: kay@medmarkaz.com
PRODUCTION MANAGER/CLIENT RELATIONS
Kim Murphy Email: kmurphy@medmarkaz.com
NATIONAL SALES/MARKETING MANAGER
Drew Thornley Email: drew@medmarkaz.com
Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE
Sharon Conti Email: sharon@medmarkaz.com
Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN
Greg McGuire Email: greg@medmarkaz.com
PRODUCTION ASST./SUBSCRIPTION COORDINATOR
Lauren Peyton Email: lauren@medmarkaz.com
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.
Those of you who know me, or have heard me lecture, know that I have been a lifelong student of orthodontics The goal to continually improve treatment techniques and final results is what keeps me excited and passionate about our wonderful profession
In fact, I can honestly say that in the past few months, I have worked harder than ever critically evaluating not only where we have been over the past 20 years but carefully analyzing where we need to go to keep improving the Damon System
In February 2013, it was very gratifying to host the 12th Annual Damon Forum in Orlando, which has become the largest privately sponsored orthodontic event in the world The take-away from my presentation and others was encouraging clinicians to 1) keep it simple by utilizing “torquing couples” in each bracket/archwire interface that gives the clinician true straightwire with three-dimensional control, 2) focus on improving the quality of final results, and 3) to truly have fun The significance of selecting “torquing couples” on each anterior tooth allows the clinician to gain first, second, and third order control with improved force management, increased patient comfort, and in many situations decrease treatment time for the patient Today, we all live in a very complicated and busy world I encourage clinicians to strive to have more fun running their businesses through improved clinical efficiencies and effectiveness
As a profession, we have often evaluated clinical proficiency based on final tooth position and how teeth fit together Often we hear the comment, “show me the plaster
on the table.” With technologies available today, I strongly encourage clinicians to also include treatment planning, clinical case management, and impact on bone and tissue during and after treatment when critically evaluating clinical proficiency Simply put:
straight teeth should not come at a long-term high cost to the periodontium
For highest quality results, clinicians must keep abreast of today’s latest technologies Unfortunately, it is often human nature to resist and fall into the trap of saying that you are for progress but in reality fear change! My advice: don’t let fear hold you back from cutting-edge treatment mechanics With the right education, training, mentors, and a proper treatment planning, you can enhance the quality of your patient results while minimizing stress on your clinical life
Lastly, set a goal to have more fun running your business in 2013 It is so much more enjoyable for everyone to be part of a practice and business that strives to create
a special, positive environment for patients and staff The energy and excitement you convey to your patients will have a positive impact on their desire to come in for appointments and also to refer other potential patients Worldwide, I have observed that happy and energetic offices are usually very busy
I have always been impressed with orthodontists who have passion to continue improving As you strive to make your practice more successful, continue to expand your knowledge, inspire growth within your staff, and diligently work towards better and better final results Remember: keep it simple Focus on quality results Have fun!
Dwight Damon, DDS, MSD, developer of the Damon System, is an industry-leading orthodontist with an office in Spokane, Washington
Widely known for his development of the Damon System — a passive self-ligation braces system that allows for low-friction, low-force orthodontic treatment — Dr Damon is a pioneer in the field whose passion has been
to improve orthodontic patient care worldwide Dr Damon has received numerous awards and professional honors including the 2009 Washington State University Regents’ Distinguished Alumnus Award, the highest honor the university confers upon its alumni He was also elected as a Fellow of the Royal Society of Surgeons
of Edinburgh www.damon-smiles.com
Forever a student of orthodontics
Trang 3Corporate profile
Ormco Your Practice Our Priority.
This leading manufacturer and provider
of orthodontic technology and services
is dedicated to supporting orthodontic practices in an ever-changing and competitive environment
8
Clinical
Dentomandibular sensorimotor dysfunction: what it is and how providing care can benefit orthodontic practices and their patients
Dr Ronald Cohen explores a systematic approach to a painful disorder of the head and neck before orthodontic therapy
10
Orthodontic technology case report: three-dimensional lingual treatment in combination with
a temporary anchorage device (TAD)
Dr Edward Lin treats a case to resolve crowding, straighten teeth, and improve the smile 16
Orthodontic concepts
Trang 4Everywhere your practice needs to be
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• Minimal upfront cost with simple monthly installments
Call 800.944.6365 or explore it here carestreamdental.com/cscloud
Trang 54 Orthodontic practice Volume 4 Number 3
Drs Ryan K Tamburrino and Shalin
R Shah explore appliance design,
delivery technique, and expansion
protocols as it relates to the
TAD-supported Haas 32
Complete Clinical Orthodontics:
treatment mechanics: part 3
Dr Antonino Secchi summarizes the
specific strategies within the CCO
System to manage space closure in
different anchorage situations 38
Research
A new regimen of Phase I care
applied to potential maxillary
canine impactions
Dr John Hayes outlines a study
of canine impactions to evaluate a
regimen of Phase I care 44
Banding together
Hector’s story
Dr Mark Reynolds tells about the many people involved in bringing this novel case to its happy conclusion 52
Education exploration
GCARE webinars: inspiration, exploration, and education: part 4
A new webinar program, GAC Clinical Alliance for Research and Education (GCARE), pertains to all stages of the orthodontic community, from residents to practicing orthodontists 54
Overcoming technology bottlenecks
Toby Buckalew discusses how new technology can steer a practice in the right direction and speed up performance 62
Materials &
equipment 64
TAD-supported
Trang 6Where Practice Growth
Takes Root
With an ever-expanding base of benefits for our members, the UOBG is constantly evolving to keep our members ahead of whatever the economy has in store In the past 12 months alone, we’ve added:
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Join over 3,000 orthodontists and start saving on products you already use by becoming a UOBG member.
Trang 7What can you tell us about your
background?
I grew up in Northwest Ohio in the small
village of Bluffton It is a quaint little college
town in a rural, country setting Like many
others in the area, my father worked for
Ford’s engine plant in nearby Lima Early on,
I took on jobs in the service sector: mowing
lawns, working in an ice cream parlor, and
helping to manage a restaurant After high
school, I attended Ohio State University
where I was sure that I was destined to be
a certified public accountant (I eventually
made my way to the University of Maryland
for dental school.)
Why did you decide to focus on
orthodontics?
After some really crazy overtime as a
CPA, I decided that I needed a career
change I realized that what I missed was
the personal interactions that I used to
have with my regular customers at the
restaurant I looked around for what would
give me that kind of interaction again and
settled on dentistry Two years into my
dental program, I was approached by
one of my orthodontic professors who
thought I had potential as an orthodontist
Fortunately, we had a fourth year
mini-residency program at school that allowed
me to take on some active cases It was
just what I had been missing, and I was
hooked
How long have you been practicing, and what systems do you use?
I am in my tenth year of private practice
We use Insignia™, the Damon® System and Invisalign®
What training have you undertaken?
Training began in my mini-residency at the University of Maryland, Baltimore After graduation, I completed an AEGD residency
at the Lancaster Cleft Palate Clinic with
a great exposure to different craniofacial disorders and the changes those disorders have on normal facial development I selected my orthodontic residency at the University of Texas, Houston due to its research program as well as its relationship with the oral surgery department This well-established interdepartmental relationship allowed me to continue to be exposed to
a wide range of skeletal malocclusions as well as some unique craniofacial disorders
Since graduation, I have continued to learn more about occlusion and facial development from The Dawson Academy,
Dr Jeffery Okeson, the Damon Forum, and recently the Academy of Clinical Sleep Disorder Disciplines
What is the most satisfying aspect
Professionally, what are you most proud of?
Patient education We work incredibly hard to connect the dots for our patients
so that they can truly understand what is going on with their teeth and what they can
do about it Every week we hear, “No one has ever explained that,” or “Now, I get it!”
It is a great feeling knowing that we have empowered people to make their lives better Additionally, it’s incredibly satisfying
to be a part of Smile for a Lifetime We have treated some amazing kids who would otherwise not have access to care
What do you think is unique about your practice?
In addition to spending a lot of time educating our patients, we also spend a lot of time getting to know them and their families We celebrate milestones in their lives with them, and enjoy relationships throughout their treatment and beyond
I have been known to send a mom our family’s favorite black bean soup recipe
or suggest a book that I know they would enjoy Greensboro, North Carolina, the location of my practice, is a small town, and
I love that my patients are always stopping
Dr Mark Reynolds
Empowering patients through smiles
Trang 8PRACTICE PROFILE
me around town to say hi I really enjoy
knowing my patients beyond their teeth
What has been your biggest
challenge?
Finding the right people to catch the vision
of our practice Getting people who are
personally committed, technically excellent,
and technologically savvy, all with a
friendly, approachable personality can be
challenging I have been very fortunate to
have a great staff supporting me all the
way
What would you have become if
you had not become a dentist?
There are lots of things that I would like to
do, but I think that due to my addiction to
HGTV, I would have to be
an architect or designer
Helping people design
and build their dream
home would be a lot of
planning and diagnosis
will soon be the norm
With this technology, we
can see so many more
things clearly Soon we
won’t know how we
ever lived without the
information I think that
this will also lead to a
better understanding of the interrelationship
of facial and occlusal development and
overall health Big strides are already being
made in sleep medicine/dentistry, and
more are on the way
What are your top tips for
maintaining a successful practice?
Build a great team Get the best people,
and then include them in the
decision-making processes A great staff can be
full of incredible ideas, and the sense of
ownership helps get them implemented
quickly The opposite can also be true —
one bad apple can spoil the whole office,
and patients can tell the difference
What advice would you give to
budding orthodontists?
Never stop learning Right out of residency,
it is easy to feel on top of the orthodontic
world, but it’s not long before the really hard cases come along, and you realize that not everything was covered in class
There is so much information available Go out there, and keep learning
What are your hobbies, and what
do you do in your spare time?
My family is really important to me One reason I chose orthodontics is because it allows me to spend time with my wife and children We love to travel, to camp, to hike, and to eat popcorn during family fun nights Recently, we have begun running 5k races together We are involved in our church and in our community I love sharing
so many different experiences with my kids and seeing those experiences through their fresh eyes
TOP 10 FAVORITES
1 Going to movies
2 Cars
3 HGTV
4 Coffee, lots of coffee!
5 My wife and four kids
Trang 9Today’s orthodontic specialist is challenged like never before With many orthodontists facing flat-to-declining patient starts, competition from other dental providers, and a more discerning healthcare consumer, it’s increasingly important to navigate a dramatically shifting marketplace and employ new strategies to truly differentiate your practice
This dramatic shift has been a topic of conversation at Ormco Corp.,
a leading manufacturer and provider of orthodontic technology and services
That’s why we invite you to learn about the strides Ormco is taking to support your practice in an ever-changing and competitive orthodontic industry After conducting extensive market research with doctors and healthcare consumers around the world, we’ve been able to better understand your needs as a clinician today This renewed understanding has led
us to a new mission statement designed
to truly focus our efforts on meeting your practice and appliance needs Unveiled
by Ormco President Vicente Reynal at our 12th Annual Damon Forum in February, the following mission statement illustrates our commitment to better your practice
Ormco builds trusted ships with the orthodontists we serve, providing a breadth of innovative products and solutions
relation-to enhance their professional lives Ormco is committed to helping orthodontists achieve their clinical and practice management objectives
Put more succinctly, “Your practice
is our priority.” This new commitment and tagline —“Your Practice Our Priority.”— is
an overarching theme driving our future initiatives, and rooting our programs in customer dedication and support From product development and educational programs to personalized service and practice marketing support, we’re taking action to serve as your valued practice partner
Ormco’s restructured customer rewards program demonstrates our desire
to address popular practice demands
The concept of the program is simple – orthodontists earn points on purchases that can be redeemed for more products
Relaunched in February as the “Ormco Lifetime Rewards” program, customers
in North America can now earn points
on Ormco and AOA Lab purchases that never expire In addition to redeeming points for Ormco products and services, members may also benefit from special offers and savings from affiliate companies, including the Gendex GXDP-700™, i-CAT®
FLX, CaviWipes™, and Orascoptic HiRes®
2 loupes Since inception of our rewards program, we’ve awarded $40 million in free product to participating customers
Innovating for your practice
When you think about the year ahead or the next 3 years, do you envision your practice growing, innovating, and adopting new technologies and techniques? For more than 50 years, Ormco has partnered with the orthodontic community to manufacture innovative products and solutions that enhance the lives of clinicians and their patients Founded in 1960, Ormco—
which is an acronym for Orthodontic Research & Manufacturing Company—is one of the few orthodontic suppliers with
a fully operational and active research and development department dedicated to design and manufacture new treatment solutions that enhance patient treatment and positively impact practice efficiency
Driven by innovation, we’re proud
to have introduced a number of notable
“firsts” in the industry, including preformed bands, direct bonding with Optimesh®, computer-aided design (CAD) brackets with Orthos®, Copper Ni-Ti® and TMA™
wires, and the first completely esthetic passive self-ligating bracket with Damon®
Clear™ With a focus on product quality, clinical efficiency and esthetics, we released more new products in 2012 than any other year
in the company’s history Last year, our team introduced a new active self-ligating bracket system, Prodigy SL™, which provides maximum rotational control and proven bond reliability Additionally, the Damon Clear product line — appealing to a
Ormco Your Practice Our Priority
wide consumer base with virtually invisible brackets — expanded to include both upper and lower arch brackets, and is now available in a convenient single-patient kit
We also introduced AdvanSync™ 2, a to-molar Class II corrector for simultaneous skeletal and dental corrections, plus a new compact Quad storage system to help organize your inventory
molar-Digital orthodontics to differentiate your practice
Did you know there are approximately
23 million U.S adults who are interested
in improving their smiles? Furthermore,
a Boston consulting group study found that patients would pay a premium for treatment that is faster, more esthetic, and more comfortable As a progressive doctor interested in increasing patient starts,
we encourage you to explore today’s advanced digital orthodontic solutions At Ormco, we’ve dedicated three decades
of intensive research and development
to create Insignia™ Advanced Smile Design™, an all-inclusive digital solution that combines 3D diagnostic technology and interactive treatment planning with customized appliances to accelerate treatment times and increase precision results
An advanced technology to differentiate your practice, Insignia is especially appealing to adult patients seeking faster results, fewer appointments, and improved comfort Today we’re proud
to share that Insignia offers the world’s most expansive menu of treatment options, including Insignia Clearguide™ Express, Damon Clear, Damon® Q™, Inspire ICE™, and completely customized self-ligating and traditional twin appliances, making it the natural evolution in appliance choice With the Insignia Clearguide Express aligner
Figure 1: Simulated canal injected with ink
Trang 10CORPORATE PROFILE
system, we’re helping you to address
patient image concerns with a sleek, clear
aligner tray that goes virtually unnoticed
Building upon Insignia’s advanced
digital platform, we’re excited to launch
the Lythos™ Digital Impression System
this summer This innovative technology
harnesses the power of digital scanning
to overcome the inherent challenges
associated with traditional impressions
With a small portable device, lightweight
wand, and fast scan time, Lythos delivers a
comfortable digital impression experience
for staff members and patients
Mark Hillebrandt, Vice President of
Marketing and Product Management at
Ormco, stated, “Ultimately, we envision the
orthodontic workflow to be 100 percent
digital, from scanning of the patient to
the creation of 3D digital treatment plans
to custom digitally manufactured, labial,
lingual, and clear aligner appliances.” With
an easy-to-use, intuitive interface, Lythos
streamlines the practice workflow with
scans that are complete in less than 12
minutes Unlike “photo capture” scanners,
where feedback is displayed a few
seconds after pushing a foot pedal, Lythos
scans in real time, which means feedback
is displayed as it is captured The Lythos
video uses the occlusal surface to register
the position of the data to show in real
time
Unique to the industry, Lythos offers
a “cash back” rebate system, where
customers are credited for every Insignia
and/or Insignia Clearguide Express case
submitted with a Lythos digital impression
With regular use of Insignia and Clearguide,
Lythos scans are virtually free!
Practice development support for your practice
How are patients finding you in today’s digital landscape? From teens to adults, the Internet is driving patient engagement, fueling patient referrals, and generating a wealth of new patient leads Social media trends and web behaviors of digital-savvy consumers have been analyzed and leveraged by Ormco for years
Targeting this growing online community, our consumer websites DamonBraces.com and InsigniaSmile
com offer current and prospective patients
an engaging educational resource
Additionally, these sites help consumers find local Damon® and Insignia™ specialists via their popular Doctor Locator search tools that are accessible from the Web,
Facebook, and web-enabled mobile devices Over the past 3 years, our marketing efforts to drive consumers
to these websites have yielded a 190%
increase in consumer site visits, and a remarkable 360% increase in Doctor Locator searches This translates into
$82 million in potential practice revenue each and every month for our Damon and Insignia doctors
To support our customers’ local practice marketing and patient education campaigns, Ormco provides an online practice marketing resource with a complete range of marketing assets and staff training tools to help increase patient starts Available 24/7, marketing.ormco
com hosts a library of patient imagery, consultation tools, practice videos, webpage assets, and more for doctors offering the Damon System, Insignia, Inspire ICE, and Prodigy SL
As a company, we have long
advocat-ed the importance of clinical advocat-education and facilitate educational opportunities for our clinicians worldwide Our flagship event in North America, the Damon® Forum, hosts more than 1,300 orthodontic professionals and is the largest privately-sponsored orthodontic event designed for the entire orthodontic team The Damon Forum is one of many events offered by Ormco’s comprehensive CE program known as the Lifelong Learning Series Designed
to support our customers’ clinical and practice success, regional seminars, in-office courses, and free online webinars enable doctors and staff to explore clinical innovations and practice management strategies from the industry’s top clinicians and consultants In June and September
2013, we invite doctors to attend one of three “Technology Symposiums” hosted in Washington, D.C., Chicago, and Atlanta With a focus on innovative technologies to advance clinical excellence and efficiency, the day and a half seminars address the latest in passive self-ligation, digital solutions, and Class II correction Doctors can learn more about Ormco’s supportive
CE offerings and register for upcoming events by visiting www.ormco.com/education
The entire team at Ormco will continue
to uphold its commitment to make your practice our priority We look forward to serving as your trusted partner in 2013 and beyond! For more information, visit Ormco online at www.ormco.com
This information was provided by Ormco.
Trang 11Dentomandibular sensorimotor dysfunction
(DMSMD) is a frequently painful disorder of
the head and neck, temporomandibular
joints (TMJ), jaw function, and dental
forces The force distortion causing
DMSMD may adversely impact the
long-term stability and reliability of dental
restorations and adaptations that patients
have received for unrelated conditions A
thorough knowledge of the problems and
a comprehensive assessment/treatment
approach with which to resolve them are
pivotal to helping orthodontists and general
dentists ensure the integrity of natural teeth
and current and future dental work, as well
as minimize or eliminate pain and other
negative symptoms This article discusses
dentomandibular sensorimotor dysfunction
and demonstrates a case in which a
systematic approach to its treatment was
undertaken prior to initiating orthodontic
therapy
Introduction
Dentomandibular sensorimotor dysfunction
(DMSMD) is a frequently painful disorder of
the head and neck, temporomandibular
joints (TMJ), jaw function, and dental
forces It stems from misalignments in the
physiology of the skull and mandible that
result in problems with bite force, muscle
movement, and/or balance of joints, leading patients to experience extreme amounts of force or improper/unbalanced dental forces.1,2
Individuals with force issues — many
of whom might not even realize that their conditions stem from DMSMD or that dentists can provide effective treatment for
it — suffer from many diverse symptoms
Those that directly impact the teeth and mandible include abfraction, bruxism, tooth erosion, fracture, or damage; instability
in the dental arch form; jaw clenching (with or without the formation of a torus);
temporomandibular joint disorder (TMD);
and clicking and popping of the jaw Other seemingly disparate, yet highly disruptive symptoms associated with DMSMD, include chronic headaches and migraines, sleep disorders, tinnitus, myofascial pain, poor airway issues, compensatory adaptations in posture, and limited range
of motion.1-3
Physiologic interconnections also contribute to complications in understand-ing, assessing, and treating this complex condition For instance, although DMSMD
is not the sole trigger of migraines — hormones, sleep problems, nutrition, and other factors may play a role as well — its connection to the trigeminal nerve is thought
to be a likely contributor to many cases of migraines The trigeminal nerve generates impulses that cause blood vessels on the brain to swell, thus transmitting pain messages to the brainstem.4
Patients with DMSMD, and dentists seeking to treat the condition’s complications, may encounter other challenges as well For example, force distortion may adversely impact the long-term stability and reliability of dental restorations and adaptations that patients have received for unrelated conditions
This will necessitate additional treatment
to achieve optimal function and to protect dental interventions from irregular forces.1,2
Prevalence of and problems to treating related conditions
These often debilitating conditions, outcomes, and complications are not isolated cases affecting a relative few According to the National Institute of Dental and Craniofacial Research, the number of Americans who suffer from TMJ and associated problems may range from
10 to 45 million individuals,5 and when the number includes those suffering from tinnitus and other conditions, the number rises to an estimated 80 million people Even more prevalent and impactful, approximately 90% of the U.S population has headaches, and individuals who suffer from migraines—estimated at more than
29 million Americans — lose between 157 million days of work and school annually.6
Research indicates that up to 80% of headaches result from some type of dental force-related problem
There are many aspects to understanding and treating DMSMD-related conditions For effective, long-lasting, and predictable results to be achieved, it is imperative that healthcare professionals and their patients understand DMSMD; why it occurs; its not-always-readily-apparent connections to other physiologic components and factors; the importance of properly diagnosing and treating it; the most effective methods/protocols for assessing and treating it; and who is best equipped to provide such assessment and treatment Unless DMSMD is properly addressed, a patient’s condition will not improve; rather it will worsen and likely become chronic, and existing and future dental restorations may consequently fail A thorough knowledge
of the problems and a comprehensive assessment/treatment approach with which to resolve them are pivotal to helping orthodontists and general dentists ensure the integrity of natural teeth and current and future dental work, as well as minimize
Dentomandibular sensorimotor dysfunction: what it
is and how providing care can benefit orthodontic
practices and their patients
Dr Ronald Cohen explores a systematic approach to a painful disorder of the head and neck before
orthodontic therapy
Ronald Cohen, DDS, MSD, received his DDS
from The Ohio State University in 1976 After
5 years as a general practice dentist, 3 years
in the USAF, and 2 years running the St
Francis Hospital Neighborhood Dental Clinic
in Honolulu, Hawaii, he returned to specialty school
at St Louis University where he attained his Master
of Science in Dentistry in 1983 He currently lectures
for SureSmile about the advances in
technology-driven orthodontics as it relates to such treatments as
sleep apnea, TMJ, and advanced orthodontic-surgical
procedures He is also an active Beta test site for
SureSmile and a member of the Clinical Advisory Board
Dr Cohen is not a paid consultant for TruDenta He can
be reached at drcohen@docronsmiles.com.
Trang 13symptoms
Until recently, healthcare professionals
who sought to help patients address their
DMSMD-related distress faced numerous
obstacles Many patients, ignorant of
the cause of their problems and having
exhausted over-the-counter (OTC) and
prescription medications, as well as
non-pharmacological options, such as physical
medicine,6 abandoned their search
for solutions and resigned themselves
to enduring lives of chronic pain and
diminished quality of life Of those individuals
who persisted in seeking help, typically
only one in five sought out a physician’s
assistance after having no success with
OTC remedies.5 Orthodontists and general
dentists, in particular, have largely been
overlooked in favor of physician-based
healthcare providers and chiropractors,
who are more likely to be considered
“headache/migraine experts” by the public
Additionally, dental professionals and their
teams lacked an integrated system and
the training necessary to provide complete
care for DMSMD-related cases
Why dentists are uniquely suited
Orthodontists and general dentists,
recognized experts in oral health, also
are knowledgeable about and trained
in managing the muscular and nervous
components of the jaw, neck, and
head, according to the American Dental
Association As such, dental professionals
can take a leading role in treating issues
relating to DMSMD, TMJ, and associated
problems.8,9 Incorporating a system for
assessing and treating improper dental
forces that cause painful conditions in
the mouth, head, face, and neck areas
represents an exciting and significant
opportunity for dentists to be of service
to their patients while also benefiting their
dental teams and practices Those who
elect to offer patients assessment and
treatment for DMSMD and associated
conditions have a competitive edge,
distinguishing themselves, their dental
teams, and practices as comprehensive
providers of an array of overall health
services in the convenience of a practice
they’re already familiar with
This patient- and practice-enhancing
opportunity is possible through the use
of a state-of-the-art proprietary system
(TruDenta, Dental Resource Systems,
Inc., www.DRSdoctor.com) The
only comprehensive approach to the
DMSMD conditions, it offers orthodontists and general dentists a Food and Drug Administration (FDA)-cleared, conservative care strategy that can be customized for managing pain and inflammation, restoring range of motion and function, and reestablishing stabilization to the mouth, jaw, and head
Dentists and dental teams who add TruDenta capabilities to their practices are uniquely trained and equipped to offer their existing patients complete care from professionals they already know and trust, as well as attract new patients
by establishing themselves as experts in providing a proven assessment and therapy that employs objective and subjective methods and state-of-the-art technologies found in less than 1% of all dental offices in the United States today.10 These combine
to enable them to comprehensively assess, treat, and manage/monitor patients’
chronic headache and face, TMJ/D, neck, and other head area pain, as well as other dental force-related conditions
Case presentation
The case that follows demonstrates the straightforward manner in which the TruDenta system enables orthodontists and their teams to achieve successful treatment and rehabilitation outcomes through a compelling visual and objective assessment, as well as scientifically based, systematic, and predictable treatment methods and technologies derived from sports medicine to offer a customized pathway of care
A 21-year-old woman presented complaining of soreness of the mouth and jaws due to clenching and grinding The patient received a complete examination that included a head health, medical, and headache history, and a pharmacological assessment Dental, periodontal, airway, orthodontic, and occlusal examinations also were undertaken
The patient showed symptoms of muscle pain and headache pains She claimed pain in the jaw joint, ear, and side
of the face There was a history of popping and clicking, and headaches on the side of the head She claimed tightness of the jaws
in the morning, and that her jaws became tired when chewing There was history of soreness in the eye and ear areas, as well
as neck and shoulder pain She indicated that she experienced the pain daily, and that she was tired of it Fortunately, she
this condition, something that is rare in stomatognathic patients, since many have tried myriad treatments and healthcare professionals prior to seeing orthodontists.The patient reported that she regularly took Excedrin, Tylenol, and Allegra-D
to combat her symptoms, but that they were becoming unmanageable with those medications
Upon palpation, the patient showed 6/10 tenderness to palpation of the lateral pterygoinds, masseter muscles, temporalis tendons, and right posterior belly of the temporalis with trigger points Additionally, she showed 7/10 in the right SCM and bilateral occipital insertion of the trapezius muscles Her opening range of motion was restricted to 42 mm, with a deviation
to the right and a restricted right range
of motion as well Diagnostics included cephalgia 784.0, muscle spasm 728.85, and headache 339.1
Crucial to establishing the severity of sensorimotor dysfunction, any abnormal, excessive, or imbalanced forces were identified objectively using mandibular range of motion (ROM) disability, cervical range of motion disability (digitally), and digital force analysis (TruDenta Scan) The ROM portion of the diagnostic process provides objective data conforming to American Medical Association (AMA) guidelines (Figure 1)
The patient’s T-Scan testing showed significant anterior prematurity with heavy force values (Figure 2) This was further confirmed by cone beam CT generated corrected tomograms, which proved distally trapped condyles due to occlusal forces and positions (Figures 3 and 4) Clench T-Scan demonstrated further the
Figure 1: Range of motion (ROM) analysis from the initiation of TruDenta treatment through to completion showing progressive improvement in the patient’s range of motion
Trang 14extent of the anterior prematurity and
the significance of the resulting condylar
position (Figures 5 and 6)
Treatment protocol
Treatment was planned to achieve
relief of the neuromuscular problems as
documented, followed by alignment and
balancing of the mandible, dentition, and
force values, as well as alleviate pain
Treatment recommendations consisted of
office visits, manual muscle testing, ROM
testing, TMJ ultrasound, applied electrical
stimulation, manual muscle therapy, cold
laser therapy, therapeutic exercises,
home care instructions, occlusal analysis,
occlusal orthopedic device (NU modifier),
and self-care home management training
Stabilization goals included
orthodontic therapy utilizing SureSmile®
(OraMetrix) advanced 3D technology
once muscle stability was achieved
Diagnostic simulations indicated that lower
incisor extraction was indicated to allow elimination of anterior dental prematurities and forward positioning of the condyles
Once achieved, equilibration would be undertaken to stabilize the dental forces within the new balanced stomatognathic envelope
Treatment outcome
The patient’s treatment consisted of five weekly in-office visits of therapeutic rehabilitation using cold laser therapy, ultrasound therapy, low-level electrical current stimulation, and manual muscle therapy A custom rehabilitation orthotic for the mouth was also worn at home until we began the maxillary orthodontic treatment
At 5 weeks, the patient’s condition had improved sufficiently so that orthodontic therapy could begin in order to eliminate the obvious dental deflective interferences (Figures 1, 7, and 8) Extraction of tooth No 24 and placement of full fixed
orthodontic appliances occurred in February 2012 (Figure 9) The SureSmile therapeutic scan was made in June 2012
so that the final plan could be fabricated virtually (Figure 10), and the robotic wires were prescribed to finalize her case A total
of three prescription wires were delivered, and the patient was debonded in January
2013, for a total orthodontic treatment time
of 11 months (Figures 11 and 12)
Dental bite force balance was confirmed at her immediate post-treatment conference in February 2013 with the T-Scan and ROM analysis, which revealed virtually normal ROM measurements and significantly lessened anterior prematurity (Figures 1, 13, and 14) We have equilibrated once so far, and she is scheduled to finalize her equilibration at her next appointment, with additional follow-up T Scans to verify force balance (Figures 15-17) The patient reports a much improved sense of her teeth “fitting together,” no muscle spasms
Figure 2: The initial force analysis (TruDenta Scan) showed significant anterior prematurity with heavy force values Figures 3 and 4: Cone beam CT generated corrected tomograms showed distally trapped condyles due to occlusal
forces and positions
Figures 5 and 6: TruDenta scans taken while the patient was clenching further demonstrated the
extent of the anterior prematurity and the significance of the resulting condylar position
Figure 7: Pre-orthodontic view of the patient’s natural smile
Figure 8: Pre-orthodontic radiograph showing the patient’s tooth alignment
Figure 9: View of the patient’s teeth following placement of the full fixed orthodontic appliances
Figure 10: The SureSmile therapeutic scan was made in order to virtually finalize the treatment plan
Trang 1514 Orthodontic practice Volume 4 Number 3
RefeRences
1 Junge D Oral Sensorimotor Function Medico
Dental Media International, Inc.: 1998.
2 Sessle BJ Mechanisms of oral somatosensory
and motor functions and their clinical correlates J Oral
Rehabil 2006;33(4):243-261.
3 Okeson JP Management of Temporomandibular
Disorders and Occlusion 6th ed St Louis, Mo: Mosby;
6 Migraine National Headache Foundation Web site
http://www.headaches.org/education/Headache_Topic_
Sheets/Migraine Accessed July 3, 2012.
7 Ostler GL Building professional referral
relationships with physicians Dental Economics
2012 http://www.dentaleconomics.com/articles/print/
referral-relationships-with-physicians.html Accessed July 3, 2012.
volume-96/issue-12/features/building-professional-8 Sardella A, Demarosi F, Lodi G, Canegallo L, Rimondini L, Carrassi A Accuracy of referrals to a specialist oral medicine unit by general medical and
dental practitioners and the educational implications J
Dent Educ 2007;71(4):487-491.
9 Dentists: Doctors of Oral Health American Dental Association Web site http://www.ada.org/4504.aspx Accessed July 3, 2012.
10 TruDenta http://www.trudenta.com Accessed January 22, 2013.
or headaches, and an incredibly positive
experience with her treatment
Conclusion
With the acceptance and incorporation
of a comprehensive assessment and
treatment system, orthodontic practices
have the opportunity to expand the scope
of services they provide to patients looking
to resolve the TMJ/D and head pain
issues associated with dental force related
problems The proprietary TruDenta
system, which incorporates assessment
devices and therapeutic technology derived
from sports medicine, uniquely empowers
orthodontists to offer a proven, long-term
solution and customized pathway to care
for DMSMD-related conditions
Treating patients with TruDenta is
straightforward; treatments are simple,
quick, effective, painless, and require no
drugs or needles Many dental practices offering the TruDenta pathway to care — including orthodontic practices — have reported that, within a 10- to 12-week period, their patients experienced life-altering relief from their chronic pain
Additionally, it now gives us the ability to properly balance our finished orthodontic
cases like never before The combination
of SureSmile virtual diagnostic and robotic treatment, and TruDenta force value detailing finally gives us the tools to perfectly finish our cases for maximum stomatognathic function and stability It’s
a dream that has finally become a reality.OP
Figure 11: View of the post-orthodontic radiograph following treatment with three prescription wires Figure 12: Post-orthodontic view of the patient’s smile after debonding
Figures 13 and 14: Immediate post-orthodontic TruDenta Scans demonstrate that the patient achieved significantly
lessened anterior prematurity
Figure 12: Post-orthodontic view of the patient’s smile after debonding
Figure 15: Following an initial equilibration, a force analysis was performed
Figures 16 and 17: After the initial equilibration, a TruDenta scan was also performed while the patient was clenching
Trang 16The Digital Orthodontist
Seeing Treatment Differently
For our patients, suresmile is that tool which allows us to
plan treatment with greater confidence and predictability
than ever before In turn, this motivates patients to
become partners in their treatment
before
Class II, subdivision R
For a detailed case study, please
call 888.672.6387 and request
suresmile clinical report no 1.
Trang 17Historically, the United States has
lagged behind other countries in
the world in regards to offering lingual
orthodontics as an option for treatment
to our patients In my opinion, the reason
for this discrepancy between the U.S and
other countries for lingual treatment is due
to the two main challenges associated
with lingual orthodontics: 1) difficult retie
appointments for both patient and clinician,
and 2) significantly longer appointments
However, I personally see this changing
very quickly over the next several years for
three main reasons: 1) esthetic orthodontic
treatment is something that is highly
desirable for our patients, 2) many patients
are now aware of lingual treatment and are
actively seeking it out, and 3) advances
with technologies such as SureSmile®
(OraMetrix), cone beam computed
tomography (CBCT), and small lingual
self-ligating brackets have made treatment with
lingual orthodontics much easier for both
the clinician and the patient Over the
past 4 years, lingual orthodontic treatment
utilized in combination with SureSmile/
CBCT has become a big adjunct for me
in my practice In this article, I will review
a complex case treated with upper lingual
and lower labial fixed appliances
Patient information
This patient presented at his new patient examination on May 20, 2009 as a healthy 44-year, 1-month-old adult male He stated that his chief complaint was to resolve his crowding, have straighter teeth, and a nicer smile
Diagnosis and etiology
Intraoral examination revealed a Class III, subdivision right molar and canine malocclusion He presented with an overbite (OB) of 20% and overjet (OJ)
of 1 mm There was excessive maxillary and mandibular incisal wear present due
to this OB/OJ relationship Arch-length deficiencies were present in both maxillary – 7 mm – and mandibular arches – 7 mm
Both maxillary and mandibular arches were asymmetric and tapered in arch forms A right posterior crossbite was present for his UR6, UR5, and LR6 An anterior crossbite was also present with his UR3, UR2, LR3, and LR2 as a result of his right Class
III malocclusion Periodontal evaluation revealed normal and healthy gingival tissue There was some minor gingival recession present with his UR7, UR6, UL2, UL3, UL6, and LR6 (Figure 1)
Frontal facial evaluation revealed a symmetrical and balanced facial pattern for his upper, middle, and lower facial third heights Profile evaluation revealed
a straight profile with normal chin His nasolabial angle was 110 degrees, and both upper and lower lips were normal and competent at repose A frontal smile evaluation revealed acceptable upper and lower smile line with buccal corridors present His maxillary midline was centered with his facial midline However, his mandibular midline was deviated 3 mm to the right of his facial and maxillary midlines Cephalometric analysis revealed a Class III skeletal relationship with ANB = -2.6 It also revealed a brachiocephalic facial pattern with a low MPA = 24.7 (Figure 2)
Panoramic evaluation revealed all third
Orthodontic technology case report:
three-dimensional lingual treatment in combination with a temporary anchorage device (TAD)
Dr Edward Lin treats a case to resolve crowding, straighten teeth, and improve the smile
Dr Ed Lin is one of two partners at
Orthodontic Specialists of Green Bay
(OSGB), a private practice in Green Bay,
Wisconsin He is also one of two partners
at Apple Creek Orthodontics of Appleton (ACOA) Dr
Lin received both his dental (DDS) and orthodontic
(MS) degrees from Northwestern University Dental
School OSGB and ACOA are both completely digital
practices and have been utilizing SureSmile (OraMetrix)
since February of 2004 at three different practice
locations Both practices have been involved with cone
beam computer tomography (CBCT) with the i-CAT
(Imaging Sciences International) since 2006 Dr Lin is
an internationally recognized speaker (U.S., Canada,
Puerto Rico, Australia, and China), has written several
articles that have been published in a wide variety of
dental journals, and has lectured at several orthodontic
residency programs across the United States He
is a faculty and Clinical Advisory Board member for
SureSmile He also sits on the Clinical Advisory Boards
for American Orthodontics and Imaging Sciences
International and is on the Editorial Board of Orthotown
and Orthodontic Practice US journals.
Figure 1: Initial records 5/20/09
Trang 18CASE STUDY
molars were present and fully erupted
Alveolar bone height was healthy and
within normal limits for both maxillary and
mandibular arches There were no other
significant findings (Figure 3)
Treatment summary
The patient is a pediatric oncologist, and he
requested treatment with lingual brackets
in his maxillary arch and labial ceramic
brackets in his mandibular arch since
esthetics during the course of treatment
was a concern for him The patient was
given a non-extraction treatment option,
which consisted of full fixed orthodontic
appliances in combination with a TAD
placed in his lower right posterior
quadrant Due to the amount of crowding
present and his Class III relationship, lower
posterior interproximal reduction was also
recommended An estimated treatment
time of 20 months was given due to
complexity of his case
On January 5, 2010, In-Ovation® L
(Dentsply GAC) lingual fixed appliances were placed for U8-8, and In-Ovation®C (Dentsply GAC) labial fixed appliances were placed for L3-3 in combination with In-Ovation®R (Dentsply GAC) labial fixed appliances for his L5s – L8s using an indirect bonding technique A 0.013 round CuNiti (G&H) lingual mushroom-shaped wire was placed in the maxillary arch, and a 0.016 round Bioforce® Sentalloy®
(Dentsply GAC) labial wire was placed in the mandibular arch A very active open coil spring was placed between his LR7 and LR6, and a Vector 1.4 mm x 8 mm Vector (Ormco) temporary anchorage device (TAD) was placed just to the distal
of the distobuccal root of his LR6 The TAD was tied with a steel ligature tie to his LR6 for indirect anchorage for distalization
of his LR7 and LR8 Posterior bite turbos were placed on his LL8, LL7, LR7, and LR8 utilizing Twinky Star (Voco) to open his bite for anterior crossbite correction Lower posterior interproximal reduction was also
performed between his L8s, L7s, L6s, and L5s due to the amount of crowding present
in his mandibular arch and for Class III correction A 3/16” crossbite elastic with 2.7 oz of force was instructed to be worn full time from the lingual of his UR6 to the labial of his LR6 A 1/4” Class III elastic with 2.7 oz of force was also instructed to be worn full time from his UL6 to his LL3
On March 10, 2010, the patient returned for his first retie appointment The same 0.013 round CuNiti (G&H) lingual mushroom-shaped wire was kept
in his maxillary arch to allow for additional leveling and aligning A new 0.016 round Bioforce Sentalloy labial wire was placed in the mandibular arch The mandibular arch wire was not placed into the LR8 and was left 3 mm long, and turned over distal to his LR7 so that the wire would not irritate and cause ulcerations of the mucosal tissue on the inside of his cheek A new very active open coil spring was placed distal to his LR6 to continue distalizing his LR8 and LR7 Indirect anchorage was still present with a steel ligature tied from the TAD to his LR6.The same elastics from his previous appointment were instructed to be worn full time again
On May 10, 2010, the patient returned for his second retie appointment
A new 0.016 round CuNiti (G&H) lingual mushroom-shaped wire was placed in his maxillary arch A new 0.016 x 0.016 square Bioforce Sentalloy labial wire was placed in the mandibular arch The mandibular arch wire again was not placed into the LR8 and was left 3 mm long and turned over distal
to his LR7 so that the wire would not irritate and cause ulcerations of the mucosal tissue on the inside of his cheek A new very active open coil spring was placed distal to his LR6 to continue distalizing his LR8 and LR7 Indirect anchorage was still present with a steel ligature tied from the TAD to his LR6 The crossbite elastic was discontinued as the right posterior crossbite had been corrected The same Class III elastic was instructed to be worn full time
On July 6, 2010, the patient returned for his third retie appointment The same 0.016 round CuNiti (G&H) lingual mushroom-shaped arch wire was kept in his maxillary arch A new 0.018 x 0.018 square Bioforce Sentalloy labial wire was placed in the mandibular arch The mandibular arch wire again was not placed into the LR8 and was left 3 mm long and turned over distal to his LR7 so that the wire would not irritate and
Figure 2: Initial records 5/20/09
Figure 3: Initial records 5/20/09
Trang 1918 Orthodontic practice Volume 4 Number 3
cause ulcerations of the mucosal tissue on
the inside of his cheek A new very active
open coil spring was placed distal to his
LR6 to continue distalizing his LR8 and
LR7 Indirect anchorage was still present
with a steel ligature tied from the TAD to his
LR6 All elastics were discontinued at this
appointment
On August 31, 2010, the patient
returned for his fourth retie appointment
A 0.4 voxel, 8 cm field of view (FOV), 10
second i-CAT® scan (Imaging Sciences
International) was taken for evaluation prior
to repositioning of his lower right TAD to
just mesial of the mesiobuccal root of his
LR7 (Figures 4 and 5) A closed elastomeric
chain (American Orthodontics) was placed
from his LL6-LR6 with direct anchorage to
the TAD for en masse retraction for right
Class III correction A 3/16” crossbite
elastic with 2.7 oz of force was instructed
to be worn for 12 hours per day from the
lingual of his UR6 to the labial of his LR6
On September 29, 2010 and
November 10, 2010, the patient returned for his fifth and sixth retie appointments to change his elastomeric chain from his LL7-LR6 to his TAD again for his right Class III correction The same 3/16” crossbite elastic was instructed to be worn 12 hours per day
On December 8, 2010, the patient returned for his seventh retie appointment
We began his transition into SureSmile at this appointment (Figure 6) His arch wires were removed, and the In-Ovation L (Dentsply GAC), In-OvationC (Dentsply GAC), and In-OvationR bracket doors were closed
Upper and lower incisal recontouring was performed to give balance and symmetry
to his incisal edges A SureSmile i-CAT scan was taken with a wax bite present with the condyle seated in the glenoid fossa with the maxillary and mandibular dentition slightly separated (~2 mm) at 0.4 voxel, 8
cm FOV, and 10-second settings Because
of the amalgam present in his LR7 and the subsequent metal scatter present with his
SureSmile i-CAT scan, a supplemental intraoral scan was taken with SureSmile’s intraoral scanner of his LR6-LR8 (Figure 7) The intraoral scan data was then merged with his SureSmile i-CAT scan data and was uploaded and submitted to SureSmile for creation of the clinical crown anatomy
as well as the root anatomy for the patient’s SureSmile virtual 3D models (Figure 8) The clinician was then able to correct the patient’s malocclusion using SureSmile’s 3D software applications (Figure 9) The patient’s SureSmile plan was completed, and his SureSmile wires were ordered to
be bent utilizing SureSmile’s proprietary software and robots (Figure 10) The same 3/16” crossbite elastic was instructed
to be worn 12 hours per day A closed elastomeric chain was placed from his LR7
to his LL6 There was nothing tied to his lower right TAD, and it was left in place to provide mechanical anchorage to prevent the LR7 from drifting forward mesially.Six weeks later, on January 18, 2011,
Figure 5: Progress 8/31/10 with Dolphin 3D Figure 6: SureSmile scan 12/08/10
Figure 7: SureSmile scan 12/08/10 Figure 8: Blue SureSmile® 3D CAD/CAM model illustrating
malocclusion present created from SureSmile®/i-CAT®
scan with supplemental intraoral scan of LR6-LR8 due to amalgam restoration for LR7
Figure 9: White SureSmile® 3D CAD/CAM treatment plan model with correction of malocclusion superimposed over blue SureSmile® 3D CAD/CAM model with malocclusion present
Figure 4: Progress panorex 8/31/10
Trang 20The Future of Orthodontics Fits on Your Desktop
Take the leap to digital orthodontics today, and:
Find out how Objet 3D printers from Stratasys can make digital orthodontics a reality for your lab.
ACCOUNT: Lily Nachinson
PRODUCTION: Tina Anderson
PROOFER:
Trang 2120 Orthodontic practice Volume 4 Number 3
the patient returned for his eighth retie
appointment for his SureSmile wire inserts
A 0.017 x 0.025 SureSmile CuNiTi lingual
wire was placed in his maxillary arch, and
a 0.017 x 0.025 SureSmile CuNiTi labial
wire was placed in his mandibular arch
Interproximal reduction was performed
in both maxillary and mandibular arches
that had been determined from his
SureSmile plan (Figure 10) His lower right
TAD was removed as anchorage was no
longer needed His right crossbite elastic
was discontinued Clear plastic buttons
(ceramic bondable button, Dentsply GAC)
were placed on his UR3,UL3, and the
patient was instructed to wear
triangle-vertical 3/16” elastics with 2.7 oz of force
bilaterally for 12 hours per day from his U3s
to his L3s and L4s Closed elastomeric
chain was placed from U6-6 and LR7-LL6
On March 16, 2011, the patient returned
for his ninth retie appointment Photos
were taken to track treatment progress
(Figure 11) His vertical-triangle elastics
were discontinued, and 5/16” with 2.7 oz
of force Class III elastics were instructed
to be worn full time on his right side only from his UR6 to his LR3 and UR3 As a result, a clear plastic button was bonded
to his UR6 in order for him to wear the new elastic, and the plastic button on his UL3 was removed Closed elastomeric chain was placed from U6-6 and LR7-LL6
On May 10, 2011, the patient returned for his tenth retie appointment, and photos were taken again to track his treatment progress (Figure 12) Utilizing SureSmile’s proprietary software, virtual wire modifications were submitted for finishing and detailing based upon clinical evaluation
of the patient’s occlusion Finishing SureSmile wires were then ordered to be bent by SureSmile’s proprietary robots (Figures 13 and 14) A closed elastomeric chain was placed from his U6-6 All elastics were discontinued at this time
On June 6, 2011, the patient returned for his eleventh retie appointment, and his
finishing SureSmile wires were placed: maxillary 0.016 x 0.022 lingual CuNiTi and mandibular 0.017 x 0.025 labial CuNiTi All plastic buttons and elastics were discontinued Closed elastomeric chain was placed for U6-6 and LR7-LL6
On July 18, 2011, the patient returned
to have his fixed appliances removed He was moved into retention with an Essix ACE® retainer with full-time wear and a L3-3 fixed lingual splint Three months later, the patient returned for his final records, and retention wear of his Essix ACE® retainer was reduced to bedtime only (Figure 15) Total treatment time for this patient was 18 months and 13 days The total number of appointments from the initial bonding appointment to his debond appointment was 16, including three emergency appointments
Summary and conclusions
In the early 1980s, lingual orthodontic treatment reached its height in popularity
Figure 10: SureSmile wires bent by SureSmile’s robots
Trang 22in the U.S However, its popularity quickly
declined as clinicians began to experience
the technical difficulties associated with
lingual mechanics: 1) visual and working
access was significantly less, and ligating
the arch wires was much more difficult in
comparison to labial resulting in difficult
and longer retie appointments, 2) shorter
interbracket distances posed problems
with being able to place certain bends in
the arch wire and engaging the arch wire
into the bracket slots, and 3) comfort of
the lingual appliances was a problem, and
certain patients could not tolerate them,
and the appliances had to be removed.1,2
The In-Ovation L bracket has given
our profession a small, low profile,
self-ligating bracket and has helped to make
the appliances much more comfortable
for the patient It has also made ligating
the arch wires into the bracket slots
significantly easier I chose to utilize the
i-CAT, Dolphin 3D, TAD, and SureSmile
technologies within my treatment plan
because I personally believe that these
RefeRences
1 Keim RG The resurgence of lingual orthodontics J
Clin Orthod 2012;46(4):197-198
2 Stamm, T, Wiechmann D, Heinecken A, Ehmer U
Relation between second and third order problems
in lingual orthodontic treatment J Lingual Orthod
2000;1(3);5.
3 Lin E Three dimensional orthodontic treatment in
combination with TADs: case report Orthod Practice
US 2011;2(3).
4 Saxe A, Louie L Mah J Efficiency and effectiveness
of SureSmile World J Orthod 2009;11:16-22.
5 Alford T, Roberts E, Hartsfield J, et al Clinical outcomes for patients finished with SureSmile method compared with conventional fixed orthodontic therapy
Angle Orthod 2011;81:383-388.
6 Phan X, Ling P Clinical Limitations of Invisalign J
Can Dent Assoc 2007;73(3):263-6.
four technologies greatly improve my capability to diagnose and treatment plan (i-CAT and Dolphin® 3D), as well as deliver active therapeutic care (TAD, i-CAT, and SureSmile).3 Utilizing SureSmile, I was able to correct his malocclusion to a high degree of precision and accuracy without having to reposition brackets or bend wires
by hand, which for lingual, is incredibly challenging This is clearly illustrated with the development of his upper smile arc,
in which I was able to utilize SureSmile’s software to intrude his UR3, UL3 and extrude his UR2-UL2 (Figure 16)
The advantages of using SureSmile have been substantiated in two recent and separate studies with SureSmile cas-
es grading better with American Board of Orthodontics (ABO) scores and complet-ing treatment with an average of 25% re-duced treatment times in comparison to conventional orthodontics.4,5 In this au-thor’s opinion, the advantages of using SureSmile in combination with i-CAT to create the SureSmile 3-D CAD/CAM mod-
els and to evaluate malocclusion and root positions are invaluable, and I truly believe that I am a better orthodontist today be-cause of them With SureSmile, treating this patient with lingual appliances is also
no longer a daunting task In the past cade, esthetic orthodontic treatment has exploded with the development of remov-able, invisible aligners However, there are limitations with what can be accomplished with aligner treatment.6 As mentioned pre-viously, lingual with SureSmile has become
de-a big de-adjunct for my prde-actice with my ing able to offer esthetic treatment with shorter treatment times and without having
be-to compromise on the finished end result And as we all know, technology will only continue to get better!
Give a child fighting cancer a beautiful smile: donate to childhood cancer charities in support of research or financial assistance, offer to provide dental care, or even offer to assist their parents with errands Thanks to all for this opportunity to raise awareness
OP
Figure 13: Maxillary virtual wire modifications Figure 14: Mandibular virtual wire modifications Figure 15: Final 10/19/11
Figure 16: Intrusion of his U3’s and extrusion of U2-2 to develop his smile arc
Trang 23In previous papers1,2, the principles
for diagnosis, designing a care plan,
communicating with the patient, and
evaluating the progress of patient care
were discussed In this article, the
approach used by the author in designing a
personalized therapeutic solution driven by
diagnosis (diagnopeutics) using SureSmile
technology is presented
Prescribing the Virtual Target
Setup (VTS)
The design of the prescription is driven
by considering six conditions defined by
the Sachdeva Virtual Target Prescription
Design (SVTPD) guidelines: Midline,
Archform, Class of Occlusion, Reference
Teeth, Occlusal Plane, and Special
Instructions These are defined by the
acronym MACROS and are embedded in
the software.3-5 The prescription can be
provided in a number of ways, by filling the
appropriate conditions in the prescription
form, adding to the text field, or providing
a simulation Generally speaking, the
“prescriptive” simulation is used in situations
where it is difficult to describe the nature of
orthodontic tooth movement desired For
patient K.S., the prescription for the virtual
targeted setup is shown in Figure 1 The
boundary/design conditions prescribed for
patient K.S are seen in Table 1
This prescription is sent to the
SureSmile digital laboratory electronically
and is used by the orthodontic digital
laboratory technologist to perform the setup If the need arises, the doctor and the technologist communicate both electronically and verbally to gain a better
understanding of the doctor’s plan for his patient (Figure 1F)
The Virtual Targeted Setup is delivered
to the doctor within 5 business days
BioDigital Orthodontics: Diagnopeutics with
SureSmile technology: part 3
Dr Rohit C.L Sachdeva explains his approach to designing a personalized therapeutic solution
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. Figures 1A-F: Setup Design Prescription for patient K.S Virtual Target Setup using the SVTPG framework defined
by MACROS F Simulation to equilibrate the incisal edges can be performed with SureSmile software and also plan for the restorative needs of a patient
Trang 24ORTHODONTIC CONCEPTS
Evaluating the Virtual Target Setup
This is done by following a comprehensive checklist guide (Figure 2) The purpose of this exercise is
to ensure that the setup has not been designed beyond the boundary conditions defined by the doctor’s prescription, and the planned tooth movements are achievable Complementary tool sets designed in the software, such as registration against the VTM, facilitate the understanding of the planned movements (Figures 3A-3C) Furthermore,
an automatic check guide using the ABO grading system can be used to evaluate individual tooth positions and score the setup (Figures 4A and 4B)
The doctor has the ability to correct the setup by moving teeth at the practice site or requesting the SureSmile digital laboratory to do so (Figure 4C)
Sachdeva Virtual Target Prescription Design
(SVTPD) guidelines Boundary Conditions Prescription
M MIDLINE Treat to the upper dental midline
A ARCHFORM Treat to lower natural archform
C CLASS Treat to a Class I molar and canine relationship
R REFERENCE TEETH Treat to the upper and lower right second bicuspid, the upper and lower left canine
O OCCLUSAL PLANE Treat to the maxillary functional occlusal plane
S SPECIAL INSTRUCTIONS Doctor will polish lower incisal edges as per simulation
Table 1: Sachdeva Virtual Target Prescription Design is used in providing instructions to the
SureSmile Digital Laboratory for the Virtual Target Setup Note that the same guidelines are
used for developing the Virtual Diagnostic Simulation (VDS)
Figures 3A-C: Patient K.S A Virtual Target Setup VTS Model registered on the B Virtual
thera-peutic model VTM C Displacement values VTM, VS, VTS These provide an indication of the
nature of tooth movement planned to achieve the target Note: It is best to look at the tooth as
a whole to determine the nature of tooth movement The displacement values are best used to
gain an appreciation of the type and magnitude of tooth movement
Figure 2: Patient K.S Virtual Target Setup evaluation checklist Note: as the doctor goes through the checklist, the corresponding images are displayed
Figures 4A-4C: Patient K.S A The ABO OGS score shown is measured against a checklist
B Each of the measurement items defined by this system are automatically identified and measured, and the scores shown The Virtual Target Setup can also be evaluated by using the automatic ABO OGS grading system C The teeth can be moved by the doctor if he/
she chooses to In this case, the buccal lingual inclination of the lower second molar is ing evaluated and corrected Notice the change in scores of the lower right second molar
be-in B versus A
Trang 2524 Orthodontic practice Volume 4 Number 3
Designing the virtual prescription
for the SureSmile precision
archwire
SureSmile software provides the
orthodontist unprecedented tools to “add
or subtract” to the design of SureSmile
precision archwires and override the base
design driven by the static setup (Please
note: No special bends were designed
into the precision wire for patient K.S The
Evaluating the final design of the
SureSmile precision archwires
The SureSmile precision archwire is
automatically designed to the Virtual Target
Setup It is best evaluated by reading
the archwire bends/geometry against
the brackets on the VTM and mentally
visualizing the effect of such bends on
tooth movement In other words, bends
are consistent with the direction of planned
tooth movement (Figure 5) Figure 5: The design of the SureSmile precision archwire can be read against the therapeutic model to evaluate the nature of the bends designed
Figure 6: Selection of material and cross-section for the fabrication of the SureSmile precision archwires
Figures 8A-8D: Patient K.S addition of torque in archwire To correct for slop in the archwire, more torque may be added in the archwire There are two approaches to achieve this A First shows the automatic addition of torque based upon slot and archwire dimension For a 017”x.025” archwire in a 018” slot, this amounts to two degrees B For
a 016”x.022”, it is five degrees C and D Overcorrection can also be built into archwire Also, note that tooth movement can be simulated to account for the additional torque in archwire
Figures 7A-7E: Patient K.S wire modifications Example of the staging of archwire bends
A-E An entire range of staged archwires can be designed from 0% to 120%, i.e., passive
to overcorrected bends for any one region to the entire arch
purpose of this part of the discussion is only to inform the reader of the capabilities
of SureSmile technology in adding or subtracting bends to affect the geometry of the precision archwire to achieve the target tooth movement.)
The doctor may choose both the cross-section and material for archwire fabrication (Figure 6) Furthermore, the expression of the archwires may be
staged from a range of 0% (passive archwire) to 120% (overcorrection) based upon the patient’s needs (Figures 7A-7E) Additionally, overcorrection bends to correct for bracket wire slop may be added
to the base archwire design to gain better control of tooth movement (Figures 8A-8D)
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Trang 27Also expansion, constriction, reverse
Curve of Spee or Curve of Spee may
be added to counteract or complement
the use of auxiliaries such as elastics,
etc (Figures 9A-9G) The wire may be
“straightened” in critical areas where
sliding mechanics are needed to close
space (Figure 10) Overrides in the
distal segments of the archwire may be
designed to accommodate for a second
molar that erupts later and has not been
scanned (Figures 11A-11C) This feature is
especially useful in clinical situations where
it may be difficult to scan the second molar
intraorally, or the doctor does not wish
to take an additional CBCT image of the
patient Furthermore, the effect of
doctor-driven subtractive or additive bends may
be simulated to understand the potential
displacive effects of these bends (Figure
10) Finally, archwire insertion may be
simulated to assess the potential of
archwire bracket collisions (Figure 16)
Figures 9A-9G: Designing the virtual prescription archwire A-C Reverse Curve of Spee in archwire
A Initial archwire C Note: 4 mm reverse Curve of Spee built into the archwire C The effect of this archwire, if allowed to express fully, can be simulated D-G Expansion
or constriction can be designed into the archwire and simulated E Note:
5 mm arch width expansion has been designed into the archwire, and the effect of using this archwire is simulated
Figure 10: Archwire modification Any segment of the archwire can be made “straight” to
allow slide to enable space closure without any conflicts arising from bends
Figures 11A-11C: Patient K.S A-C Note: the archwire has been distally extended and torque placed on the wire
Overcorrection may also be added
by affecting tooth movement in the setup rather than using the “virtual plier.” The choice of either using a tooth-driven approach to affect archwire geometry or virtual plier is dependent upon the doctor’s preference In patient K.S, 017” x 025”
CuNiTi for both the upper and lower were selected to achieve the target treatment
Trang 28ORTHODONTIC CONCEPTS
SureSmile precision archwire
insertion and patient management
The SureSmile precision archwire is
shipped to the practice site within 10
business days of accepting the final design
of the virtual prescriptive archwire It
takes 4 business weeks from the time the
therapeutic scan is taken to the time the
archwire is delivered to the practice (Figure
6) Commonly, the doctor schedules the
patient visit for insertion of the SureSmile
precision archwires 6 weeks
post-therapeutic scan For patient K.S., this visit
was scheduled 4 weeks post-therapeutic
scan
The design of the archwire is printed
on the box that carries the archwire This
allows the doctor to compare the physical
archwire design to the virtual design Note:
The image of the SureSmile precision
archwire is also available for viewing in
Figures 12A-12B: Placement of archwire in vivo Laser marks on the archwire are etched
These are used as guide marks to ensure proper archwire placement These marks can also
be seen on the virtual archwire and on a printout that comes with the box the archwire is shipped in to the practice
Figure 14: IPR tracking chart
Figure 13: Patient K.S archwire insertion In order to minimize any archwire bends and bracket conflicts, engagement points can be simulated to optimize archwire
placement The blue hash line on the archwire should match with the slot
the patient’s SureSmile electronic record (Figure 12A) Accurate placement of the archwire and proper management of tooth constraints is vital to achieve success with SureSmile precision archwires Visual checkmarks to confirm correct positioning
of the archwire are available as a reference for the doctor or staff to place the archwire (Figure 12B) Also guidelines for the tooth best suited to first engage the archwire are available for viewing in the SureSmile patient record (Figure 13) In addition, IPR can be tracked during treatment to ensure tooth collisions do not occur, and excessive enamel is not removed (Figure 14)
Trang 2928 Orthodontic practice Volume 4 Number 3
ordered in a series in advance or later
Additional archwires for refinement
purposes during treatment can be ordered
by either modifying the setup or adding
modifications directly into the archwire A
checklist in the software is embedded to
guide the doctor in assessing the potential
root cause for misalignment that may be
observed during the use of the SureSmile
precision archwires (Figure 15) This is
often related to mismanagement of the
constraints or improper placement of the
archwire (Figures 16A-16D)
Generally speaking, the SureSmile
prescription archwires are allowed to “work
out” for 8 weeks before the patient is seen
Upon the patient’s return to the practice at
the next visit, the archwire deactivation is
matched against the staged virtual target
simulation When the intraoral results match
the final VTS, it may be inferred that the
archwire has worked out It is best to view
the relative bracket positions to gauge the
proximity of the occlusion to the planned
target At the patient check visit (8 weeks
post precision archwire insertion), the
patient’s response was evaluated against
the VTS Note how closely the planned final
position of the brackets on the VTS match
patient K.S.’s intraoral condition (Figures
16 and 17) At this visit, it was concluded
that most of the tooth movement had
been accomplished (Figure 17), and the
patient was appointed for a final checkup
4 weeks later At this appointment, the
patient was once again evaluated against
the VTS It appeared clinically that the final
target occlusion had been achieved (Figure
16D), and the patient was scheduled
for debonding a month later (Figures
17C-17D)
In situations where the in vivo
positions of the teeth do not match the
virtual setup, the checklist guide in the
SureSmile software is used to perform
a root cause, and then the precision
archwire is redesigned with the virtual plier
or with simulations to achieve the desired
effect match (Figure 14) These refinement
precision archwires are generally received
within 10 business days or sooner In most
situations, orthodontists will insert the
refinement archwire approximately 4 weeks
from the time the refinement prescription
is ordered In patient K.S.’s situation, no
refinement was required, and the patient
was debonded 16-weeks post SureSmile
wire insertion The total active treatment
time for patient K.S was 12 months
Figure 15: Checklist to manage SureSmile precision archwire
Also note refinement in the precision archwire can be made at any point in the care cycle to achieve the desired response But this is best accomplished by progressing step-wise through this checklist and identifying the root cause of any spurious tooth movement before affecting change in the precision archwire geometry
Figures 16A-16D: Patient K.S A and B The intraoral results match C and D The final target virtual setup It may be inferred from this that the archwire has worked out
Figures 17A-17D: Patient K.S Post SureSmile precision archwire insertion progress A
8 Weeks B 12 Weeks C Initial D Final The total treatment time was 12 months
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Trang 311 Sachdeva RCL BioDigital orthodontics: Planning
care with SureSmile technology: part 1 Orthodontic
Practice US 2013;4(1):18-23.
2 Sachdeva RCL BioDigital Orthodontics:
Designing customized therapeutics and managing
patient treatment with SureSmile technology: part 2
Orthodontic Practice US 2013;4(2):18-26.
3 Sachdeva RCL, Feinberg MP Reframing clinical
patient management with SureSmile technology
Pacific Coast Society of Orthodontists NewsWire
2009;2(1):1-24.
4 Sachdeva RCL Integrating digital and robot
technologes: diagnosis, treatment planning, and
therapeutics In: Graber LW, Vanarsdall RL, Vig KWL,
eds Orthodontics Current Principles and Techniques
5th ed Philadelphia, PA: Elsevier Mosby; 2011.
5 Sachdeva RCL, Kubota T, Hayashi K, Uechi J
Transforming Orthodontics-4: BioDigital Orthodontics
(1): Planning care with SureSmile Technology Journal
of Orthodontic Practice 2012;7:83-97.
made, and the patient was debonded a
month later
Conclusions
Successful therapeutic management
of a patient with SureSmile technology
requires thoughtful synchronization of
the straightwire technique with use of the
SureSmile prescriptive appliance High risk
patients, who require precision control of
tooth movement at the onset of treatment,
are better served by utilizing SureSmile
prescription archwires at the beginning of
treatment Extraction patients are better
managed with SureSmile prescriptive
archwires post space closure; however,
as the orthodontist builds proficiency
in the use of SureSmile technology, the
prescriptive archwires are commonly used
within the first few months of treatment
In future papers, patient histories will be
presented to highlight this point
SureSmile technology provides
the orthodontist with great flexibility in
staging and adapting the prescription of
an archwire to suit the patient’s needs as
treatment progresses Such an “adaptive
capacity” is not offered by customized
brackets
Acknowledgements
It is with the deepest sense of gratitude
that I wish to thank both Dr Takao Kubota,
DDS, PhD, and Dr Sharan Aranha,
BDS, MPA, for their unconditional and
enthusiastic support in the preparation of
this manuscript
Visit Dr Sachdeva’s blog on http://
drsachdeva-conference.blogspot.com All
doctors are invited to join the “Improving
Orthodontic Care” discussion blog Please
contact improveortho@gmail.com for
access information.
Figures 17A-17D: Patient K.S Post SureSmile precision archwire insertion progress A 8 Weeks B 12 Weeks C Initial D Final The total treatment time was 12 months
Figures 17A-17D: Patient K.S Post SureSmile precision archwire insertion progress A 8 Weeks B 12 Weeks C Initial D Final The total treatment time was 12 months
OP