volume 01 / issue 01

The Academy for Clear Aligner Therapy the

AmericanJournal Academy of Cosmetic Orthodontics moving not removing enamel. Peer-Reviewed solutions that will make Clear Aligner Treatment that much easier. Like this Journal? start receiving your quarterly issue today!

The official academy for Clear Aligner Therapy. Become a member TODAY! www.aacortho.com AACO Board Members Dr. David Galler: President

the Dr. Mark Hodge: Vice President Dr. Perry Jones: Director of Education Dr. Jeffrey Galler: Editor AmericanJournal Academy of Cosmetic Orthodontics Dr. Len Tau: Director of Media Relations Dr. Bruce McFarlane: Orthodontist, Advisory Board Article is Peer Reviewed Article offers CE Credit at www.aacortho.com Dr. David Harrnick: Orthodontist, Advisory Board Dr. Sandi Bosin: Orthodontist, Editorial Board Case Reports Dr. Peter Rivolli: ClearCorrect Clinical Expert Dr. Yana Shampanksy: Invisalign Expert 2 Upper Lateral Incisor Crossbite with Dr. Lori Trost: MTM Clinical Expert Lower Premolar in Lingual Version by Dr. Cathy Sherry 4 Invisalign Correction of a Teenager’s Class 2 Division 1 Malocclusion by Dr. David J. Harnick 8 Upper Arch Spacing and Lower Editorial Arch Overcrowding I’ve been reading ­numerous by Dr. David Galler dental journals every Practice Development month for many years, 14 The Economics of Buying vs. but don’t ­remember ever Renting Your Next Office ­actually ­reading an editorial ­completely, from beginning by Jake Jacklich to end. 16 “Doctor, I’ve been your patient for I resolved that in this, my first 10 years; how come you never editorial for the Journal of the American mentioned orthodontics before?” Academy of Cosmetic ­Orthodontics, by Gary Kadi I would write an editorial that readers Retention would, in fact, read from the very first to the very last word. 20 Post-Treatment Fixed Lingual Retainers by Arlen J. Hurt So, here goes. In this Journal, we will endeavor to Product Review give our members content that will 26 Ultradent’s Opal Seal enable them to treat patients with by Dr. David Harnick less stress, greater productivity, Innovative Techniques and greater ­profitability. That’s it. Thank you for joining us. 28 Success in Rotating or Extruding Canines by Dr. Perry Jones The Lighter Side 34 Maggie’s TMJ Dr. Jeffrey Galler by Dr. Jeffrey Galler Editor

American Academy of Cosmetic Orthodontics is designated as an ­Approved PACE Program Provider by the Academy of ­General ­Dentistry. The formal continuing education programs of this program­ Advertising: [email protected] provider are accepted by AGD for Fellowship, Mastership and Editorial: [email protected] ­membership maintenance credit. Approval does not imply ­acceptance by a state or provincial board of dentistry or AGD endorsement. Cover illustration by Ari Steiner The current term of approval extends from 10/1/2012 to 9/30/2013. Provider ID# 350507 Journal designed by AetherQuest Solutions Case Reports

Upper Lateral Incisor Crossbite with Lower Premolar in Lingual Version by Dr. Cathy Sherry A 58 year-old female patient presented with a Class I ­occlusion, Treatment sequence 40% overbite, and 3mm overjet. She had lower anterior We delivered her first set of aligners along with whitening gel, ­overcrowding and attrition, with tooth #20 lingually inclined, which the patient applied for two weeks, inside the aligners. and tooth #7 in crossbite. She had mild periodontal recession. The resultant dramatic improvement in her appearance was This case was clearly going to be complex and challenging, a very effective positive reinforcement, and gave her added but the patient was very enthusiastic about the improvements incentive for continuing her excellent compliance. in esthetics and oral health that could be achieved, and was At her second appointment, we placed the indicated clearly going to be a very compliant, cooperative patient. ­attachments, as per ClinCheck, and performed a ­minimal This case illustrates how Invisalign clear aligner treatment can amount of interproximal reduction (IPR). The IPR was succeed in correcting a considerable amount of overcrowding ­accomplished using diamond strips, primarily in the lower without resorting to extractions, and also correct a significant left quadrant, and averaged 0.2 - 0.3 mm per tooth. anterior crossbite. Achieving a healthier, more esthetically At each visit, we made sure to check all the relevant contact pleasing smile and facial profile was extremely gratifying to points with dental floss, to ascertain that the involved teeth both the patient and clinician. had sufficient room to move into proper position.

Dr. Sherry practices in Yukon, Oklahoma and is a graduate of the University of Oklahoma College of Dentistry. She practices cosmetic dentistry as well as orthodontics, and won the award for the best orthodontic case, at last summer’s annual Invisalign Meeting in Las Vegas. That case was also recently featured in the June issue of Inside Dentistry. She explains that, “My philosophy is that the least amount of dentistry is often the best. I would prefer to move teeth first then restore if necessary. Frequently, a very appealing esthetic result can be achieved through clear aligner therapy, alone.” [email protected]

Pre- and post- treatment retracted smile.

4 the Journal: volume 01- issue 01 Pre- and post-treatment of the mandibular arch. Pre- and post-treatment of the maxillary arch.

Refinement This strategy worked successfully, and final, Vivera retainers After the patient wore the first 20 aligners, it was clear that a were ordered, in order to retain the outcome and help prevent refinement would be needed, and that #7 and #20 would need relapse. We prefer Vivera retainers because of the consistent considerably more repositioning. A refinement like this simply strength and retention that they provide. involves removing the attachments, taking new impressions, and beginning a new treatment phase. Summation The total active treatment time for this very gratifying case was The upper arch refinement and completion required only 16 months, and the average appointment required 15 minutes. four additional aligners, while the lower teeth required 13 ­additional aligners. Besides the obvious and dramatic improvement in the ­patient’s appearance, correcting the traumatic occlusion of the Ordinarily, we instruct patients to remove their aligners while ­malpositioned teeth provided for a healthier and more stable eating; however, we find that when one or more teeth are in occlusion, and correcting the overcrowded teeth significantly crossbite, it is extremely helpful to have the patient eat while improved her periodontal health. the aligners are being worn. By having the patient do this, we can minimize occlusal interferences that can hinder the The patient was very pleased with the change in her facial ­successful correction of the crossbite. Fortunately, this patient ­profile, in the way “her chin wasn’t so pointed,” and in the way n was extremely cooperative and compliant. her friends commented on how much younger she appeared. This second phase of treatment, or refinement phase, required There is a 30 second video of this patient on YouTube, titled, a 0.4 mm interproximal reduction between the upper centrals. “How old do you think this Invisalign patient is?” This IPR provided the extra space needed for the upper right lateral to finally move into position. It is, of course, always To access the video, go to: http://bit.ly/OntIHg. beneficial to be as conservative as possible when performing interproximal reduction.

Final touches When the final upper aligner was delivered, we noted that a minor amount of rotation was still needed on the upper right lateral. To accomplish that, we placed a dimple, in the aligner, on the mesial-lingual of tooth #7, to apply rotation pressure to the tooth. This dimple functions much like a rotating wedge in conventional braces.

the Academy for Clear Aligner Therapy 5 Upper Lateral Incisor Crossbite with Lower Premolar Case Reports in Lingual Version by Dr. David J. Harnick Introduction Introduced by Align Technology in 2008, Invisalign Teen is an excellent alternative to fixed appliances for someteenagers. ­ ­Initially, Invisalign was primarily used to correct minor ­alignment, crowding, and spacing issues 1-4. However, as Clear Aligner Treatment (CAT) appliances gained acceptance this treatment modality was increasingly used to correct more complex malocclusions as well 5-9. Today, these techniques can be used predictably on teenagers.­ There are a number of teenagers that would prefer not to wear fixed appliances, for the obvious reasons. Since there is ­occlusal coverage during the entire treatment duration, ­Invisalign ­treatment presents new opportunities and challenges that need to be clearly understood. All types of malocclusions ­exist in these younger patients, including complicated skeletal disharmonies. Many of the patients are still growing. This case report of a Class 2 malocclusion demonstrates some important Figure 1: Initial montage photographs. Note the narrow arch forms with factors in utilizing Invisalign Teen to achieve the best esthetic palatally inclined buccal segments. Also, because of the end-on occlusion and functional result. of the canines, there is flattening of the maxillary canine cusp tips.

Diagnosis Chief Complaint: This 14 year old female’s chief complaint was a “bite problem.” Her medical history was clear. Facial: Symmetrical from frontal view. Normal incisor and ­gingival display for her age. Profile is within normal limits. The smile photograph shows palatally inclined buccal ­segments. Fig.1.

Dr. Harnick is in the private practice of ­orthodontics in Albuquerque, New Mexico.

Diplomate of the American Board Figure 2: Initial panoramic radiograph. Note the moderately short root of Orthodontics. development of the maxillary central incisors. Master of the Academy of General Dentistry. www. harnickorthodontics.com

Radiographic: Panoramic radiograph shows that all wisdom teeth are developing. Teeth #s 8, 9 have short root formation. Fig.2. Cephalometrically, she has an ANB of 6 degrees which is suggestive of a Class 2 skeletal problem. Her incisors are of normal angulation. Fig.3. Dental: There is a Class 2 Division 1 malocclusion with mild ­upper and lower crowding. The mandibular midline is off, 1mm to the right. There is mild excess overjet and normal ­overbite. The maxillary arch is constricted with a moderate Figure 3: Initial cephalometric radiograph.

6 the Journal: volume 01- issue 01 Figure 4: Seven month progress photos. Note buttons for class 2 elastics on the buccal of the mandibular first molars. Arch forms have improved and the Class 2 malocclusion is resolving.

Figure 8: Tracing superimpositions show retraction of the upper incisors, good vertical control of the molars, and a small amount of ­mandibular growth.

“V” shaped arch. Fig.1. Wear of the maxillary canines was noted. The patient­ was aware of night bruxism.

Treatment Plan Figure 5: Final photographs. The Class 2 malocclusion has been resolved, The patient was given the choice of Clear Aligner ­Treatment the arch forms are more ideal, and the maxillary canines have been (CAT) or conventional fixed appliances. CAT is capable of reshaped for a more normal cusp tip appearance. There is good alignment ­correcting Class 2 malocclusions8, and that is what the of the teeth with ideal overjet and overbite, and the buccal segments have been uprighted. ­patient selected. It is important to offer the choice of CAT or ­conventional fixed appliances to the patient, whenappropriate. ­ Careful case selection is critical because of the increased need for patient compliance and cooperation with CAT. PVS ­impressions were taken and the case submitted for ­Invisalign Teen.

Treatment Progress Cutouts were done for the mandibular first molars, brackets were bonded for Class 2 elastics, and these elastics were utilized at initial delivery. The patient was given 3 sets of aligners at a time, and was seen every 6 weeks. Photos were taken at 7 months showing good progress Fig.4, and the case was ­completed after 9 months of treatment. No case refinements were needed. The maxillary canines were reshaped, the incisal Figure 6: Final panoramic radiograph. Note that the roots of the maxillary central incisors appear to be unchanged. edges were smoothened, and clear retainers fabricated.

Results The Class 2 malocclusion was corrected with ideal overjet and overbite. Good tooth alignment was accomplished. Fig.5. No Interproximal Reduction (IPR) was needed. The maxillary width and archform were improved. The midlines were improved but not ideal. To make the midlines ideal would have required IPR, but both the patient and author felt it was not warranted. ­Panoramic evaluation showed no changes in the root shapes of the teeth, including the maxillary centrals. Fig.6. ­Cephalometric imaging Fig.7 and cephalometric ­superimpositions Fig.8 revealed there was a small amount of mandibular growth that contributed to the Class 2 correction.. The maxillary incisors were uprighted and retracted to a more normal and pleasing­ Figure 7: Final cephalometric radiograph.

the Academy for Clear Aligner Therapy 7 Case Reports

Figure 9: Seven months post treatment photos. There has been no change in the Class 2 correction.

position. There was essentially no vertical eruption of the ­molars contributing to the Class 2 ­correction. Finally, seven month post treatment photos were taken to verify the stability of the Class 2 correction. Fig.9.

Discussion It is important, especially on our younger patients, to provide the best esthetic and functional result possible, and, whenever appropriate, to correct the occlusion in order to achieve an ­optimum result. Figure 10: Pre- and post-treatment photos of the maxillary arch. Note the arch form improvement. In this case, it was imperative to develop the maxillary width for both functional and esthetic reasons. If not properly ­corrected, the resultant smile would not be harmonious with the width of the lips. Also, if merely alignment were to be accomplished,­ the Class 2 correction would not be possible; as a result, either ­post-treatment excess overjet would remain, or significant­ ­maxillary Interproximal Reduction (IPR) would become ­necessary. Most Class 2 patients have insufficient maxillary width. Note the photos showing the change in arch form achieved via the orthodontic treatment. This maxillary width development was a key factor in achieving the best ­cosmetic outcome Fig.10-11. Figure 11: Pre- and post-treatment photos of the mandibular arch. Note improvement of the rotation of #20 and #29. Advantages of Clear Aligner Technology Clear Aligner Treatment provides some advantages over fixed appliances in certain cases. In this case, treatment time was very efficient (less than one year) because the class 2 elastics were able to commence with the initial delivery. By contrast, when using Class 2 elastics along with fixed appliances, itgenerally ­ takes many months to be able to utilize wires that are of s­ufficient size and strength10-11 . Also, when using Class 2 elastics along with fixedappliances, ­ there can be canting of the occlusal plane because of the Figure 12: These before and after photographs, with teeth out of ­occlusion, demonstrate judicious reshaping of the teeth. The uprighting of the ­resulting vertical component of force. With Clear Aligner ­maxillary buccal segments contribute to the successful orthodontic result.

8 the Journal: volume 01- issue 01 ­Treatment, because the occlusal surfaces are completely ­covered, the typical “Class 2 elastic effect” is eliminated or reduced. This theoretically would mean a more forward position and better profile correction. This particular case did not need significant profile correction. Although confirming research needs to be done, it appears that Clear Aligner Treatment has less potential for causing root resorption than conventional fixed appliances. This makes it an ideal choice for teeth that may be susceptible to root ­resorption. Note how in this case, there was minimal, if any, change in the already shorter maxillary central incisors.

Enhancing the final result While achieving proper width and archform improve the Figure 13: Note the improved smile via uprighting of the buccal segments. cosmetic aspect of orthodontic treatment, subsequent tooth reshaping helps enhance the final cosmetic outcome. Initially, because of the end-on Class 2 relationship of the canines, there was significant wear on the maxillary canine cusp tip. The patient and family did not want restorative treatment, so simple tooth recontouring and reshaping succeeded in ­attaining a more normal canine appearance. Fig.12. This was accomplished by never touching the deepest part of the worn area, and by sloping the mesial and distal in Figure 14: Pre- and post-treatment photos of the left buccal occlusion, order to give the appearance of a more normal tooth form. showing the correction of the class 2 relationship. ­Reshaping of the incisal edges to remove small discrepancies­ can significantly improve the final cosmetic result. This ­contouring, of course, needs to be done with care.

Conclusion To achieve the best functional and cosmetic result possible, a very thorough and complete orthodontic diagnosis is ­necessary when using Clear Aligner Treatment. Correction of the malocclusion can be an integral part of achieving the desired cosmetic and esthetic result. This modality is not merely limited to the re-alignment of malposed teeth, but can also Figure 15: Pre- and post-treatment photos of the right buccal occlusion, also showing the correction of the class 2 relationship. ­successfully correct Class 2 occlusal relationships. Fig.13-16. n

References 1. Vlaskalic V, Boyd R. Orthodontic treatment of a mildly crowded malocclusion using the Invisalign System. Aust Orthod J 2001;17(1):41-46. 2. Christensen GJ. Orthodontics and the general practitioner. J Am Dent Assoc 2002;133(3):369-371. 3. Boyd R, Miller R, Vlaskalic V. The Invisalign system in adult orthodontics: Mild crowding and space closure cases. J Clin Orthod 2000;34(4):203-212. 4. Chenin DA, Trosien AH, Fong PF, Miller RA, Lee RS. Orthodontic treatment with a series of removable appliances. J Am Dent Assoc 2003;134(9);1232-1239. 5. Boyd RL. Complex orthodontic treatment using a new protocol for the Invisalign Figure 16: Pre- and post-treatment photos highlight the appliance. J Clin Orthod 2007;41(9):525-547. midline improvement. 6. Boyd R. Esthetic orthodontic treatment using the Invisalign appliance for ­moderate to complex malocclusions. J Dent Educ 2008;72(8):948-967. 7. Boyd R, Vlaskalic V. Three-dimensional diagnosis and orthodontic treatment of complex malocclusions with the Invisalign. Sem Orthod 2001;7(4):274-293. 8. Harnick D, Briceno J. InvisalignTeen , Rev Esp Ortod. 2011;41: 9. Harnick, David Using Clear aligner therapy to correct malocclusion with crowding and an open bite General Dentistry,May/June 2012,vol60,(#3):218-223 10. Langlade M. Optimization of orthodontic elastics. London: GAC International Inc.;2001:54-55,74-76. 11. Stewart CM, Chaconas SJ, Caputo AA. Effects of intermaxillary elastic traction on orthodontic tooth movement. J Oral Rehabil 1978;5(2):159-166.

the Academy for Clear Aligner Therapy 9 Upper Arch Spacing and Lower Arch Overcrowding Case Reports by Dr. David Galler

Abstract This Invisalign case appears deceptively simple, but demonstrates two important principles. First, diastema spacing cases, although sometimes viewed as the bread and butter of clear aligner treatment, can sometime be challenging. Second, in creating space within an overcrowded arch, Inter Proximal Reduction (IPR) is often preferable to traditional extraction methods.

Case Report Lisa, a 35 yr old single white female, presented with an ­unremarkable medical and dental history, normal Class I molar and canine relationship bilaterally, very little overjet, and no functional issues or TMJ pain. She had no previous history of orthodontic treatment. Her chief complaint was that the space between her upper central incisors has been widening, and the crowding among her lower anteriors has been becoming more severe, over the past 10 years. She reported becoming increasingly very self-conscious about her appearance Fig.1 because of the space between teeth #8 and #9, and has had an increasingly more difficult time flossing between her lower central incisors. She was concerned about

occasional bleeding between #24 and #25, and trouble with Figure 1: “I hate the space between my upper front teeth, and my crooked plaque retention around the overcrowded lower anteriors. lower front teeth.” Lisa was understandingly insistent about rejecting any ­treatment plans that involved fixed brackets and wires, or Treatment preparation of her nature teeth for porcelain coverage. Lisa’s Clear Aligner treatment was visualized and planned on ClinCheck software, and consisted of 20 Upper and Lower ­Invisalign Aligners. Eight horizontal bevel attachments were placed, one on each premolar, to aid in retention of the aligners. A total of .3mm Dr. Galler is the President of the ­American IPR was performed on each of the six lower anterior teeth, Academy of Cosmetic ­Orthodontics, and #22–27. Fig.2. has proudly transformed hundreds of smiles All of the interproximal reduction and placement of with Invisalign® aligners. A featured speaker ­attachments were performed between stages 1–3. All of at numerous study clubs, webinars, national the IPR was achieved utilizing the GST technique.* and regional events, Dr. Galler has been ­featured in educational and marketing materials designed After initial therapy, the patient required five additional aligners to help practices learn more about Invisalign treatments to further tighten the contact between 8–9. and ­clinical techniques. The New York State Dental Journal Post-treatment retention in the upper arch was achieved (Jan 2009) published his multi discipline case incorporating­ through the use of a fixed lingual appliance, bonded to ­Invisalign, implant, prosthetic, and aesthetic treatment goals. each tooth with a composite pad. Note how this appliance, He is the creator of the GST system being utilized by more ­fabricated by Specialty Appliance Laboratories, has their unique than 3500 doctors across the country every day. scalloped design Fig.8. This shape enhances the patient’s ability to successfully floss and maintain excellent oral hygiene. www. drdavidgaller.com The fixed retainer was bonded with Assure adhesive and FlowTain flowable resin (Reliance Orthodontics). To prevent post-treatment relapse on the lower arch, Vivera Retainers, fabricated by Align Technologies, were utilized, and consisted of four clear aligner retainers, replaced quarterly for the first year.

10 the Journal: volume 01- issue 01 Discussion Several issues make this a very interesting case. 1. The Golden Proportion First, the closing of an anterior maxillary diastema, at least initially, would seem like an extremely easy, everyday, bread and butter example of Clear Aligner Treatment. Many ­documented case have shown the successful closure of diastemas of anywhere from 2–5mm. Fig.3. By contrast, attempting to close the diastema space ­restoratively, via porcelain crowns, laminates, or interproximal resin bonding, would have been an extremely poor ­treatment plan for this patient’s problem. Such restorative options are best avoided, if possible, because they often involve cutting away irreplaceable tooth structure, need periodic Figure 2: ­retreatment, and, worst of all, often result in bulky-appearing, unaesthetic restorations. In a case like this one, attempting to close the space through restorative means would violate the golden proportion rule of anterior cosmetics. And, this is a perfect example of why it is preferable for dentists to provide their patients with Clear Aligner Treatment, rather than attempt porcelain solutions for orthodontic problems. The Golden Proportion, or Golden Ratio, is widely considered­ as a key to any aesthetic outcome, and teeth are no ­exception. The human eye naturally picks up on proportion, and when something is out of proportion, our brain instantly reacts negatively. Discovered by the Greeks thousands of years ago and further explored by Leonardo Da Vinci, the mathematical ratio for the Golden Proportion is approximately 1 to 1.618 (New Beauty Magazine Dec. 3, 2010). By attempting to close the diastema by adding bulk to the mesial of teeth #8–9, a dentist would not be able to able to avoid violating this ideal Golden Proportion, and would, ­unfortunately, be forced to produce a look that would be Figure 3: Upper anterior diastema. offensive to the eye of the beholder. The length/width ratio of the centrals would be disproportionately wide and ­unaesthetic in appearance. 2. Lingual Constriction Second, what makes this case challenging, is that Clear Aligner Treatment is easy to plan and execute when dealing with similar arches. For example, treating an upper and lower arch that both have spacing, or treating an upper and lower arch that both exhibit overcrowding, is relatively easier than treating a mixed case. Why is it difficult to treat a patient like this, who presents with an upper arch that has spacing and a lower arch that has overcrowding? Fig.4. The most common movement of aligner treatment for ­closing anterior spacing in a Class I individual is to utilize Figure 4: Upper spacing, lower overcrowding, and a minimal overjet make “lingual constriction.” That is, flattening or narrowing the arch this a difficult case.

the Academy for Clear Aligner Therapy 11 will result in a smaller arch circumference, thereby ­closing Conclusion any existing space. Fig.5. The easiest Invisalign Clear Aligner treatment in a Class I ­ Case Reports For this lingual constriction of the upper arch to be successful, individual is where there are equal amounts of space in both there must be either: arches. By ­contrast, one of the most complicated Clear Aligner 1. Similar spacing in the lower arch, so that both arches may treatment cases is when there is spacing in the maxillary arch, undergo similar constriction; or, overcrowding in the mandibular arch, and little horizontal­ 2. Sufficient overjet, so that constricting only the upper arch ­overjet. When evaluating the difficulty level of closing a will not result in post-treatment anterior interferences. ­maxillary diastema in a Class I individual, it is important to ­evaluate the degree of ­upper and lower arch spacing Lisa’s case presents a major difficulty. Her arches, although and overjet. in Class I relationship, present with little overjet and without similar anterior spacing. Therefore, the question becomes, how Also, note that in order to create lower anterior space, does one close the space between teeth #8–9? Pure maxillary judicious and prudent IPR is usually preferable to anterior n lingual constriction will not be possible because of the lack ­mandibular extraction. of overjet, and because there is no matching maxillary and ­mandibular spacing. Fig.4. Note also, that the concept of mesialization, or of simply sliding the anterior maxillary teeth to the mesial to close the diastema, is ­similarly unworkable here, because that movement would simply recreate the same diastema between lateral-canine or ­central-lateral. In order to solve this dilemma, Inter-Proximal Reduction was ­judiciously performed on the mandibular anterior teeth. By carefully and exactly removing only 0.3 mm of tooth ­structure between two proximal surfaces, there was no ­significant danger to the health or contours of the anterior teeth. The extra space thus created, allowed for lingual constriction of the lower arch, similar to the lingual constriction of the upper Figure 5: Lingual constriction closes anterior spacing by flattening the arch. By retracting the lower teeth along with the upper teeth, arch circumference. ­post-treatment anterior interferences were avoided. 3. Extraction vs. IPR Another approach to this case, could conceivably have been to extract a single mandibular anterior tooth, in order to ­ create lower anterior spacing and thereby compensate for the ­difference in spacing between the arches. This scheme, however, could present a serious difficulty. When treating a patient with clear aligners, it is often difficult to close a space between lower anterior teeth while keeping­ the roots of the lower anterior teeth parallel. Oftentimes, the ­adjacent teeth will be inadvertently tipped into position; this movement would result in a very unaesthetic look and in a large, unnatural, gingival embrasure space and difficult-to-clean food trap area. Fig.6 (from a different patient) ­illustrates this potentially poor result.

Results The results for Lisa were excellent, and she is now five years post treatment with no relapse. An excellent and compliant­ ­patient, she wears her lower Vivera retainer nightly, and ­maintains excellent­ oral hygiene around her upper fixed Figure 6: If the lower arch overcrowding would be resolved via bonded retainer. Fig. 7-11. ­extraction rather than Inter-Proximal Reduction, this post-treatment photo (of a ­different patient, who was treated with a lower anterior extraction), ­illustrates the resultant unaesthetic tipping appearance and unhygienic, large gingival embrasure space.

12 the Journal: volume 01- issue 01 Figure 7: Before and after. Figure 8: Before and after maxillary arch. Note the bonded lingual retainer with composite pads.

Figure 9: Before and after mandibular arch. Figure 10: Before and after - note the overjet.

*For more information about interproximal ­reduction via GST (Galler Spacing Technique), readers can ­access: http://www.drdavidgaller.com/events

Figure 11: Before and after.

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The AACO Journal asked financial advisor, Mr. Jake Jacklich, to discuss the relative advantages and disadvantages of renting rather than owning dental office space. This article discusses the potential cash flow impact of the buy vs. lease decision on the dental practice. The central argument is that the ownership interest in the building does not improve the standard of care nor does it grow the practice. Several advantages of leasing are discussed.

The Economics of Buying Vs. Renting Your Next Office. by Jake Jacklich CFP®, Muhlendorf Shepherd Financial Group

Making important business decisions based on gut-feel or Should you, as a dentist, buy or lease your office space? ­tradition rarely makes sense. Given the reality of today’s From a business point of view it is important to ask yourself ­economy how does one build and maintain a thriving practice? two ­fundamental questions: Smart doctors know that they must rethink and rebuild their First, does owning the building improve the quality practices to take advantage of good times and survive the of patient care? lean ones. Dental practice financial management is key. Given the precarious state of our commercial real estate market, Second, does owning the building help to grow the “should I buy the building” question has come full circle. the practice? The answer to both questions is usually no. Building equity in your office neither improves the standard of care nor grows the practice. Jake Jacklich is a CERTIFIED FINANCIAL Commercial real estate is similar to other illiquid investments, PLANNERTM who works with successful and it is wise to think of a dental office as such. In many ways, ­dentists to help them better understand it would be similar to owning a beach house. their money and get rich. Consider the situation from a business cash flow point of view: Jake has a BS in Mechanical Engineering What is the opportunity cost if the after-tax current cost of from the University of Washington in Seattle ­ownership is more than that of a long-term lease? All things and a MS in Operations Research from the Naval Postgraduate being equal, the practice with the lower overhead is more School in Monterey California. Jake is a retired Naval Officer. ­profitable and may be more likely to succeed in hard times. His father is Dr. Jack Jacklich, a retired dentist, who resides in Kissimmee Florida. Jake and his wife live in Norfolk with their There are many advantages to renting rather than owning a two sons. dental office: • Leasing might be cheaper per month than owning when you Direct: 757.777.3149 calculate the financed principal, interest, and property taxes Cell (preferred): 757.374.6979 associated with owning the facility. Fax: 757.490.9239 • Potentially more cash flow is available for technology and [email protected] staff training, giving you the ability to reinvest in the practice www.muhlendorfshepherd.com and improve the quality of care. • When local economic or business conditions change, you will have the flexibility to move the office without having to sell the building.

16 the Journal: volume 01- issue 01 • When renting, you may be able to get the property manager • Since you don’t own or depreciate the building there is no to pay for some upgrades, and you will almost certainly “recapture tax” due upon moving or selling the practice. ­encounter lower out of pocket initial build-out costs. • Leasing simplifies dental practice valuation and • Currently there is a good supply of available rental locations practice transitions. throughout most communities. • Simpler asset protection strategies are available–no need to • When compared to a fully bank-financed purchase, it may own “the building” inside a separate entity from the be easier for you to get a long-term lease with favorable dental practice. renewal terms. • Leasing simplifies the doctor’s estate plan–less liquidity risk. • With less debt exposure, it may be easier to expand if With today’s ever changing business environment it rarely ­additional financing is required. makes sense to make long-term commitments which don’t • Potentially lower overhead means that you may be more able improve patient care or grow the business. As a self-employed to fund retirement plans and other employee benefits. dentist it makes sense for you to think through the buy vs. • You can lease the “right sized space” for what your practice lease decision. n needs today. You’ll still have the flexibility to expand the ­office or to move if more operatories are needed later. Muhlendorf Shepherd Financial Group • Leasing disconnects the commercial real estate business One Columbus Center, Suite 800 cycle from the doctor’s career path. The best time to sell the Virginia Beach, Virginia 23462 building may not be the best time to sell the practice. Jake Jacklich CFP® is a registered representative and investment advisor­ • You are not responsible for the maintenance of the building ­representative of Lincoln Financial Advisors Corp., a broker/dealer and grounds. ­(member SIPC), and registered investment advisor, offeringinsurance ­ • Significant tax benefits exist. These include “cost segregation” through Lincoln affiliates and other finecompanies. ­ This ­information and the ability to depreciate leasehold improvements over should not be construed as legal or tax advice. You may want to consult a legal or tax advisor regarding this information as it relates to your personal the statutory recovery period for the leasehold ­circumstances. Neither Lincoln Financial Advisors nor its representatives improvement type. offer legal or tax advice. CRN201208-2070526

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the Academy for Clear Aligner Therapy 17 Practice Development The AACO Journal asked Gary Kadi, international expert in marketing, business, motivation, and empowering people’s lives, to consider the following scenario: a practicing dentist, newly certified in treating patients with Clear Aligners, is enthusiastically recommending ­treatment to a patient of record, and the disconcerted patient asks:”But I’ve been your patient for 10 years. How come you never mentioned orthodontics before?”

An effective response to the patient could be: “Mrs. Jones, the field of Clear Aligner Treatment is a relatively new treatment that has developed and grown remarkably over the past few years. Today, it is so technologically advanced, and predictably successful, that we feel comfortable ­recommending it in certain circumstances. Patients have been telling us they love how it’s so user-friendly today, too. We see very gratifying, predictable results. “I know____(health, function, aesthetics)___ is important to you. You have ___(state problem)___, and if left untreated ___(state consequence)___. Clear Aligner Treatment can accomplish ______. So, I recommend Clear Aligners as the right solution for you.”

“Doctor, I’ve been your patient for 10 years; how come you never ­mentioned orthodontics before?” by Gary Kadi

Suddenly discussing a new treatment option with a patient, that stops progress in our practices and hinders our ability to after you haven’t done so for many years, subconsciously brings ­provide greater wellness for our team and patients. up many concerns. We often let our internal considerations become roadblocks that get in the way of implementing new What drives consumers? strategies or offering products and services to patients who I’m going to share with you here, a step-by-step action plan would greatly benefit from them. Here is a step-by-step action for implementing any new product or procedure that aligns plan for implementing any new product or procedure that with your values and the needs of the patient; but first, let’s aligns with your values and with the needs of the patient. It is understand what is driving consumers today. As you can see also helpful to examine what is driving consumers today. in the visual, “Evolution of Dentistry,” the complete health ­revolution has taken center stage. The consumer 40-years-old The dentist’s concerns and above is driven by longevity, and those younger are driven Dentist might subconsciously be experiencing anxieties in by ­sustainability. Older people don’t want to lose their lives and discussing a new treatment option. Here are a few: younger people want to keep theirs great. • I’m not confident I can produce the result so I’m not going to present the case. • Is the patient thinking I’m trying to “sell” them something they don’t need? • If I’m suggesting treatment now, are patients going to think that I’ve been neglectful in caring properly for them prior to now? • Will patients think I’m only “all about the money?” • Is the patient going to think I’m pushing the next hot item- of-the-month because I need to pay for my new Porsche?

So often we let our internal considerations become roadblocks getting in the way of implementing new strategies or offering products and services to patients that would actually benefit them. We don’t allow ourselves to have a profitable business. This new understanding, that we are in the Complete Health And where it all starts and begins is in our minds. We can be Dentistry Era, where patients are seeking more longevity and our own worst enemies. Often it is our very own thoughts optimal health, gives us another perspective with which to

18 the Journal: volume 01- issue 01 discuss Clear Aligner Treatment benefits as they relate to health and improved function. This actually allows those patients who are concerned for their future health the opportunity to invest in a healthier future, versus having no other option than to react to your efforts to “sell” them the luxury of straight teeth, which they may not feel is truly necessary. There are still many who are motivated by wanting straight and beautiful teeth, but we must understand what is really driving each individual patient to want to engage in treatment: is it a beautiful smile or a longer, healthier life? Now that we understand how the patient is purchasing in today’s world, let’s get your practice set up to that it can deliver what the patient wants and needs. Here are the 5 Steps to getting your patient healthier, which will immediately allow you the freedom to offer Clear Aligner ­Treatment as a solution, without your own internal ­considerations and roadblocks getting in the way. 2. Understand Patient Personal Motivators • When all team members engage with a patient, listen ­attentively to a patient’s conversation, and ask earnestly about what is going on in a patient’s life, they can determine Known for his positive contributions what a patient’s “personal motivation” is. For example, is it: to the lives of dentists and dental health, function, aesthetics, time, or cost? teams across the globe, Gary Kadi is • Later, you can connect the dots on how your recommended a recognized authority on ­leadership, treatment fits in with that patient’s objectives. management, organizational ­transformation, and performance. 3. Present the Case • Use visuals: photos, x-rays, intraoral photos, pictograms, Kadi’s multifaceted interests and passion for research and models to clearly illustrate the patient’s condition. has lead to discoveries and methods that result in profit ­margin increases and total life transformation, beyond • Follow this sequence: present the problem, the consequence what dentists have ever imagined possible. of not doing anything about it, and then the solution.

Combining his business management education from 4. 5-Times Trust Transfer Rutgers University with his passion for marketing, • Repetition builds trust and is key to building patient ­business, motivation, and empowering people’s lives, ­confidence and acceptance. was the foundation for his creating the NextLevel Practice • Repeat treatment recommendations in front of the patient dental success program. This program implements the every time the patient transfers to another team member’s cutting-edge, team-driven, Complete Health Dentistry care. The patient is left with the same or more trust than with business model, giving reliable solutions for measurable the prior team member. results. Doctors and their teams are re-inspired as they n Hygienist explains findings to Patient. embrace their new key role as providers of TOTAL HEALTH. n Hygienist explains findings to Doctor, in front of [email protected] the patient. www.garykadi.com n Doctor reiterates or expands on hygienist’s findings to patient.

n Hygienist summarizes findings, motivators, and treatment The 5-Step Healthy Patient Blueprint to Treatment Coordinator, in front of the patient. 1. Establish a Healthy Mouth Baseline n Treatment Coordinator repeats summary of findings and • Establish across your practice the description and treatment to the patient. ­expectations of what a complete healthy mouth baseline is. • Use a visual or checklist to illustrate to patient what a “100% 5. Fitting Treatment into Patient’s Lifestyle healthy mouth standard” is, and how the patient compares • Remove barriers that may prevent patients from following (see Healthy Mouth Baseline chart at www.garykadi.com). trough on treatment.

the Academy for Clear Aligner Therapy 19 Practice Development n Remove the money barrier.

n Offer a five percent “Pay Today Courtesy” discount.

n Offer third party zero percent financing.

n Plan ahead in a way that patients can embrace

s Is time their #1 priority? Make appointments accordingly.

s Is anxiety or fear an overriding issue? Address the issues and be clear on a plan that will work for patient.

Conclusion Most people are living in the “Some day when...” epidemic. “Some day, when I do more Invisalign, I will feel more ­confident.” It doesn’t work that way. What does work is to courageously step into where your fears lie. You do one at a time, learning from each one. It’s just like when you were in dental school learning to do a crown. You went through the “being uncomfortable being ­uncomfortable” stage, then to the “comfortable being ­uncomfortable” stage, and then you can do crowns with your eyes closed. The same is true with Clear Aligner Treatment. Take the first step now, and build confidence that way. You’ll also be ­building a happier and healthier practice and helping more patients become happier and healthier. n

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20 the Journal: volume 01- issue 01 One bottle. Simple.

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Reliance Assure Ad_AACO.indd 1 9/13/12 10:09 AM Retention

Post-Treatment Fixed Lingual Retainers by Arlen J. Hurt C.D.T. Abstract Both dentists and laboratory technicians understand that there The widespread use of bonded lingual retainers has is no dental appliance or fabrication that is indestructible, and been increasing, as clinicians and patients strive to retain that patients who do not comply with post-op instructions put ­post-orthodontic treatment results and avoid relapse. any device to the ultimate test. This article discusses various types of fixed retainers such as Several studies and articles have addressed the longevity metal mesh pad retainers, custom composite pad retainers, and success of bonded lingual retainers.1 It is estimated that dual retention techniques, and the use of a unique indirect tray ­approximately 20 to 25% of upper retainers will have some system that enhances bonding of the appliance in the mouth. debonding issues within five years, and that 12 to 16% of lower Bonding techniques are reviewed, along with the use of newer retainers will experience similar difficulties.2 digital scanning technology, 3D technology, and the ability to construct multiple retainers from one model. Most of these failures are attributable to extraoral or intraoral trauma.3 Even though these types of failures are not able to Numerous articles have explored the effectiveness and be controlled by either clinicians or laboratories, keeping ­dependability of bonded retainers following ­orthodontic track of failures, and recognizing and identifying if the patient 1 ­treatment, and there are several videos on YouTube™ has ­experienced any such trauma, is crucial in evaluating the ­demonstrating different methods for fabricating these ­retainers. ­success of retainer use in your practice. Bonded lingual retainers are not only a great way to preserve a patient’s smile by preventing orthodontic relapse, but also are Increased Usage extremely valuable in stabilizing periodontally involved teeth. Laboratories report a steady increase in the use of bonded ­lingual retainers over the past 25 years, and attribute this ­increase to two factors: First, each year, more and more orthodontic patients Arlen Hurt C.D.T., graduated from ­Indiana undergo retreatment because they did not responsibly wear University in 1984 with a Dental ­Laboratory their ­retainers after their initial orthodontic treatment; once Technology Degree. He has been ­working they are retreated, patients will almost always insist upon at Specialty Appliances since 1984, and is fixed ­retention. ­currently their Vice President. Second, with ready internet access, today’s patients are more Arlen has ­traveled to numerous ­Orthodontic knowledgeable and aware of differing treatment options. ­meetings as an exhibitor and presenter, has lectured at These well-informed patients will often want to avoid anterior regional and national meetings, and has assisted in Hands-On orthodontic relapse by requesting bonded retention after Herbst™ training for 9 years, with Dr. Terry Dischinger.­ In 2008, researching online or asking family or friends. he was the winner of the NADL Harry Hagman­ inventor of the year award. Types of Indirect Retainers Laboratories generally manufacture two basic types of [email protected] ­retainers: metal mesh pad retainers, and custom composite pad 800.522.4636 retainers.3 Both of these designs have unique features and are in wide usage. Materials and manufacturing processes have evolved over the last quarter century, and the specific designs

22 the Journal: volume 01- issue 01 for each retainer are flexible and variable depending on the particular clinician’s instructions. The most popular upper fixed lingual retainers generally utilize a .016 x .022 stainless steel wire contoured to the centrals and laterals. In some situations, dentists will wish to include the upper cuspids as well, depending upon the available clearance with the lower teeth. Fig.1. The most popular lower fixed lingual retainer design utilizes a solid stainless steel .016 x .022 wire contoured and bonded to the lingual surfaces of all the anterior teeth; sometimes, the dentists will wish to include the lower pre-molars as well. Fig.2. Figure 1: The wires can come in different sizes and the wire shapes can vary from braided to rectangular. In addition, the wire can also be scalloped below the papilla to help avoid plaque build-up in hygienically challenged patients. In the 1980s, the most frequently utilized retainers were the fixed metal mesh pad type,4 featuring small metal mesh pads on each tooth connected by a solid wire. Fig.3. These ­retainers were very successful and stable in the mouth, but were ­extremely technique sensitive, and difficult to fabricate in the laboratory. The retainers were difficult to fabricate because soldering procedures often resulted in solder flowing into the mesh pad area. Ten years ago, with the advent of laser welders, these difficulties­ Figure 2: were eliminated. Today, labs can now laser weld these retainers­ with great precision and even add auxiliary hooks to them, if desired. These hooks are extremely useful in ­helping to ­discourage tongue thrust and in preventing an anterior ­open-bite from relapsing. Currently, the most commonly fabricated fixed lingual retainer produced by Specialty Appliances is the custom composite pad retainer type.5 Fig.4 and Fig.5. In the lab, a retention wire is adapted to the teeth on the model, and a custom composite pad placed on the designated teeth. This pad is then cured and formed directly onto the dental cast, resulting in a pad that is custom fit to that tooth’s lingual surface. This process allows the clinician to bond the retainer chairside Figure 3: and use the lab’s unique, indirect tray system and flowable composite, greatly reducing the amount of excess adhesive and resin flash that has to be removed. These custom pads are durable, and the size of the pads can be adjusted as per the dentist’s preference. Laboratories generally charge $50 for the custom ­ composite pad retainers and $75 for the traditional metal mesh pad ­retainers.

Bonding the Retainer One of the important decisions in choosing a particular ­laboratory to fabricate the fixed lingual retainers, would be their ability to provide special, two-tray transfer systems, also known 6 Figure 4: as indirect tray systems. This is a two-part tray system that ­allows the dentist to handle the retainer with stability, yet has

the Academy for Clear Aligner Therapy 23 Retention

Figure 5: Figure 6A:

Figure 6B: Figure 6C: Clinical photo by Dr. Tim Shaughnessy.

the flexibility to allow easy removal of the tray once the retainer has been bonded in place. This greatly reduces the amount of chair time and also allows the doctor to bond the appliance with a flowable composite. Figs.6A, 6B, 6C. The lab fabricates a flexible inner tray made from a ­pressure-formed vinyl material that covers the brackets, and an outer hard acrylic material that is processed over the inner tray. This outer tray acts as a carrying and seating tray. The system helps the dentist position and seat the appliance, while ­maintaining a clear field of vision. The retainers can be bonded with either a self-curing or a light cure material. Generally, clinicians will used the light-cured Figure 7: method on the custom-composite retainers and the self-cure method on the metal mesh pad type. This technique, using dual retention, is especially accepted and appreciated by patients who have been in orthodontic Enhanced stability ­treatment more than once, and understand how important it An additional technique for enhancing orthodontic stability is to avoid relapse. and avoiding relapse is to utilize not only these fixed, bonded retainers, but also a vacuum-formed invisible retainer. Fig.7. New technologies The advantages of this dual retention system are that: We are living in an age of advanced digital technology, and • Patients occasionally forget to wear the removable retainer some labs, such as Specialty Appliances, are uniquely equipped at night, but the fixed retainer will still protect them; to incorporate these advances. They can utilize the dentist’s digital intraoral scans to manufacturer the retainers, or digitize • Patients achieve not only anterior fixed retention, but also the dentist’s models or impressions with tabletop scanners. posterior retention; This allows them to digitally remove any brackets or r­etention • Patients have additional security if one of the appliances ­buttons, block out any undercuts, and manufacture the breaks or is lost. ­retainers on the digital models. Labs equipped with an Objet

24 the Journal: volume 01- issue 01 Q: How do you make certain a beautiful smile stays that way? A: Use Fixed Lingual Retainers from Specialty Appliances.

“I’ve been using Fixed Lingual Retainers from Specialty Appliances for over 14 years with a 98% success rate. Specialty has developed a flawless A popular upper FLR design utilizes a solid .016 Another often prescribed lower FLR design product making the x .022 stainless wire contoured to the lingual features a solid round wire contoured to the clinical procedure one surfaces of the teeth. anterior teeth and bonded to just the cuspids. of the most efficient in my office.”

- Dr. Lynn Davis FIXED LINGUAL RETAINERS League City, Texas FROM SPECIALTY APPLIANCES

“Indirect bonding You and your patient have worked The FLR uses a wire contoured to the lower cuspid to cuspid hard to produce a beautiful smile. lingual of the anterior teeth secured by a composite pad bonded to the teeth. At retainers has changed Despite the best intentions of the the way I practice. It Specialty, we use light cured composite most diligent patient, anterior teeth takes little of my time to form the pads and the FLR is delivered with our proven “2 tray” indirect to place it, and the can relapse with removable retainers. bonding technique. Ideally, FLR’s from fit is always perfect. I Being able to tell your patients they Specialty are delivered at the same look forward to seeing will experience little if any anterior appointment the braces are removed my retention patients shifting is the primary benefit of to reduce the chances of undesirable because I know their tooth movement. Whatever your FLR using a Fixed Lingual Retainer (FLR) lower incisors are requirements are, Specialty can deliver straight.” from Specialty Appliances. with quality and consistency. - Dr. David Sain Murfreesboro, TN Please visit our web site for additional information on our FLR service. www.SpecialtyAppliances.com 1-800-522-4636 260V 3D printer, accurate to within 80 microns, can receive a scan of the patient’s mouth from an e-mail, print the models,­ and manufacturer the appliances directly on the printed

Retention ­models. Fig.8. 3-D printing technology allows multiple retainers to be ­constructed from one model. With this technology, the scanned final impression can be stored, and the dentist can have ­multiple retainers made at one time, or order them from the lab on an as-needed basis. Step-by-step bonding procedure The following step-by-step process for bonding fixed lingual retainers is recommended by Specialty Appliances: Figure 8: Step 1: Make sure the retainer fits properly. This is done by inserting the tray with the retainer into the patient’s mouth and checking closely with a mirror to be sure the composite pads Note: Most ­clinicians feel that a small amount of light-cure fit flush with the lingual surfaces of the cuspids. Once the fit is ­material should be used in case of any discrepancies in the verified, the pads should be cleaned with acetone to remove impression taking, model pour-up, or laboratory fabrication. any debris from the trial fit. Step 8: Seat the retainer in the mouth and apply firm ­pressure Step 2: Clean the lingual surfaces of the teeth with plain to the hard outer tray. ­prophy paste. Note: This step is easy to perform ­because the incisal edges of the transfer tray will orient exactly to the teeth. Step 3: Apply etchant to the lingual surfaces of the teeth using a small syringe. Allow 30 seconds for etchant to take effect. Step 9: Activate the light-cure material using a hand-held ­curing light. Thirty seconds helps ensure a good initial bond. Step 4: Thoroughly rinse the etchant from the teeth and dry with compressed air until the typical chalky white appearance Step 10: Remove the transfer trays from the mouth, and light is obtained. cure each pad again for 10 seconds. The final result should have an even seal around the periphery of the composite pads. Step 5: Apply a plastic conditioner on the composite pad and allow 90 seconds.* A small burr may be used to trim any excess flash. Some ­clinicians also elect to add a small amount of ­flowable Step 6: Paint a thin film of light-cure primer on the back of the ­composite over the edges of the pads, after the indirect composite pads and on the lingual surfaces of the teeth.* ­procedure, to give a completely smooth finish to the pads.n

*Steps 5 and 6 can be combined into one step using Assure® bonding resin because it Step 7: Apply a flowable composite with a small metal syringe acts as a conditioner and primer. tip, so the minimum amount of paste is used.

References 5. Renkema, A., Al-Assad, S., Bronkhorst, E., Weindel, S., Katsaros, C., & Lisson, J. (2008). Effectiveness of lingual retainers bonded to the canines in preventing 1. Lumsden, K. W., Saidler, G., & McColl, J. H. (1999). Breakage incidence with direct mandibular incisor relapse. American Journal of Orthodontics and Dentofacial bonded lingual retainers. Journal of Orthodontics, 26(3), 191-194. Retrieved from Orthopedics, 134, 179.e1-179.e8. Retrieved from http://bit.ly/RQdf4H. http://bit.ly/RQcWa0. 6. Zachrisson, B. U. (1977). Clinical experience with direct bonded orthodontic 2. Dahl, E. H., & Zachrisson, B. U. (1991). Long term experience with direct bonded ­retainers. American Journal of Orthodontics and Dentofacial Orthopedics, lingual retainers. Journal of Clinical Orthodontics, 25, 619-630. 71,440-448. 3. Butler, J., & Dowling, P. (2005). Orthodontic bonded retainers. Journal of the Irish Dental Association, 51(1), 29-32. Retrieved from http://1.usa.gov/OW5ofz. 4. Lee, K. D., & Mills, C. M. (2009). Bond failure rates for v-loop vs straight wire lingual retainers. American Journal of Orthodontics and Dentofacial Orthopedics, 135(4), 502-506. Retrieved from http://1.usa.gov/UKtrU2.

26 the Journal: volume 01- issue 01 The AACO has something to say. AetherQuest Solutions delivered the tools to do so. When your message needs to be heard, AetherQuest will provide you the Solutions. • Logos • Email Campaigns • Marketing Collateral • Newsletters • Websites • And Much More Partner with AetherQuest Solutions to establish a strong brand identity while gaining dynamic tools to allow your practice to grow. For more information, email us at [email protected] or visit www.aqscreative.com to view our online portfolio.

“In the tough dental marketplace, you need to have something a little bit special about your brand and the marketing of your dental practice. I have had tremendous success with what Aetherquest Solutions has designed for my office - and patients always comment on how much they love our logo. They are also able to do everything in one spot from patient mailers to websites to marketing. A one stop solution for everything” Dr. David Galler, DMD President, AACO

www.aqscreative.com [email protected] 571.297.4009 Product Reviews

Opal Seal (Opal Orthodontics- a division of Ultradent) by Dr. David Harnick

Have you ever encountered this frustrating experience? Another advantage of Opal Seal is that it is more heavily filled You’ve successfully completed an orthodontic­ case, and you with greater strength yet flows nicely due to the advantageous and your patient are very pleased with the results. However, at properties of nanoparticles. a ­post-treatment recall visit, the patient complains that one or Yet another benefit of the material is that it takes up more teeth have areas that tend to stain very quickly. ­fluoride, which is of particular benefit in helping prevent the n You examine the patient, and soon realize that when you ­development of decalcifications. removed the attachments, you had inadvertently left behind­ For more information: some spots of the bonding material, and those spots, http://bit.ly/RR714E ­unfortunately, have a propensity to stain. http://bit.ly/Om2x57 The problem, of course, is that it’s hard to tell if we’ve http://bit.ly/Q3RRbo ­succeeded in polishing off all of the residual resin and adhesive that was under our attachments, buttons, or brackets. After all, we want to be very careful not to accidently remove enamel while judiciously cleaning off the resin. Fig.1. A new product helps solve this difficulty and other ­problems as well. Opal Seal is a primer that is placed directly on the enamel when bonding attachments. This primer’s unique feature is that it ­fluoresces under a black flashlight. Fig.2. These flashlights are ­available at home improvement centers at a nominal cost. (Opal Orthodontics actually offers an Opal Seal black light, and also sell an accessory for their VALO curing light, that serves the Figure 1: same purpose.) Once the attachments are bonded, I use the flashlight to ­indentify flash, and use a finishing bur, as necessary, to make sure all the excess has been removed properly. At the conclusion of treatment, the attachments must be removed. I use a multi-fluted finishing bur, and then check with the flashlight to identify any remaining primer or attachment material. In this way, I can, with confidence, determine that I have succeeded in removing all residual material from the tooth.

Figure 2: This photo shows Opal Seal in place following bracket removal. Notice how it fluoresces. Note how easy it is to locate and remove.

28 the Journal: volume 01- issue 01 Today is a good day.

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800.300.3046 | carecredit.com Come see at AACO Fall Symposium Innovative Techniques with Clear Aligners

Success in Rotating or Extruding Canines by Dr. Perry Jones Problem: One of the difficulties faced by dentists who utilize Clear Aligner Treatments (CAT), such as Invisalign, is to successfully­ rotate and/or extrude teeth that have a “rounded” shape, ­especially canines. Canines, with their large surface area and concave proximal root surfaces, tend to offer a root morphology that is moreresistant ­ to rotation. Additionally, extrusion of any tooth has been a recognized challenge with clear aligner systems, because the “V” shaped aligner almost always has difficulty “gripping” the “V” shaped tooth; this difficulty is especially pronounced when a tooth has minimal interproximal undercuts, as is the case with Figure 1: The maxillary canine with an optimized attachment ­exhibits most canine teeth. movement lag at the incisal edge as well as a misfit of the bonded ­attachment to aligner reservoir. Invisalign advances, such as the latest G3 and G4 “innovations” have greatly improved the predictability of more complex movements. The development of “optimized” attachment shapes, certainly aid rotation and extrusion movements. These attachments are unique to the Invisalign system and offer a much improved force system that can more predictably execute clinical movements.

Dr. Jones is a graduate of Virginia ­Commonwealth University School of Figure 2: Occlusal view of the “rotation” movement lag. ­Dentistry, where he now serves as ­Director of Continuing Education and Faculty However, space, force, and time are the three key elements Development, as well as Adjunct Faculty, to tooth movement, and even with the use of Invisalign Associate Professor, Department of Oral ­“optimized” attachments, tooth movement may lag and some Maxillofacial Surgery. He is Director of the Virginia Academy of movements may be most challenging to execute clinically. General Dentistry MasterTrack program, and is a Master of the Fig.1-2 Academy of General Dentistry. One of the very first GP Align This article will offer an auxiliary method that will help ­clinicians Technology education speakers, Dr. Jones lectures extensively predictably create space, create a properly directed and and has given some 300+ Invisalign and iTero presentations. ­sufficient force, and, assuming patient compliance, time for Currently, Dr. Jones serves as Director of Education for AACO, desired tooth movement. and maintains an active private practice in Richmond, VA. Over the years, various helpful “adjunct” techniques have been suggested. One such proposed technique involves modifying

30 the Journal: volume 01- issue 01 Solution: This article will describe a technique that can succeed in ­simultaneously extruding and rotating “stubborn” canines. These “stubborn” canines often exhibit significant movement lag that can threaten successful completion of the case. The basic concept is to create a model or cast of the arch with the “lagging” canine. Material is added to the model/cast to create space via a movement “bubble.” A bonded button­ is ­attached to the tooth to be moved. The thermoplastic ­appliance is then modified with thermoforming heated pliers that form an attachment “dimple” on the appliance, and elastic Figure 3: Completed removal of the composite resin attachment material forces are applied with chain elastics or single loop elastics. with a multi-fluted high speed carbide finishing bur. The patient is given proper instructions for placement and removal of the chain elastic. Given a compliant patient, this technique will work with reasonable certainty and successfully rotate and extrude difficult teeth such as canines.

Technique: 1. Carefully evaluate the available intraoral interproximal space with dental floss. Check the IPR values. If the contacts seem tight, perform 0.10mm of interproximal reduction by either using a slow-speed disc, or a diamond coated strip manually or mechanically. This author prefers using the ­slow-speed disc. 2. Remove any composite resin attachments from the “lagging” Figure 4: Stone model with Triad gel material formed to create a tooth and polish the tooth Fig.3. movement “bubble”. 3. Take an impression of the arch with either VPS or alginate. A digital iTero scan is an option, and a “refractory” model made of a virtually unbreakable plastic material may be ­ordered. If VPS or alginate is used, a stone model is poured. 4. When set, the model is trimmed and cleaned. Dentsply Triad gel is used to cover the “lagging” canine. It is crucial to be absolutely certain to free the proximal areas and the incisal area, so as to allow for the needed extrusion and rotation movements of this canine. This step is very important­ as the “movement bubble” must create the “space” to allow the tooth to move Fig.4. The operative principle is to ­create space for movement. Add Triad clear gel to the labial, Figure 5: The labial view of the canine tooth, treated with conventional ­lingual, and incisal areas to create the movement bubble. etch-bonding technique. 5. Using the above model or cast, a vacuum-formed the clear aligner with a cut that creates a slit for an attachment “suck down,” of Essix ACE .040 thermoplastic material is hook, and placing a bonded button onto the tooth. Various ­completed. There are several important steps for success. force elastics are then placed between the aligner slit and the The “vacuum” machine must be “red” hot before moving the bonded button, to create forces that will successfully encourage element over the material to be heated. Use only ACE .040 tooth movement. thermoplastic material, and do not allow more than 3/8 inch material sag. The 3/8 inch “sag” value is about equal to Unfortunately, this technique is often unsuccessful for the flange thickness of the material holder. These cautions several reasons: are critical to appliance strength. Immediately “quench” the 1. As the cut slit weakens the aligner, the cut area is often the material with either a “freeze” spray or cold water. Remove point where the aligner fails and breaks. the appliance from the cast/model and trim it, such that 2. The cut slit is often challenging to hold the elastic force, the thermoplastic material extends 2-3mm beyond the as the slit may bend/break and the slit may cut the elastic. ­cemento-enamel junction of the teeth. 3. Further, the aligner has proximal plastic that offers 6. Using conventional bonding techniques Fig.5-6, a ­bonded ­resistance to the adjunct rotation forces and, therefore, button (available in the Align auxiliary kit), is bonded­ to the tooth resists rotation.

the Academy for Clear Aligner Therapy 31 Innovative Techniques the labial of the “lagging” canine. The button should be placed slightly coronal to the gingival margin, in a position that optimizes the applied force. In this case, the button was placed to the mesial as the tooth rotation force was ­counterclockwise toward the distal. Light cure the adhesive and remove excess with scalers and/or finishing burs Fig.7. The Align “kit” includes buttons, etch, bonding liquid, and bracket adhesive. 7. Cut an ovoid slot in the labial of the thermoplastic appliance,­ such that it clears the bonded bracket and allows room for the bracket to rotate/extrude Fig.8. 8. The “Rule of 3’s” is applied to the elastic force system for Figure 6: Conventional bonding technique, light curing of the both positioning the posterior buccal and lingual bonding agent. ­attachment dimples, as well for as determining the minimal movement force. If using a single loop elastic force, place a 1/8 inch x 8 oz. elastic over the labial button on the “lagging” canine Fig.9. 9. Using a hemostat, pull the loop to the distal and note where the elastic loop is stretched two more loops for a total of 3 loops Fig.10. Mark this area, as this is where you will want to place the attachment dimple described in the following step #s 10 and 11. In this case, the retention dimple was placed on the buccal of the first molar. 10. Using a purpose-made Essix “Microramp” plier, heat the “prong” end Fig.11 to about 200 degrees F. Note the heat Figure 7: The attachment button is bonded in place in a manner that source must be a “butane” flame. An inexpensive cooking maximizes the force applied; in this case, to the mesial, because the force “Crème Brule” torch Fig.12 is an excellent heat source. applied is to the distal. A thermocouple may be used to quantify the heated value, or, alternately, you may simply take a cold plier tip, apply a butane flame and count “1-2-3.” This gives an approximate value sufficient to heat and stretch the plastic. The idea is to create a dimple that extends from the inside to the outside of the thermoplastic. This dimple will be further modified to create an attachment point for the elastics Fig.13. 11. Using a sharp instrument, such as a 12B Bard-Parker scalpel blade, cut carefully at the base of the “dimple” on the side away from the lagging tooth. Cut about 1/2 of the ovoid diameter to create a retention hook. Fig.14-16.

12. The patient is instructed to wear the appliance and apply Figure 8: Small curved scissors used to modify the labial aspect of the the elastic forces constantly, except when eating or when ­thermoplastic appliance to create an ovoid cut-out and allow room for cleaning the teeth. Give the patient several long lengths the bonded button. of chain elastic or a bag of individual elastics such as 1/8 x 8 ounces. This clinician has had most success using chain elastic as the force system Fig.17-18. 13. The “hooks” can easily be preloaded on the movement ­appliance Fig.19, making it more convenient for the patient to stretch the chain elastic to place over the bonded button onto the “lagging” tooth. The patient is given inexpensive­ non-surgical grade small straight hemostats to take home and make application of the chain elastics easier. The ­intraoral occlusal view shows the appliance loaded for ­simultaneous rotation and extrusion Fig.20.

Figure 9: The rule of 3 is applied to stretch an elastic loop with a small hemostat to determine the location for the appliance retention dimple.

32 the Journal: volume 01- issue 01 Figure 10: The rule of 3 demonstrating the stretched elastic and the Figure 14: Occlusal view of the retention dimple created with the ­location of the heated plier retention dimple that was placed on the buccal ­MicroRamp heated pliers. of the first molar.

Figure 11: Butane heat source, used to heat the “prong” end of the Figure 15: Occlusal view of dimple cut, created to allow for retention of the ­Microramp heated plier to about 200 degrees F. elastic force.

Figure 12: Butane heat source: Crème Burle cooking torch. Figure 16: Occlusal view of the elastic in place, in the retention dimple hook.

Figure 13: Heated plier used to create a dimple from the inside of the Figure 17: Preferred elastic force system of clear chain elastic with an extra ­thermoplastic appliance to the outside. “tail” to aid in elastic placement.

the Academy for Clear Aligner Therapy 33 Innovative Techniques 14. In general, movement is successful after 3-4 months Fig.21-22. If movement is successful, the patient may resume wearing the next aligner in sequence, and the movement appliance can be discarded. If there had been an attachment that, for purposes of this technique, had been removed (as per step #2), it may now be placed again, by ­ordering and utilizing a new attachment template from Align, for that specific stage. Or, instead, the original ­attachment template may be used for this purpose, by carefully cutting a custom single tooth template from the original attachment template.

15. Aligner wear, with the planned sequential Invisalign Figure 20: Occlusal view with the thermoplastic movement appliance in ­aligners, may now resume and continue until treatment place with simultaneous application of extrusion and rotation chain elastics. is complete. Summary The described adjunct/auxiliary technique can be used ­successfully to rotate and extrude rounded teeth such as ­canines, with reasonable certainty. The technique is ­inexpensive, does not require an outside lab, and is easy to create in-house, with commonly available materials and ­instruments. Given a sufficient and properly directed force, ­sufficient space, and patient compliance, canines that have been exhibiting movement lag can be either extruded or ­rotated successfully. Simultaneous rotation and extrusion can also be treated, as described, with excellent results. n Figure 21: Occlusal view of the “lagging” canine tooth, demonstrating the degree of rotation lag, prior to application of the forces created with the described thermoplastic movement appliance.

Figure 18: Placement of elastics to execute simultaneous extrusion and rotation. Note the extra length loop of chain elastic that makes it easier for the patient to place the chain elastic. Figure 22: Occlusal view, after movements were completed with the ­described thermoplastic movement appliance.

Figure 19: The appliance may be loaded with the chain elastics prior to placement in the patient’s mouth. Note the lingual retention dimple created on the cuspid. An elastic stretched from the lingual rentention dimple of the cuspid to the attachment button on the buccal of the cuspid, will cause extrusion of this lagging tooth.

34 the Journal: volume 01- issue 01 ROPI FlowTain.AJO 8/11/04 12:48 PM Page 1

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Reliance FlowTain_AACO.indd 1 9/13/12 10:32 AM theLighter Side

Maggie’s TMJ (Or, the pain in Spain is mainly on the occlusal plane) by Dr. Jeffrey Galler

You won’t have to talk to anyone,” vowed my wife, “you can sit and had been next to the window and nap, read books, or catch up on your ­getting ­terrible journals. No one will bother you. I promise.” TMD-type pains My wife was advocating a tour of Spain for our summer every ­morning ­vacation. I, however, hate tours. I hate being told when to wake on ­arising. A long list of up in the morning. I hate being told when to get on and off the ­internists, ­neurologists, and tour bus. But most of all, I hate having to be nice to, and get into ­chiropractors had not been able to help her. conversations with, others on the tour who I may genuinely not “Well,” I pronounced, “you’re telling me something very like. I want to be grouchy when I feel like it. ­important when you say the pains only happen when you wake Instead, I longed to spend our vacation on a secluded beach in up in the morning. Sometimes, people get into the ­habit of the Caribbean. But, after being married for over 30 years, clenching or grinding their teeth at night. I have learned the art of compromise: we went on the tour “The ­following morning, the muscles and ligaments around the of Spain. tempero-mandibular joint can become very sore and painful. A surreal experience “If this is what’s happening to you, you can help yourself On the second day of the tour, I was staring at a painting in the by ­doing two things: First, ask your dentist to make you a Salvador Dali Museum in Girona, straining to hear the heavily­ ­nighttime mouthguard. This way, if you can’t stop clenching accented voice of the museum guide explain the ­ your teeth at night, the guard will cushion the pressure, and artist’s ­surrealism. you won’t get such pains. Suddenly, I felt someone tapping my elbow. I turned to see a “Second, try relaxation exercises before bedtime. You can fellow tourist trying to get my attention. try ­inhaling and exhaling deeply and slowly, while saying to ­yourself, ‘Lips together, teeth apart,’ to remind yourself that “Hi,” she said, “my name’s Maggie. We’re on the same tour.” when we’re at rest, our lips are closed lightly, but our upper She had an annoying, high-pitched, whining voice that and lower teeth have about a pencil thickness of separation drowned out the tour guide. I instantly disliked her. between them. “Are you a dentist?” she whined. “If you try these things, the pains may get much better,” I looked around, desperately, for my wife. She wasn’t in sight. I concluded. The museum tour was ending. I would never get “Uh, not at this actual moment, I’m not,” I replied, hoping she’d to find out why Dali portrayed all those melted watches in his get the hint. paintings. But, I didn’t care. I was a healer. I was a very good person. I had helped a suffering human being. Subtlety didn’t stop her. “Do you know anything about TMJ?” she continued, “I wake up every morning with terrible ­headache She’s back pains around my ears.” The following afternoon, our tour stopped at the Maritime ­Museum in Barcelona. Our tour guide suggested that we I gave up trying to hear the museum guide and became picture in our mind’s eye how the Spanish galleons must ­interested in what she was saying. In five minutes, I heard her have looked as they set sail from that very harbor, explorers, whole life story. She was in her mid-forties, single, lived on ­conquistadors, and priests sailing for “Glory, gold, and god.” the Upper East Side in Manhattan, was a physician’s assistant,­

36 the Journal: volume 01- issue 01 I felt someone tugging at my elbow. It was Maggie. “You know,” “My neurologist took CAT scans of my brain and couldn’t find she confided, “I was able to make an appointment for next ­anything,” she said. week, with a very famous neurologist! What do you think he’ll “I’m not surprised,” I mumbled. tell me about my headaches?” “Huh?” asked Maggie. My wife was yards away, engrossed in an animated ­conversation with some new friends, completely oblivious “Oh, nothing,” I said. to my suffering. My eyes became even moister. “Well, Maggie,” I tried to explain,­ “What do you think?” insisted Maggie, “what do you think the “Different health professionals approach problems from neurologist will say?” ­different angles.” I put on my concerned dentist face, and found myself using­ I sensed that I wasn’t getting anywhere. I prided myself the voice I reserved for explaining full lower dentures to on ­being an excellent communicator. Suddenly, I had ­octogenarian patients. “Neurologists are very intelligent and an ­inspiration. very helpful. But, you might want to consider postponing that “Maggie,” I pleaded, let’s play a game. ­Pretend I’m a new patient appointment for a few weeks, to see if you feel better when you in your office. I come in, ­complaining that every day at exactly start wearing a nighttime mouthguard, and try those relaxation­ 4:30 in the afternoon, I get a terrible, excruciating pain right in exercises that we talked about,” I intoned. I proceeded­ to the middle of my forehead.­ What’s the first thing that you would ­explain, again, in detail, what I was recommending. ask the patient?” When we got back on the bus, everyone was ­comparing the Maggie’s brows were knitted in ­concentration. wonderful souvenirs that they had purchased while I had been “Would you like to see a neurosurgeon?” she suggested. busy with Maggie. My wife smiled at me approvingly, nodded “That’s good,” I replied, kindly and gently. “But remember, the sagely, and said, “Good! I see you’re making an effort to be pains come every day at exactly 4:30 in the afternoon. Aren’t friendly with the other people on the tour. It’s good for you to you going to ask the patient what he does every day at 4:25?” relate to other people.” I prompted. Monumental “Yes!” exclaimed Maggie, “what does he do at 4:25?” Our tour spent the next day in Seville. I was trying to capture the entire Christopher Columbus monument in my camera’s “Well,” I continued our imaginary scenario, “every day at 4:25, viewfinder when I heard someone clearing her throat next to the patient stands up from his computer. He feels very tense me. It was Maggie. and very frustrated. He walks over to the wall and bangs his head into the wall, very hard, five times!” “Do you think I should try a new chiropractor?” she whined. “My god, that’s terrible!” Maggie said. “What did your first chiropractor do?” I asked, as I bought a ­picture postcard of the Columbus statue, instead of trying to “Yes it is,” I agreed, “but aren’t you going to suggest to the take a picture myself. ­patient that he put on a strong football helmet at 4:20 so that he doesn’t hurt his head, and that he try relaxation exercises to “My first chiropractor pushed and hammered at my jaw! It hurt try and get out of this habit? terribly, and he didn’t help me at all!” she recalled. “In the same manner,” I concluded, “you may wish to wear a “What makes you think that a different chiropractor can do any night time mouthguard, and try muscle relaxation exercises better?” I asked, reasonably. “What you might want to try, is ­before bedtime.” I was speaking very, very slowly, in my asking your dentist to make a very simple mouthguard to wear Mr. ­Rogers voice and staring at her intently. overnight, and doing those muscle relaxing exercises that we spoke about,” I suggested. I found myself speaking very slowly, “I understand,” Maggie nodded, “you’re suggesting that I see and enunciating very carefully, as I patiently explained my an acupuncturist!” ­recommendations again, in excruciating detail. Pain in Spain I was feeling dizzy. I figured I must have been getting That night, in our hotel room, I had difficulty falling asleep. ­dehydrated in the hot Spanish summer. I tossed and turned. I turned the television on and off. I opened and closed the light. My restlessness woke my wife. I explained Torture to her that I had a headache and couldn’t sleep. Two days later, our group was standing at the Carcel de la Inquisicion in Madrid. The guide explained that victims of the My wife listened sympathetically. “Sounds to me like TMJ,” Spanish Inquisition would be tortured at length and then burnt she concluded sleepily. at the stake. My eyes were moist as I heard of the horrific acts (This article originally appeared in the New York State Dental Society Journal) perpetrated by the Inquisitors. “Are you saying that my first neurologist misdiagnosed me?” demanded the querulous voice at my side. It was Maggie.

the Academy for Clear Aligner Therapy 37 Do you hate IPR? IT’S TIME TO LEARN THE EASIEST, FASTEST, SAFEST AND MOST PREDICTABLE WAY TO DO IPR…

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“This course makes me feel so much more comfortable now when doing IPR with any case – I now look forward to performing IPR instead of dreading it – Thanks for encouraging me to attend this course. I think your company should MANDATE this course to every Invisalign provider before they start submitting cases – it would definitely make them feel much better with every case that requires IPR – I would highly recommend this course to all my peers ” – Mike Strity DMD Having trouble with a Case? Join the fastest growing academy in the country and the official Academy for everything related to Clear Aligner Treatment.

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