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Diagnostics, Implants

& Ortho Education

Volume 14, Issue 4

TABLE OF CONTENTS

32

14

26

10
FEATURES

10 Digital Cameras: Your Practice.


Your Choice!

14 Exploring the First Two Keys of Class II


Correction: Maxillary Arch Development
& Maxillary Molar Position

26 Salivary Diagnostics: Tailoring Your Care


To Your Patients

32 Dental Implants & Orthodontics Part 2:


Mini Dental Implant Placement, Use
and Protocols

40 AOS Annual Meeting Recap

DEPARTMENTS
8

Ortho Industry News

42 AGpO Membership News


44 AOS Membership News
On the cover: Keith Wilkerson DDS,MS
attended the University of Texas Health Sciences
Center in San Antonio and received his dental
degree in 1990. He completed both a residency
in pediatric dentistry and a Masters of Science
degree from Baylor College of Dentistry and
Baylor University in 1994. He has been board
certified by the ABPD since 2000. Keith has been
using the Tip-Edge technique since his 1994
graduation from the Academys Hands-On
Course. He is an AGpO Diplomate and past
President. Keith lives in Midland, TX, where he
has been in private practice since 1993. Early
orthodontic/orthopedic and interceptive
treatments are his major focus, with an emphasis
on correct facial growth and oral posture.

This peer-reviewed journal is published as the official publication of the


American Orthodontic Society and the Academy of Gp Orthodontics.
www.orthodontics.com Fall 2014 5

EDITORS WELCOME

ASSOCIATION STAFF

Greg Cannizzo, DDS, CDE, JAOS Editor


3617 Municipal Drive, McHenry, IL 60050
Phone: (815) 344-2282 Fax: (815) 344-5815
Email: drgrc@joltmail.com

The 18th Camel: Finding


Solutions To Problems
Denver was a wonderful city and a
great backdrop to our Annual Meeting. It
was great to meet with so many wonderful doctors at the lectures, in the exhibit
hall and during meals over those three
days. As I spoke with other doctors
during the meeting, quite a few would
ask me what they could do about solving
or correcting a challenging orthodontic
problem they had encountered. Some
had become frustrated, angry and even
disillusioned with orthodontics due to
this issue. Most of the time all that was
needed was to stop and look for an innovated solution. Stepping back and looking at the issue from another angle or
allowing someone else with more experience a chance to view the issue can help
solve the problem that can be driving
you crazy.
A great example of this can be found
in a story I once read. In this story, a
father has 17 camels but he is elderly and
his health is failing. After a full life, he
passes away and leaves his prized 17
camels to his three sons. When the
father's will is read, it is stated that the
eldest son should receive half of the 17
camels while the middle son should be
given a third, and the youngest son is to
be given one-ninth of the father's 17
beloved camels.
Since it is not possible to divide 17
into half or 17 by 3 or 17 by 9, the three
sons started to fight with each other.
They became frustrated and angry with
not being able to find a solution to their
issue. Finally, the three sons decided to
go to a wise man with their problem.
The wise man listened patiently to the
details about the will. After giving the
matter some thought, he brought one
camel of his own and added it to the
original 17, increasing the total to 18

camels. Then he started reading the


father's will again. Half of 18 equals 9, so
he gave the eldest son 9 of the father's
camels. One-third of 18 equals 6. So he
gave the middle son 6 of the fathers
camels. One-ninth of 18 equals 2. So he
gave the youngest son 2 camels. There
was one camel left, and so the wise man
took back his one camel he had added to
the original 17.
So, when you are confronted with a
challenging problem, remember the 18th
camel and try to come up with an innovative solution. Thankfully, there are always
others within our organizations who can
give us a different comprehensive perspective on a problem or issue plaguing us.
Instructors, lecturers and Diplomates are
available to help you solve your orthodontic problems and issues.
Take the time to meet with them at
the many courses and lectures that are
available for you to attend. Dr. Len Carapezza, Dr. Juan Echeverri, Dr. Ralph
Nicassio and Dr. Ron Austin all have
courses or lectures coming up soon
addressing many of the problems you
may run into in orthodontics. Each of
them has innovative solutions they are
waiting to share with you. All you have
to do is decide its time to take the next
step. Problems are nothing but wake-up
calls for creativity.
Remember both our organizations are
available to help you and back you
through our, speakers and Annual Meetings. No one makes a lock without a key.
That's why we can't have a problem with
out solutions. Make sure you take advantage of the chance to answer your questions by attending the courses and speaking with the lecturers who can be that key.

ADVERTISER INDEX
Academy of Gp Orthodontics ........4

Johns Dental Labs ..................24, 39

American Orthodontic Society ........48

KaVo Kerr Group ............................2

CliniPix, Inc. ................................13

OrthoArch....................................25

Dolphin Imaging Systems ............46

RMO, Inc. ....................................31

Henry Schein Orthodontics ..........47

United States Army ........................3

6 Fall 2014 JAOS

Adam Griswold
AGpO Executive Director
Academy of Gp Orthodontics
509 E. Boydston St.
Rockwall, TX 75087-3956
(800) 634-2027
E-mail:
agriswold@academygportho.com
Thomas N. Chapman, CAE
AOS Executive Director
American Orthodontic Society
11884 Greenville Avenue, Suite 112
Dallas, TX 75243
(800) 448-1601
E-mail: tchapman@orthodontics.com
EDITORIAL STAFF
Greg Cannizzo, DDS ...............AGpO
Editor
Jordan Balvich, DMD ................AOS
Co-Editor
Jim Mcllwain, DDS, MSD ..........AOS
Co-Editor
Lisa A. Wright ..................AOS/AGpO
Managing Editor
Email: lisa@wrightgrp.com
EDITORIAL REVIEW BOARD
Ron Austin, DDS............................AGpO
Chris Baker, RN, DMD......................AOS
Ernest Barbosa, DDS ......................AGpO
Eugene Boone, DDS.......................AGpO
Steve Bradley, DDS ........................AGpO
Felecia Burridge, DDS ....................AGpO
Fred Der, DDS ................................AGpO
Joe Drinkwater, DDS......................AGpO
Twana Farley-Duncan, DDS..............AOS
Debra Ettle-Resnick, DDS .................AOS
Joe Fallin, DDS...............................AGpO
Edward Gonzalez, Jr., DMD..............AOS
Joe Haack, DDS .................................AOS
Kevin J. Hester, DDS .........................AOS
Roy Holexa, DDS ...........................AGpO
Thomas Jacobsen, DDS..................AGpO
Giancarlo Maldonado, DDS ..........AGpO
Kyle McCrea, DDS .........................AGpO
Sherman Menser, DDS...................AGpO
Brian Olsen, DDS...........................AGpO
Ann Mary Orr, DDS ..........................AOS
James Orrington, DMD ....................AOS
Leslie R. Penley, DDS .....................AGpO
Joseph R. Schmidbauer, DDS............AOS
Robert Shirley, DDS .......................AGpO
Jill Snyder, DDS .............................AGpO
Juan J. Solano, DDS ..........................AOS
Kurt Stodola, DDS..........................AGpO
David Thorfinnson, DDS..................AOS
Walter Tippen, DDS.......................AGpO
John Wells, DDS ............................AGpO
Bradford R. Williams, DDS ...............AOS
Paul L. Winborn, DDS ......................AOS
William Wyatt, Sr., DDS ...................AOS

PUBLISHED BY
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(727) 343-5600
E-mail: lisa@wrightgrp.com
www.wrightgrp.com
ADVERTISING SALES & ANNUAL
MEETING EXHIBIT MANAGER
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CONTRIBUTOR BIOGRAPHIES
Josh Brower DDS, MIAMDI, FAASDI, is a
general practitioner who practices using both
orthodontics and dental implants of all sizes. He is
Master of the International Academy of Mini Dental
Implants (IAMDI), a Founder/Fellow of the American
Academy of Small Diameter Implants (AASDI) and
founding member. He does not practice exclusively
with small diameter implants. The author would like to
extend special thanks to Dr. Larry White, a Board
Certified Orthodontist, teacher at Baylor College of
Dentistry and instructor of the AOS.

ADVERTISING & EDITORIAL POLICY


The American Orthodontic Society welcomes
advertising in its publications as an important
means of keeping the orthodontic practitioner
informed of new and better products and
services for the practice of orthodontics. Such
advertising must be factual, dignified, tasteful
and intended to provide useful product and
service information. These standards apply to
all product-specific promotional material
submitted to the American Orthodontic Society. The publication of an advertisement is not
to be construed as an endorsement or
approval by the American Orthodontic Society unless the advertisement specifically
includes an authorized statement that such
approval or endorsement has been granted.
The fact that an advertisement for a product,
service or company has appeared in an American Orthodontic Society publication will not
be referred to in collateral advertising. The
American Orthodontic Society reserves the
right to accept or reject advertising at its sole
discretion for any product or service submitted
for publication.

COPYRIGHT
2014. Journal of the American
Orthodontic Society. The material in each
issue of the JAOS is protected by copyright.
None of it may be duplicated, reprinted or
reproduced in any manner without express
written consent from the publisher. All
inquiries and/or requests should be
submitted in writing to The Thornton Group
via e-mail to jennifer@thorntongrp.com.

SUBSCRIPTIONS
The Journal of the American Orthodontic
Society is a benefit of membership for
current American Orthodontic Society and
Academy of Gp Orthodontics members.
Annual subscriptions to the quarterly journal (4 issues per year) are available at a rate
of $50/year for US residents, $100
USD/year for Canada and $120 USD/year
internationally. Back issues are available at
a rate of $10 per copy until supplies run
out. To subscribe to the JAOS, please visit
www.orthodontics.com.

Jonathan Engel, DDS, a product of Southern


California, Dr. Engel graduated from the University of
the Pacific School of Dentistry in San Francisco in 1982.
He has also completed a mini residency in Esthetic
Dentistry from Esthetic Professionals as well as any other
areas of dentistry. Besides being a member of the
American Dental Association, the California Dental
Association, the Los Angeles Dental Society, AAOSH and
the World Congress of Minimally Invasive Dentistry.

David W. Jackson, DDS, FAGD, IBO, graduated from Baylor College of Dentistry in 1978. Dr.
Jackson, was a member of the AOS and AGpO, as well
as other professional organizations. He lectured extensively for the American Orthodontic Society as well as
the International Association of Orthodontics. His
insight to the real world of orthodontics in the
general practice was honest and informative. We are
saddened by Dr. Jackson's recent passing. He was a
constant contributor to this Journal and a great friend.

Randy K. Newby, DDS, is a Diplomate of the AOS


and has practiced orthodontics for 30 years and has
completed over 2,000 cases. He graduated from Wichita
State University in 1976, and the Creighton University
School of Dentistry in 1980. He has completed the
Master Program in implant dentistry at the GIDE Institute in Los Angeles, CA. Dr. Newby practices multidisciplinary dentistry in Mount Hope, KS, a small community outside of Wichita with his associate Katie L.
Neidig, DDS, an AOS member. honest and informative.

www.orthodontics.com Fall 2014 7

ORTHO INDUSTRY NEWS

Whitening Dental Strips


Brighten Smiles in Two Weeks

Diatechs new Hygienist Choice


Whitening Dental Strips are helping patients find a reason to smile,
while boosting the dental practices bottom line.
Available for sale to patients
through the dental practice hygiene
department, this powerful new
whitening system can brighten a
patients teeth in as little as two
weeks as a take-home product.
It contains the same ingredients
used by dentists to whiten teeth.
Easy to use, the strips are no-mess,
dry-touch strips and are to be used
only once a day for 14 days. Application requires only four quick and
easy steps.
Your patients can see results in
as little as three days and are just
two weeks from a brighter smile,
said Alicia Oliver, Diatech president.

Hygienist Choice Whitening


Dental Strips are a convenient,
simple-to-use product that can
generate additional revenues for
dental hygienist departments.
Each box comes with instructions, and does not require any
expensive collateral such as
pamphlets or brochures to sell.
The three-layer formula uses
non-slip technology to adhere to
teeth that allows longer contact
of the whitening agent. By using
the strips for 30-60 minutes a day
for 14 days, patients can dramatically whiten their teeth. The strips
are specifically designed to whiten
only natural teeth. The system
should not be used on loose teeth,
dental braces, or temporary and
loose dental work.
The whitening strips are part of
Diatechs Hygienist Choice line.
The Hygienist Choice line is
devoted specifically to dental
hygienists and focuses on providing ways to make life easier, more
efficient and more productive for
dental hygienists.
For more information on the
Hygienist Choice Whitening
Strips, the Hygienist Choice line
or any of Diatechs outstanding
products, call 800-222-1851 or
visit www.DiatechUSA.com.

New Mobile App For Ortho Patients


The new My Orthodontist mobile app from Dolphin Imaging gives
patients access to information about themselves and their doctors practice.
The app is avaialble for both iOS and Android devices, providing easy access
to patient information, appointments, account balance, online questionnaires and Dolphin Aquarium patient education videos. Additionally, the
patients have easy to navigate information about their doctor's practice and
staff, FAQs and their practitioner's Facebook, Twitter and Google+.
The application is entirely customizable by the dental and orthodontic
practitioner's practice. Via a new My Orthodontist setup screen on
AnywhereDolphin, the user can setup information about the practice,
doctors, staff, media and news items. Even personalize the app via uploading logos and choosing from more than 25 color themes.
8 Fall 2014 JAOS

Space Maintainers
Laboratories Launches
Global Website
SML (Space Maintainers Laboratories) has announced the debut of
its new website, SMLGlobal.com.
The move is part of an in-house
rebranding effort initiated with
the new SML logo and the handson manifestation of the companys
drive toward increased message
clarity, client connection and
service satisfaction.
As VP of Marketing Scott Veis
explains, SMLGlobal.com is a
fresher, faster, far more satisfying
online experience. Its our virtual
storeand perhaps more significantly, a vast repository of quickaccess information on all things
dental and orthodontic. The
website serves the fourfold purpose
of 1) educating the dental professional as to the function, clinical
application, and treatment modalities of more than 500 available
made-to-order dental appliances
2) providing digital solutions and
expert diagnostic recommendations for dental professionals at all
levels of expertise and 3) facilitating the order, delivery and tracking of the product or appliance
that gets the job done.
Founded in 1957, SML is a labbased consortium of core-supporting dental/orthodontic specialties,
e.g. appliance manufacture; ADA
CERP-recognized continuing
education; digital services; diagnostic consultation; and supplies.
The companys worldwide network
of labs is renowned for providing
dental practitioners with the
opportunity to receive the service
and caring of a mom-and-pop lab
and the technological assets and
resources of a large, globally realized company.
Practitioners interested in learning more about the SML laboratory franchise may request an
introductory orientation by calling
1-800-423-3270. For more detailed
information on the offerings and
advantages of SML, visit us online.

ORTHO INDUSTRY NEWS


ADA Encouraged by
Soda Makers' Pledge
The American Dental Association
(ADA) is pleased that three leading
soda manufacturers recently
announced that they hope to reduce
the number of calories that Americans consume from sugar-sweetened
beverages by more aggressively
marketing smaller sizes and drinks
with less sugar.
Coca-Cola, PepsiCo and Dr Pepper
Snapple Group announced at the
Clinton Global Initiative in New York
City that their goal is to reduce the
number of sugar-related calories that
American's consume by 20 percent
over the next decade, according to
recent news reports.
The ADA says that a steady diet
of sugary foods and drinks, including juice and sports drinks, can
damage teeth. Cavity-causing bacteria in the mouth feed on sugar and
produce acids that attack tooth
enamel for up to 20 minutes after
you eat or drink. Sipping sugary
beverages or eating sugary foods all
day results in repeated acid attacks
that weaken tooth enamel which
can lead to cavities.

eXceed Computerized
Bracket Placement Service
New from Great Lakes, the
eXceed Computerized Bracket
Placement Service is
a patented suite of
computer-aided,
bracket placement
services that scientifically calculates the
ideal digital placement coordinates for
each bracket on the
teeth. Then, through
cutting-edge 3D
model printing technology, bonding
trays are manufactured with unrivaled fit and bracket
position accuracy. Outcomes are
more predictable and consistent,
and adjustments to brackets and
archwire are minimized or eliminated. eXceed significantly reduces
time spent placing brackets, minimizes chair time, and increases
patient comfort.
eXceed offers two different
methods to calculate ideal bracket

positioning. eXceed Rx uses pretreatment occlusion to determine


the position of
appliances; and
with eXceed Tx,
the position of
appliances is optimized with the
help of a virtual,
post-treatment
target simulation.
Regardless of the
method selected,
eXceed is fast and
efficient, and gives
you ultimate
control. User-friendly software
allows doctors to adjust bracket
placement and approve the files
prior to tray fabrication.
For more information about the
eXceed Computerized Bracket Placement Service, contact Great Lakes
laboratory customer service at
800.828.7626 and ask to speak with
an eXceed technical specialist, or
visit www.exceed-ortho.com.

www.orthodontics.com Fall 2014 9

Fig. 1

10 Fall 2014 JAOS

By David W. Jackson, DDS, FAGD, IBO

enry Ford once said: I am not


the smartest, but I surround
myself with competent
people. I think its safe to say
that Henry Ford had more than a mild
degree of success. In fact with the Ford
automobile, he rocked the world. Weve
heard in a variety of ways people
saying that a leader should surround
himself with people better than him.
According to leadership literature,
successful leaders surround themselves
with good people, but great leaders
surround themselves with people who
are even better than they are. But this
is something not so simple to achieve.
While I owned two very successful
large practices, I never reached my
potential. I had great staffs, great labs,
etc., but I failed to surround myself
with people even better than me. Ironically it took a health crisis in my life 12
years ago to begin to employ this secret
and success, I was out of my practices
for four weeks while I was gone I
brought sharp folks in and when I
returned the practices had had one of
the best months in my dental history.
I was a slow learner. But I finally got it!
And the last ten years I owned my two
offices, they produced the most
income. My last decade as owner was
incredible. So what does this have to
do with Digital cameras?

Fig. 2

www.orthodontics.com Fall 2014 11

Fig. 3

I am not a camera guru. In fact I barely get by


figuring out the settings for a dental camera. But I
found a company owned by a gentleman who
knows quite a bit. His name is Fred Friedman,
Fellow of Intl. ACAD. Facial Dental Esthetics. His
company is CLINIPIX (Office 561.793.4142/ email:
clinipix @
bellsouth.net). I met
Fred and his lovely wife
at a meeting and what
impressed me was he
explained his cameras,
but made no attempt
to up-sell me.
In the early nineties,
I invested into a high
dollar ring flash
monster that only I
was allowed to pick up.
I was afraid that my
assistant might drop it
that is true trust, huh?
This was the last decade
where we used slide
photography for a few
of you who may not be
familiar with the world
twenty years ago, once upon a time; cameras used
rolls of film. We would fill up the roll with our
pictures and then take it to the drug store camera
department where it was either sent to a lab or
processed on site. It took about a week to get the

pictures back. The problem was that we were not


looking at the slides before we placed them in plastic
sleeves. When in 1998, I began to really catch the
teaching bug; I began to organize the slides from this
killer camera. I found many slides were in the
wrong charts; pictures were not straight on the slide
you cannot rotate
these; there were over
exposed slides, and
underexposed slides.
AND I WAS AFRAID TO
LET MY ASSISTANTS
TAKE PICTURES!! LOL!!
In 2000, I purchased
my first digital camera,
again a ring flash warrior
with all the bells and
whistles. I continued to
take most of the pictures
with this 1 megapixel
wonder, but I could see
if I got a picture and if it
was good!! Technology
had given me a change
to begin to document
good pictures. We used
this camera for around
three years, but megapixels began to rise and I began
to hunt for another camera. But this time I decided
to change strategy. I had read about these point and
shoot cameras. So I ordered two for each office.
Now these cameras looked like a vacation camera

Choose the camera that


enables you and or your staff
to provide the best possible
images to satisfy your
particular requirements. Let
your patients see the work
your practice can accomplish
and how it will improve their
looks and their self- esteem.

12 Fall 2014 JAOS

and the assistants were not afraid of them. Plus as we


were now taking pictures on every patient every
time, I was now delegating pictures to my staff. Now
we were able to quickly and easily capture intra-oral
to portrait images; there was nothing to add or
remove; and minimal photographic skills were
required. There is a truism: Some people just cannot
take pictures!! But the majority of the assistants
excel. All of my photos in my articles and course are
taken with these simple cameras. The main reason
an assistant fails at picture taking is the lack of training and lack of patience with them when they fall
short of a perfect picture. Some assistants get it faster
than others and that is a fact. And if the doctor
does not provide adequate training, or they themselves cannot take pictures, how would one expect
the staff member to take good photos.(Fig. 1)
While the Point & Shoot cameras are well suited
to my needs in my orthodontic practice and for
pictures to lecture with, there are those dentists that
might prefer the quality obtained from a single lens
reflex camera. The SLR cameras may look intimidating, however, when purchased from a dental
specialty company, and set-up properly, they become
as simple to operate as the P&S cameras that have
been modified for dental applications as opposed to
an off the shelf product. Without any photographic skills, an office can be up and running with
the ability to take outstanding digital images in a
matter of minutes.
It is not necessary to purchase the most expensive camera body as these usually have features
that are likely overkill for the dental office and
truly serve no purpose. Technology has drastically
changed the landscape of digital cameras within
the last five to six years, quality has risen and
prices have dropped. Todays digital cameras are
smaller, lighter and with the advances being made
the sensors are fast approaching
the quality level of film.
While camera manufacturers
stress higher and higher megapixel levels, for dental applications, higher is not necessarily
better. Many cameras today are in
the 18-24 MP range. Our feeling is
that 8 to 10 MP are more than
sufficient and that is how we set
our cameras. A higher level does
not equate to a better image and
takes longer to download. The
camera sensor, the optical quality
of the macro lens being used, as
well as the lighting, have more to
do with a better image than the
amount of megapixels.
A variety of macro lenses are
available, 60mm, 90mm and

100mm. Usually the 60mm is not the recommended lens as the subject to camera distance for
both close-up and facial views is too close. The
90mm or 100mm macro lens yields a comfortable
working distance when taking intraoral views and
eliminates distortion when taking portraits. While
lenses can be used in the autofocus mode, we
suggest that the manual mode be selected, and with
this in mind, our lenses are imprinted with the
preferred Orthodontic views for accurate, consistent
before & after images .
The complete SLR system should include a camera
body, macro lens and the proper lighting. There are
currently two choices that are suggested, the traditional Ring-light and the latest advancement, the
Wire-less Ring-flash which eliminates the power pack
and offers a lighter weight system. (Figs. 2 and 3)
Choose the camera that enables you and/or your
staff to provide the best possible images to satisfy
your particular requirements. Let your patients see
the work your practice can accomplish and how it
will improve their looks and their self- esteem. In
addition, photography is the ideal way to communicate with a laboratory when necessary. Remember the old saying, one picture is worth a thousand words. This is especially true when marketing your practice.
And as a final thought to leave you with, support
is critical for folks who so not have a great knowledge of photography. Due to the different lighting in
various offices, sometimes the preset settings that
come on the camera need to be changed quickly.
That is again the advantage and importance of working with a company like CLINIPIX. If I have issues
with a camera, I simply pick up the phone and
scream, Hey Fred!! Help!!!

www.orthodontics.com Fall 2014 13

EXPLORING
the First Two Keys of
Class II Correction:

Maxillary Arch Development & Maxillary Molar Position


By Randy K. Newby, DDS

Fig. 1

n the Spring 2014 issue of the JAOS, my friend and


mentor Leonard J. Carapezza, DMD wrote an article
titled: Six Keys to Early Mixed Dentition Class II
Correction: A Quantified Approach to Diagnosis and
Treatment.2 Dr. Carapezzas article gives an overview of
many important aspects of Class II treatment. In the
next several issues of the JAOS, I will use the Six Keys
described as an outline to explore each in depth.
This article will focus on the first two keys: Maxillary
Arch Development and Maxillary Molar Position,
describing techniques utilized in my practice and when I
use them. A potential biomechanical problem exists
when expanding transversely across the maxillary arch.
This will be discussed and possible solutions to minimize
or avoid it are offered. Many of the techniques described
apply not only to the maxilla but to the mandible as
well and also to Class I and Class III malocclusions.

Big Daddy
The .032 stainless steel overlay arch was aptly
named the Big Daddy by William Wyatt, DDS, FACD,
14 Fall 2014 JAOS

Fig. 2

FICD.13 Fig. 1 demonstrates the appliance in the


mouth. In the maxilla the Big Daddy inserts into the
headgear tubes. From the headgear tubes the appliance steps down and proceeds anteriorly where it is
secured to the archwire by three ligature ties. If the
appliance is to be used in the mandible the appliance
inserts into the lip bumper tubes and is secured similarly as in the maxilla.
Figs. 2-5 demonstrate fabrication and activation of
the Big Daddy. Six mm of activation is programmed
into the appliance. Before insertion into the mouth the
appliance is heated with a flame to a straw color to
increase its stiffness. Move the flame evenly around the
appliance. If the appliance is heated too much it will
become dead soft and is not effective. Upon activation
in younger patients the response can be rapid. In adults
there may be no visible response for a few months, but
in time the desired expansion will occur.8
Mulligan Mechanics in the Horizontal
(Transverse) Plane

Fig. 3

Fig. 5

Fig. 4

Fig. 6A
Fig. 6B

Maxillary molar distal rotation and expansion


requirements may be accomplished by applying the
principles of Mulligan mechanics in the horizontal
plane using a round stainless steel archwire. In an .018
slot use an .016 or .018 round stainless steel archwire.
In an .022 slot use an .018 or an .020 round stainless
steel archwire.8
Either fabricate the round stainless steel archwire on
a turret or use a preformed stainless steel archwire that
has been adjusted to the proper width. Dr. Mulligan
demonstrates eight commonly used configurations in
the horizontal (transverse) plane to affect maxillary
molar position.8 Four of these configurations affect
maxillary molar expansion and rotation.

Fig. 6D
Fig. 6C

Fig. 7

If 6|6 expansion is needed, utilize Out-Bends


distal of 3|3 (Fig. 6A)
If 6|6 expansion and distal rotation are needed,
utilize Toe-in Bends mesial of 6|6 (Fig. 6B)
If 6|6 expansion and distal rotation are needed,
utilize Toe-in Bends mesial of 6|6 and Out-bends
distal of 3|3 (Fig. 6-C). This bend is a parallel (step)
bend. It delivers the highest force magnitude of any

www.orthodontics.com Fall 2014 15

Fig. 8
Fig. 9
of the bends described. It should be used in adults
where higher force magnitudes may be desirable.
If 6|6 distal rotation only is needed, utilize Toe-in
Bends mesial of 6|6 and In-Bends distal of 3|3
(Fig. 6D)
Make these bends in the mouth after the archwire
has already been placed. Use a Tweed loop plier (Fig. 7A)
that will produce a 45 bend. Hold the plier vertically
and at a right angle to the archwire and squeeze the
plier fully. You need to create consistent 45 bends. I
lace 3,2,1 | 1,2,3 for control when making these bends
so that the anterior teeth maintain their position.
Figs. 7B, 8, and 9 demonstrate a clinical case in the
late mixed dentition. The maxillary arch is narrow
and V-shaped. 3,2,1 | 1,2,3 were bracketed and 6|6
were banded. Toe-in bends were placed mesial of 6|6
and out-bends were placed distal of 3|3. The result
will be expansion and distal rotation of the maxillary
first molars.
The formed archwire configurations outside of the
mouth might appear very strange looking. However,
these configurations are correct and will provide great
results (Fig. 10)8 Mulligan mechanics may seem abstract
and difficult to grasp at first. Dr. Mulligans text is a
great resource for understanding the concepts. I have
found Mulligan mechanics principles to be effective
and easy to implement.
Nitanium Palatal Expander 2 (NPE)
The following is a brief overview of how to size, use,
and reactivate the Nitanium Palatal Expander 2 (NPE).
For a technique guide about the NPE refer to the Ortho
Organizers Instructions for Use Sheet REF 1010760/101-770.10 Another excellent source is the Gerety
Orthodontic Seminars titled: Palatal Expansion With
the Nitanium Palatal Expander (NPE) pages 277-285.3
Figure 11 shows the NPE in a patients mouth with the
components labeled.
NPE features:
Rotates 6|6 distally
16 Fall 2014 JAOS

Fig. 10

Expands the maxillary arch


Can be used for anchorage
The low continuous force is the result of a transition temperature of 94F and shape memory
Mouth warmth activates movement in the thermal nickel titanium energy wire toward the NPEs
pre-programmed shape3
Ortholoy arms and bayonet ends may be adjusted
for arch expansion and molar torque control
Available in 10 sizes sequentially in 2mm increments
Requires an .036x.072 slotted horizontal lingual
sheath to be welded onto the molar bands
How do I determine the correct size NPE to use?
There are several alternative methods to determine
the correct size of NPE to use. Either in the mouth or
on a stone model, I measure from the lingual of the
maxillary first molars straight across the arch and add
4mm to determine the correct size of NPE to use.

Fig. 13

Fig. 11

Fig. 12

Fig. 14

How do I place buccal root torque in 6|6?


With an Adams plier (triangular flat on flat) grasp
the bayonet end of the NPE and rotate approximately
15 degrees to the buccal. Repeat on the other side (Fig.
12A).
Why do I place buccal root torque in 6|6?
We are expanding occlusal to the COR in the transverse plane. The possibility of tipping 6|6 to the
buccal exists if buccal root torque is not programmed
into the NPE.
How do I re-activate the NPE?
On a subsequent visit remove the NPE from the
mouth. Squeeze one of the lateral ortholoy loops to
flatten it slightly. Move the now buccally rotated
ortholoy arm back toward the lingual to its original
position (Fig 12-B) and repeat on the other side.
Place buccal root torque as described earlier and reinsert into the lingual molar band sheaths. If more
expansion is still required proceed to the next larger
NPE at the next visit.

Additional benefits of the NPE:


If the skeletal vertical needs to be decreased, when
measuring from the lingual of the 6|6s add 2mm
instead of 4mm to determine the appropriate size of
NPE to use. The appliance will be flatter across the arch
as opposed to following the contour of the palate. As
the patient swallows the tongue will engage the NPE
and help to intrude the molars. The patient may
complain at first about the appliance position, but
explain to them the benefits of a normal skeletal vertical. A patient with straight teeth but with a long face is
not attractive.
The NPE may also be used as a tongue thrust correcting appliance. Have the patient place and keep the tip
of the tongue on the thermally activated Nitanium
loop of the NPE and swallow 20 consecutive times
twice daily. This exercise helps to convert an infantile
swallow pattern to an adult one.
Transpalatal Bar (TPB)
The TPB that I use in my practice is the mesial loop
PAB from Dentsply/GAC International, Inc. (Fig. 13A)
www.orthodontics.com Fall 2014 17

Fig. 15

Fig. 17

Fig. 16
The TPB has many capabilities:4
Torque
Intrusion or extrusion
Expansion
Rotation
Distalization
Molar uprighting
Reinforcement of anchorage
How do I prepare the mesial loop (Palatal Arch
Bar) to be added prior to activation and
determine which size to use?
The mesial loop PABs come in eleven sizes starting
with 35mm and increasing in 2mm increments up to
55mm. Measure in the mouth or on a stone model
from the lingual tissue to tooth junction of one maxillary first molar adapting the plastic measuring device to
the curvature of the palate to the lingual tissue tooth
junction of the other maxillary first molar (Fig. 13B).
In this example a 47mm mesial loop PAB was selected.
With the Adams plier bend one terminal loop 30 (Fig.
18 Fall 2014 JAOS

Fig. 18
14A.) Repeat on the other side and view laterally to
make sure that the bends are symmetrical. In the
middle of one straight wire portion of the PAB place a
30 bend (Fig 14B). Repeat on the other side and view
laterally to make sure that the bends are symmetrical.
Making the bends in the middle of the straight wire
portion of the PAB allows for proper adaptation to the
curvature of the palate. At the junction of the straight
wire portion and central loop place a 30 bend (Fig.
14C). Repeat on the other side and view laterally to
make sure that the bends are symmetrical. Figs. 14D
and 14E demonstrate a passive PAB prior to activation.
A multitude of actions may be programmed into the
TPB, far too many to cover in this article. I will focus
on bilateral expansion, buccal root torque, distobuccal
rotation, and distalization of maxillary first molars - the
main issues encountered in constricted Class II cases.
Only two activations should be performed at the same
time. Excessive multi-directional activations can
compromise results and lengthen treatment time.
I link bilateral expansion and bilateral buccal root
torque of 6|6 and perform these activations first. To
program bilateral buccal root torque into the appliance
bend the terminal loop on one side several degrees to

the lingual with the Adams plier (Fig. 15A). If the


torque activation on this side is correct, when placing
this torqued terminal loop back into the lingual sheath
the opposite terminal loop should be 3-5mm occlusal
to its lingual sheath (Fig. 15B). Repeat these steps on
the opposite side. To expand the TPB 2mm, flatten the
center loop with the Adams plier (Fig. 16A) and then
bend the lateral arms back to their correct position
(Fig.16B). Insert the TPB into the lingual sheaths on
both sides and secure with rubber ligature ties (Fig.
16D). The maxillary arch will expand and the maxillary
first molar roots will torque buccally.
After the maxillary first molars have been widened
and torqued sufficiently, distobuccal rotation and
distalization are linked and may take place. If both
molars require distobuccal rotation place 15 toe-in
bends on both terminal loops, expand 1.5mm, and
insert into the lingual sheaths (Fig. 17).
If 6|6 require both distalization and distobuccal
rotation place a 15 toe-in bend on one terminal loop
only and insert both terminal loops into the lingual
sheaths. The activated first molar will rotate distobuccaly and the opposite first molar will distalize (Fig. 18A
and B). Now place a 15 toe-in bend on the terminal
loop on the opposite molar and insert both terminal
loops into the lingual sheaths. The now activated first
molar will rotate distobuccally and the opposite first
molar will distalize (Fig. 18C and D).
Fig. 19 demonstrates a clinical case where a mesial
loop PAB was used to expand and torque the maxillary
first molars. The arch was expanded 8mm measuring
from the buccal cusp tips of the second bicuspids.
TransForce2 Transverse Arch Developer
The TransForce2 Transverse Arch Developer (TFT) is a
fixed appliance that allows for arch expansion from the
cuspid on back. The TFT comes in four sizes (when
fully compressed): 18, 20, 22, and 24 mm. Each appliance has 8 mm of expansion potential. Ortho Organizers provides a transparent TransForce2 Transverse Arch
Development Planner for proper appliance selection.

Fig. 19

Fig. 20
Fig. 20B demonstrates a clinical case with the TFT
placed in the mandibular arch. Small composite beads
on the lingual of the cuspids help to lock the TFT
down so that the appliance does not rise up occlusally
as it expands.

TFT Features:
Expands the maxillary and mandibular arches
On the palate but with a tight lingual profile,
therefore not as obtrusive as some palatal appliances
Nitanium coil springs enclosed in the expansion
modules provide a slow continuous force11
Allows for up to 2 mm expansion every 6-8
weeks11

Hyrax
The Hyrax is a fixed laboratory fabricated maxillary
arch widening appliance. Molar bands are used on the
first molars and are optional on the first bicuspids.
Hyrax Features:
The midline screw assembly is closer to the COR
(Center of Resistance) in the transverse plane
allowing for close to bodily buccal movement of
the maxillary molars

Bayonet ends (blades) fit into .036 x .072 horizontal sheaths on the lingual of the first molar bands

A strong rigid expansion appliance for narrow arches

To be used in cases where the molars do not need


rotation (i.e., Class I and III)

An excellent appliance to attach auxillary hooks


to for connection with NiTi closed coil springs
to TADs to reduce the vertical in skeletal open
bite cases

Fig. 20A shows a TFT with the components labeled.

May be used in rapid palatal expansion cases

www.orthodontics.com Fall 2014 19

Fig. 21

Fig. 23

Fig. 22

Fig. 24
indications for use, advantages, disadvantages, vendors,
and cost.
An excellent appliance in Class III cases where the
maxilla is deficient horizontally; Class III elastics
are worn from extended buccal arms on the appliance to a removable mandibular bow that is worn
during sleep to protract the maxilla (Fig. 21
demonstrates such a case)
Fig. 21A demonstrates that the midline screw assembly
is close to the COR in the transverse plane, allowing for
translation of the maxillary first molars when expanding.
This case has both maxillary expansion and protraction
components. Figs. 21B and C demonstrate 5mm of maxillary expansion.
Figures 21D and E demonstrate the removable
mandibular bow. Class III protraction elastics connect
from the extended buccal arms of the Hyrax to hooks
on the bow.
Archwire Sequence
It is generally accepted that if an archwire sequence
has a broader arch form than the dentition, then approximately 2 mm per side of lateral expansion may be
achieved without significant buccal tipping of the posterior teeth.
Table 1 summarizes the appliances used, actions,

20 Fall 2014 JAOS

BIOMECHANICS DISCUSSION
A review of some fundamental biomechanical definitions and principles is necessary to understand clinically what happens when a force(s) is/are applied to a
tooth/teeth.
Force a push or a pull that acts in a straight line7
(Fig. 22A)
Center of Resistance (COR)the point through
which a force will result in translation of a/the
tooth/teeth without rotation12; the COR of a tooth
depends on the root length, morphology, number of
roots, and the level of bone support 9 (Fig. 22B)
Translationall points on a tooth move in a parallel
straight line (bodily movement) when a force is
applied12 (Fig. 22C)
When a force acts away from the COR, there is a
perpendicular distance established between the
applied force and the center of the object8 and a
moment is produced (Fig. 22D). A moment is the
product of force times distance.7 Half of the force
times twice the distance produces the same moment
as half the distance times twice the force8 (Fig. 22E).
When the line of force does not pass through the COR

Table 1

www.orthodontics.com Fall 2014 21

Fig. 25

Fig. 26

Fig. 27

22 Fall 2014 JAOS

of the tooth, a moment is produced and rotation


occurs7 (Fig. 22F).
Rotation the turning of a tooth by movement
around its long axis.12
Point of force application (PFA)the point at which
a force starts an action.5
A molar tooth, like all objects, is considered in three
planes of space: mesial to distal represents the sagittal plane,
buccal to lingual represents the coronal plane, and occlusal
to apical represents the transverse (horizontal) plane.
On an extracted maxillary right first molar, I removed
a wedge of the tooth down to the level of the COR in all
three planes of space. I painted the resultant three walls
(Fig. 23A). Red represents the sagittal plane (Fig. 23B),
blue represents the coronal plane (Fig. 23C), and green
represents the transverse plane (Fig. 23D). The internal
white dot is where the three planes intersect (COR).
If a vertical pushing force is applied to the tooth
occlusally where the red and blue walls intersect, bodily
intrusion of the tooth will result (Fig. 24A). If a mesial
to distal pushing or pulling force is applied to the tooth
where the red and green walls intersect, bodily distalization of the tooth will result (Fig. 24B). If a buccal
pulling force (e.g., the Big Daddy) is applied to the
tooth where the blue and green walls intersect, bodily
buccal movement of the tooth will result (Fig. 24C).
Biomechanically what is the main issue to identify
and overcome when applying expansion forces transversely across the maxillary arch?
Whether we are pulling on the maxillary first molars
from the buccal (e.g., Big Daddy or Mulligan mechanics
in the horizontal plane) or pushing from the lingual (e.g.,
NPE, TFT, Hyrax, or TPB) (Fig. 25A) a vertical component
is created (Figs. 25B and C). The vertical component in
the force system creates a moment in which the maxillary molar crowns over-rotate to the buccal as the tooth
moves buccally.

Fig. 29

Fig. 28
Is the buccal tipping of the maxillary molars clinically significant? The younger a patient is (mixed
dentition) and the lesser the amount of expansion
required, can tilt the scales toward the tipping issue
not being clinically significant. The older a patient is
(adult dentition) and the greater the amount of expansion required results in a higher degree of buccal
tipping that is clinically significant. In his book Dr.
Mulligan shows that the long axis of the maxillary and
mandibular posterior teeth should be parallel with the
muscles of mastication for ideal function8 (Fig. 26A).
He describes two curves: Monson and Wilson (Fig
26B). The curve of Monson refers to the ideal curve
where the buccal and lingual cusp tips of the maxillary
first molars contact. The curve of Wilson refers to the
ideal curve where the buccal and lingual cusp tips of
the mandibular molars contact.6
When these curves are coincident, excellent axial
loading occurs. However when the crowns of the maxillary molars are tipped buccally there is an excessive
curve of Monson with a loss of axial loading3 (Fig.
26C). Furthermore, the molar crowns are not uprighted
over their roots and will not be stable. Fig. 27 demonstrates an expansion case using the NPE. Despite
programming buccal root torque into the appliance,
the maxillary molar crowns tipped excessively to the
buccal as they were expanded. Upon removal of the
appliance the crowns will upright over their respective
roots and the amount of actual expansion gained will
be less than what was originally thought to be.
I am currently working on developing a prototype
first molar band with Jerry Anderson of Anderson
Orthodontics1 that will place a second buccal tube
level with the COR in the transverse plane (Fig. 28).
Using the Big Daddy, the pulling force would be
applied at the level of the COR and bodily buccal
movement of the molars without tipping would
theoretically take place (Fig. 29).
CONCLUSION
Several of the appliances that I use satisfy the
requirements of Key One: Maxillary Arch Development
so that the the shoe (maxilla), and the foot (mandible)

Fig. 30
will fit.2 Some of the appliances (Mulligan mechanics
in the horizontal plane, Nitanium Palatal Expander 2,
the transpalatal bar, and to a lesser extent the Big
Daddy) satisfy the requirements of Key Two: Maxillary
Molar Position. These appliances have the capability of
distobuccally rotating maxillary first molars. From a
biomechanical standpoint it was demonstrated that
when a maxillary arch is developed transversely with
forces occlusal to the COR, tipping of the maxillary first
molars occurs and may be problematic in some cases.
Fig. 30A shows a common problem when expanding
the maxillary arch transversely. In those cases I would
recommend using a Hyrax for expansion as the midline
screw assembly approximates the level of the COR.
Another option if utilizing the Big Daddy pulling technique would be to use a molar band that has a double
buccal tube and use the more gingivally positioned
tube (closest to the COR). A final option would be to
utilize a custom made molar band that has a second
buccal tube placed at the level of the COR. This would
allow for the potential of the maxillary first molars to
expand buccally in a bodily fashion (translate with no
tipping) when using the Big Daddy pulling technique.
Figure 30-B shows the ideal goal of maxillary arch
expansion TRANSLATION of the maxillary molars!

www.orthodontics.com Fall 2014 23

References
1. Anderson, Jerry. Anderson Orthodontics, Inc. Laboratory. 4318 W. Central, Wichita, KS 67212, Box 48745,
Wichita, KS 67201. 316-942-8703/Fax 316-942-6315/800456-1954
2. Carapezza, Leonard J., DMD. Six Keys to Early Mixed
Dentition Class II Correction: A Quantified Approach to
Diagnosis and Treatment. Journal of American Orthodontic Society; Spring 2014.
3. Gerety, Robert G. Gerety Orthodontic Seminars. Palatal
Expansion with the Nitanium Palatal Expander 2 (NPE).
Straight Wire Concepts: Diagnosis and Technique.
Produced by Kay C. Gerety, CDA
4. Greenfield, Raphael L. DDS, MSCD. Non Ex Factors.
98.5% Nonextraction Therapy using Coordinated Arch
Development. DaehancNarae Publishing, Inc. Seoul,
South Korea; 2010.
5. http://medical-dictionary. the freedictionary.com/application.
6. http://www.ptcdental.com/dentaldictionary/c/curve-ofmonson/curve-of-wilson/

24 Fall 2014 JAOS

7. Mulligan, Thomas F., DDS, MSD. Common Sense


Mechanics. CSM Publishing, Phoenix, Arizona 1982.
8. Mulligan, Thomas F., DDS, MSD. Common Sense
Mechanics in Everyday Orthodontics. CSM Publishing,
Phoenix, Arizona 2012.
9. Nanda, Ravindra, BDS, MDS, PhD. Biomechanics and
Esthetic Strategies in Clinical Orthodontics. Elsevier Saunders. St. Louis, Missouri 2005.
10. Ortho Organizers. 1822 Aston Avenue. Carlsbad, CA
92008. 1-800-547-2000. www.orthoorganizers.com
11. Ortho Organizers. Transforce2 Arch Developer Appliances Clinical Cases. New Horizons in Orthodontics.
www.orthoorganizers.com
12. University of Illinois at Chicago Department of
Orthodontics College of Dentistry. Orthodontic Glossary.
Chicago, Illinois. UIC. http://www.uic.edu/depts/dort/glossary.html
13. Wyatt, William, DDS, FACD, FICD. and White, Larry,
DDS, MSD. Orthodontics In Todays Dental Practice. A
Four Session AOS Sponsored Education Series; Session 1.

By Jonathan Engel, DDS


urrent advancements in salivary diagnostics and other
oral tests now give dentists
the ability to help tailor the
care for their patients. One can now
test for periodontal pathogens, periodontal genetic markers, HPV and
caries risk using various salivary
diagnostic tools. These tests can
help dentists achieve the best possible outcome for their patients.
The sources of saliva are the
three pairs of major salivary glands
(parotid, submandibular and sublingual glands) along with many
minor salivary glands found
throughout the mouth. Whole
saliva, as opposed to gland specific
saliva is mostly used for diagnostics
since it is more readily collected
and contains the important serum
constituents. Whole saliva also
includes gingival crevicular fluid,
nasal and bronchial secretions,
serum and blood derivatives from
wounds, desquamated epithelial
linings, food components, and
micro organisms that reside in the
oral cavity.1
In September of 1999, the
National Institute of Dental and
Craniofacial Research held a
workshop on salivary diagnostics
with the specific intent of pushing forward research and technology to make it a feasible reality.
And, in a 2010 article, Dr. Loo et.
al. stated that over 2,290 proteins
or proteomes have been identified
in human saliva and 40% of
plasma proteins associated with

Fig. 1A
26 Fall 2014 JAOS

different disease processes can be


found in saliva.2
For years, the standard for testing
has been blood serum and plasma,
however, saliva has several significant advantages over blood testing.
It is easy to collect, it doesnt stress
patients like a needle stick, doesnt
require special training to collect and
is easily stored. One goal of the
NIDCR is that salivary tests be able
to be tested chair side to speed up all
the potential benefits of the testing.
Currently, a UCLA research group
has a prototype called the OFNASER
(oral fluid nanosensor test) which,
when available, will be able to
provide chair side results.3
Saliva has been found to carry
markers for a host of diseases. They
include Sjogrens syndrome, cystic
fibrosis, different malignancies
(including oral and breast cancer)
infectious disease and viral diseases.
It is also possible to monitor the
systemic levels of drugs including
recreation drugs (amphetamines,
barbiturates, benzodiazepines,
cocaine, PCP and opioids)4
The purpose of this article is to
further explore where salivary testing and other oral testing has
progressed in particular to the field
of dentistry.
An article published in The Scientific World Journal in 2012 5 looked at
whether there were any markers in
saliva that could be evaluated during
orthodontic treatment. Done in
Malaysia, the study followed three
female orthodontics patients. The

Fig. 1B
www.orthodontics.com Fall 2014 27

Fig. 2

results of their study showed that


eight different proteins changed
expression in the saliva during
orthodontic tooth movement. These
results may signal the ability to
monitor orthodontic movement
using salivary diagnostics.
Salivary diagnostics for periodontal disease are based off of the
science of DNA-PCR testing. PCR
(Polymerase Chain Reaction) was
developed in its current form by Dr.
Kary Banks Mullis in 1983 for
which he received a Nobel prize in
chemistry in 1993. PCR is a quick
and relatively inexpensive way to
make millions and even billions of
copies of a single DNA strand so
that molecular and genetic analysis
is available from a small sample.6
In recent years, attention to a
link between the degree of severity
in periodontal disease and increases
of local inflammatory mediators has
been studied.7 Dr. Kenneth Kornman et al published an article in
the Journal of Clinical Periodontology in 1997 reporting that their
study showed that patients with
specific genetic markers (those associated with increased IL-1 production) also were at higher risk of
having periodontitis as adults.8
Salivary testing using DNA PCR is
an important tool to help in deter28 Fall 2014 JAOS

"It is very exciting that


as clinicians we can be
more progressive in
actually preventing
disease as opposed to
the standard of treating
dental disease."
mining if a patient is positive for
the genetic polymorphism (or any
of its variants), which would indicate that the patient has a predisposition and increased susceptibility
to periodontal disease. In addition
to using PCR for the evaluation of a
patients risk for periodontal
disease, PCR can also be used to
identify which bacteria associated
with periodontal disease are in a
patients saliva.
It is estimated that at least 50%
of all Americans over the age of 30
have some form of periodontal
disease according to the Centers for
Disease Control and Prevention
(August 2012). In reality, this
number may be much higher today.
The significance of periodontal
disease cannot be overstated in light
of the Oral Systemic Link. A paper
published in Circulation (the Journal of the American Heart Association) estimates that up to 50% of all
heart attacks are a result of oral
bacteremias.9 Periodontal disease
has been linked to atherosclerotic
vascular disease,10 diabetes 11 and
demetia,12 to name a few.
OralDNA is a leader in the field
of salivary diagnostics as it relates
to periodontal disease. Their first
salivary diagnostic test is the MyPerioPath. This simple test (a 30-

second rinse) can be performed by


anyone in the office, packaged and
sent to the lab in Minnesota.
Shortly after, on a secure portal, you
can view the report. (Figs. 1A and
1B) It gives the doctor the levels of
the 11 most pathogenic bacteria
involved with gum disease and a
recommendation on a course of
treatment including what antibiotics to use. This test can also be
run after treatment has been
completed in order to assess the
outcome of treatment. (Fig. 2)
The second test is the MyPerioID
PST. This test determines if the
patient is positive for the genetic
polymorphism for the IL-1. Interleukin 1 (IL-1) is a cytokine, and it
plays a major role in regulation of
immune and inflammatory
responses to infections.13 The prevalence of this positive genotype is
approximately 30% across the board
for the total population.14
Patients who are positive for the
IL-1 are at higher risk for more
aggressive breakdown due to periodontal disease should they get it.15
When considering other risk factors
for periodontal disease such as
smoking, diabetes, other systemic
diseases and the patients home care,
the PST test gives the doctor
another tool to help guide a patient

to better oral health. When used in


conjunction with MyPerioPath, the
doctor has better knowledge as to
the current state of bacterial load
and whether or not the patient is at
higher risk for aggressive periodontal disease.
The third salivary test that
OralDNA labs have is the OraRisk
HPV test. According to Mount Sinai
Hospital webpage, there has been a
4-5 fold increase in oral cancer due
to HPV-16 in the last decade. Over
60% of new oropharyngeal cancers
are attributed to HPV infection.16
The OraRisk HPV test can tell a
doctor if their patient has the HPV
16. According to OralDNA, the test
would benefit patients with the
traditional risk factors for oral
cancer, patients with a family
history of oral cancer, and patients
who present with suspicious oral
lesions. It is important to note that
not everyone who tests positive for
the virus will end up with oropharyngeal cancer.
Interluekin Genetics based in
Waltham, MA is a company that
has been developing genetic tests to
help improve management of
chronic diseases. They also have a
test for detecting the presence of
the genetic polymorphism for the
IL-1. While it does not use saliva
like the OralDNA test does, it is as
simple to do and as quick. The PerioPredict method uses a swab of
both right and left buccal mucosa
and then placing the swab in a vial
and sending it to the lab. Within 14
days, the results should be available.
If a patient is positive for this variant, then the health care provider
can now work with the patient to
lower their risks for gum disease.
In 1959, Ericsson developed a
laboratory buffer capacity test to
check the ability of ones saliva to
neutralize the acids after sugar
exposures.17 Today, dentistry has
Cambra (Caries Management by
Risk Assessment) to help predict
whether a patient is at high risk for
getting cavities in the future. The
CRA form, developed by CariFree to
be used as part of the caries risk
assessment of a patient, lists oral
appliances as one of the risk factors.
CariFree uses a three-prong

Fig. 3

approach to determining the overall


risk of a patient including its patent
pending CariScreen Caries Susceptibility Test. This chairside test
(while not purely a salivary test this
simple test is of great advantage to
clinicians) is simple to perform,
takes about a minute and helps
identify oral bacterial load and has
been proven to correlate with
patients risk for decay. (Fig. 3)
The CariScreen Caries Susceptibility Test is based off of the science of
ATP Bioluminescence, a science that
has been around since 1966.18 When
the acidity of the biofilm associated
with cavities drops, aciduric bacteria
adapt to the environment in several
different ways, all of which require
ATP use. The bacterial load and
biofilm activity can be assessed from
the ATP levels in the biofilm.19 The
CariScreen test results can serve as a
risk tool and can act as a potential
biometric to determine the cariogenic bacteria level and later on act
as a test to measure the effectiveness
of anti-caries therapy (which
CariFree also manufactures).
To perform the CariScreen test,
one just swabs the lingual surfaces
of the mandibular teeth and places
the swab in the CariScreen meter. In
15 seconds, the meter will report
the level of ATP. Under 1500 is

considered to be relatively healthy


while anything above 1500 is
considered to be another risk factor
for future decay risk. CariFree also
has a form that the patient and
doctor both have separate sections
to complete that assess for other
risk factors for caries. After filling
out the form completely, the
patient and doctor can discuss
different tools to help reduce the
risk of future caries.
As a general dentist, I use the
above tests as tools to show that
our office is committed to providing the latest technology and care
for our patients. It is not just about
treating disease, it is about educating the patients (who want to be
educated) as to what risks they
have going on in their mouth and
what tools are available to help
them reduce their risk of breakdown due to dental disease.
I am a strong believer in the
Oral-Systemic link so I try to
educate my patients about prevention. Both the MyPerioID and the
PerioPredict test (Fig. 4) are important tools as it relates to the epigenetics (the study of changes in gene
expression that come from outside
of the genome) of those that test
positive for it. These patients have
the potential of changing their

www.orthodontics.com Fall 2014 29

8. Kornman et al, The interleukin-1


genotype as a severity factor in adult
periodontal disease, Journal of Clinical Periodontology Volume 24, Issue
1, pages 7277, January 1997
9. Bacterial Signatures in Thrombus
Aspirates of Patients With Myocardial Infarction. Circulation. 2013
Mar 19;127(11):1219-28.
10. Detection of Periodontal Bacteria in
Atheromatous Plaques. J of Periodontology, (doi:10.1902/jop.2011.100719)
11. Efficacy of Periodontal Treatment
on Glycemic Control in Diabetic
Patients. Diabetes Metabolism 2008
Nov; 34(5)497-506
12. Serum antibodies to periodontal
pathogens are a risk factor for
Alzheimer's disease. Alzheimers
Dement. 2012 May;8(3):196-203.

Fig. 4
habits, home care and even
frequency of hygiene to help reduce
the chance of getting periodontal
disease that has the potential of
being more aggressive compared to
other patients. I use the MyPerioPath to help educate the patient to
the level of periodontal pathogens
in their mouth. I use the report to
help with antibiotic therapy and
can do the test at a follow up to see
if the patient has effectively lowered
their bacterial load.
All new patients are given the
CRA form developed by CariFree so
that they can start some self-assessment as to their own individual
risk of getting cavities in the future.
If the patient elects to move
forward, they are given the
CariScreen test and after the exam,
I review all the findings with the
patient. They are then given
options (including CariFree products) as to how they want to
handle their individual risk factors.
In conclusion, there are new
tools that dentist can use to help
predict who might be at risk for
dental disease, what bacteria are
present in the biofilm and who
might be genetically predisposed to
more aggressive reactions to periodontal disease. It is very exciting
that as clinicians we can be more
progressive in actually preventing
disease as opposed to the standard
of treating dental disease.
30 Fall 2014 JAOS

References
1. Kaufman, Lamster The Diagnostic
applications of Saliva A Review.
Critical Reviews in Oral Biology &
Medicine, March 2002 vol 13 no 2
187-212
2. Loo, Yan, Ramahcandran, Wong.
Comparative human salivary and
plasma proteomes. JDR October
2010. 89 (10):1016-1023
3. Gau, Wong. Oral fluid nonosensor
test (OFNASET) with advanced electrochemical-based molecular analysis
platform. Amm N Y Acac Sci 2007
march, 1098:401-410
4. Kaufman, Lamster The Diagnostic
applications of Saliva A Review.
Critical Reviews in Oral Biology &
Medicine, March 2002 vol 13 no 2
187-212
5. Ellias,Ariffin et all Proteiomic analysis of Saliva Identifies Potential
Biomarkers for Orthodontic Tooth
Movement,The Scientific World Journal, Volume 2012, article id 647240
6. Website of National Human Genone
research Institute (National Institutes
of Health) www.genome.gov/
10000207
7. Nabors, McGlennen, Thompson,
Salivary Testing for Periodontal
Disease Diagnosis and Treatment,
Dent Today. 2010 Jun;29(6):53-4, 56,
58-60

13. Dinarello, Immunological and


inflammatory functions of the interleukin-1 family, Annu Rev Immunol.
2009;27:519-50. doi:
10.1146/annurev.immunol.021908.1
32612
14. Caffesse et all, Interleukin-1 gene
polymorphism in a well maintained
periodontal patient population, Braz
J Oral Sci. 2002;1:1-6
15. Laine, et al, IL-1RN gene polymorphism is associated with periimplantitis, Clin Oral Implants Res,
2006;17:380-385
16. NCCN Clinical Practice Guidelines
in Oncology. Head and Neck
Cancers. Version 2.2011
17. Kitasako, Burrow, Stacey, Hug,
Reynolds, Tagami. Comparative
analysis of three commercial saliva
testing kits with a standard saliva
buffering test. Aust Dent J. 2008
Jun;53(2):140-4. doi: 10.1111/j.18347819.2008.00023.x.
18. Aledort, Weed, Troup. Ionic effects
on firefly bioluminescence assay of
red blood cell ATP. Analytical
Biochemistry, Volume 17, Issue 2,
November 1966, pages 268-277
19. Sauerwein, Pellegrini, Finlayson,
Kimmell, Kasimi, Covell Jr. Maier,
Machida. ATP Bioluminescence:
Quantitative Assessment of Plaque
Bacteria Surrounding Orthodontic
Appliances. IADR Abstract #1288
2008

dental
implants
& orthodontics:
Mini Dental Implant
Placement, Use
and Protocols

PART 2
By Josh Brower DDS, MIAMDI, FAASDI
Fig. 1

n the last issue of the Journal, I covered indications


for use and availability of mini dental implants in
orthodontics and their use in general dentistry. In
this issue I am going to cover mini dental implant
placement, use and associated protocols. As both
orthodontic and general practitioners we are constantly
seeking new and better ways to serve our patients.
Mini dental implants will allow many procedures that
have been referred out in a dental practice to be kept in
office making your patients and your bottom line
happier. With a better bottomline comes new and
creative solutions to problems that dentists previously
had not been able to solve satisfactorily. This article
will show some of the creative solutions available.
CRA newsletter author and noted practitioner
Gordon Christensen lectures that if something is better,
faster and cheaper it is here to stay regardless of the
current opinion to the contrary by some practitioners.
Mini implants fall squarely into that definition for
many reasons. When I used mini implants for the dual
purpose of a TAD (temporary anchorage device) and
then concurrently in the longterm support for a pros-

32 Fall 2014 JAOS

thetic crown, I found that mini's met Dr. Christensen's


criteria for something that is here to stay.
In addition to their use in orthodontics mini dental
implants can also be used in general dentistry for
denture stabilization, stabilization of periodontally
involved teeth, stabilization of fixed prosthesis as
"sleeper" implants, salvage cases, bridges, and full
mouth reconstructions.1,2
Mini implant placed in 1969 next to periodontally
involved teeth for stabilization with photo 20 years
later (1989) still outperforming the natural teeth (Courtesy Dr. Martin Spiller Townsend, MA)
Dr. Victor Sendax popularized the use of mini
implants in multiple instances and published a wonderful text in 2012 titled "Mini Dental Implants". His text
covers all of the previously mentioned uses and would
be a great addition to any practitioner wishing to
continue learning about their uses and indications that
go beyond the scope of this article.
When I would use mini dental implants vs. conventional size implants?
As modernization takes place in medicine patients

expect faster less invasive treatment with less recuperation time. The same is true with dentistry, as it continues to modernize patients will also expect less invasive
treatment with shorter recuperation time. Sizing an
implant to the available bone so grafting is not necessary, using immediate load implants so that the crown
can be fabricated and used during osseointegration ,
using bone mapping or 3D radiographic techniques to
evaluate the bone without creating a flap for implant
placement are all important improvements and
enhancements of old techniques that makes the treatment faster, cheaper, and better which meets the
patients criteria and expectations.

entry was 4 to 12 months later after osseointegration


had occurred to remove the healing cap and place a
healing abutment that would exend through the tissue
to create the proper emergence profile.
4 weeks healing time after exfoliation of the primary
tooth as an adult.(Fig.2)
Surgical length round bur was used to cut through
keratinized tissue until scoring of the cortical bone
occurs, and to mark the location of the implant. The
implant should be placed half way between adjacent
teeth and in a position where the prosthesis can properly support the bite. Implant crowns should have a flat
occlusal plane, narrow occlusal table, and vertically
applied force vectors only if possible.(Fig.3)

Mini implant prosthetics and protocol examples


Past Dogma would indicate that large implants are far
better or have better success, but literature does not
support that assumption.7,8,9 Using a larger diameter
implant is sometimes useful in either shorter bone,
weaker bone where the larger thread pattern will hold
more medullary space during healing, or to quickly fill
large holes created from single rooted tooth removal so
that as the socket heals the implant is integrated. If there
is less bone than required for a conventional implant a
mini implant might be a better alternative. The following
photos exemplify this more modern philosophy.
Step-by-step Placement and Temporization
Case 1 - A female in her 30's presented with the
need for a 3.0mm mini implant placement for a single
crown due to a congenitally missing lower premolar.
This case is representative of the exact same steps you
would use on a conventional implant up to 6mm in
diameter that was done with a one-piece implant and
flapless entry. Conventional implants are based on size
and not technique, but advanced techniques that can
also be used in conventional sizes include flapless
entry, immediate load vs delayed load based on design
and manufacturing designs, and immediate temporization. Older techniques required double surgical entry.
The first entry was for laying the flap and creating a
full size osteotomy to match the size of the implant
since primary stability was not needed. The second

Fig. 3
Creating a pilot hole with a 1.8mm bur for a 3.0 mm
implant (at this stage a paralleling pin can be used to
check the angle and placement of the implant placement) Radiographs are sometimes necessary at this stage
when minimal bone is available between adjacent tooth
roots.(Fig.4)

Fig. 2

Fig. 4
Using the final drill designed for a 3.0mm implant
after the tissue punch and countersink have been used
to prep the implant for placement.(Fig.5)
Begin by using the manufacturers carrier to thread in
www.orthodontics.com Fall 2014 33

Fig. 5

pressure...about
the implant as far as possible with fi
ffinger
nger pressure
about
35ncm. Once you have achieved this tightness you know
the implant will have good primary initial stability.
Mini dental implants have an osseoapposition phase
where they are mechanically locked into the bone while
waiting for osseointegration. Osseointegration begins
occurring with bone growth very rapidly, but final
growth of bone onto the implant is dependent on many
factors and can take more than 9 months10,11,12 With
this in mind loading of the implant is of paramount
importance. There must be no working or nonworking
interferences and a flat narrow occlusal table works best
to avoid horizontal overloading forces. (Fig.6)

adjusting for adequate space on the right. The picture


on the left shows the implant abutment prior to
cutting off 2mm of clearance. This one piece implant
has 1mm division marks on the abutment so you can
cut off exactly the amount you want. A carbide dental
bur used with copious irrigation works best to cut off
the amount needed.(Fig.8)

Fig. 8
Immediate temporary in place created from composite directly placed on implant #20 and then carved to
shape with a dental bur. Pt previously completed mini
implants and crowns in two other locations.(Fig.9)

Fig. 9

Fig. 6

Rachet and 3mm crown and bridge driver used for


final tightening to height wanted for restoration with
emergence profile. Leaving the collar at the tissue in a
noncosmetic area is sometimes useful for cleansability.
Ideally just subgingivally gives the proper emergence
profile of a natural tooth while being easily cleansable.
(Fig. 7)

Fig. 7
An impression has been taken after checking
occlusal clearance in the picture on the right and
34 Fall 2014 JAOS

A live patient video showing me placing a mini


implant available by typing this address into youtube
www.youtube.com/watch?v=-8E8r1eDAtQ.
The length of this video is from the beginning of
the scoring of the tissue until the mini implant is at
full depth and shows an additional method of placement that is more traditional for implants in the 2.0
to 2.5mm diameter. In the video I use a surgical
length 957 bur and cut through the tissue and the
cortical plate where my pilot drill will go. I then use a
1.5mm pilot drill 50% of the way to full implant
depth since the maxillary bone is much softer than
the mandibular bone.
Case 2- Dr. Todd Shatkin patented the placement of
a mini implant using a surgical guide and single crown
at the same time. (Patent #7108511) In addition he
also patented the concept of using two implants for
molars, and one for single rooted teeth due to loading
forces. (Fig.10)
Tray set up with included materials and armamentarium. A Minnesota retractor, mirror, drill guide for the
1.25mm drill are not included from Shatkin labs. The
white bottle is the implant chosen by Dr. Shatkin from
Interlock that will be picked up with the mini implant
driver. The yellow powder is dampened tetracycline
which I dip my surgical tools in during use. Any parts
that are used temporarily and then planned for reuse
are also placed in the powder till reused. (Fig. 11)
Surgical guide with sleeves provided by Shatkin
dental lab with implant location and size picked by Dr.
Shatkin followed by a pilot hole with 1.25mm drill for

Fig. 12

Fig. 10

Fig. 11
2 5mm implants.
2.5mm
implants The 1.25mm
1 25mm drill does come with
every case planned, but not the implants unless you
request them. Since you don't know which sizes he will
pick and scheduling is always tricky I recommend you
have him also send the implants he recommends with
the case. The second photo shows the maxillary bone
on the pilot drill after use. This must be cleaned off
prior to use again or drilling will become difficult.
(Fig.12)
Placing the implant using the handpiece and driver
through the surgical guide. The implant driver will

Fig. 13
not place the implant to full
f ll depth,
fu
depth so the guide must
be removed and the implant driver used to get the
final depth. Be careful when placing multiple implants
on the same guide that you put each one to depth
prior to proceeding to the next implant, or the various
angles you produce may make removing the surgical
guide impossible. (Fig. 13)
Implant at full depth with guide removed. The
implant should be left out as far as possible so that
www.orthodontics.com Fall 2014 35

Fig. 17

Fig. 14

Pano taken immediately postoperatively of implant


placement and cementation on this patient. This is
truly what are patients are asking and expecting of
us.(Fig .17)

there is maximum use of the interior of the


crown.(Fig.14)

Fig. 18
Fig. 15
The
is d
driven just ffar enough
h implant
l
h in ffor the
h
crown to seat and blanch the tissue. There is a slight
white blanching of the tissue shown in this photo. The
crown is cleaned with a waterpik, or by flossing down
and then under the crown right up to the implant.
Since the crown is a full ridge lap like some bridge
pontics you will find that very little if any debris are
able to get under it.(Fig.15)

Typical mini implant molar also done with immediate placement and cementation of crown by Shatkin
labs (Courtesy of Melinda Marino DDS, San Diego CA)
(Fig.18)

EXAMPLES OF MINI DENTAL IMPLANT


APPLICATIONS & PROSTHETICS
Fig. 19

Fig. 16
Crowns cemented on the implants immediately after
placement. Note the lingual emergence profile also
going directly to the tissue. (Fig .16)
36 Fall 2014 JAOS

Mi i iimplant
Mini
l
crowns
PFM on mini implant for lateral incisor next to natural teeth (For some cases you can avoid lateral forces-- I

prefer a stiffer retrievable


Fig. 20
cement like zinc phosphate
in these cases) (Fig.19)
PFM (Porcelain fused
to metal) molar using 2
mini implants. (Fig. 20)
PFM bridge with mini
implant support (mini
implant is cemented with
ZOE based cement-retrievable--You can use a glass
ionomer or other permanent cement for the natural
teeth) Since the implant is very rigid and there is some
micro-movement of the periodontal ligament I prefer
to mix a flexible cement on the implant with a rigid
cement on the natural teeth, or flexible retrievable
cement on all three) (Fig .21)

RPD (Removal Partial


Denture) with no clasps
and 5 posterior implants
for support.(Fig. 24)

Fig. 24

Full Mouth
Restorations
Lifetime denture wearer
initially wanted denture
stabilization on the upper.
Was so happy with stability of denture that she
immediately changed her
ion she did not have to
mind and wanted a restoration
remove. Zirconium roundhouse completed compared to
stabilized denture with patients new smile.(Fig. 25)

Fig. 25

Fig. 21
PFZ (Porcelain fused to Zirconium) bridge all
implants with splinted implants (cemented with
retrievable cement) (Fig.22)
Fig. 22

Lifelong denture wearer hated the bulk and loss of


taste with palatal coverage. Deep vestibules required
large denture. After having denture stabilized and palate
removed patient chose to continue to fixed zirconium
roundhouse for smaller more stable restoration.(Fig.26)

Removable prosthetics held in with mini


dental implants
Upper or lower denture stabilization with the upper
denture (6 year post op) with no palate supported by
mini implants.(Fig. 23)
Fig. 23

Fig. 26

www.orthodontics.com Fall 2014 37

Fig. 27

Fig. 31

Full PFZ (Porcelain Fused to Zirconium) Roundhouse


with immediate removals and implant placement. (Fig.27)
Natural tooth abutments failing in fu
ffull
ll cleft palate
patient with obturator. Mini implants are placed into
almost no bone to hold the denture in place. (Fig. 31)

Fig. 28

Fig. 32

Fixed final restoration by Dr. Victor Sendax1 (Fig.28)

Fig. 29
Fixed final PFM restoration combining mini dental
implants and natural teeth by Dr. Victor Sendax1 (Fig. 29)
Salvage cases
Conventional implant
failed and pt didn't want
sinus augmentation so
implants were placed into
buccal and palatal bone as
shown in the previous
article for bicortical stabilization. PFZ restoration.
(Fig. 30)
38 Fall 2014 JAOS

Fig. 30

Dr. Juan Echeverri shows how from 2006 to 2010 all


the conventional implants on this patient failed and
mini implants were used to replace the implants as
they failed on the upper arch. Pt now has mini implant
supported denture. (Fig. 32)

Cementation
There is a dirth of literature on cementation of
dental implants. Failure of the implant and prosthesis
due to leaving excess cement is a common concern
(3,4,5). I would highly recommend modern retrievable
cements. Numerous studies support retrievable cements
(6) Being able to remove the crown or crowns in the
future as an adjunct to treat peri-implantitis, occlusal
loads, or to change the use of the implant should their
natural dentition change in a way that makes it a logical choice is crucial. I cement most of my prosthesis
with a zinc oxide eugenol cement for the additional
benefit of having the antibacterial effect from eugenol.
If you would like to see additional information or cases involving
mini implants in the journal please email Dr Greg Cannizzo at
drgrc@joltmail.com and put in the subject line mini implants.

Sources
1. Dr. Victor Sendax (Mini Dental Implants textbook 2012)
2. Shatkin TE, Shatkin S, Oppenheimer BD, et al. Mini dental
implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed over a five-year period.
Compend Contin Educ Dent. 2007;28:92-99.
3. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with
excess cement around crowns or osseointegrated implants; a clinical report. Int J Oral Maxillofac Implants. 1999;14:865-868
4. Gapski R. Neugeboren N. Pomeranz AZ, et al. Endosseous
Implant failure influence by crown cementation: a clinical case
report. Int J Oral Maxillofac Implants. 2008;23:943-946

5. Callan DP; Cobb CM. Excess cement and peri-implant disease.


Journal of Implant and Advanced Clinical Dentistry. 2009;1:61-68.
6. Garg P, Pujari ML, D R P, Khare S. Retentiveness of various luting
agents used with implant supported-Prosthesis: An Invitro Study
J Oral Implantol. 2014 Mar 3
7. Vigolo P, Odont Dr MScD/Givani Andrea MD,DDS/Majzoub Zeina
DCD, DMD, MScD/Cordioli MD, DDS. Clinical Evaluation of
Small-Diameter Implants in Single-Tooth and Multiple-Implant
Restorations: A 7-year Retrospective Study. Int J Oral Maxillofaci
Implants 2004;19:703-709
8. Shatkin, TE DDS, Shatkin Samuel DDS MD, Oppenheimer
Benjamin D DDS, Oppenheimer Adam J MD. Mini Dental
Implants for Long-Term Fixed and Removable Proshetics: A retrospective Analysis of 2514 Implants Placed Over a Five-Year Period.
Compendium 2007;28(2):36-41
9. Morneburg TR, Proschel PA. Success rates of microimplants in
edentulous patinet with residual ridge resportion. Int J Oral
Mazillofac Implant. 2008:23:270-276
10. Acta Orthop. 2012 Apr;83(2):107-14. doi:
10.3109/17453674.2012.678798. Epub 2012 Apr Low BMD affects
initial stability and delays stem osseointegration in cementless
total hip arthroplasty in women: a 2-year RSA study of 39
patients. Aro HT1, Alm JJ, Moritz N, Mkinen TJ, Lankinen P.
11. Johan Olsson, Nathon Stearns Institute of Odontology Karolinska
Institute, Osseointegration of immediately loaded dental implants
in the edentulous jaws. A study of the literature.
12. Biological factors responsible for failure of osseointegration in oral
implants. Hadi SA1, Ashfaq N2, Bey A2, Khan S21Postgraduate
Student, Postgraduate Certificate in Oral Implantology-2010,
IGNOU, India. Department of Periodontics and Community
Dentistry, Dr. Z.A. Dental College and Hospital A.M.U.,
Aligarh, India.

www.orthodontics.com Fall 2014 39

By Tom Chapman, CAE, AOS Executive Director

he AOS membership
came together for our
Annual Meeting in
Denver, CO this past August. If
you were not there, you
missed out on beautiful
weather and gorgeous scenery
that allowed for golfing,
hiking, zip-lining and dancing
to the sounds of the All in
the Family Band, all
combined with a stellar educational program. An exhibit
hall full of industry partners
were able to show their newest
products to an interested audience when classes were not in

40 Fall 2014 JAOS

session. While doctors were in


session, their spouses and
guests (and maybe a few of the
doctors), were at 8,000 feet
enjoying an eight-segment
zipline and several miles of
hiking trail. Quality education,
mixed liberally with plenty of
time to enjoy Colorado, made
the AOS Annual Meeting a
special week.
Plan now for next years
Annual Meeting, as we move
MUCH further south to the
white sand of Clearwater
Beach, Florida, October 8-11,
2015. See all of you there!

www.orthodontics.com Fall 2014 41

AGpO MEMBERSHIP NEWS

AGpO On Top

www.academygportho.com

Academy of
Gp Orthodontics
2014 Officers
President
Kyle McCrea, DDS
President Elect
Eugene Boone, DDS
Vice President
Steven Bradley, DDS
Secretary - Treasurer
Sherman Menser, DDS
Immediate Past-President
Fred Der, DDS

Board of Directors

Budda said, "To keep the body in good health is a duty... otherwise we
shall not be able to keep our mind strong and clear. With that in mind,
three AGpO members and a non-dentist wife, tackled one of the most
scenic segments of the John Muir Trail this summer. Months of conditioning preceded the three day backpack trip, ensuring our ability to handle
the altitude and the mileage. The question came up during our trip. "Why
do people do this?" Several answers came to mind: the serenity of wilderness, enjoying the scenic beauty, the spirituality of the experience and the
physical challenge. Without question, the practice of orthodontics
demands a "mind strong and clear". I think Buddha would have approved.
--Tom Jacobsen, Ron Austin, Fred Der, Margaret Leighton

Ernest A. Barbosa, DDS


Felicia Burridge, DDS
Joseph Drinkwater, DDS
Giancarlo Maldonado, DDS
Brian Olsen, DDS
Jill Snyder, DDS
Kurt Stodola, DDS
John Wells, DMD
Advisory Board
Ron Austin, DDS
Greg Cannizzo, DDS
Joe Fallin, DDS
Roy Holexa, DDS
Thomas Jacobsen, DDS
Leslie Penley, DDS
Bob Shirley, DDS
Walter L. Tippin, DDS
Executive Director
Adam Griswold
Executive Director Emeritus
Cynthia Bordelon
42 Fall 2014 JAOS

Assistants Course Held in Plano, TX


The Academy held its second
2014 Assistants Course this year
with Instructor Dr. Charles
Young at the Marriot Legacy
Town Center in Plano Texas on
July 31 to August 3, 2014. Nineteen assistants attended this
intensive four-day course which
included orthodontic staff training with an optional half-day
session covering cephlametric
training and model analysis for
the orthodontic assistant. Over
the past seven years, more than
125 assistants have attended this
AGpO course. Watch for dates
for the 2015 course to make
your assistant a vital active part
of the orthodontics you provide
to your patients.
Front row, left to right: Maria Espinoza, Josie Herrera, Patricia Gonzalez. Second row, left to
right: Amanda Blue, Zelyna DeLatorre. Third Row, left to right: Myra Ramirez, Andrea Dodd,
Danielle French, Donna Payne. Fourth Row, left to right: April Fletcher, Alicia Hodge, Lorin
Werline, Judy Brock. Fifth Row, left to right: Tammy McClain, Angel Zartman, Angela Blakeney.
Sixth Row, left to right: Amanda Nix, Megan LeBlanc (Dr. Youngs assistant), Mandy Hurdle (Dr.
Youngs assistant). Seventh Row: Roxanna Compton

AGpO MEMBERSHIP NEWS

Member Participation is Key


Kyle McCrea, DDS
AGpO President

I was fortunate to come upon the Academy of Gp


Orthodontics at a time in my practice life when I
thought I just couldnt prep another Class II restoration. Instructors Ron Austin, Jeffery Gerhardt, and Bert
Vasut taught and helped me through the 12 Session
Course in Austin, TX. A couple of years later, Dr. Austin
coached me through more advanced cases in his
Advanced Tip-Edge course in Tishomingo, OK. All of
these great talented instructors were available to me via
e-mail during and well after I was done with the
formal education part of my orthodontic training. The
Annual Sessions and the Spring Refreshers provided
opportunities to learn new theories and techniques
from outside sources and from fellow Academy
members like Tom Jacobsen and Kurt Raak.
Most recently, I have been assistant teaching with
Robert Allen at the Rockwall 12-Session Course where I
have been learning far more than I have been teaching.
I discovered how much time, thought, hard work, and
preparation goes into everything the Academy accom-

plishes when I was appointed to my first Board position. As I moved up the slate of officers in the
Academy, I learned more about the nuts and bolts of
making the Academy work from first Cynthia Boreleon
and then Adam Griswold, the Academy Executive
Director. Every one of these valued members struggles
to find the formats, topics, and meeting locations that
will excite and motivate the Academy members.
Being a part of the Academy for the past nine years
has been great! It has been an honor to serve as your
President this last year. I have found that the best way
to get the most out of membership in the Academy is
to participate. Attend the annual meetings, take one of
the advanced or specialized courses offered, join a
message board, or even just keep in touch with your
fellow classmates from your 12-Session Class. Be a part
of the Tip Edge Community and you will grow.

Kyle McCrea

AGpO Graduates Seven in Tishomingo, OK


The Academy of Gp
Orthodontics graduated
its most recent 5-session
advanced Tip-Edge course
in Tishomingo OK. Dr.
Ron Austin served as the
instructor for this intense
learning experience.
This unique course ran
from April 11 through
August 23 and requires
that the applicant must
be a licensed dentist, a
graduate of the 12session AGpO hands on
course or completed a
minimum of ten cases
using the Differential
Straight Arch Technique.
Seven doctors completed
this course.

Front row, left to right: Jamie DA, Robin DA, Lourdes DA, Dr. Wendy Winarick, Tamara DA, Abby DA.
Back row, left to right: Dr Amy Laymon, Dr. Ron Austin, Dr Brad Donabauer, Dr. Harold Reel, Dr. Olan Rotowa,
Dr. Adam Beers, Dr. Oscar Luna

www.orthodontics.com Fall 2014 43

AOS MEMBERSHIP NEWS

AOS Upcoming Ortho Courses

The American
Orthodontic Society
2014-15 Officers
& Directors
President
David M. Thorfinnson, DDS
President-Elect
Juan C. Echeverri, DDS
Secretary-Treasurer
W. Edward Gonzalez, Jr., DMD
Immediate Past President
Michael J. Newman, DDS

Board of Directors
Twana Farley-Duncan, DDS
Robert G. Gerety, DDS
Emeritus
Kevin J. Hester, DDS
James E. McIlwain, DDS, MSD
Anne Mary Orr, DDS
James L. Orrington, DMD
Allan Rotberg, DDS
Kimberly Suter, DDS
Bradford R. Williams, DDS
Paul L. Winborn, II, DDS
William E. Wyatt, Sr., DDS
Emeritus

Board of Examiners
Jeffrey H. Ahlin, DDS
Azita Anissi, DDS
Leonard J. Carapezza, DMD
Kenneth Ellis, DDS
Joseph M. Haack, DDS
Debra Ettle-Resnick, DDS
Executive Director
Thomas N. Chapman, CAE
JAOS Editor
Greg Cannizzo, DDS
44 Fall 2014 JAOS

If your assistants need a little


brushing up on their skills, send
them to Robin Schmidbauer's
Advanced Straight Wire for
Assistants November 7 & 8 in
Atlanta. This class is designed to
meet the needs of offices currently
utilizing Straight Wire mechanics
and wanting to expand the delegable
duties performed by the assistant. (13
CDE hours)
Dr. Juan Echeverri is teaching his
Art and Science of Skeletal
Anchorage with TADs class in
Chicago November 14 & 15.
Designed to give the treating dentist
first-hand knowledge of skeletal
anchorage using Temporary Anchorage Devices, this course uses lecture
and hands-on exercises to equip
participants with a new set of tools
to incorporate in their practices for
improved comprehensive patient
treatment. (14 CDE hours)
Dr. Brad Williams will conduct a
Case Finishing for Straight Wire
Mechanics seminar the weekend of
November 21 & 22 in Orlando,
Florida. This two-day course is
designed for doctors familiar with
Straight Wire treatment, mechanics,
and concepts. The focus of the
program will be a hands-on approach
to mechanics and techniques necessary to successfully finish and detail
cases. (15 CDE hours)
RUMOR HAS IT... that next year
will be Drs. Larry White and Bill
Wyatt's last to teach their perennial
Orthodontics in Today's Dental
Practice course, which begins
January 23 & 24 in Dallas. This intermediate four-session course will
teach the dynamics of Three Dimensional Diagnosis, the fundamentals
of Biomechanics, direct and indirect
bracket placement techniques,
among many other skills. This may
be your last chance to sharpen your
orthodontic skills with two iconic
instructors! (64 CDE hours)

Dr. Ed Gonzalez will conduct


his in-office Early Treatment
for the Pediatric and General
Dentist in Orlando Feb. 6 - 8.
This intensive two-and-a-half day
course will teach participants when
to start Phase I treatment and/or
when to refer. Let a doctor who
has performed over 4,000 Phase I
cases give you the tools to treat
young patients and grow your
practice. (18 CDE hours)
Dr. Ralph Nicassio is offering a
NEW weekend course for the experienced practitioner Feb. 6 & 7 in
sunny Phoenix! Differential
Diagnosis of All Class II and
Class III Cases will focus on
differential case diagnosis, allowing you to better understand and
diagnose a variety of dental conditions. Offering new treatment plans
and techniques to reduce patients
compliance will greatly expand the
variety of cases you can treat
successfully, efficiently, and profitably. Making the right diagnosis
converts a difficult case into a relatively easy one! (14 CDE hours)
Dr. Leonard Carapezza leads his
comprehensive Early Treatment
of Malocclusion in the spring,
with the Beginning course starting March 12 - 14, and the
Advanced kicking off the following weekend. Each session of this
in-office course has been arranged
to give the participant an in-depth
study of the Straight Wire system
using state-of-the-art audio/visual
and hands-on procedures. Start
treating your own patients after the
second session! (80 CDE hours)

Scan with
your smartphone
to view all
course details.

Learn more about the


Annual Meeting and
all AOS courses on
www.orthodontics.com.
Follow us on Facebook!

AOS MEMBERSHIP NEWS

Proud To Serve the


Star of Dentistry
David M. Thorfinnson, DDS
AOS President

My home state, Minnesota, is known as, "L'Etoile du


nord", meaning The Star of the North. Native
Minnesotans are proud of our northern European
heritage, our independent spirit, our beautiful
resources, and our unrelenting work ethic.
Emboldened by these same characteristics in the
AOS, I know that I am ready and very proud to be your
President. The AOS nearly 40 years of successful
courses taught by well-known names such as Gerety,
Jackson, Wyatt, and Carapezza leave a heritage worth
continuing for the next generation. The AOS, too, has a
spirit of independence. Teaching new techniques, years
before dental schools are prepared to adopt, allows our
members to benefit from new ideas, concepts, and
technology while others are still reading about them.
Our beautiful resources are our people. From instructors
to our Diplomates, we are committed to helping
colleague to colleague when and wherever we can.
Finally, we carry the same work ethic as my
Minnesota family. Our instructors work more hours
outside of the classroom than inside. Preparation, assistance, and advice from our instructors to their students,
requires hundreds of hours to make a course and an
association successful. We have a great and welldeserved reputation for quality academics. The AOS is
truly, La star de lart dentaire, the Star of Dentistry.
I am proud to serve you this coming year and I
would also like to share with you a poem that my
grandfather wrote in 1950, Which Road?:

Which Road?
by Snorri M. Thorfinnson
(grandfather of David M. Thorfinnson)
Two old men sat at the end of the trail,
Life's gains in their toil-worn hands.
Besides them a Youth stood, tall and strong,
His eyes on Life's distant lands.
"Which road shall I take?" the young man cried,
And he turned to the tired old men.
"Shall I spend my life in the quest of gold
Or the love of my fellowmen?"

Slowly, one old man raised himself


And rose to his tottering feet,
In one hand clutching a bag of gold,
His voice hard with scorn and conceit.
"Young man, if you travel the road I trod
You must strive for SUCCESS alone,
Gold shall be your ideal, and God,
Your friends but a stepping stone.
Life is a battle, grim and stern,
To dream is useless and wrong;
Think only of the end in view,
The spoils to the victor belong.
"The world does not ask how you made your way,
It only asks that you make it.
So harden yourself, feel no remorse;
when you want a thing, you take it."
"But what does it bring you?" the young man cried.
"Your health and your friends, are lost;
In your clutching hands, are the dreams of youth,
And they, like the rest, are dross.
Youre whole life spent in this ruthless game,
Your goal but an idol of gold, No loving friends to cherish your name,
For your life has been heartless and cold.
My life, the other old man said,
Has had troubles and hardships aplenty,
But after a lifetime of toil and strife
My dreams are as fresh as at twenty.
And, son, tho my hands are not filled with gold,
Im proud of the pathway I trod.
On the road of Service to other men
You walk on the highway of God.
1950 Snorri M. Thorfinnson

David M. Thorfinnson, DDS

"Tell me, you who've travelled the road of Life


And come to the end of your quest,
Who know the trails, the troubles and strife,
Which road is the finest, and best?"
www.orthodontics.com Fall 2014 45