Orthodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Psychological factors improve with better dentofacial appearance

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The July 2014 issue of Angle Orthodontist includes a study about the relationship between satisfaction with dental esthetics and oral health-related quality of life among treated adults. Its authors also compared patients’ esthetic satisfaction and quality of life when appearance evaluations were performed by people other than the patients themselves—laypersons, orthodontists and dental students.

The scientists studied 52 patients who had undergone orthodontic treatment or a combination of surgery and orthodontic care in the Oral and Maxillofacial Department of Oulu University Hospital in Finland.

Subjects filled out the OHIP-14, a questionnaire widely accepted for its validity and reliability. Patients assessed themselves in seven conceptual dimensions of oral health-related quality of life, as defined in the OHIP-14: functional limitation; physical pain; psychological discomfort; physical disability; psychological disability; social disability and social handicap.

Patients also estimated their satisfaction with their dental appearance on a visual analogue scale. The question was: “How satisfied are you with your current dental appearance?”

Three panel groups, comprised of 10 orthodontists, 30 laypersons and 30 fourth-year dental students judged before-and-after treatment images using the Aesthetic Component of the Index of Orthodontic Treatment Need.

Results showed that oral health-related quality of life and esthetic satisfaction improved after orthodontic treatment. The positive change in esthetic satisfaction was especially associated with the changes in psychological discomfort and psychological disability dimensions of the OHIP-14.

Orthodontists graded the before-treatment circumstances of patients as worse and the after-treatment outcomes as better than did the laypersons. The authors noted that prior studies have shown experienced dental professionals to be more critical of dental esthetics than lay groups. Dental students’ ratings fell in between these two groups.

The gradings of laypersons and orthodontists were positively correlated with oral health-related quality of life and esthetic satisfaction. Student gradings were not.

“These findings suggest that laypersons and orthodontists are able to estimate the kind of esthetic impairments that have the greatest effect on patients’ psychological and social well-being,” authors said about the findings. “The reason why the change in students’ evaluations did not correlate with the change in dental esthetics or oral health-related quality of life may be that students pay more attention to functional features and posterior occlusion and that patient-orientated understanding grows with clinical experience.”

There was no significant difference in oral health-related quality of life in orthodontic patients compared with orthodontic-surgical patients. Authors said this finding may suggest that severe malocclusion with functional and esthetic disadvantages and treatable with conventional orthodontics can be as harmful for patients as malocclusion requiring orthognathic surgery.



Consulting Editor: Lee W. Graber, DDS, MS, MS, PhD
Diplomate, American Board of Orthodontics

Documenting occlusal plane characteristics

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Authors of an article published in the March 2014 issue of the Journal of the World Federation of Orthodontists examined the effectiveness of three intraoral photography techniques for diagnosing the cant of the occlusal plane (OP) and its photographic representation, and made recommendations for accurate diagnoses and proper treatment planning.

They focused on transverse plane occlusal inclinations, which in addition to altering functional relationships, may affect patient appearance.  Because patients often become acutely aware of this condition after it has been pointed out to them, it is imperative that the patient’s true cant be evaluated, studied, documented and treated, authors advised.

The intraoral photography options evaluated were:

Authors found multiple drawbacks in the first two methods, as well as potential strengths. However, the third technique proved the most convenient for clinicians and the most revealing.

“This method (with the photograph exhibiting a frontal view of the face, eyes and intraoral structures) is highly recommended for its convenience and for providing an accurate visualization of the true OP inclination,” authors reported. Among other conclusions, they noted that the properly oriented photograph also can be used in court as legal evidence.


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CS Solutions
CS Solutions gives practitioners the ability to scan, design, mill and place a restoration within their practice in just one appointment. The product portfolio consists of an intraoral scanner, CBCT impression scanning system, restoration design software, a milling machine, and a hosted, Web-based platform created to share and manage restoration cases between dentists and laboratories.



Adult patients with perio problems and orthodontic success

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For orthodontists, more adult patients also means more patients with periodontal problems (see editor’s note).

Orthodontic treatment of teeth that have been partially loosened or moved because of periodontal disease remains controversial, but recent studies suggest that light forces can be used for correction. Still, complicating factors remain a concern. Periodic periodontal maintenance, strength and direction of orthodontic force and surveillance of periodontal status are integral to treatment success and can be challenging for clinicians.

A case report published in the May 2014 issue of the American Journal of Orthodontics and Dentofacial Orthopedics explains how researchers implemented a multidisciplinary approach to prevent worsening periodontitis and occlusal trauma, while improving esthetics.

A 22-year-old male patient of the orthodontic clinic at the West China Hospital of Stomatology, in Chendu, complained of displaced upper and lower front teeth and large gaps between incisors. Self-conscious about his appearance, he sought corrective treatment.

Diagnosed with a skeletal Class 1 malocclusion with severe periodontitis and pathologic tooth movement, the treating clinicians aimed for stable occlusion; esthetics, function, periodontal health in the anterior, and maintenance of the existing occlusion in the posterior. They developed a treatment plan and divided it into four stages—systemic, hygienic, corrective and maintenance—with the stipulation that before the corrective phase could ensue, the patient’s periodontal condition would have to meet minimally their criteria established for this patient with advanced disease:

After consulting with physicians to rule out the possibility of systemic diseases, the researchers required the patient to attend periodic periodontist appointments. Three months after scaling and root planing, the team of orthodontists and periodontists held a consultation and confirmed that all of the criteria for periodontal status were met.

In the report, authors described the monitoring protocol of the patient’s periodontal status throughout the treatment process and observations made at various steps.

 “The post-treatment panoramic radiograph showed acceptable root parallelism and no marked root resorption; most importantly, the level of alveolar bone had been maintained,” authors explained.  “Newly formed trabecular bone could even be seen in some regions where resorption had been severe.”

They were excited by this result, which suggested to them that the treatment had prevented further resorption of alveolar bone and enhanced the potential for long-term dental health.


Editor’s note: The most recent National Health and Nutrition Examination Survey (3,742 adults, 30 years of age and older) documented prevalence of periodontitis in the U.S. adult population to be 47.2 percent. These findings underscore the importance of a thorough periodontal evaluation and appropriate treatment prior to orthodontic tooth movement. Multidisciplinary considerations (as reflected in this report of a patient with severe preexisting disease and multidisciplinary treatment) are less obvious in “routine” prospective adult orthodontic patients, but are important nonetheless.


Patient behaviors add up when calculating wear times

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Prescriptions for removable appliances can and should be adapted according to patient wear behavior as well as wear time, research published in the August issue of the American Journal of Orthodontics and Dentofacial Orthopedics states.

“The median wear time of removable appliances has only limited value if the patient’s wear behavior is unknown,” authors found.

Previous research shows that patients readily accept wear-time information and that those who learn their actual times adhere better to times prescribed. But only recently have clinicians been able to measure wear behavior using temperature-sensitive microsensors embedded into appliances by polymerization. Using this technology, the clinician can determine patient wear times at 15-minute intervals based on temperatures in the mouth. The data can be instantly retrieved at any point during treatment—during patient checkups, for example—and is displayed as a graph.

Scientists in Germany used such microelectronically quantified wear-time data to study how patients individualize wear times. To do this, the reseachers investigated how patients carry out their prescriptions.

They first determined mean daily wear times for 281 patients aged 6 and 17 years, who wore appliances for six months and were enrolled in the study between November 2010 and May 2012. The removable orthodontic appliances were prescribed to be worn 12-15 hours per day.

The scientists found high fluctuations with some median wear times as high as 17.7 hours and others as low as 1.5 hour. One hundred and forty of the 281 patients reached the median wear time of nine or more hours a day.

A common pattern was to not wear the appliance for some days and then to try to compensate by wearing it more on other days. Regular and constant wear-time patterns, without any zero wear time per day, was found in only 42 of 281 patients. In all other patients—239 of 281—the individual wear times and wear behaviors were so variable that categorization of patterns was impractical. Only 15 percent of the study population showed any kind of continuous wear behavior approaching the median value of 9 hours per day.

Scientists evaluated more closely patients with median wear times of less than nine hours per day. They learned that such patients often compensated for little or no wear time on some days by wearing the appliance for up to 22.75 hours per day on others.

For example, one graph showed that over the first three months of treatment, a patient wore the appliance between zero and 2.5 hours per day more frequently than the prescribed half day. The low median wear time of 6.4 hours led to concerns that poor adherence would lead to treatment failure.

About half way through treatment, the patient was shown his prior wear behavior graph and encouraged to comply with the wear time prescription. The more frequent average wear times after this point (median 14.7 hours) is not apparent from the 10.23 hours of median wear time over the six month course of treatment. However, the results showed authors that wear time documentation can be used to clarify patient behavior objectively and comprehensively and potentially motivate better compliance.

“Because of the easy and immediate visualization of wear time and wear behavior at checkups, both the practitioner and the patient can be made aware of the potential failure of planned therapy; at this point, optimization of adherence, or even a change in therapy, can be initiated,” authors said.
In discussion, authors noted that the quantification of both wear-time duration and behavior has the potential to trigger a paradigm shift in orthodontic treatment from standardized to individualized wear-time prescriptions.

“The wear behavior, a major factor to be considered in compliance, has so far largely been ignored in the literature,” authors said. “It can be assumed that a removable appliance worn daily for an above-average length of time, but irregularly or not at other times, is not more effective than the same appliance worn constantly but for significantly less time.”


Capture high-resolution images with the CS 3500 intraoral scanner

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With CS Solutions for Orthodontists, users have the option to create digital impressions with the CS 3500 intraoral scanner for use with new CS Model software.

The CS 3500 intraoral scanner acquires true color, 2D and 3D images without the need for a heater, powder or trolley system. The scanner features high-angulation scanning of up to 45 degrees and to a depth from -2 to +13 millimeters. It also includes an autoclavable tip available in two sizes, a smaller tip for children or adults with small mouths and a larger tip for adults, to ensure users adhere to the best practices for infection control.
With the scanner, practitioners can capture high-resolution images digitally rather than using the putty associated with traditional impressions—eliminating the need for using impression material, pouring molds or waiting for stone models to set.

Once digital impressions are created, CS Model software takes basic distance measurements—including overjet, overbite, pressure map, arch length, tooth size, crowding measurement and more—to further improve clinicians’ diagnostic capabilities. CS Model enables orthodontists to quickly create digital models; review and store them electronically; and produce orthodontic appliances through preferred labs.

Creating digital models is an environmentally friendly solution that ensures that patients’ models are not damaged, lost or mixed-up over time. Plus, CS Model gives practices access to all cases 24/7, without the need to access third-party storage via the Internet.

Digital models not only save time and money, but also serve as a powerful tool to engage patients in treatment planning and increase case acceptance.


ADA offers discount on orthodontic brochure

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Now through Oct. 3, the ADA is offering members a patient education brochure on orthodontic treatment at a 15 percent discount.

Members can order “Orthodontic Treatment for a Healthy Smile” (W308) through the ADA Catalog, using promo code 14361E.  The 8-panel brochure is available in packets of 50 for $27; retail price $40.50.  Discounts also are available at higher quantities.

The brochure focuses on braces and aligners and is suitable for both children and adults. Before-and-after photos describe the benefits of treatment. Do’s and don’ts of braces help patients get the most from treatment.  

Members can preview this and other ADA brochures online at adacatalog.org. Orders can be placed online or by calling the ADA Member Service Center at 1-800-947-4746.

Remember to use promo code 14361E to receive the 15 percent discount.

The template calls for the image at 160 by 160 but adjustments can be made

CS Solutions
CS Solutions gives practitioners the ability to scan, design, mill and place a restoration within their practice in just one appointment. The product portfolio consists of an intraoral scanner, CBCT impression scanning system, restoration design software, a milling machine, and a hosted, Web-based platform created to share and manage restoration cases between dentists and laboratories.



What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on orthodontics, the third in the series on this topic for 2014. Other Specialty Scan issues are devoted to periodontics, endodontics, oral and maxillofacial radiology and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.

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