Cover / Editorial / Content / Concepts - goals and techniques for successful orthognathic surgery cases / Orthodontics and esthetics: A multidisciplinary approach / How ‘a penguin’ can help your practice (really!) / Industry / Submissions / Imprint
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01 - 01 viewEditorial
03 - 03 viewContent
04 - 04 viewConcepts - goals and techniques for successful orthognathic surgery cases
06 - 15 viewOrthodontics and esthetics: A multidisciplinary approach
18 - 24 viewHow ‘a penguin’ can help your practice (really!)
26 - 40 viewIndustry
41 - 41 viewSubmissions
49 - 49 viewImprint
50 - 50 viewArray
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[1] =>
ortho
North America Edition • Vol. 2 • Issue 1/2013
issn 2161–7228
the international C.E. magazine of
orthodontics
1
2013
_C.E. article
Concepts, goals and techniques for successful orthognathic surgery cases
_clinical
Orthodontics and esthetics: A multidisciplinary approach
_technique
How ‘a penguin’ can help your practice (really!)
[2] =>
[3] =>
editorial _ ortho
I
Why orthodontics?
In a profession dedicated to the tiniest of movements, it seems as if orthodontics is in constant
motion. There is always something new to catch the eye and capture the imagination: new brackets and
bands, new techniques and treatments, new ways to treat and diagnose patients. Even when we reread
classic orthodontic books or articles, we are able to pick up some new tidbit or detail that we weren´t prepared to understand the first time we went through them. It never ceases to amaze me how much there
is to learn once we graduate from school.
As orthodontists, we typically perform full-mouth rehabilitation cases every day. Canines and molars
in Class I, a correct overbite and overjet and the completion of the six keys of occlusion are typically our
main goal.
In a perfect world, every case would conclude with picture-perfect results. Unfortunately, there are
times when the result doesn´t look as beautiful as we hoped it would. As clinical beings, we need to ask
ourselves what is the problem in these cases, and how can we eliminate these problems in the future.
To me, the answer starts with this: a multidisciplinary knowledge is essential from the beginning of
our treatments. Just like a sculptor, we must have a comprehensive understanding of facial proportions
and how these proportions relate to the teeth.
Just as important, we also need the cooperation and input of an esthetic dental specialist to customize
each smile. Working in conjunction, these two elements will help us elevate our results so that they attain more than just average results, and achieve a natural smile that reflects the beauty of our patient’s
personality.
So getting back to the overriding question that we started with: why orthodontics? For me, the answer
comes down to a single word — joy. Because in orthodontics as in life, the final destination is important,
but how we get there is what makes life worth living.
Julia Garcia Baeza, DMD
Best Regards,
Julia Garcia Baeza, DMD
ortho
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[4] =>
I content _ ortho
page 06
page 06
I C.E. article
06
page 18
I industry
oncepts, goals and
C
techniques for successful
orthognathic surgery cases
_Theodore D. Freeland, DDS, MS
41 Managing your practice’s online reputation
_Diana P. Friedman, MA, MBA
42 Powering up your practice
_DENTSPLY GAC
I about the publisher
I clinical
49
50
18
_submissions
_imprint
ortho
North America Edition • Vol. 2 • Issue 1/2013
issn 2161–7228
rthodontics and esthetics: A multidisciplinary
O
approach
_Julia Garcia Baeza, DMD, and David Garcia Baeza, DMD
the international C.E. magazine of
orthodontics
1
2013
I technique
26
ow ‘a penguin’ can help your
H
practice (really!)
_Jerry R. Clark, DDS, MS
_C.E. article
Concepts, goals and techniques for successful orthognathic surgery cases
_clinical
Orthodontics and esthetics: A multidisciplinary approach
_technique
How a penguin can help your practice (really!)
ORCE_01-2013.indd 1
I on the cover
4/21/13 9:26 PM
Cover image provided by DENTSPLY GAC
page 18
04 I ortho
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page 26
page 26
[5] =>
[6] =>
I C.E. article_ orthognathic surgery
Concepts, goals and
techniques for successful
orthognathic surgery cases
Author_Theodore D. Freeland, DDS, MS
_c.e. credit
This article qualifies for C.E.
credit. To take the C.E. quiz,
log on to www.dtstudyclub.
com. Subscribers to the magazine may take this quiz for
free and will be emailed an
access code after the magazine’s release. If you do not
receive the code, please write
to support@dtstudyclub.com.
Non-subscribers may take the
quiz for $20. You can access
the quiz by using the QR code
below.
_In this article, you will be introduced to the
concepts, goals and techniques needed to diagnosis
surgical cases, when surgical cases should be started
and how to gain the knowledge needed to create
successful results.
We’ll delve into joint status, soft-tissue analysis,
surgical treatment objectives, pre-treatment surgical setups and surgical setups. We’ll then follow-up
by looking at the concepts of natural head position,
the axis-horizontal plane and the true vertical line
will be introduced. By the end of this article, you
should have:
• An overview of the knowledge needed for
successful treatment.
• An introduction into what, when and how to
perform successful cases.
• An overview of joint health.
• A summary of the soft-tissue analysis.
• An outline of the surgical treatment objective.
• An overview of diagnostic and surgical setups.
Remember that this article is an introduction
only; it’s not intended to teach you how to do surgical cases. Advanced training will be needed to master
successful orthognathic surgical cases. So with no
further ado, let’s get started.
_Functional occlusion
The goal is to obtain functional occlusion. Before
treatment, you have to determine if you have an
orthognathic surgery case. You don’t want to begin
orthodontic treatment with the idea that if orthodontics fails, we will do surgery.
You’ll see in Figures 1–3 that this case involves
every facet of dentistry. Changes occurred not only
in the facial features, but also in the teeth themselves.
It involved orthodontic and orthognathic surgery,
but also lengthening the front teeth by the restora-
06 I ortho
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tive dentist to achieve the natural smile in balance
(Figs. 1–3). To this end, we need to look at five areas:
• joint status,
• soft-tissue analysis,
• surgical treatment objective,
• pre-surgical setup/surgical setup technique,
• surgery.
We’ll give you a brief overview of the goals for
each of the areas, then do an in-depth look into each
of them individually.
_Joint status
Starting with the first area, you need to know the
joint status. Is the joint healthy, is it degenerating, is
there a disc problem? This means you’ll need to apply
not only a good clinical exam, but also articulated
models that can measure the difference between
centric occlusion and centric relation.
_Soft-tissue analysis
You’ll need to know how to analyze the soft tissue.
You’ll need this because you are looking at everything
from a soft-tissue standpoint, or put another way,
you’re recording the basic measurements that come
from soft tissue, not hard tissue. If you deal with hard
tissue only, then you will come up short in the soft tissue. Ignoring the soft tissue will result in a face that’s
not improved, just different.
_Surgical treatment objective
You need to know how to do a surgical treatment
objective. You’ll need to know the technique, and
you’ll need to know how to apply it because the surgical treatment objective allows you to treat the face,
the occlusion, in a two-dimensional medium.
[7] =>
C.E. article_ orthognathic surgery
_Pre-surgical setup/surgical setup
technique
Fig. 1a
Once you have established what you’ll need to
do from the surgical treatment objective, you will
need to do what we call a pre-surgical setup. Otherwise you’ll need to apply the knowledge you’ve
gained from the patient, soft-tissue analysis and
the surgical treatment objective, and perform a
three-dimensional workup to make sure what you
have planned will work with the joints, muscles and
nervous system.
I
Fig. 1a_Patient profile. (Photos/
Provided by Dr. Theodore D.
Freeland)
Fig. 1b_Patient frontal.
Fig. 1c_Patient oral casting.
Fig. 2_Joint degeneration.
Fig. 3_Panoramic X-ray of the soft
tissue on top of the hard tissue.
_Surgery
Finally, you need to know surgery. I recommend
that the orthodontist be in the operating room so
you know what the surgeon is doing, and how the
surgery goes. It’s very important to know that the
surgeon gets the joints seated in a passive manner. If
the joint is stressed, then there’s a good chance that
we’ll have some surgical relapse.
Fig. 1b
Fig. 1c
_Joint status
Joint analysis will include three portions: history,
a clinical examination and imaging.
Building a history will be similar to traditional
patient assessment. We need to know if there are any
family members who exhibit TMJ problems. If yes,
then there’s a good chance the patient will develop
significant joint issues that will affect the outcome
of treatment.
After an oral investigation, a thorough clinical
examination of the joints will need to occur. We’ll be
on the lookout for any type of injuries to the mandible. If the patient has had any injury that involves the
chin, there’s a good chance that the joint may have
been damaged.
Finally, we need to look into any past treatment.
Has the patient had orthodontics before? Has the
patient had a lot of restorative dentistry? This is
important because all of the above have a tendency
to affect joint status.
_Clinical examination
Fig. 2
Fig. 3
Next is the clinical examination. Clinical examination includes the following:
• range of motion,
• symmetry of jaw motion,
• palpation,
• auscultation,
• muscle splinting,
• CR position.
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I C.E. article_ orthognathic surgery
Fig. 4
Fig. 4_A state of degeneration: a
condyle that is actually changing.
Range of motion should be between 45 mm and
55 mm on opening and includes assessing movement. We’re looking for a symmetrical mandible
motion — meaning the chin should not deviate to the
left or right on opening — and it should be relatively
free of dental interference.
Now check for palpation of the muscles of mastication. If you don’t check the muscles that move the
mandible, then there’s a good chance that you’ll miss
some sort of functional bite issue.
We also listen to the joint with a stethoscope, and
we apply some anterior pressure to the disc through
external auditory meatus to make sure the disc is
functioning properly.
When trying to manipulate the mandible, one
can feel the muscles. If the muscles will not let you
obtain a centric joint position, then we cannot do
a diagnosis because the muscles aren’t holding the
condyle out of the socket. This is usually due to some
inflammation.
Finally, we’ll check what we call the centric relation position, which you should be able to feel. It
should feel solid and the patient should be able to
open from this position with relative ease, and there
should be no noises.
_Imaging
The clinical examination will tell us a lot about the
joint status. The use of imaging will help us build our
base of case-specific intelligence. We’ll use two types
of imaging: MRI and cone beam.
08 I ortho
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LCBCT
Most of the time, we start with cone beam because
it’s easy to obtain a 3-D image of the joints. Thanks
to the work of Rickets and Dr. Ikeda, we have a way to
measure joint position and get an idea if the condyle
is basically seated. With cone beam, we can measure
the health of the condyles.
Our imaging showed a joint that is in a state of
degeneration. The condylar head has changed in
vertical height. Therefore, we would expect to see an
asymmetrical opening where the chin deviates to the
affected side. In all three views (saggital, coronal and
axial), we have a condyle that is actually changing,
especially when you make a comparison to the left
condyle (Fig. 4).
In a side-by-side presentation, you can see that
the left side is definitely in a lot better shape, having a
more rounded effect to it. The size of the coronal view
is one that shows a definite symmetric outline to it as
compared to the other side. The axial view confirms
this; you see that the shape is better and has a more
dense outline.
Thus, our basic imaging system helps us determine
that, in this case, one side is going to be the problem
side, especially as it pertains to orthognathic surgery.
If we go to the two-dimensional images created
in the cone beam, we can see that the right joint has
definitely lost vertical height, and we definitely have
a joint spacer that is excessive (Figs. 5, 6).
In the coronal view, we can even see that there
may be some sort of cyst formation. When you compare the right side to the left side in the coronal view,
you get a more traditional image, which is what we’d
like to see. However, there have been some changes
that have occurred, because we’re starting to see a
“bird-beaking” effect in the left joint. The images of
the joint are ones that are important in determining
if we should proceed with any kind of a surgical correction.
In the saggital view, the right side, the joint looks
pretty normal. However, if we look at it in a transverse
direction, you’ll see less joint space laterally than you
do medially, something we see in both the left and
right joints (a much bigger joint space). That’s why it’s
important that you not only look at a saggital view,
but you also need to look at the coronal view to see if
you have a transverse problem occurring in the joints.
_Soft-tissue analysis
When we’re trained in orthodontics, we’re trained
in hard-tissue analysis, otherwise all of our cephalometric analysis are based on hard structures. If you
use hard structure to determine soft-tissue corrections, then you’ll come up short of good facial esthetics. That’s why a soft-tissue analysis is so important.
[9] =>
C.E. article_ orthognathic surgery
I
Fig. 5
Fig. 6
Fig. 7
Using soft-tissue markers with 3-D facial mapping, we are able to diagnose the soft tissue, and we
can also relate it to the hard tissue.
In Figure 5, we’ve overlaid the soft tissue on top
of the hard tissue. With the markers on, after we
convert it to a two-dimensional X-ray, we can see
where the sub-pupal area is, where the cheekbones
are and where the alar base is. In addition, you will
see a marker that we call a hinge access marker, which
comes from establishing the true hinge axis of the
patient. There is also a marker that’s placed on the
nose that we call the horizontal point.
We are going to analyze everything from a basic
coordinate system of a true vertical to an axis horizontal.
The image is orientated from the axis horizontal
plane and the true vertical plane, which is based on
the patient’s natural head position.
Figure 6 shows how these two corners are at 90
degrees from each other. In this analysis, we’re going to record all the soft-tissue measurements, both
horizontal and vertical, and we’re going to base them
on the line that runs through the subnasale (SN). This
establishes the true vertical line based on natural
head position.
Furthermore, we’re including a few hard-tissue
measurements that will tell us about the architecture
of the mandible. These come from Rickets and from
the Jarabak analysis. With this analysis, we can cover
the basis that we need for orthodontics, but we can
also cover what we need in a surgical workup.
We also need a frontal analysis, which is taken
from the patient’s face. Most of the frontal workup is
done in examining the patient clinically. This enables
us to look at the orbital rim, cheekbone, sub-pupil,
alar bases, nasal bases and canthus of the eyes.
All of this enables us to assess if we have transverse asymmetries, where the occlusal plane is
canted instead of level. This also holds true with the
mandibular plane, which we may also find is canted.
This is especially true in cases where there’s a degenerative process happening in one joint.
Fig. 5_Overlaid soft tissue on top of
hard tissue.
Fig. 6_ Establishing the true vertical
line based on natural head position.
Fig. 7_ Glabella to subnasale (SN).
_Head position, profile and frontal
analysis
The natural head position is different for each individual patient. This will make the distance recorded
for glabella to the true vertical line different.
To measure how far glabella is from SN (true
vertical line), we first need to establish the patient’s
natural head position (Fig. 7). To do so, we have the
patient stand in front of a mirror. First, the patient is
asked to close his eyes and bob his head up and down
three times.
After this is complete, the patient is asked to open
his eyes and look himself directly in the eyes in the
mirror. After we have established the natural head
position, we then use the measurement gauge. Our
goal is to make sure the leveling bubble is in the lines.
This will allow us to take a measurement from the true
vertical line to glabella.
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I C.E. article_ orthognathic surgery
Fig. 9
Fig. 8
Fig. 8_ Establish the horizontal
position.
Fig. 9_Surgical treatment
objective.
Fig. 10_Completed the
extrusion
of the maxillary segment and
balanced the occlusal plane.
Fig. 11_Establishing the true
vertical line.
Fig. 10
Fig. 11
Fig. 12_Shows true hinges
access mounting.
Fig. 13_Open bite on hingeaxis mounted model.
Fig. 12
Keep in mind that everybody’s head position is a
bit different. The further that glabella is from the true
vertical line will affect how we look at the lower third
of the face.
Now we need to establish the axis-horizontal
plane (Fig. 8). First, we establish the horizontal position using the ear bow. We’ll use the pointer on the ear
bow to make a mark on the nose when the bow is level.
We have previously established, through axiopath tracing, the hinge axis position on the patient’s
right and left sides. In combining the horizontal point
10 I ortho
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Fig. 13
with the two axis points, the axis-horizontal plane
can be established. The axis-horizontal plane is then
transferred to the articulator. This allows us to orientate the CBCT data with the articulator mounting.
Now we have the true axis-horizontal plane and
the true vertical line combined, and now facial, skeletal and functional issues can be assessed.
In the example we are using, the patient has a
mandible that has an architecture problem, which
causes her to occlude only on the molars with an
anterior open bite.
[11] =>
C.E. article_ orthognathic surgery
This is precisely the kind of case where you should
be looking for degenerative joint disease. All of the
above enables us to establish the parameters and coordinates we need to analyze the face and occlusion
and then apply the correct treatment so the patient
will have a functioning stable occlusion with the
necessary facial improvements.
_Soft-tissue analysis
The treatment objectives are based on the soft
tissue. You perform the surgical treatment objective
in this order.
1) Establish the position of the upper lip to the true
vertical line in a vertical and horizontal manner.
2) Determine what you need to do with the anterior teeth to create the correct upper lip position.
3) Once you established the anterior part of the
maxilla, then proceed to the posterior part of the
maxilla and determine if you need to do an intrusion
or extrusion of the posterior segments to level the
occlusal plane.
In most cases where there’s a retrusive chin and a
skeletal open-bite, the patient has an occlusal plane,
measured from the true vertical line that is somewhere between 102 and 108 degrees. By leveling the
occlusal plane, based on the anterior tooth position,
you can set the mandible to the maxilla. This will usually balance the lower third of the face. If you still find
the chin is too far forward or too far back, you may
need to do genioplasty.
In the example case (Fig. 9), we have performed
a surgical treatment objective, established the true
vertical line and we have our axis-horizontal plane.
In this patient, we need to move the anterior teeth up
because in the frontal analysis the patient showed
too much tooth structure and too much gingival tissue. To fix this, we balance the maxillary anterior teeth
based on the upper lip position.
Once we’ve established the correct tooth position
in the anterior, we’re able to set up our occlusal plane
at 95 degrees, showing us what we need to do with
the posterior segment. In the example case, we need
to extrude the posterior segment.
Figure 10 shows how we’ve completed the extrusion of the maxillary segment, and we’ve balanced
the occlusal plane. The next objective is to place
the mandible with the correct overbite. This is not 2
mm but 4 mm. This is because you want to have an
adequate overbite to create adequate disclusion. In
establishing the mandible, you can see in our example how the lower part of the face is placed normally
enough with the true vertical line (Fig. 11).
In establishing the surgical treatment objective,
we see that we want to place the anterior section
in the superior direction and the posterior in the
inferior direction. These are all the measurements we
I
need to establish a surgical setup. Hopefully, this is
performed pre-treatment so the patient has a good
idea of what needs to be done.
_Pre-surgical and surgical setups
The pre-surgical and surgical setups are techniques that do require the clinician’s time. It’s not
something that can be outsourced to a lab. You need
to spend the time in doing these setups to determine
if it’s something that can be treated. Remember, there
are cases where you cannot achieve the goals.
Before we get to the setup, it’s worth examining
the three basic concepts that this whole system is
based on. That’s not just orthognathic surgery, but
orthodontics itself.
Concept No. 1: You need to start with a seated
congular position. You will need to learn techniques
to know when you have a seated condyle, and if it’s
in a stable position.
Concept No. 2: You can’t believe what you see in
the mouth. This is foreign to what we’re taught in the
orthodontic profession. We’re trained that when we
finish a case we have the patient bite down, and we
say that the occlusion looks good or it doesn’t. However, you need to understand that this is a learned
muscle position. It’s not a position that is usually
conducive to normal joint function.
Concept No. 3: Quit trying to do the impossible
with orthodontic tooth movement. This is where
orthognathic surgery comes into play. Don’t try to fix
skeletal aberrations with orthodontic tooth movements. Too often cases are treated with a compromised treatment plan, but due to the skeletal dysplias
it is impossible to establish a functioning occlusion,
thus resulting in failure.
We need a ruler to measure how we come up
with a diagnosis and then we need the same ruler
to measure our successes. So in the sample case, the
ruler consists of five goals: joints, face, perio, teeth
and function.
In a pre-surgical diagnostic setup, which is a trial
treatment, the case can be diagnosed and treated
before you start. This way you have the result in mind
before beginning (five goals). The orthodontic, surgical and restorative modalities can all be combined
pre-treatment. This way the patient knows what is
needed to solve his or her particular malocclusion.
These pre-treatment setups are based on the VTO
(tooth movement) and the STO (skeletal movement).
Once all treatment modalities have been tried, the
clinician will know if orthognathic surgery will work
for the patient.
The surgical setup is performed just before
surgery to determine the skeletal changes needed
to correct the skeletal malocclusion and see if the
prediction setup is correct. We use our ruler again
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I C.E. article_ orthognathic surgery
a
b
c
Fig. 15
d
Fig. 16
e
f
g
h
Fig. 14
Figs. 14a–h_Diagnostic setup .
Fig. 15_Measuring Glabella to
subnasale.
Fig. 16_Surgical models mounted
according to axis-horizontal plane.
to make certain that the five goals are obtainable.
The surgical splint can also be constructed from the
surgical setup. The surgical splint is used to place the
skeletal parts in their correct position.
_Steps in pre-surgical setups
First, we need to get the maxilla positioned in the
articulator. We still recommend that you use the articulator as a tool to do your setup. Virtual setups tend
not to include the patient’s true functioning hinge
axis. If you don’t have the axis, you’re liable to setup
an arc of closure that distracts the condyle.
We establish the functioning terminal hinge access of the patient on both the left and right. We’re
then transferring the hinge access to the side of the
face. Once we have it on the side of the face, we can
do our axis-horizontal transfer. The dot shows the
functioning hinge axis on the patient, represented
on both the right and left sides.
The axio-path tracing that we created while trying
to find the terminal hinge axis of this patient allowed
us to look at the angle of eminence. What we like to
see is a steep angle of eminence as that helps disclude
the posterior teeth in lateral border movements.
Moreover, we like to see nice, smooth curved lines in
the jaw motion, as that tells us the condyle and disc
are working in harmony with each other.
We determine the best centric relation position
in the mouth. Nevertheless, remember, you can’t
believe what you see in the mouth. That means this
may even be worse, especially when we do a true
hinges-axis mounting.
Figure 12 shows a true hinges-axis mounting. We
12 I ortho
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have the true hinge axis, we have the axis-horizontal
plane and we have the teeth position according to
this setup. That means the pin, which was removed
for the photograph, would be the true vertical line.
The articulator mounting is now the same as the
CBCT imaging.
What we see in the next image is that this patient
only hits on the left side. Nothing touches on the
right. As you can also see, the open bite is even worse
on hinge-axis mounted models (Fig. 13)
_Diagnostic setup
The diagnostic setup we’ve been discussing is
based on the VTO, STO and the articulated cast
mounting. The orthodontic setup, as well as a surgical setup, can be done on the same set of hinge-axis
mounted models. We can also include in the diagnostic setup the correct arch form so a mutually
protected occlusion can be obtained (Fig. 14).
_Surgical setup
The surgical setup allows us to plan the surgery
case before we go to the operating room. We perform
this after we’ve finished the pre-surgical orthodontics and we’re getting ready for the surgery itself.
What you should find when you compare the pretreatment setup with the surgical setup is that the
bony part should look very similar on the articulated
mounting as the pre-treatment.
In this case, we’ve leveled the occlusal plane as
part of our surgical setup. In doing so, we gained a
large correction of the mandible without doing gen-
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C.E. article_ orthognathic surgery
I
Fig. 14
Fig. 17
Fig. 18a
Fig. 18b
Fig. 19
ioplasty. Again, this is based on the axis horizontal
and the true vertical line.
Now that the surgical orthodontics has been
completed, and the patient is now ready for surgery,
we go back and do the natural head position and
measure how far glabella is from SN. We then do our
axis transfer and place the markers. Then we doublecheck that we have the natural head position (Fig. 15).
Next, we do our axis transfer, placing the maxilla
exactly how it’s related to the axis-horizontal plane.
This is important because it enables us to place the
maxilla on the articulator exactly as it exists on the
patient, to the functioning axis.
Figure 16 shows the surgical models mounted according to the axis-horizontal plane. We use a centric
bite to position the mandible to the maxilla, allowing
the musculature to seat the condyles up and forward.
We then get into our surgical correction. We’ve
corrected the maxilla. To maintain the proper torque
of the anterior teeth, we’ll need a four-part maxilla.
Now we have our anterior segment (lateral to lateral)
and two posterior segments (cuspid to second molar)
and the palate. The anterior segment is positioned
vertically and horizontally to the maxillary relaxed lip
position. In addition, we take into account the tooth
and gingival display the patient exhibits.
We’ve done the correction in the maxilla, putting
the uncorrected mandible on. This shows the discrepancy you see once you’ve leveled the maxillary
occlusal plane. Now we position the mandible. If
we’ve done our pre-treatment surgical orthodontics
correctly, things should fit together. Thus, after the
mandibular correction is completed in the setup, an
uncorrected maxilla is placed on the articulator. You
should see a large posterior open bite.
This is also an easy way to construct our intermediate surgical splint, which you can see in Figure 17.
Note how we changed the plane of the mandible. This
is based on doing the mandible first. By placing the
mandible correctly in all three planes of space, we can
establish the functional axis of the mandible.
This helps eliminate some of the errors that occur
in orthognathic surgery. If we do the mandible first,
and we know the vertical measurement that we need,
it’s easy to place the maxilla correctly to the mandible.
There are certain surgical techniques that need to
be applied to accomplish the surgical corrections. By
following the proper surgical techniques, the postsurgical relapse can be kept to a minimum.
The other thing that we can do is establish even
centric stops, according to the axis position. That’s
why in Figures 18a and 18b the models are painted
red. We can do an occlusal analysis and equilibration
and establish a stable tooth fit before surgery; all of
which is based on the true terminal hinge axis.
We’re able to get a Class I and we’re able to gain
enough overbite. We will need to do some postsurgical orthodontics to finish the occlusion, but the
image shows the hinge axis closer on the articulator.
If you were able to hold the model, you would
notice that there’s no rocking. Everything is stable.
You don’t want the patient to come out of surgery
Fig. 17_Intermediate surgical splint.
Figs. 18a, b_Adjustments.
Fig. 19_Post-treatment intra-oral
and extra-oral photos.
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I C.E. article_ orthognathic surgery
Fig. 20
Fig. 20_ Cone-beam data, both preand posttreatment.
and find that the patient has trouble finding a stable
maximal intercustation with the joint seated.
In order to gain even stops, we had to remove
some tooth enamel around the upper and lower
arches. That’s what we do in the operating room before we begin the operation. We do the equilibration
when the patient is asleep and before the operation
begins.
As you can see in the post treatment intra-oral
and extra-oral photos (Fig. 19), the facial changes
include a shortening of the lower facial third. An
adequate overbite has been established so a mutually
protected occlusion can seen. The proper disclusion,
where the back teeth separate by at least 2 to 3 mm,
has been established.
If we apply the second concept (“you can’t believe what you see in the mouth”), we need to go to
post treatment hinge-axis mounted models. Figure
20 shows the cone-beam data, both pre- and post
treatment. Note the double plates on the mandible
to establish a stable platform to position the maxilla.
_Surgery
One of the most important take-away lessons
from this article is that you need to know your sur-
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geon. Establishing a one-on-one relationship with
your surgeon can be challenging. If the orthodontist
does not know what the surgeon goes through, then
in the planning stage pre-treatment, the teeth may
be placed in a position that the surgeon will have
trouble establishing in the correct skeletal position.
This is a relationship that simply takes time.
Once you have knowledge of the surgeon, then
you need to know what happens at the hospital
because this becomes an important part, especially
during recovery.
The people who are handling recovery need an
exceptional level of compassion, and they need to be
able to handle emergencies. Oftentimes the patient
will get sick, and his or her teeth are held together
with elastic and wires. The healing period normally
lasts 10 weeks. It may be longer depending on how
the segments are healing. The point is that we don’t
get into post-surgical orthodontics before the segments have stabilized
_Additional considerations
We know that you need to know the joint status.
You’ll need to know how to do a soft-tissue analysis
and how to establish a surgical treatment objective.
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C.E. article_ orthognathic surgery
You’ll need to know how to do pre-treatment setups
and surgical setups. You need to apply all of these
techniques on all patients (mixed dentition, adolescent or adult).
If the teeth aren’t in the correct position in the jaw,
then there’s no way the surgeon can place the parts
correctly, resulting in surgical failure. Most surgical
failures happen because of orthodontics.
One of the things you need to keep in mind in
your pre-treatment surgical orthodontics is that you
established the correct arch form. Without the correct arch form, it’s difficult to put the parts together.
The other thing to keep in mind is the actual 3-D
position of the teeth. If you have up-righted the upper anterior teeth, the surgeon will have a difficult
time fitting the mandible to this.
If you have tipped the lower anterior teeth back
too far — such as in a Class III — then you cannot
obtain a good maximum inter-cusptation because of
the incorrect torque of the anteriors. The setup part
of the procedure will give you this information.
_Age
If it’s an adolescent patient, you can do the presurgical orthodontic and establish the correct axial
position of the teeth in each jaw. However, do not try
to fix the occlusion. That means the teeth will be in
the proper positions when you approach the surgery.
As a rule, I won’t get into a surgical case before a
female is in her early 20s, and with males in their mid
20s. I’ve seen cases where they were done earlier and
actually grew out of the correction.
_Learning these techniques
We all need to be taught to do these things, and
it needs to be from someone who has done them
for a number of years so you can be certain that the
methods you are learning will work. They are taught
in the Advanced Education in Orthodontics (AEO)
course, and we do practice them.
I
That includes surgical setup, orthodontic setup,
soft-tissue cephalometric analysis and surgical
treatment objective. They need to be practiced a
number of times. It’s not something you can learn on
your own. You need a mentor who will teach you all
the characteristics you’ll need.
In the lab phase of the AEO class, we do get into
mounting cases on the true hinge axis. You will learn
how to establish these on patients. They are not time
consuming. Normally, establishing a hinge axis in the
axio-path tracing and transfer takes no more than
six or seven minutes, so the clinician is not using a
lot of his or her time to establish a correct hinge-axis
mounting.
The instructors will demonstrate how it’s done,
and then have you perform the procedures. Under
the proper guidance, you can learn these techniques
and apply them in an office setting in an economical
manner.
Without the coaching, these procedures can feel
like too much of a chore. Moreover, without coaching, there’s no way to do a surgical workup for the
benefit of the patient, which of course, is the main
reason you need to know these procedures.
It also helps if you work with the surgeon and the
restorative dentist because it’s the restorative dentist
who obtains the final outcome, and he or she needs
to finish the case from where you left it.
It takes some time and it takes some effort to learn
these protocols. But once you do learn them, and you
have the technique, your surgical cases will be more
stable, and you’ll cut down the instances of surgical
relapse that you see.
Above all, remember this is all for the benefit of
the patient. You need to spend time learning and you
need to spend time in the operating room to know the
problems the surgeon encounters. Then you need to
spend time in the diagnoses and workup.
However, the benefit is for the patient, who winds
up with a functioning occlusion and improved face,
and the gingival tissues are healthy and the jaw functions correctly._
_about the author
Theodore D. Freeland, DDS, MS, is a board-certified orthodontist in Gaylord, Mich. After
graduating from Albion College in 1967, he attended the University of Detroit Mercy, earning a dental degree in 1971 and his master’s of science in orthodontics in 1978. Freeland
has completed Dr. Gene Williamson’s course in occlusion and TMJ and the Roth/Williams
course in advanced orthodontics. In addition, Freeland has served as an adjunct professor
in orthodontics at the University of Detroit Mercy, and held appointments at the University of
Detroit in fixed prosthetics and orthodontics; the Roth/Williams Center as a clinical instructor;
and the Advanced Education in Orthodontics Group as director and instructor. Freeland is an
accomplished author who lectures nationally and internationally.
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Orthodontics and esthetics:
A multidisciplinary approach
Authors_Julia Garcia Baeza, DMD, and David Garcia Baeza, DMD
_These days, we are seeing a growing number
of adult orthodontic patients. However, adult cases
present unique challenges to the orthodontist. Missing teeth, root canals and periodontal problems
are all common situations when dealing with adult
patients.
Unrealistic esthetic expectations are another
challenge when dealing with adult patients. This is
the patient who comes in with a request that his (or
her) smile look like his favorite movie star. That’s why
it’s important to make sure the patient has a firm
grasp of what is possible and what is not.
The patient should know that we have the ability
to level and align teeth, to coordinate arches and to
improve occlusion, but we do not have the ability
to change the texture of the enamel or the shape
or form of teeth.
With adult treatments on the rise, establishing
a good multidisciplinary team is essential. This is a
two-way street. Just as a secondary team of specialists can be essential to achieving a successful
orthodontic outcome, orthodontics is also a valuable
tool for other specialties to have at their disposal. This
includes esthetics, but can also be a means to improving the health of the soft and hard tissues.
We’re going to look at a case that will highlight
the importance of the orthodontist in working with
other specialties.
_Case report: Part I
(Photos/Provided by Drs. Julia and
David Garcia Baeza)
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In this case, the patient had a trauma and presented the left central incisor apically displaced
(Fig. 1). The patient not only showed a fracture of the
left central incisor, but also an apical displacement of
the root (Fig. 2), taking the gingival margin to a higher
situation (Fig. 3).
This case could be approached in two different
ways: extracting the damaged tooth and placing an
implant or extracting the damaged tooth and regeneration (with the risks that regeneration entails).
The risks associated with implantology include
the loss of soft tissue and the loss of volume when
implants are placed. This means that if the starting
Fig. 1
Fig. 2
Fig. 3
point of the gingival margin is higher than it should
be after the implant placement, the gingival margin
will be even more apically. This means a complete
asymmetry of the soft tissues.
With this aspect in mind, the vision of a prosthodontist is to extract the damaged tooth while trying
to increase the soft and hard tissues to avoid the
gingival margin asymmetry between both central
incisors.
These types of treatments are technique sensitive
when mucogingival procedures are involved. Orthodontists must show their colleagues that they have
the tools to help improve situations such as the one
presented in this article.
In this case, the orthodontist can make the situation more favorable for the prosthodontist. The left
central incisor was to be extruded in order to bring
the gingival margin even lower than the right central
incisor. As we said before, what the prosthodontist is
simply looking for is a favorable situation.
When the gingival margin of the left central
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Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
incisor is higher than the right central incisor, the
situation is complicated. When the gingival margin
is at the same level, it is less complicated. However,
when it is even lower, the problematic situation of
losing soft tissue might not be entirely solved, but it
is a much more favorable situation.
In this case, the extraction of the tooth was expected from the very beginning, so why not use it
before its extraction by bringing the soft tissue to a
better position by using different orthodontic forces
and vectors and facilitate the work of the rest of the
multidisciplinary team?
Depending on the type of extrusion, soft or hard
tissue can be extruded. The boundaries of hard and
soft tissue extrusion are not clear in the literature.
Yet, what is clear is that soft tissue will come down
with an extrusion. In the case shown here, the new
soft tissue formed after the orthodontic extrusion
will help the outcome.
In the next peripheral radiographs (Fig. 4), the extrusion of the left central incisor is shown as a visual
reference of the orthodontic extrusion, so the excess
of gutta-percha can be used. A 4 mm displacement
of the root was created, which was the amount of
gingival margin needed for the prosthodontics to
work (Fig. 5). At this point, the gingival margin of the
left central incisor is even lower than the right central
incisor. The amount of hard tissue extrusion in this
case was almost imperceptible.
In these types of cases, an excess of soft tissue will
facilitate the implant surgery (Fig. 6). Even though
new soft tissue is formed orthodontically (vertical
dimension), every time an implant is placed in the
anterior zone, a soft-tissue graft is performed at the
time of the surgery at the buccal zone. This is how the
prosthodontist will reproduce the volume of soft tis-
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sue in the area of the implant (Figs. 7, 8). This will help
avoid future translucency of the implant.
Once the braces are placed, the orthodontist can
solve the small rotations to achieve a better situation
in the anterior zone.
During the healing period (Fig. 9), no orthodontic
movements must be done. It is of great importance
that during this period, the temporaries perfectly seal
the soft tissue. A comfortable temporary is fabricated
to use during orthodontic treatment. Because of the
round wire used at this point in the treatment, we
use a stainless-steel ligature to fix the brackets and
avoid any orthodontic movement. The temporary will
seal and protect the soft tissue of the compromised
area (Fig. 10).
Two months after surgery, the soft tissue presents
healthy and the soft tissue at the compromised area
is below the level of the gingival margin of the right
central incisor.
_Case report: Part II
Orthodontic treatment in this multidisciplinary
case was used not only to align the teeth but also to
extrude the left central incisor (which was going to
be extracted from the beginning) in order to create a
more favorable situation for the rest of the specialists.
The treatment plan option for this case was set up
before starting the orthodontic treatment. A tooth
replacement was planned for the left central incisor,
and a veneer was planned for the right central incisor
to achieve a great esthetic result.
Knowledge of the treatment plan before beginning will allow the orthodontist to help improve
future restorative procedures.
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Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14a
Fig. 14b
Fig. 14c
At this point, everything that could possibly be
done for the left central incisor was finished. However, could the orthodontist help with the future
restoration of the right central incisor?
When tooth preparation is done for a future
veneer, the prosthodontist will remove the enamel.
Even though adhesion to dentin is good, adhesion
to enamel is better. When prosthodontists work with
veneers, if they can bond to enamel they will improve
the result.
Having this knowledge, the orthodontist can still
create a more favorable situation for his or her colleagues. In this situation, if the right central incisor
was placed a little more lingualized, the amount of
tooth structure that will need to be removed for the
veneer preparation will be less.
Would it be possible for the orthodontist to lingualize that tooth? How is the orthodontist going to
control the amount of tooth displacement? In this
case, a composite veneer was built on the buccal face
of the right central incisor (Fig. 11). The future veneer
has a thickness of 0.5–0.8 mm. The same thickness
was built for the composite veneer. A caliper was used
to confirm the thickness before and after the composite veneer was placed. The orthodontist placed
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the bracket on top of the temporary veneer, and the
tooth was palataly displaced 0.5–0.8 mm. This way,
the tooth preparation will be less aggressive, and the
final veneer will have better adhesion to the enamel
than to the dentin.
With the orthodontic treatment in this case, we
achieved a more favorable situation with the soft tissue around the tooth that was going to be extracted,
and a more advantageous position for the other
central incisor via a less aggressive tooth preparation.
After the orthodontic treatment, it was time for the
rest of the specialties to take over the case.
Model (Fig. 12) wax-ups for the temporaries (not
only for the extracted tooth but also a wax-up of the
veneer) (Fig. 13) enable us to achieve the best symmetry after orthodontic treatment.
The relatively long temporaries phase (Figs. 14a, b)
helps encourage a successful result (Fig. 14c). After
the patient and the prosthodontist are satisfied with
the provisional results, another specialist plays a role
in the patient’s treatment. The lab technician needs
as much information as we can offer to be able to
achieve the proper color and shade. Color guidance
(Fig. 15) photographs and models should all be provided to the lab technician.
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Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Figure 16 shows the minimal amount of tooth preparation that was needed before the veneer placement
because of the orthodontic treatment. Figure 17 shows the importance of the soft-tissue extrusion and the
connective tissue graft placement at the surgical site. This will maintain the buccal volume to achieve a great
emergence profile to recreate the final tooth (Figs. 18–20)._
_about the authors
Julia Garcia Baeza, DMD, is a diplomate of the American Board of Orthodontics and a member of the Spanish Society of Orthodontics and American Association of Orthodontics. She
received her DMD from the European University of Madrid; and her certificate in orthodontics
and master’s of science in oral biology from the University of Pennsylvania. Garcia Baeza’s
interest in research in orthodontic appliances now finds her in a PhD program at the University
Complutense of Madrid. She has published in various research and orthodontic journals
and presented an investigation at the 2010 IADR meeting in Barcelona and at the 2012 EOS
meeting in Santiago.
David Garcia Baeza, DMD, is a 2002 graduate of the European University of Madrid. He
received a certificate in dental implantology from the European University of Madrid in 2006
and a master’s in oral biology from the University Complutense of Madrid in 2007. Garcia
Baeza has been running a multidisciplinary dental practice, CIMA, in Madrid since 2005. He
also serves as both an associate professor and assistant professor at University Europea of
Madrid and University Complutense of Madrid. He’s had numerous articles published in the
leading Spanish-speaking orthodontic journals and remains a sought-after lecturer in the
greater European area since 2008.
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I technique_ appliances
How ‘a penguin’ can help
your practice (really!)
Author_Jerry R. Clark, DDS, MS
Figs. 1–9_Initial records including
panoramic X-ray revealing third
molars. (Photos/Provided by
Dr. Jerry R. Clark)
Fig. 1
_This complex orthodontic case was chosen to
illustrate the significant benefits of using In-Ovation
R self-ligating brackets. Throughout this article I
plan to demonstrate how these self-ligating brackets allow one to treat cases more efficiently and
effectively, thus reducing patient discomfort, treatment time, the number of patient visits and also the
amount of patient chair time needed to successfully
treat the case. I know from experience that the CCO
bracket prescription for the InOvation bracket consistently delivers precision torques and angulations
making it an ideal choice for all of my patients.
Fig. 5
Fig. 7
Fig. 6
Fig. 8
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Lizzy B. presented in our office with a Class II, division 1 dental malocclusion with significant maxillary
and mandibular dental crowding; excessive overjet;
an end-on molar and canine relationship; an excellent nasolabial angle; a mildly retrusive mandible;
and a small chin.
The panoramic X-ray was negative, with the exception of the presence of third molars that will need
to be removed in the future (Figs. 1–9).
Fig. 3
Fig. 2
Fig. 4
_Case presentation
Fig. 9
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Fig. 9a
Fig. 11
Fig. 10
Fig. 9a_Initial clinical records.
Fig. 10_Penguin Appliance.
Fig. 11_Six months after wearing Penguin Appliance.
Fig. 12a
Fig. 12b
Fig. 12c
Fig. 12d
Figs. 12a, b_Molar and canine relationship before wearing
Penguin Appliance.
Figs. 12c, d_Molar and canine relationship after wearing
Penguin Appliance.
Fig. 14
Fig. 13
Fig. 15
Fig. 16
Fig. 13_Case bonded, Nance Appliance placed.
Figs. 14–16_.014 Sentalloy archwires stop at first
molars.
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Various treatment options were considered
before I elected to treat this case using the Penguin
Appliance, developed by Dr. Joe Mayes of Lubbock,
Texas. This appliance is easy to use and does a very
effective job of distalizing maxillary molars in order
to correct dental Class II malocclusions and create a
Class I molar relationship (Figs. 10–12).
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Fig. 17
Fig. 18`
Fig. 19
Fig. 21
Fig. 20
Fig. 23
Fig. 22
Fig. 24
Fig. 25
Figs. 17–26_Four
months of treatment
with .014 Sentalloy
archwire.
Fig. 26
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After six months of wearing the Penguin Appliance, please note that the relationship of the molars
has changed from an end-on molar relationship to
a solid, if not slightly overcorrected, Class I molar
relationship. There has been a significant amount
of space created by the distalization of the maxillary
molars that will allow for the correction of the maxillary crowding problem. Also, note that the maxillary
incisors and the overjet and overbite relationship
have not changed (Fig. 12).
The case is now bonded and a Nance Appliance
placed so as to maintain the position of the distalized molars and maintain maxillary anchorage. The
.022 x .028 slot In-Ovation R-brackets have been
bonded, the molars banded, and please note that the
.014 Sentalloy® archwires stop at the first molars to
prevent these flexible wires from coming out of the
mandibular second molar tubes (Figs. 13–16).
After just four months, please notice how much
tooth alignment has been achieved and how much
space has closed due to the ability of the .014 archwire to freely slide in an almost frictionless manner.
The bicuspids and canines have distalized and the
maxillary anterior teeth have aligned without the
upper incisors protruding. The alignment of the lower
anterior teeth has improved significantly and at this
appointment, a second .014 Sentalloy archwire is
placed to eliminate the remaining rotations in the
mandibular arch (Figs. 17–26)
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I technique_ appliances
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Fig. 31
Fig. 32
Fig. 33
Fig. 35
Figs. 27–35_After six months, .020 x. 020 Bioforce archwire is placed.
32 I ortho
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Fig. 34
After six months, an interactive .020 x .020 Bioforce archwire is placed in both arches. Bioforce is a
fantastic archwire that allows for optimum force to
be exerted to move teeth in a highly effective manner
via low force in the anterior area, more force in the
bicuspid area and higher force in the molar area. In
just six months, almost all the space is closed, the
archform has been established and in the lower arch,
the incisors have aligned without increasing the
inter-canine width (Figs. 27–35).
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I technique_ appliances
Fig. 38
Fig. 37
Fig. 36
Fig. 41
Fig. 40
Fig. 39
Fig. 42
Fig. 43
Fig. 44
Fig. 45
Figs. 36–45_At eight months, the
upper elastic chain is changed to
close space and a panoramic X-ray
taken to check for root parallelism.
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At eight months, the upper elastic chain is changed
to close the remaining space. In the mandibular arch,
a .0215 x .028 Bioforce archwire is placed and a panoramic X-ray is taken to verify the root positions and
their parallelism (Figs. 36–45).
At 10 months, a full-sized .0215 x .028 Bioforce
archwire was placed in the maxillary arch to allow
the wire to interact with the customized bracket
prescription to produce the proper torque and angulation for each individual tooth. The Nance Appliance
is also removed at this time. Elastics are now placed
to start the working phase of treatment to correct
the biting relationship, with a Class II elastic being
employed on the left side to correct the midline discrepancy (Figs. 46–49).
At 12 months, the final set of .018 stainless-steel
archwires with soldered spurs are placed to provide
for the finalization of the biting relationship, and the
seating of the cusps. The mandibular midline is still
off to the left, so short triangular elastic are being
utilized to correct the midline and seat the cusps.
This process of detailing will continue for six months
to ensure the proper alignment and occlusion is
achieved to promote the stability of the final occlusion (Figs. 50–54).
At 18 months, the appliances are removed and
final treatment records are obtained. Results were
achieved with only 14 appointments and less than six
hours of chair time was needed to successfully treat
this case (Figs. 55–64).
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Figs. 46–49_At 10 months,
Nance Appliance removed, .0215
x .028 Bioforce archwire is placed
as well as elastics.
Fig. 46
Fig. 47
Fig. 49
Fig. 48
Figs. 50–54_At 12 months,
final set of .018 stainless-steel
archwires with soldered spurs
are placed.
Fig. 50
Fig. 51
Fig. 53
Fig. 52
Fig. 54
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I technique_ appliances
Fig. 56
Fig. 55
Fig. 58
Fig. 57
Fig. 59
Fig. 60
Fig. 61
Fig. 62
Fig. 63
Fig. 64
Figs. 55–64_Appliances removed at 18 months, final treatment records obtained
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One-year post-treatment photos are also included to show how the stability of the case has been
maintained and the occlusion has continued to improve, as has the profile and appearance. Also, please
note the attractive smile line that has been created.
(Figs. 65–71).
The interactive nature of the In-Ovation bracket is
the key to efficient and effective treatment. Initially,
with small round wires, the teeth are free to slide and
move with incredible speed. Once square and rectangular archwires are placed, they interact with the
active clip and exert the force to express the torque
and angulation that has been built into the bracket.
With the precise nature of the CCO bracket prescription, the crowns and roots of the teeth are aligned in
the most exacting manner available today._
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Fig. 66
Fig. 65
Fig. 68
Fig. 67
Figs. 65–71_One year
posttreatment.
Fig. 69
Fig. 70
_about the author
Jerry R. Clark, DDS, MS, maintains a successful orthodontic
practice in Greensboro, NC. He received his BS and DDS segrees
from the University of North Carolina and his master’s degree in
orthodontics from St. Louis University. He is board certified and
has practiced orthodontics for more than 35 years and been
lecturing on various orthodontic topics for more than 30 years.
He is also a partner in Bentson, Clark and Copple, a company
dedicated to assisting orthodontists with successful succession
planning, practice valuation and sale of their orthodontic practices. For more information call, (800) 621-4664.
Fig. 71
40 I ortho
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industry_ Sesame Communications
I
Managing your practice’s online reputation
Author_Diana P. Friedman, MA, MBA
By paying attention to what patients say about you on social media, and participating when it’s appropriate, you can help ensure your
practice is fairly and positively represented online.
ments at your practice. Studies have shown that for every person who
complains online, 26 more could complain but don’t, so virtually every
negative comment is worth considering.
_’Claim’ your online business listings
_Respond appropriately to patient comments whether
positive or negative
Without a complete, accurate and up-to-date listing on web portals such as Yelp! and Google+, you’ll miss attracting the attention of
many potential patients. After claiming and verifying your practice’s
listing on these sites, you can create brand-consistent profiles and
monitor them to see what patients are saying. Having verified, standardized listings will also net you a number of SEO benefits.
_Monitor online conversations relevant to your
practice
By monitoring social media conversations about your practice,
you can determine what patients love about their experience and what
they don’t. Using this feedback, you can initiate meaningful improve-
Create a swift and effective response to negative online feedback
when appropriate. Be authentic and compassionate: own up to valid
complaints, apologize and, if necessary, outline what you’ll do to make
things right. Conversely, don’t be afraid to gently correct patients
whose complaints contain information you can verify is incorrect.
Most issues should be resolved through private correspondence, not
in a public forum such as your practice’s Yelp! or Facebook page._
Friedman is president and chief executive officer of Sesame Communications. She has
a 20-year success track record in leading dental innovation and marketing. Throughout
her career Friedman served as a recognized practice management consultant, author
and speaker. She holds an MA in sociology and an MBA from Arizona State University.
AD
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about the publisher _ submissions
I
submissions
formatting requirements
Please note that all the textual elements
of your submission:
_complete article
_figure captions
_literature list
_contact info (e-mail addy please)
_author bio
must be combined into one Microsoft Word
document. Please do not submit multiple files
for each of these items. In addition, images
(tables, charts, photographs, etc.) must not
be embedded in the text document.
All images must be submitted separately, and details about how to do this
appear below.
If you are interested in submitting a C.E.
article, please contact us for additional instructions before you make your submission.
_Text length
Article lengths can vary greatly — from a
mere 1,500 to 5,500 words — depending on
the subject matter. Our approach is that if
you need more or less words to do the topic
justice, then please make the article as long or
as short as necessary.
We can run an extra long article in multiple parts, but this is usually discussing a subject matter where each part can stand alone
because it contains so much information. In
addition, we do run multi-part series on various topics. In short, we do not want to limit
you in terms of article length, so please use
the word count above as a general guideline
and if you have specific questions, please do
not hesitate to contact us.
_Text formatting
Please use single spacing and do not put extra
space between paragraphs. We also ask that
you forego any special formatting beyond the
use of italics and boldface, and make sure that
all text is left justified.
If you would like to emphasize certain
words within the text, please only use italics
(do not use underlining or a larger font size).
Boldface should be reserved for article headlines, headers and subheads please.
Please do not “center” text on the page,
add special tab stops or use underlines in your
text as all of this must be removed manually
before layout. If you require a special layout,
please let the word processing program you
are using help you to do this formatting
automatically rather than doing it manually.
If you need to make a list or add footnotes
or endnotes, please let the word processing
program do it for you automatically.
There are menus in every program that
will help you apoply all sorts of special formatting.
_Image requirements
Please number images consecutively by
using a new number for each image. If it is
imperative that certain images are grouped
together, then use lowercase letters to designate the images in a group (i.e., Fig. 2a, Fig.
2b, Fig. 2c).
Insert figure references in your article
wherever they are appropriate, whether that
is in the middle or end of a sentence, but
before the period rather than after. Our
preference is to have figure references noted
in the appropriate place within the text as it
helps the readers to orient themselves when
moving through the article. In addition,
please note:
_We require images in TIF or JPEG format
_These images must be no smaller than
4 x 4 inches in size at 300 DPI.
_Images should be 1 MB in size each
If you have an image that is greater than
1 MB, please do not bother “sizing it down”
to meet our requirements, but send us the
largest file size available. The larger the
starting image is in terms of bytes, the more
leeway the designer has in terms of resizing
the image to fill up more space should there
be room available).
Also, please remember that you should
not embed the images into the body of the
text document you submit. Images must
be submitted separately from the textual
submission.
You may submit images through a
zipped file via e-mail, unzipped individual
files via e-mail or post a CD containing your
images directly to us (please contact us for
the mailing address as this will depend upon
where you will be mailing them from).
Please do not forget to send us a head
shot photo of yourself that also fits the
image requirements noted above so that it
can be printed along with your article.
_Abstracts
An abstract of your article is not required.
However, if you choose to provide us with
one, we will print it in a separate box.
_Contact info
At the end of every article is a contact info
box with contact information along with a
head shot of the author.
Please note at the end of your article the
exact information you would like to appear
in this box and format it according to the
previously mentioned standards.
A short bio (50 words or less) may precede the contact info if you provide us with
the necessary text.
_Questions? Comments?
Please do not hesitate to contact us for our
International C.E. Magazine Author Kit or if
you have other questions/comments about
the article submission process:
Group Editor Robin Goodman
r.goodman@dental-tribune.com
Ortho Managing Editor Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor Fred Michmershuizen
f.michmershuizen@dental-tribune.com
ortho
I 49
1
_ 2013
[50] =>
I about the publisher _ imprint
ortho
the international C.E. magazine of laser dentistry
U.S. Headquarters
Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
Designer
Kristine Colker
k.colker@dental-tribune.com
Education Director
Christiane Ferret
c.ferret@dtstudyclub.com
Marketing Director
Anna Wlodarczyk-Kataoka
Group Editor
a.wlodarczyk@dental-tribune.
Robin Goodman
r.goodman@dental-tribune.com com
Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Product/Account Manager
Mara Zimmerman
m.zimmerman@dental-tribune.
com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
Product/Account Manager
Charles Serra
c.serra@dental-tribune.com
Latin America Product/
Account Manager
Jan Agostaro
j.agostaro@dental-tribune.com
International Products/
Account Manager
Maria Kaiser
m.kaiser@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com
Editorial Board
Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert
Tribune America is the official media partner of:
ortho_Copyright Regulations
_the international C.E. magazine of ortho published by Tribune America is printed quarterly. The magazine’s articles and illustrations are
protected by copyright. Reprints of any kind, including digital mediums, without the prior consent of the publisher are inadmissible and liable
to prosecution. This also applies to duplicate copies, translations, microfilms and storage and processing in electronic systems. Reproductions,
including excerpts, may only be made with the permission of the publisher.
All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
holder and no other individual(s) or publisher(s) holds the copyright to the material. The editorial department reserves the right to review all
editorial submissions for factual errors and to make amendments if necessary.
Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items will
be disposed of unread should they be received.
Tribune America strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Robin Goodman at r.goodman@dental-tribune.com. Opinions expressed by authors are their own
and may not reflect those of Tribune America and its employees.
Tribune America cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not
assume responsibility for product names or statements made by advertisers.
The responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability
arising from inaccurate or faulty representation are excluded. General terms and conditions apply, and the legal venue is New York, New York.
50 I ortho
1_ 2013
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