Sean Holliday, Author at The Ortho Cosmos Page

Erupting Dentition in Aligner Therapy

August 29, 2017 by Sean Holliday Leave a Comment

Managing Erupting Teeth

When it comes to the treatment of adolescents with aligners, there will be cases where patients are in the mixed dentition or have unerupted teeth. Previously, aligners were not favored when teeth had not erupted and waiting for the permanent dentition was a factor in case selection. I used to consider the ability to have aligner coverage of all the teeth and attachment control were critical components. With current treatment options and developments in the Invisalign system, we can implement various techniques for handling unerupted teeth. These features take additional considerations and careful planning for managing tooth eruption successfully.

Eruption Tabs

This feature is available in the Invisalign Teen product. Eruption tabs work on the premise of teeth erupting passively into available space. The concepts of driftodontics and natural tooth eruption make these features effective when enough space is created. That is the key factor. The eruption tabs are like pockets to guide teeth to erupt. They prevent over-eruption of these teeth.

Case 1 — Progress images of Class III correction using elastics and opening space for maxillary canines.

Case 1 pano — Initial panoramic image showing favorable path of eruption.

Pontics

When eruption tabs are not available, pontics are a useful substitute. Pontics are generated by the technicians at Align Technology. It is important to consider the pontic should be a full pontic, and not have undercuts as they taper gingivally. Consider pontics in these cases are not designed to retain a tooth-colored pontic material, but are designed to be eruption tabs. As such, they should be designed as closely as possible to the eruption tab shape and with lesser inciso-gingival length. I have also found that is it helpful to request pontics that are larger than the anticipated size of the erupting teeth.

Case 2 — Full step Class II case treated with distalization and Class II elastics. Erupting maxillary canines were managed with pontics where eruption tabs were not available.

Additional Aligners

Adolescent aligner cases commonly need orders of additional aligners when teeth have not fully erupted. For that reason, patients and parents should be advised of additional scans when teeth erupt. We advise Invisalign treatment works similarly to the way that additional brackets are bonded when we make space for teeth in a bracket system. The difference being that we rescan and order additional sets of aligners to continue the treatment progress. Informing ahead of time on what is expected helps to manage questions and concerns on the new teeth that suddenly appear.

The timing of those additional scans is therefore predicated on the timing of eruption. Design of the clincheck should be doctor directed, by intuitively looking at the time it would take for an erupted tooth to come into the arch. This is where accepting the clincheck must make sense to you, as the doctor. I recommend to err on the longer number of stages. It is far more efficient to initiate an early refinement, instead of having to rescan and order additional aligners while still waiting for the teeth to erupt.

Create Enough Space

Another piece of advise I give when it comes to erupting teeth is to make sure sufficient space is created. In most clincheck setups I have reviewed, there is oversight in the fact that maxillary canines often are wider mesio-distally on the gingival third. In these cases, insufficient space is created and teeth remain “stuck” because an aligner system is much more passive in it’s approach. In a fixed appliance system the brackets are wires will force the tooth into position. I often accept a pontic or eruption tab design and request space to be opened on the mesial and distal of the virtual object.

Case 3 — A deep bite case where insufficient space was created for an erupting maxillary canine. Additional aligners were used to address arch length discrepancy.

Pontic spacing — Request additional space mesial and distal to the pontic or eruption tab.

The Value of Mentorship

August 15, 2017 by Sean Holliday Leave a Comment

Finding Those Who Walk With You

Finding a great mentor is an invaluable experience. Fortunately, in life and business we have the opportunity to see the value of mentorship when we are open to it. A great mentor not only offers incredible guidance, but can also open many doors.

Mentorship is not a one way street and it is about influence. It is about guidance. It is about finding your way. The inspiration of a man or woman who can balance you and help you on your path both professionally and personally. I would like to honor those mentors in our lives who have walked with us. Let’s review some of those mentors in our lives

Spiritual Mentors

These are role models who come from literature, politics and history. We have not met them in person, but we read about them, or read their works that inspire and mentor us. Examples of some who have mentored and inspired many spiritually are Gandhi and Mother Theresa. They have walked with many in spirit, influencing and inspiring. Undoubtedly spiritual role models such as Jesus and Buddha have been spiritual mentors to millions through their teachings.

Mythic Mentors

These are the characters who inspire us, despite the fact they are literary figures. These are the heroes that empower us when we think of what they stand for, and where they serve as models and guides. Figures such as Superman, King Arthur, Dorothy from the Wizard of Oz, Zeus, and many others influenced us in our youth. These are the imaginary heroes who have inspired us through their mythic significance.

Living Mentors

These are the men and women who significantly influenced your immediate world. Teachers who made an impact in your life and career. Family members who guided and mentored you into the man or woman you are today. Recall teachers, coaches, grandparents, friends who inspired you. These are perhaps the most powerful mentors for they have truly walked our journey.

Mentorship is a journey. Sometimes a short crossing, sometimes a lifelong one.

Seek out mentorship. And don’t forget to become a mentor to repay those who have walked with you, by walking with another.

Phase I Treatment with Aligners

August 11, 2017 by Sean Holliday Leave a Comment

Interceptive Aligner Therapy

Why would an orthodontist or an orthodontic patient consider treatment with clear aligners in the mixed dentition? My thoughts center around the same premise why adults and teens are offered aligner therapy: for a more comfortable patient experience. While the orthodontic world is full of appliances used for Phase I treatment, aligner therapy is finding a place in this age. Invisalign is already in the process of tailoring their product to function more seamlessly for interceptive treatment, but the extended refinement period on approved cases has opened the doors for most practices to start offering this option.

Considerations

For any of you considering integrating aligners into a Phase I treatment plan, you should take into account a few factors that will make your experience, as well as the patients, the most positive it can be. First being the purpose and objectives of your Phase I treatment. Since patients are often in the early mixed dentition, the treatment should be focused on the limited goals. Ordering several sets of additional aligners can easily prolong treatment when managing erupting teeth. Keep the goals and limits very clear to avoid getting sucked into multiple and excessive refinements.

Anterior crossbite — Six months of Phase I treatment with aligners to correct an anterior crossbite.

Clinical Crowns

Second, the clinical crowns in the mixed dentition are short, so beware. Short clinical crowns in aligner treatment can spell fit and retention issues, if not managed properly. To address this challenge, add many more of attachments for retention. I add attachments on the primary molars and try to avoid the primary canines since their loosening can cause issues with fit.

Phase I attachments — Retention attachments for a Phase I case.

Tooth Eruption

Third, beware of erupting teeth. We have had a few patients where we scanned and by the time the aligners came, they wouldn’t fit! Whenever possible, I have been more selective with cases that are in a less transient mixed dentition where the four incisors have erupted and you have several months before any more primary teeth erupt. Remember that eruption tabs are quite specific and more designed for late mixed dentition cases. When incisors have not erupted, or even first premolars, I find I was chasing the case until I could scan again and again. Therefore, be selective in timing of cases. Also be creative using pontics where eruption tabs are not available. The advantage of the developing and erupting dentition, is that once space is opened, teeth will erupt into place and commonly drift into pontic spaces or eruption tabs. These are advantages in an aligner system, compared to the obstruction brackets bonded on exfoliating primary teeth.

Phase I Features

There are also some additional features in the pipeline that are well suited for early treatment. These include pending features such as a Phase I aligner product, an expansion appliance in the works, and the MFA appliance that will facilitate Class II correction.

Despite some potential challenges, and many young patients requesting colors for treatment, proper case selection in Phase I aligner cases can lead to success. Aligners for young patients can offer another great option that was not available before. Knowing these potential challenges and proper preparation for these treatment plans can offer the same advantages teens and adults experience while in the early mixed dentition.

Using TAD’s with Aligners

July 31, 2017 by Sean Holliday 10 Comments

In orthodontic treatment, we are fortunate to have several different resources to address a variety of malocclusion. Since the 1980’s TAD’s (temporary anchor devices) were introduced as a tool in orthodontics. They allow us to use an anchorage system that widens the scope of treatment plans.

Similar to many other tools in orthodontics, TAD’s are primarily used with fixed appliances to facilitate different corrections. Direct or indirect anchorage setups can be combined with braces. In an aligner practice, the use of TAD’s also becomes an option and can serve to increase the ability of the orthodontist to setup patient care for success. Consider we can use the force systems and the strengths of a TAD, to enhance aligner therapy.

There are many options for integrating TAD’s with aligner systems. I am not an expert with them, but I want to share my experience in using this orthodontic tool to better serve patients. I have found TAD’s help broaden the range of applicability in complex, aligner treatment.

Molar Intrusion

TAD’s can be placed and supported by elastics or chain to intrude posterior teeth in combination with an aligner system. Usually buccal and lingual TAD’s with elastics will support the intrusion. If lingual TAD’s are considered, add a significant amount of expansion to counteract the lingual component in the intrusion.

Molar intrusion 2 — To intrude lingual cusps, buttons were tied to palatal TAD’s.

Pontics and TAD’s

The use of aligners allows for custom pontics to be placed in edentulous regions. This allows for the pontic and the aligners to be seamlessly integrated with a TAD supported, pontic crown. The temporary crowns can be used as an anchorage system to facilitate mesial or distal movement where insufficient posterior support is present.

Anchorage — In order to move canines into a Class I position, TAD supported pontics were integrated into aligner therapy.

Segmental Treatment

Sometimes, the use of limited, fixed appliances are best suited for significant root movements or tooth translation. Segmental mechanics with a TAD supported appliance allows for challenging movements in localized areas. A TAD supported pontic with bracket segments can be used along side aligner therapy.

TAD’s and Power Arms

In some cases, tools available in the Invisalign system can be combined with TAD’s to broaden the range of movements. Power arms can be used to support significant mesial movements and root control in an otherwise challenging aligner force system.

Mesialization — Due to a missing premolar, a custom power arm was designed to move the left side mesially into a Class II molar, Class I canine position.

These are but a few examples of the integration of TAD’s into aligner therapy. These tools offer many creative options when we allow our imagination to develop treatment plans for our patients.

Culture Shifts in Orthodontics

July 26, 2017 by Sean Holliday Leave a Comment

The delivery of orthodontic treatment has remained the same for many decades. With the digital influence in orthodontics, and the changes from patient expectations in care, our specialty is undergoing perhaps one of the largest culture shifts ever.

The primary shift in culture is the change from a doctor centric practice, to a patient centered culture. Ultimately, as the consumer’s values have changed, those who succeed will learn to adapt. This is where adapting the orthodontic journey becomes so important.

With the influence of new technologies comes increasing costs to deliver orthodontic care. This has made the entry into private practice much more difficult to achieve, and has contributed to the corporatization of orthodontics. With higher costs, the challenges of a single doctor practice increase. The growth of group practices and corporate service organizations will continue to shift the model of the orthodontic care.

Technology is also democratizing the access to care, and new delivery methods have opened the opportunity to deliver orthodontic products direct to the consumer. Sure, doctors are contracted to oversee the treatment, but the model now shifts to a business model called Mechanical Turk. Where the excess supply of orthodontic and dental practitioners accept legal responsibility and low reimbursement to deliver volume outcomes for corporate goals. When there is no direct link between the practitioner and the patient, the culture of care changes. As more outlets for this model are developed, the commoditization of straight teeth develops.

Direct to consumer delivery of care will continue to grow. Doctor delivery will also evolve and we should accept the fact that patients have different priorities and expectations of orthodontic care. Many will continue to expect the traditional delivery of care with better experience and convenience. While others value a lower cost and self driven solution.

The shift in culture out there is many ways out of our control. What is not out of our control is what we do about it. Improving your team culture and the practice culture will help us attract those who are interested in what we offer. Offering a unique and patient centered experience will drive continued growth. Some developments in culture and technology are inevitable, but we should continue to focus on the areas we can improve and control.

The Opportunities in Failure

July 20, 2017 by Sean Holliday 2 Comments

Learning From Failure

Failure is not something we like to consider. But oftentimes, experiencing failure is one of the ways we grow and become better. Making mistakes often means you are trying, and learning from failure is a key factor. We all will experience failure at some point in our lives. It becomes critical to avoid repeating those failures and accept that not all failures are bad. We should properly learn from such difficulty. Even a genius like Einstein, made many mistakes.

The opportunity in failure is not commonly acknowledged since failure is regarded as always being bad. Certainly there is bad failure, but there is failure that is sometimes unavoidable, and at times a good thing. Developing a process to detect the failure and properly learning from it is not easy.

We should avoid jumping straight into finding blame, and build a learning culture in our practices. Blame prevents failure from being reported, and this is a basic step for your team to learn. A learning culture also offers the opportunity for your team members to take risks. No risk, no reward. In a blame culture, as opposed to a learning culture, team members will avoid experimenting, developing and implementing change. Because change is risky, and can lead to failure, it is often avoided. Change continues to happen all around us, so we must accept failure is bound to happen if we plan to embrace change, adapt and grow.

When considering strategies for learning from failure, Amy Edmondson suggests a spectrum of failures that start with blameworthy failures and progresses to praiseworthy failures. This allows us to see that not all failures are equal:

Let’s consider acknowledging failure and finding its causes. Once we avoid denial and embrace a process of learning from failure, we can stop living behind excuses and work to make our future better.

Extraction Treatment with Invisalign

July 13, 2017 by Sean Holliday 8 Comments

Et monuit

Extraction treatment with aligners is possible and can be effective, but be warned. I regularly warn doctors that more complex treatment plans with aligners do need a minimum level of proficiency. The reason being, that anyone can finish a successful case. The true measure of your skill is how you recover from a case that doesn’t go “by the book”.

Warnings aside, we all will encounter patients that will insist on aligner therapy where an extraction treatment plan is indicated. Some of you like a challenge like I do, and may elect to treat select cases with this technique. I can appreciate that when done properly, cases with extraction treatment can be predictable and a positive experience for both the orthodontic practice and patient.

It’s a different skill

I know many orthodontists who use aligner therapy regularly, who do not do extraction treatment with Invisalign. Depending on your patient demographics, you may never feel the need to use this technique. If you are pulling punches on teen cases, Class I, Class II, deep bites, etc, just stay away. It’s really not funny to see doctors who have treated very few cases jump into aligner extraction treatment. Sometimes they get lucky, but often I see an orthodontist leave with a bad taste for aligner therapy when there are plenty of opportunities to treat other types of cases. Sometimes, you don’t know what you don’t know.

Diagnosis, diagnosis, diagnosis

Are you sure it’s an extraction case? Unlike fixed appliances that expand and procline, Invisalign is a closed system that has to be intentionally designed to procline and expand. From my experience, it’s strength is in retraction and constriction. IPR, expansion, distalization, etc. are tools available in an aligner system if integrated to address various crowding issues.

Measure twice, cut once

Use Clincheck as the diagnostic tool it is designed to be. I enjoy how a patient can be run through various treatment scenarios before even starting to move a single tooth. This is a powerful tool often overlooked. You don’t have to guess, simply setup various plans and see how the outcomes change. Then select the treatment plan that best matches your treatment objectives.

Setup for success

Extraction treatment often caters to the mastery of all 3 dimensions with an aligner system. The most predictable extraction cases present with severe crowding where tipping teeth into the extraction sites leads to a great outcome. Some cases are more challenging when a deep bite is present and when root movements are necessary. Often, the most challenging cases present as bimaxillary protrusion with little to no crowding.

Some of the considerations when planning extraction cases include objectives in anchorage, root control, attachment design, staging, incisor root torque, curve of Spee and AP changes. It is important to control the roots of the canines, bicuspids and molars. Add significant attachments on canines, bicuspids and molars with maximum length from occlusal to gingival, or better yet, optimized designs.

Extraction attachments — A sample of attachment design for aligner extraction cases

Consider the anchorage in each case (mild, moderate or maximum). G6 protocols should never be used when any mesial movement of the posterior teeth is incorporated and is only effective in maximum anchorage cases. Significant mesial movement of posterior teeth may also require attachment on second molars and more hefty attachments on the first molars.

G6 extraction — Case 1 – Four bicuspid extraction case in progress, treated using G6 protocols

G6 extraction pano — Case 1 – Initial and progress panoramic views

Extraction2 — Case 2 – Moderate anchorage using posterior attachments to control root positions

Extracion2 pano — Case 2 – Initial and progress panoramic views

Don’t jump without a parachute

Especially if you don’t have many cases under your belt. Seek mentorship, learn from all the CE that is available at lectures and online. Don’t forget as orthodontists there are many tools at our disposal. Inform patients that finishing with fixed appliances is a possibility. It is best to warn than to give excuses.

What’s Your Story?

July 5, 2017 by Sean Holliday Leave a Comment

[Read more…]

Strategic Thinking in Orthodontics

June 27, 2017 by Sean Holliday Leave a Comment

Setting a Business Strategy

Any business, orthodontic practices included, should have a strategy in place. Setting a strategy, and incorporating true strategic thinking are critical. A commanding general should have a strategy to go into battle and a coach should have a strategy before playing a game. Otherwise they could suffer heavy losses. Similarly, we must consider strategic thinking as a factor for success in the core competencies of an orthodontic practice.

As a business is developed, a strategic plan should be set in place. These plans begin by incorporating a vision or mission statement. These are the goals set for the business and set the tone for the core strategy. The second component is a list of initiatives that the business will carry out to pursue those goals. These initiatives devise the larger part of a business plan, with a long affirmation of the core competencies. Finally, the planning is rounded out by the financial projections that will set budgets for the business.

The challenge continues in that business strategy is not a static exercise. As a practice grows and years go by, planning needs to evolve into true strategy. A plan and a strategy become inherently different. Where planning looks at cost allocations, strategy focuses on revenue. That focus should incorporate the customers that will affect that revenue. Strategic positions can be based on the needs of our customers, their accessibility, and the variety of the products and services we provide.

Planning can’t and won’t make revenue magically appear, and the effort you spend creating revenue plans is a distraction from the strategist’s much harder job: finding ways to acquire and keep customers.” Roger Martin

Strategic thinking becomes more important since it focuses on long-term goals of growth and revenue creation, versus the short-term goals from planning. Our focus should be on the top line vs. the bottom line in orthodontics. Certainly, planning on bottom line gains are key components in business where revenue can be profitable for that business. But it is strategy that compels customers to give the company that revenue. The trap for strategy makers lies in the way planning and cost management commonly dominate strategy rather than serve it.

Strategic thinking should be considered regularly to maximize the potential of several components of an orthodontic practice. These should include clinical strategy, financial strategy, marketing strategy, strategy in the implementation of technology, and a strategy in maximizing human capital. Ultimately, who will you target and how will you target them? Those questions help to set your strategy for success.

Styles of Leadership

June 22, 2017 by Sean Holliday Leave a Comment

Find Your Leadership Style

Each team thrives on effective leadership. As we discussed the value of leadership, developing a leadership culture is highly effective in improving the capabilities of your team. Effective management facilitates the processes in an office to achieve success. It is often used interchangeably with leadership, which is a whole different skill. Leadership is a talent that goes beyond job titles and inspires teams to sustain success.

Management is doing things right; leadership is doing the right things.” Peter Drucker

Great teams value a culture of leadership and promote habits that develop leadership. The first step in this development comes from learning who you are as a leader and your favored leadership style. Each style of leadership has its strengths and weaknesses.

Command and Control Leadership

This leadership style is autocratic, and promotes strong team culture. In this style, the leader can be very effective, while at the same time micromanaging the team’s performance. Examples of this type of leader are George Patton and Martha Stewart.

Relational Leadership

This leadership style promotes a “people come first” culture. As opposed to the autocratic nature of the previous style, a relational leader gains employee buy-in by allowing them to be involved in the decisions of the company. They develop a culture where the team follows the leader in a journey together. An example of this leadership style is Tony Hsieh from Zappos.

Expert Leadership

Expert leaders have vast knowledge in their respective field. These visionary leaders use that specialized knowledge to build and guide their teams. Their expert knowledge in the field they are in business motivates those around them to achieve more. An example of this leadership style is Bill Gates, as he led Microsoft.

Charismatic Leadership

This leadership style comes from a leader who inspires greatness in others because of their engaging personality. These leaders use transformational vocabulary that take advantage of their charisma to lead others to success. This style is highly effective in gaining a following and inspiring others. When used by the wrong individual, it can be manipulative and lead to disillusionment. Under the right leader, it can inspire great loyalty and trust. An example of this leadership style was shown by President John F. Kennedy.

Synergistic Leadership

This style of leadership is developed by combining some of the best characteristics of the previous four styles. Those styles have their advantages and disadvantages. By taking the best parts of each style, synergistic leaders have the best chance to achieve great things. The risk to synergistic leaders is that they need to focus to avoid confusion from drawing from too many leadership styles and preventing a consistent message.

Now consider these styles, and get a better sense of what kind of leader you are. What kind of leader do you want to be? Being a synergistic leader can be a great goal, but remember that we are balancing from our own leadership style and the style that our team needs.

Regardless of style, every leader must understand and be willing to implement certain leadership basics. First, they must establish cultures that hold all team members accountable for the outcome of collaborative efforts while also allowing them to participate by providing ideas. Second, they must make sure that there is consistency between their expectations for others and their own actions.” – Don Yaeger, Author, “Great Teams”