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clinical articles • management advice • practice proles • technology reviews
March/April 2014 – Vol 5 No 2
PROMOTING EXCELLENCE IN ORTHODONTICS
Occlusal philosophy:
investigating the
reasons orthodontists
have for occlusion
preference
Drs. Colin M. Webb and
Donald J. Rinchuse
Posterior
occlusal guides
Drs. Larry W. White
and Kim Fretty
Practice profile
Dr. Stuart Frost
The biology of
orthodontic tooth
movement, part 3

Dr. Michael S. Stosich
ClearCorrect
™

correction of a
Class I impinging
deep bite with
crowding
Dr. Colin Gibson
AAO Preview
The use of Propel to
increase the rate of aligner
progression
Dr. Thomas S. Shipley
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March/April 2014 - Volume 5 Number 2
EDITORIAL ADVISORS
Lisa Alvetro, DDS, MSD
Daniel Bills, DMD, MS
Robert E. Binder, DMD
S. Jay Bowman, DMD, MSD
Stanley Braun, DDS, MME, FACD
Gary P. Brigham, DDS, MSD
George J. Cisneros, DMD, MMSc
Jason B. Cope, DDS, PhD
Neil Counihan, BDS, CERT Orth
Eric R. Gheewalla, DMD, BS
Dan Grauer, DDS, Morth, MS
Mark G. Hans, DDS, MSD
William (Bill) Harrell, Jr, DMD
John L. Hayes, DMD, MBA
Paul Humber, BDS, LDS RCS, DipMCS
Laurence Jerrold, DDS, JD, ABO
Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD,
FAMS
Marc S. Lemchen, DDS
Edward Y. Lin, DDS, MS
Thomas J. Marcel, DDS
Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS,
DOrth RCS
Mark W. McDonough, DMD
Randall C. Moles, DDS, MS
Elliott M. Moskowitz, DDS, MSd, CDE
Atif Qureshi, BDS

Rohit C.L. Sachdeva, BDS, M.dentSc
Gerald S. Samson, DDS
Margherita Santoro, DDS
Shalin R. Shah, DMD (Abstract Editor)
Lou Shuman, DMD, CAGS
Scott A. Soderquist, DDS, MS
Robert L. Vanarsdall, Jr, DDS
John Voudouris (Hon) DDS, DOrth, MScD
Neil M. Warshawsky, DDS, MS, PC
John White, DDS, MSD
Larry W. White, DDS, MSD, FACD
CE QUALITY ASSURANCE ADVISORY BOARD
Dr. Alexandra Day BDS, VT
Julian English BA (Hons), editorial director FMC
Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government
for Wales
Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private
Dentistry
Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of
Boots Dental, BUPA Dentalcover, Virgin
Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St
referral implant surgeon
PUBLISHER | Lisa Moler
Email: Tel: (480) 403-1505
MANAGING EDITOR | Mali Schantz-Feld
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Email: Tel: (727) 393-3394

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consequence arising from it. The views expressed herein are those of the
author(s) and not necessarily the opinion of either Orthodontic Practice US or
the publisher.
In today’s image-conscious world, professional adults who did not have the opportunity
for treatment while they were growing up are flocking to orthodontic offices. These new
orthodontic patients are happy with their results posttreatment, according to a recent American
Association of Orthodontists (AAO) survey of individuals who, as adults, had orthodontic
treatment provided by orthodontists:
• Of adults surveyed, 75% reported improvements in career or personal relationships, which
they attributed to their improved post-orthodontic treatment smiles.
• Citing newfound self-condence, 92% of survey respondents say they would recommend
orthodontic treatment to other adults.
The AAO recently debuted a public relations initiative, the Adult Patient Hall of Fame.
The Hall of Fame celebrates the choices of adult professionals who have compelling stories
and who pursued orthodontic treatment from AAO member orthodontists. Inductees include
Amielle Zay Abshire, a private jet pilot in her early 30s who flies celebrity and high-profile
passengers around the world and wanted to greet them with a wonderful smile. Another
inductee, Dr. Steven Couch, is an ophthalmologist affiliated with Washington University in St.
Louis, one of the most prestigious medical centers in the country. Dr. Couch did not have
orthodontic treatment as a youngster, and in his early 30s felt the time was right.
The number of adult orthodontic patients increased 14% from 2010 to 2012, to a record
high of 1,225,850 patients ages 18 and older. More men are also opting for orthodontic
treatment. As of 2012, 44% of adult patients were male, a 29% increase as compared to 2010
survey results. These data are from the 2012 AAO’s “The Economics of Orthodontics” survey.
The AAO is working to ensure that all adults who are candidates for orthodontic treatment
seek out qualified orthodontists when they are ready to begin. The AAO Consumer Awareness
Program, which began in 2006, has utilized national advertising in all types of media, as well
as public relations campaigns and social networking initiatives, to educate the consumer as to

the orthodontist’s unique qualifications. In 2012, the Consumer Awareness Program expanded
its focus beyond reaching parents of children and teens to messaging and media placements
intended for adults who could benefit from treatment.
Ads from the 2012-2013 My Life. My Smile. My Orthodontist.
®
campaign appeared in
national media outlets in the United States and Canada and regional outlets in Puerto Rico. The
ads continued the core message that orthodontists are specialists with advanced training in
straightening teeth and aligning jaws, with many of the ads showcasing adult patients.
The 2013-14 My Life. My Smile. My Orthodontist.
®
campaign is taking a similar approach
and will reach nearly 350 million consumers by this summer. Adult patients are also profiled in a
series of professionally produced testimonial videos that the AAO makes available for member
use and are showcased on the AAO consumer website — mylifemysmile.org.
Data indicate that the My Life. My Smile. My Orthodontist.
®
campaign is having a positive
impact on adult patient decisions about orthodontic treatment. In 2010, Millward Brown, a
research company retained by the AAO, began conducting consumer research designed to
track consumer decisions about orthodontic treatment before and after the launch of the My
Life. My Smile. My Orthodontist.
®
campaign in 2012.
Adults wearing braces and receiving treatment from orthodontists increased from 76% in
2011 to 83% in the third quarter of 2013. Adults utilizing clear aligners and receiving treatment
from orthodontists increased from 56% to 59% during the same time period. The Adult Patient
Hall of Fame and other current initiatives were designed to help expand these positive trends.
Materials from the My Life. My Smile. My Orthodontist.
®

campaign are not just for use by
the AAO. They are also available to develop customized advertising for member practices and/
or for use on member websites and social media pages. Many AAO members use association
materials in local promotion of their practices. Dr. James “Jep” Paschal, current chair of the
AAO Council on Communications, recently offered some insightful remarks on this topic.
“The value of the Consumer Awareness Program (CAP) program for the individual
orthodontist is more than just marketing your practice, although the materials are often very
effective for that purpose,” said Dr. Paschal. “It provides an opportunity to reinforce the AAO’s
national campaign and help shape the thinking of the public so that when people think of
orthodontic treatment, they automatically think of an orthodontist.”
To learn more about the AAO Consumer Awareness Program and customizable marketing
materials, visit the AAO member website www.aaoinfo.org.
Dr. Gayle Glenn
Gayle Glenn, DDS, MSD, has an orthodontic practice in Dallas, Texas, and is
president of the American Association of Orthodontists.
AAO consumer messaging impacts
adults’ orthodontic treatment decisions
1 Orthodontic
practice
Volume 5 Number 2
INTRODUCTION
TABLE OF CONTENTS
2 Orthodontic
practice
Volume 5 Number 2
Clinical
Posterior occlusal guides
Drs. Larry W. White and Kim Fretty
discuss simple, inexpensive, and
patient-friendly supplements to the

Class II corrector armamentarium
18
Research
Evaluating the diagnostic
value of lateral cephalogram
radiographs
Drs. Jay V. Patel, Harold Slutsky,
Jeffrey Godel, Jie Yang, and James
J. Sciote study the necessity of
lateral cephalograms for orthodontic
diagnosis 28
Occlusal philosophy:
investigating the reasons
orthodontists have for occlusion
preference
Drs. Colin M. Webb and Donald
J. Rinchuse delve into functional
occlusal schemes 32
Practice profile 6
Dr. Stuart Frost
Technology, creativity, and patient care are hallmarks of Dr. Frost’s practice
Orthodontic concepts 8
Management of Class 2 non-extraction patients: part 8
Drs. Rohit C.L. Sachdeva, Steve Moravec, and Takao Kubota discuss the
application of SureSmile
®
technology in the management of patients presenting
with Class 2 malocclusions
ON THE COVER
Cover photo courtesy of Dr. Thomas S.

Shipley. Article begins on page 52.
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So the next time you think of innovation in orthodontics, think beyond the bracket. Think GAC.

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4 Orthodontic
practice
Volume 5 Number 2
Case study
ClearCorrect
™
correction of a
Class I impinging deep bite with

crowding
Dr. Colin Gibson presents a case that
previously would need fixed-appliance
therapy 37
Banding together
Thu’s story
After 2 decades, a postcard from
a former patient proves to Dr. Jerry
Clark that changing a smile also
changes a life 40
Product profile
New innovations from Ormco
Corporation 42
Continuing
education
Buccolingual inclinations of
maxillary and mandibular
first molars in relation to facial
pattern
Drs. Lindsay E. Grosso, Morgan
Rutledge, Donald J. Rinchuse, Doug
Smith, and Thomas Zullo investigate
buccolingual inclinations of patients
with dolichofacial, brachyfacial, and
mesofacial vertical facial growth
patterns 43
The biology of orthodontic tooth
movement part 3: the importance
of magnitude
Dr. Michael S. Stosich delves into

the clinical consequences of force
magnitude 50
43
TABLE OF CONTENTS
Product insight
The use of Propel to increase the
rate of aligner progression
Dr. Thomas S. Shipley discusses
increasing the bone remodeling rate
for more rapid aligner progression
52
Service profile
Who is ”minding the store” of your
practice? 58
Materials &
equipment 59
Practice
management
3 reasons you need to re-evaluate
your digital marketing strategy
Diana Friedman discusses ways to
keep online marketing strategies fresh
60
Industry news
Groundbreaking clinical trial
evaluates faster tooth movement
with clear aligner treatment using
AcceleDent
®
OrthoAccel

®
Technologies, Inc.,
enrolls first patients to start 12-week
orthodontic evaluation 64
Buccolingual inclinations
of maxillary and mandibular
first molars in relation to facial pattern
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TREATMENT PLANNING & ANALYSIS CAD DESIGN OF ALL TYPES OF APPLIANCES
What can you tell us about your
background?
My father was a dentist, and my twin
brother and I would go down to his office
when we were teenagers and fool around
in his dental lab. We knew we would be
dentists when we graduated from high
school. I have three brothers-in-law that
are dentists as well. After graduating

from dental school at the University of the
Pacific School of Dentistry (UOP), I worked
with my father for 5 years before going
back to school. I spent a year doing a
TMJD fellowship in Rochester, New York. I
learned how to read MRIs and make splints
to treat patients who suffered from acute
and chronic pain. After that, I completed
my orthodontic residency at Eastman
Dental Center. I have been in practice
for 13 years, and my passion is creating
beautiful smiles.
Why did you decide to focus on
orthodontics?
I have always had a fascination with the
creating process, especially in dentistry.
I loved cosmetic restoration cases as
a general dentist, but I wanted more.
I wanted to be able to create a beautiful
smile without grinding the teeth down
and adding porcelain to create the smile.
The other motivation for me to go into
orthodontics was the fact that patients
want to be at the orthodontist. They love
braces, and it is fun to see them so excited
about improving their smiles. Going to work
each day is a pleasure! Not a downer!
How long have you been
practicing, and what systems do
you use?

I have been practicing for 13 years with the
Damon
™
System.
Who has inspired you?
I have been inspired by Dr. Dwight Damon
and Dr. Tom Pitts. I learned early on in my
career which orthodontists had the most
beautiful cases. Dwight and Tom are two
of the best orthodontists in the world.
What is the most satisfying aspect
of your practice?
The most satisfying aspect of my practice
is the end result. It is very satisfying when
treatment is finished, the final shaping of
the smile and teeth are done, and seeing
the patients so happy with their new smiles.
Professionally, what are you most
proud of?
I love teaching, especially love to teach
the residents at UOP in the orthodontic
department. I am also very proud of being
able to teach other orthodontists how to
be better at using the Damon System and
share what I have learned over the past 13
years.
What do you think is unique about
your practice?
Our practice treats about 50 percent adults.
We pride ourselves on communicating

with them. Additionally, we are now
using Ormco’s Lythos
™
Digital Impression
System to streamline our workflow and
eliminate PVS impressions, which has
helped us enhance the patient experience
and make our practice a state-of-the-art
digital environment for efficient treatment.

What has been your biggest
challenge?
The biggest challenge in practice is the
business side of orthodontics. Also,
working with staff members and assembling
the right team players and keeping them
motivated to succeed.
What would you have become if
you had not become a dentist?
I would have become a plastic surgeon. I
love helping others make positive changes
in their lives, and I could have enjoyed that.
Dr. Stuart Frost
6 Orthodontic
practice
Volume 5 Number 2
PRACTICE PROFILE
The most satisfying aspect of my
practice is the end result. It is very
satisfying when treatment is finished,

the final shaping of the smile and teeth
are done, and seeing the patients so
happy with their new smiles.
PRACTICE PROFILE
Volume 5 Number 2 Orthodontic
practice
7
What is the future of orthodontics
and dentistry?
I still believe that the future of dentistry as a
whole is bright. The future of orthodontics
lies in technology. Patients are willing to
pay for technology, and they recognize
the practices that continually are striving
to keep up on the latest advances in
orthodontics.
What are your top tips for
maintaining a successful practice?
The most important tip for maintaining a
successful practice is patient care. Not
just being good at straightening teeth, but
taking care of the patient from the initial
phone call to the day the braces come off.
What advice would you give to
budding orthodontists?
I would encourage young budding
orthodontists to ask themselves three
questions. What kind of an orthodontist do
you want to be? What kind of orthodontics
do you want to do? Where do you want to

be in 5 years? Write it down!
What are your hobbies, and what
do you do in your spare time?
I enjoy going to the lake and wake surfing.
I love to golf, ride mountain bikes, and
motorcycles. In my spare time, I like to
watch football.
Top Ten Favorites
1. Beautiful smiles
2. Damon
™
Q brackets
3. i-CAT
®
cone beam 3D imaging
4. Lythos
™
Digital Impression System
5. G25 Nautique wakeboard boat
6. Cancun
7. First-class seat
8. Titleist ProV1x
™
golf balls
9. Mexican food
10. Oversized recliner
OP
8 Orthodontic
practice
Volume 5 Number 2

ORTHODONTIC CONCEPTS
Introduction
The Class 2 malocclusion does not simply
manifest itself as a sagittal problem of
the craniofacial complex. Its etiology and
manifestation is a result of a blending of
a complex of elements that also have
a temporal and functional component.
Careful dissection, planning, and manage-
ment of the contributing factors, and
the three-dimensional recognition of the
morphological and spatial components
of the presenting malocclusion play a
significant role in the efficient and effective
care of these patients. Table 1 provides
a list of high-level factors that need to be
considered in formulating a plan of care for
a Class 2 patient.
The focus of this paper is limited to
discussing the application of SureSmile®
technology
1-10
in the management
of patients presenting with Class 2
malocclusions by discussing specific
patient histories.
II. Application of SureSmile in treatment
of patients with Class 2 malocclusion
In general, SureSmile technology provides
five major functionalities in aiding the

orthodontist in managing the care of Class
2 patients (Sachdeva). These are:
A. Decision support with 3D simulations
These simulations provide a visual interface
for the orthodontist to understand the
severity of the presenting a problem in
3D. Furthermore, it augments the doctor’s
ability to plan the nature of Class 2
correction. This may be orthopedic and or
dentoalveolar in nature. The magnitude of
the correction designed in the simulation
is based upon the doctor’s mental
model, reality, research findings, patient’s
expectations, and expected participation
in care, and also the doctor’s skills.
Recognition of the contributory factors
that potentially aid in the correction of
the malocclusion and the directionality of
Management of Class 2 non-extraction patients: part 8
Drs. Rohit C.L. Sachdeva, Steve Moravec, and Takao Kubota discuss the application of SureSmile
®

technology in the management of patients presenting with Class 2 malocclusions
Rohit C.L. Sachdeva, BDS, M Dent Sc, is
the co-founder and Chief Clinical Officer at
OraMetrix, Inc. He received his dental degree
from the University of Nairobi, Kenya, in 1978.
He earned his Certificate in Orthodontics and Masters
in Dental Science at the University of Connecticut in
1983. Dr. Sachdeva is a Diplomate of the American

Board of Orthodontics and is an active member of the
American Association of Orthodontics. He is a clinical
professor at the University of Connecticut, Temple
University, and the Hokkaido Health Sciences Center,
Japan. In the past, he held faculty positions at the
University of Connecticut, Manitoba and the Baylor
College of Dentistry, Texas A&M. Dr. Sachdeva has over
80 patents, is the recipient of the Japanese Society for
Promotion of Science Award, and has over 160 papers
and abstracts to his credit.
Visit Dr. Sachdeva’s blog on http://drsachdeva-
conference.blogspot.com. All doctors are invited to
join the “Improving Orthodontic Care” discussion blog.
Please contact for access
information.
Table 1: Considerations in the management of Class 2 patient treatment
Table 2: Strategies for using SureSmile targeted precision therapeutics to manage the correc-
tion of a Class 2 condition in a patient (Sachdeva)
Volume 5 Number 2 Orthodontic
practice
9
ORTHODONTIC CONCEPTS
their displacement supports the clinician’s
decision in selecting and designing the
appropriate appliance and therapeutic
approach in managing care. Additionally,
various treatment scenarios may be
planned, and the optimal design selected.
Figure 1: Gives an overview of the two most common Clinical Pathway Guidelines – Protocol A
and Protocol B developed by Sachdeva

Figures 2A-2C: Patient PK is an example of Protocol A for Class 2 correction. 2A.
Initial 2B. Class 2 correction is initially achieved using conventional mechanics with
the Forsus
™
spring. Note the distal movement of the upper first molar to correct the
Class 2 molar relationship is achieved prior to engaging SureSmile technology. Once
the correction is achieved, a mid-treatment scan is taken, and a SureSmile archwire is
designed to correct the residual malocclusion
Figure 3: Patient BK. An example of Protocol B using a lower hybrid SureSmile archwire.
Patient presents with a Class 2 subdivision 1 left. 3A. Initial intraoral photographs. 3B. An
initial .017” x. 025” NiTi hybrid lower SureSmile archwire has been designed. It is active
anteriorly to correct the crowding and passive in the buccal segments to hold them stable.
A Forsus™ spring is being used unilaterally on the left to correct the Class 2. Similar to the
lower archwire, the upper archwire is also designed as a hybrid archwire
Figure 4: Patient SK. 4A. Initial intraoral records show that patient presents with a Class 2
Div 1 Subdivision right. 4B. Initial panoramic radiograph
B. Communication
The visual interface provides an extremely
valuable and persuasive approach to
enhance the learning experience of the
patient with regard to her affliction and
also discusses the virtual plan in an
interprofessional environment.
C. Patient management
The visual plan also provides the patient, the
doctor, and the staff with a useful approach
to track and manage the progress of patient
care and, most importantly, to motivate the
patient through the course of care.
10 Orthodontic

practice
Volume 5 Number 2
ORTHODONTIC CONCEPTS
5A: Patient SK. A. Virtual Diagnostic Model (VDM). (Note: The model was scanned
a few months post initial photographs. The patient shows a more severe Class II
relationship in the right buccal segment than is reflected In the intraoral images.)
5B: VDM (blue) vs. VDS (white) are shown. The initial step in the Virtual Diagnostic Simula-
tion (VDS) entailed simulating asymmetric orthopedic changes to partially correct the
Class 2 on the right side while maintaining the Class 1 relationship on the left. Also, in
the inset table, one notes the amount of corrective displacement required to achieve the
desired orthopedic effect
5C: VDS shows post orthopedic correction 5D: VDM (blue) and VDS with dentoalveolar and orthopedic changes (white). The next step
in the simulation involves dentoalveolar correction of the Class 2 malocclusion. Also, note
the slight archwidth changes planned to accommodate for the new mandibular position
5E: VDS shows post orthopedic and dentoalveolar correction
5F: Shows the nature and magnitude of displacements of the dentition to correct the
“dental portion” of the malocclusion
Figures 6A-6C: Patient SK. 6A. Virtual diagnostic model. 6B. Shows correction of midline of VDM through orthopedic
simulation 6C. The archwidths were corrected through dental movement as a continuum of orthopedic simulation
D. Targeted precision therapeutics
SureSmile targeted precision appliances
may be used in six different ways (Sachdeva)
(Table 2) to manage the correction of the
Class 2 malocclusion.
E. Outcome evaluation
SureSmile visual tools may also be used
very effectively to measure treatment
outcome and implement the findings into
a continuous quality improvement initiative
in the practice.

II. Clinical Pathway Guidelines
for managing patients with
Class 2 malocclusion
Effective use of SureSmile technology
mandates the management of a patient
suresmile.com
to be sure.
© 2014 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix.
surezen.
For our most recent detailed suresmile case studies,
please call 888.672.6387.
In the bend resides wisdom.
Dr. Eric Howard
Landcaster, PA
June 2012
Initial intraoral.
July 2012
Planned result.
Upper arch treated lingually.
August 2013
Final result.
Yoga_Ad_Howard_OPUS_FNL.indd 1 2/10/14 2:12 PM
12 Orthodontic
practice
Volume 5 Number 2
ORTHODONTIC CONCEPTS
Figures 7A-7F: Patient SK. Shows the clipping plane in different segments to show the archwidth changes in the VDS
with orthopedic correction and VDS with dentoalveolar and orthopedic changes. 7A and 7D. Clipping plane at the second
bicuspid level. 7B and 7E. Clipping plane at the first molar level. 7C and 7F. Clipping plane at the second molar level
Figure 8: Patient SK. Shows staged linear movements used to monitor the patient’s overjet, crowding, midline correction, and archwidth changes. This

is also a useful tool for the patient to monitor progress of care
Figures 9A-9B: Patient SK. 9A. Mid-treatment intraoral photos at the time of Therapeutic scan. 9B. Mid-treatment X-rays. (Note: Correction achieved with use of asymmetric Forsus
™

appliance.)
by following processes that are defined
by Clinical Pathway Guidelines (CPG).
Exceptions to CPG occur to suit individual’s
needs; however, in most situations, they
provide a reasonable approach to navigate
the care of a patient in a systematic and
progressive manner.
Common to all Clinical Pathway
Guidelines (CPG) to manage patients with
Class 2 malocclusion is the use of the
decision support system to plan care at the
onset of treatment. The type and timing in
use of SureSmile precision archwires varies
and is driven by the dictates of the plan
(Figure 1).
Class 2 Clinical Pathway Guidelines
(Sachdeva) broadly fall under two
categories: namely, a Protocol A and
Protocol B. These are shown in Figure 1.
Volume 5 Number 2 Orthodontic
practice
13
ORTHODONTIC CONCEPTS
Figures 10A-10E: Patient SK. 10A. Virtual Therapeutic Model (VTM). 10B. VTM (white)
was compared with the initial VDS (green) with dentoalveolar and orthopedic changes.

Both the upper and lower arch widths were expanded slightly more than planned. Note:
All objectives were met as initially planned. 10C. Virtual Therapeutic Simulation (VTS)
with prescription archwire designed. 10D. Prescription archwire viewed against VTS. 10E.
Displacement values for VTS
Figures 11A-11C: Patient SK. 11A. Final intraoral photos at debond. 11B. Virtual Final
Model (VFM). 11C. Final panoramic radiograph
14 Orthodontic
practice
Volume 5 Number 2
ORTHODONTIC CONCEPTS
REFERENCES
1. White L, Sachdeva R. Transforming orthodontics-Part 1
of a conversation with Dr. Rohit Sachdeva, Co-founder and
Chief Clinical Officer of Orametrix Inc. by Dr. Larry White.
Orthodontic Practice US. 2012;3(1):10-14.
2. White L, Sachdeva R. Transforming orthodontics-Part 2
of a conversation with Dr. Rohit Sachdeva, Co-founder and
Chief Clinical Officer of Orametrix Inc. by Dr. Larry White.
Orthodontic Practice US. 2012;3(2):6-10.
3. White L, Sachdeva R. Transforming orthodontics-Part 3
of a conversation with Dr. Rohit Sachdeva, Co-founder and
Chief Clinical Officer of Orametrix Inc. by Dr. Larry White.
Orthodontic Practice US. 2012;3(3):6-9.
4. Sachdeva R. BioDigital orthodontics: Management
of Class 1 non–extraction patient with “Fast–Track”©–
six month protocol: Part 5. Orthodontic Practice US.
2013;4(5):18-27.
5. Sachdeva R, Kubota T, Hayashi K. BioDigital
orthodontics: Management of Class 1 non–extraction
patient “Standard–Track”©– nine month protocol: Part 6.

Orthodontic Practice US. 2013;4(6):16-26.
6. Sachdeva R, Kubota T, Hayashi K. BioDigital
orthodontics: Management of space closure in Class I
extraction patients with SureSmile: Part 7. Orthodontic
Practice US. 2014;5(1):14-23.
7. Sachdeva R. BioDigital orthodontics: Designing
customized therapeutics and managing patient treatment
with SureSmile technology: part 2. Orthodontic Practice US.
2013;4(2):18-26.
8. Sachdeva R. BioDigital orthodontics: Diagnopeutics with
SureSmile technology: part 3. Orthodontic Practice US.
2013;4(3). 2013;4(3):22-30.
9. Sachdeva R. BioDigital orthodontics: Outcome
evaluation with SureSmile technology: Part 4. Orthodontic
Practice US. 2013;4(4):28-33.
10. Sachdeva R. BioDigital orthodontics: Planning care with
SureSmile Technology: Part 1. Orthodontic Practice US.
2013;4(1):18-23.
Figures 12A-12B: Patient SK. Outcome Evaluation. 12A. VFM (green) superimposed on
the Initial VDS (white). Note: The final result is quite similar to the proactively planned
treatment. 12B. VDM (green) compared with the VFM (white). Note: The asymmetric
change in the mandible achieved with the unilateral use of Forsus™ helped correct the
asymmetry in the buccal occlusion as well as the midline
III. Patient SK history —
Protocol A
The following is a description of the
management of a patient presenting with
a Class 2 Div 1 Subdivision right using
Protocol A. Patient SK presented as a
12-year-old male pre-peak velocity. The

initial records of the patient are shown in
Figure 4.
The SureSmile decision support
system was used to design a 3D treatment
plan for the patient. The plan, as shown
in Figure 5, considered both orthopedic
and dentoalveolar displacements. Figure
6 shows a close-up view of the midline
correction and the archwidth changes as a
result of both orthopedic and dentoalveolar
movements. In deciding the amount of
archwidth changes, one needs to consider
the buccolingual axial inclinations of
the molar and premolars in the buccal
segments shown in Figure 7. An additional
aspect in planning the care for patient SK
involved developing incremental milestones
to evaluate the progress of care as shown
in Figure 8.
The initial treatment of the patient
began with the use of a unilateral Forsus
™

appliance on the patient’s right side on a
near full sized .017” x .025”, A
f
27ºC NiTi
both in the upper and lower arch with a
.018” bracket. The Class 2 correction was
achieved over a period of 7 months. At

this time, records were taken to initiate the
SureSmile process (Figure 9). The patient
was scanned for the Virtual Therapeutic
Model (VTM), and a Virtual Therapeutic
Setup (VTS) was designed (Figure 10).
Both upper and lower .017” x .025”, A
f

35ºC NiTi SureSmile prescriptive archwires
were installed 8-weeks post Therapeutic
scan and backed up with light Class 2
elastic wear. (The wire should have been
installed a month earlier, but this was
not possible because the patient missed
an appointment.) The SureSmile active
treatment phase lasted 3 months, and
the patient was debonded 4 months from
the initial installation of the SureSmile
archwires.
An outcome evaluation for the patient
was performed by superimposing the
models representing different stages
shown in Figures 12 and 13.
Conclusions
Effective management of Class 2 correction
requires careful planning and execution.
SureSmile technology provides a valuable
technology platform to extend the skill
sets of an orthodontist to accomplish
these goals. Future papers will discuss a

spectrum of patient histories showing the
versatility of using SureSmile technology in
treating patients with Class 2 malocclusions
governed by the philosophy and principles
of BioDigital Orthodontics.
Acknowledgments
The authors thank both Dr. Sharan Aranha
and Maya Sachdeva for the preparation
of this manuscript. The authors are also
grateful to Peter Kierl, DDS, MS, Ortho
(Edmond, Oklahoma); and Darrell Schmidt,
DDS, MS, Ortho (Rhinelander, Wisconsin)
for sharing some of their patient records.
Figures 13A-13F: Patient SK. Outcome Evaluation. 13A and 13D. Clipping plane at the
second bicuspid level. 13B and 13E. Clipping plane at the first molar level. 13C and 13F.
Clipping plane at the second molar level. 13A-13C. VTM (white) vs. VDS (green) and
13D-13F. VFM (white) vs. VDS (green). Note upper left segment is minimally tipped. The
left side is tipped and expanded buccally more than the right side
OP
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Posterior occlusal guides

Abstract
Class II malocclusions make up a large
part of the difficult orthodontic maladies
that clinicians must correct. Traditional
techniques, such as elastics, headgears,
and removable functional appliances, have
recently been supplanted with so-called
noncompliant appliances that are fixed
in the mouth, requiring patients to use
them 24 hours per day. While these fixed
appliances have had remarkable success,
the non-acceptance by many patients, the
frequent breakage, and considerable cost
have discouraged many orthodontists from
routinely using them. Posterior occlusal
guides (POGs) offer a simple, inexpensive,
and patient-friendly supplement to the
Class II corrector armamentarium.
Introduction
For several decades, European orthodon-
tists successfully used removable
functional appliances far more extensively
than their American counterparts for the
treatment of Class II malocclusions. This
was probably due to the fixed appliances
that appealed more to early leaders in
American orthodontics, such as E.H. Angle
and Calvin Case. Over the past 4 decades,
European clinicians have endorsed fixed
appliances far more than in the past.

Although removable functional appliances
have seemingly lost much of their appeal
throughout the world, those of the fixed
variety enjoy remarkable popularity, e.g.,
Herbst
1
, MARA
2
, MPA
3
, Forsus
4
, and so
on.
The fixed functional appliances’
large allure rests upon their cemented
attachments that must remain in the
mouth. Doctors have enjoyed using these
since they obligate patients to wear them
until corrections take place. Because of this
feature, they have acquired the cognomen
of noncompliant appliances. However,
anyone who has treated orthodontic
patients for a minimum of time knows that
Posterior occlusal guides
18 Orthodontic
practice
Volume 5 Number 2
CLINICAL
Drs. Larry W. White and Kim Fretty discuss simple, inexpensive, and patient-friendly supplements to the

Class II corrector armamentarium
Larry W. White, DDS, MSD, graduated from
Baylor Dental College and then served for
2 years in the U.S. Air Force Dental Corps.
He returned to Baylor Dental College and
received a graduate degree in orthodontics,
and then practiced in Hobbs, New Mexico, for 31 years.
He was the first director of the University of Texas
Health Science Center in San Antonio’s orthodontic
residency program. Dr. White has published more
than 100 professional articles, authored several books
about orthodontics, and edited numerous professional
publications. He is a Diplomate of the American Board
of Orthodontists and a Fellow in the American College
of Dentists. Dr. White has authored over 100 clinical
articles, lectured in 35 countries, and was editor of the
Journal of Clinical Orthodontics for 17 years.
Kim Fretty, DDS, is a senior resident at Texas A&M
University, Baylor College of Dentistry, Dallas, Texas.
Figure 1: Note the clear Triad occlusal overlay on the
mandibular premolar that reinforces posterior anchorage
during space closure
Figure 2: Schematic of original Class II subdivision
malocclusion with midline deviation
Figure 3: Posterior teeth with Triad Gel templates that
advance the mandible unilaterally and correct the midline,
overjet, and overbite
Figure 4: Left occlusal template removed to allow
dentoalveolar adaptation
Figure 5: Right occlusal template removed when midline

and occlusion stabilize
Figure 6: Triad Gel
a high level of compliance is needed for
patient acceptance of the noncompliant
mechanisms. There is nothing a clinician
can put in patients’ mouths that they
cannot remove — one way or another.
Although many patients have
used these noncompliant apparatuses
successfully, there are large numbers
that have refused to use them or have
succeeded in developing into “serial
destroyers.” These latter patients break
so many appliances that it finally results in
doctors seeking alternate therapies.
Several features of noncompliant
appliances bear responsibility for patient
non-acceptance:
•thesizeandbulkoftheappliances
•the connection that keeps the maxillary
andmandibularirretrievablyconnected
•theinterferencewithnormalchewingfor
severalweeks
•the unnatural and therapeutic bite it
forcesonthepatient
•parental objections regarding the
restrictedmovementsoftheappliances
 Even with their recent popularity
among orthodontists, these Class II
appliances have a number of negative

featuresthatdiscouragedoctors’use:
•costoftheappliances
•needofalaboratoryprocedure
•patientandparentalcomplaints
•patientrefusaltowearafterplacement
•patientbreakageoftheappliances
•anteriordisplacementofthemandibular
dentition
 Clearly, an alternative to the current
xed functional appliances that is
more patient friendly and easier for the
orthodontic clinician to apply would be
welcome. As with many discoveries in
life, a serendipitous development has
opened new and effective possibilities for
ClassIIcorrectionsthatcanbeusedboth
unilaterallyandbilaterally.
Theory, technique, and
therapeutic examples
Dr. Birte Melsen and Dr. Giorgio Fiorelli
5

were using Triad
®
 Gel (Dentsply) to
augmentanchoragebyincreasingocclusal
pressure on the anchor or reactive part
of the orthodontic appliance (Figure 1)
when Dr. Fiorelli
6

 discovered he could
Figure 7: Triad leaf Figure 8: Original Class II subdivision with a midline
discrepancy
Figure 9: Class II subdivision with midline, overjet, and
overbite corrected and Triad Gel added to the occlusal
surfaces of the mandibular left posterior teeth
Figure 10: Completed therapy with corrected midline,
overjet, overbite, and Class I occlusion on both sides
Figure 11: Typical Class II mixed dentition Figure 12: Maxillary primary second molar removed to
accommodate mandibular template
Figure 13: Maxillary primary second molar sliced to
accommodate mandibular template
Figure 14: Mixed dentition malocclusion Figure 15: Left side with primary molar removed and
template in place
20 Orthodontic
practice
Volume5Number2
CLINICAL
reposition  the mandible and correct
slight midline deviations, overjet and
overbite discrepancies along with Class II
subdivisions by building up the posterior
teeth with Triad Gel while holding the
mandibleinthenewpositionthatcorrected
the midline, overbite, and overjet (Figures
2-7).
 Light-cure Triad Gel is supplied in
a tube with a variety of colors, but many
who use this technique prefer a more
viscous product. Other clinicians express

a preference for the Triad material that
comesasa sheetandiscommonlyused
to make Hawley retainers or splints. The
sheet’sviscositypreventsitfromspreading
uncontrolledandgivestheoperatormore
timetoreviewitsplacementbeforecuring
withthelight.EitheroftheseTriadmaterials
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Volume 5 Number 2
CLINICAL
will form a useful occlusal guide, and the
selection will depend on the clinician’s
experience and choice. Other materials,
such as bonding composites, glass
ionomer cements, and others, can also
serve successfully for POGs.
The posterior occlusal guides, which
Dr. Fiorelli fortuitously developed, act
somewhat akin to fixed functional appli-
ances that can cause temporomandibular
fossae and dentoalveolar remodeling
7-9
.
He reveals this strategy with the following
images of patient therapy (Figures 8-10).
Interestingly, a colleague of Dr. Fiorelli,
Dr. Paola Merlo
6

, expanded on this idea
of posterior occlusal guides and came up
with a brilliant idea for intercepting Class II
malocclusions in the mixed dentition. She
either removes or slices the distal portion of
the maxillary second primary molar, which
allows her to build up a template of Triad
Gel on the lower dentition that encourages
the mandible to slide forward. Figures 11-
17 illustrate how she guides these patients
into Class I occlusion.
Figure 16: Occlusal view of clear Triad
Gel templates
Figure 17: Maxillary occlusal view showing sliced primary
molar
Figure 18: Self-etching sealant used for a
shallow etch. A deep etch makes the removal of
Triad more difficult
Figure 19: Self-etching sealant mixture for
application to the occlusal surfaces of the
mandibular posterior teeth
Figure 20: Curing of Triad
Gel. Note the anterior
incisal wax bite to hold
corrected bite steady
during the light cure
Figure 21: Cured Triad Gel on the mandibular
molar occlusal surface. Note the maxillary molar
indentations of the altered bite
Figure 22: Patient with a Class II subdivision malocclusion and an anterior crossbite

of tooth 2.2
Figure 23:. Before treatment, cephalometric tracing
and the Visualized Treatment Objective (VTO) illustrates
the needed incisor positioning (cross-hatched teeth).
Maxillary incisors are exactly on the A Line and need
only slight torquing to achieve an ideal position and a
slight extrusion. The mandibular incisors need a slight
protraction and intrusion for ideal incisal position
POG technique and application
The following Class II subdivision patient will illustrate one technique for applying POGs (Figures 18-21).
Patient therapy
The images shown in this article display a
sequence of photos during the orthodontic
therapy for a Class II subdivision patient us-
ing Posterior Occlusal Guides (POGs). The
patient’s models display a firm Class I oc-
clusion on the right side, a Class II occlu-
sion on the left side, a lingually displaced
maxillary left lateral incisor in crossbite, and
a maxillary midline deviation to the left. The
patient used .022 Insignia
™
brackets sup-
plied by Ormco
™
. Ostensibly, the Insignia
formula builds first, second, and third order
24 Orthodontic
practice

Volume 5 Number 2
CLINICAL
movements within the brackets and also
supplies customized arch wires for the pa-
tient.
Figure 22 illustrates the original
malocclusion, while Figure 23 displays the
initial cephalometric tracing combined with
the Visualized Treatment Objective (VTO).
The VTO shows that the maxillary incisors
lie exactly on the A Line
10
and need no
facial or lingual movement with only a slight
amount of torque to correctly position the
roots and crowns; and they need only
slight extrusion. The lips have contours that
closely conform to the Holdaway ideals.
11,12

The mandibular incisors can move facially a
slight amount with minimum intrusion.
Figures 24-31 show a series of photos
from the initiation of treatment through
completion of therapy. It took 4 months for
the Class II side to correct into a Class I. No
typical Class II mechanics, e.g., elastics,
functional appliances, or headgears were
used during this first phase of treatment.
The patient used light Class II elastics on

the left side for a couple of months near
the end of therapy, but no other Class II
mechanics were used at any point.
Figures 32A and 32B illustrate the
after cephalometric tracing and the super-
imposition of the before treatment and
after treatment cephalometric tracings.
The superimpositions were made by
superimposing on the line S-N at the
most anterior part of the sella turcica as
suggested by Melsen.
5
Some mandibular
terminal growth is expressed by a
downward and forward movement. The
maxillary incisors extruded and essentially
stayed in place anteriorly-posteriorly. The
mandibular incisors intruded but stayed in
place anteriorly-posteriorly. The maxillary
molars moved forward slightly but did
Figure 24: Models of Class II subdivision patient Figure 25: Patient at treatment initiation with Triad POGs
Figure 26: Patient with POGs after 1 month of therapy
Figure 27: Patient with POGs after 2 months of therapy
Figure 28: Patient with POGs after 3 months of therapy Figure 29: Patient with POGs after 4 months of therapy. No elastics have been used
not extrude, while the mandibular molars
showed little movement at all. Although the
maxillary and mandibular incisors moved
more than the VTO forecast, the extrusion
and position of the maxillary incisors were
the movements indicated by the prediction

as was the slight amount of crown
inclination. The mandibular incisors did
not display the slight forward movement
forecast by the VTO, but they did intrude
as needed. The lips remained essentially
unchanged and conform to the Holdaway
norms for Caucasian females.
Discussion and conclusion
These therapies show the potential and
effectiveness of posterior occlusal guides,
and their ease of application should
soon result in their adaptation by many
orthodontic clinicians. Compared with any
of the available functional Class II correctors