PRACTICE POTENTIAL:

Doctor, How am I going to eat or go out inpublic? I hate this flipper, and I just can'tafford implants or a bridge now. Isn't thereanything you can do for me?

Little Jimmy, age eight doesn't seem to haveenough room for all his teeth. In fact, two ofthem appear to be in cross-bite. Could youexplain to Jimmy's parents why he doesn'thave enough room for all his teeth? Evenmore important, could you treat Jimmy'sproblem?

A patient comes in with a horizontal frac-ture just above the crest of the bone in tooth#8. Because of the patient’s high lip line, itis clear that an extraction or osseoussurgery would severely compromise anesthetic result. Could you save tooth #8?

Everyday we are faced with new challengesthat effect how we deliver our care. Earlytooth loss, drifting teeth, tipped molars, pos-terior bite collapse, anterior flaring, andocclusal trauma are just some of the difficultclinical problems we constantly face. Whenclinical situations like these arise, we mustbe equipped with alternatives in therapy tomaintain a healthy, intact masticatory sys-tem.1 By integrating appliance therapy intoyour armamentarium, you can gain the ver-satility you need to meet these challenges.

In the past, the term “appliance therapy”only referred to the use of simple orthodon-tic appliances like a space maintainer or aHawley retainer. Today, this term encom-passes a wide variety of appliances which areused through every phase of a patient’streatment. Whether you are placingimplants, performing periodontal surgery,or simply doing interceptive orthodontics,you will need to use appliances to help con-trol and direct your patient's treatment.

Last year, The Manual of Appliance Therapyfor Adults and Children was introduced tohelp you integrate the use of appliances intoyour practice. In this Practice Building Bul-letin, I would like to share with you some clin-ical cases that demonstrate many of the inno-vative ways that appliances are being used.

INDICATIONS:

I. Interceptive Orthodontics for Children

a. Simple Space Maintenance

Pediatric space management is often the keyto preventing a serious malocclusion in thepermanent dentition. The early loss of prima-ry teeth can result in a reduction of archlength directly effecting the later eruption ofthe adult teeth. If the permanent teeth are notgoing to erupt within six months of primarytooth loss, appliance therapy is indicated.

The early loss of a tooth is usually due to dentalcaries or trauma and if space loss has notalready occurred, rapid intervention with aspace maintaining appliance is of utmost

importance. If space loss has already occurred,a space regaining device should be considered.

Our clinical case exemplifies the prematureloss of anterior teeth due to Baby BottleSyndrome. On the day of the extraction thedoctor delivered a Groper Fixed AnteriorBridge. Esthetics and strength are the keyadvantages to this popular design. The ante-rior bridge is made extra strong by attachingeach tooth separately to a specially designed,stainless steel pad (a Space Maintainers’exclusive). Each unit is then welded and sol-dered to the arch wire. As you can see, in thephoto taken one week later, the tissue ishealed, excellent esthetics has beenachieved, and the patient is able to maintainnormal speech and function.

Customary Fees and Income Potential:

Space maintenance is a relatively simpleprocedure. Follow-up appointments are gen-erally only needed to keep an eye on thepatient’s growth. The average fee for thistype of procedure ranges between $150 to$400. Even if you only place one appliance amonth you can add up to $4800 each year toyour bottom line.

b. Crossbite Correction

Crossbites are one of the most commonorthodontic problems that we see in grow-ing children. They usually occur as a resultof disharmony in either the skeletal, func-tional, or dental components of the ortho-gnathic system of the child.3

It is essential to treat a crossbite in the pri-mary and mixed dentition. Allowing thismalocclusion to continue into the perma-nent dentition without correction can leadto: occlusal trauma, enamel abrasion orfractures of the teeth, the development ofabnormal chewing and swallowing prob-lems, abnormal growth of the maxilla andthe mandible, the development of a perma-nent dentofacial abnormality and temporo-mandibular joint dysfunction.4,5,6

Many methods have been used to correctcrossbites. These range from the use of anacrylic incline plane for a simple anteriorcrossbite to a rapid palatal expander for asevere posterior crossbite.

The Practice Building Bulletin

continued

(Treatment by Dr. Ron Singer)

THE ECONOMICS OF APPLIANCE THERAPY

(Treatment by Dr. Walt Pfitzinger : How toDo Orthodontics in the General Practice)

In the case shown here, an eight year oldgirl exhibited both an anterior and a posteri-or crossbite. The upper device used to cor-rect these crossbites was a modified expan-sion appliance. Turning the central screwonce a week allowed for bilateral develop-ment of the arch. Posterior occlusal cover-age was used to remove any inhibition totooth movement that might occur as aresult of the occlusion. A recurved finger-spring was used to move the central out ofthe anterior crossbite. Correction of thecrossbites were completed in four months.

Customary Fees and Income potential:

Early treatment of a crossbite can usually bedone rapidly and inexpensively. Although feesare always subject to the cost of doing businessin your area, the average fee for this treatmentaround the country seems to range between$300 and $800. By treating just two patients amonth, you can conservatively add 12,000 dol-lars a year to your practice income.

II. Minor Tooth Movement for Adults

It's a fact that most adults are unwilling toundergo complete orthodontic care. Yetmany of them would love to do something toimprove the way their teeth look. Fortunate-ly, there are minor tooth movement proce-

dures to give your patients the estheticresults for which they are looking.

(Treatment by Dr. David Ouelett)

A typical example of adult minor toothmovement is illustrated here. This patienthas overlapping centrals and two peg lateralsthat are lingually placed. After a diagnosticwax up was completed, it became clear thatthe patient had two choices. He could eitherhave his teeth prepared for four crowns orhe could undergo some minor tooth move-ment followed by the placement of sixveneers. The patient chose the less invasiveprocedure. In this case the orthodontics wascompleted by using a simple Hawley retainerwith distal kickers and finger springs.Retainers of this type can be seen in theIndividual Tooth Movement section of theManual of Appliance Therapy.

Customary Fees and Income Potential:

Depending on the complexity of the case,fees for adult minor tooth movement mayrange between $500 and $1,500. These casescan be the bread and butter of your prac-tice. Don't be surprised if you are soon find-ing at least one case per week. At an averagefee of $750, you can expect to add $39,000 toyour yearly gross production.

III. Bleaching

The introduction of the home bleachingtechnique in March 1989 has opened thedoor for thousands of people to enjoy thebenefits of tooth bleaching without experi-encing the disadvantages of the traditionalin-office techniques.

It is incredible to watch the transformationof a patient with a dull smile to one that isvibrant. Passive tooth bleaching is a proce-dure that can transform an average smileinto an attractive more youthful smile.Enhancing a patient’s smile can do wondersfor that patient's self-image. The power of awhiter, brighter smile cannot be overstated.Notice the dramatic esthetic improvementseen in the following clinical case. Whichsmile would you want to have?

The key to success in bleaching is an excel-lent custom tray that properly holds thebleach against the surface of the teeth. Astock tray or an ill-fitted custom tray willnot accomplish the desired results. An ill fit-ted tray will also subject the patient to tissueirritations that will cause them to return toyour office, consuming your valuable chairtime.

Customary Fees and Income Potential:

How much should the patient be charged forthis procedure? To determine this, askyourself the following questions. What areyour overhead expenses? How much timewill you spend with the patient? How muchchair time will be consumed? I hear feesbeing quoted across the country that rangebetween $200 and $1,000. If you are charg-ing $500 and you treat just two patients amonth, you will add an extra $12,000 a yearto your gross income.

IV. Mouthguards

The purpose of the mouthguard is to reduce

the incidence and severity of injuries duringsports and athletic activities of any type.Intraoral mouthguards have been used foryears to protect against injuries to the teethand lips. Current mouthguard studies showthat by separating the jaws and preventingthe condyles from being displaced upwardand backward against the wall of the glenoidfossa, they are also effective in reducing theforces that can cause jaw fractures, neckinjuries, concussions, cerebral hemorrhage,and even death.7,8

Due to the diversity of sports that can pro-duce oral trauma, it is recommended thatmouthguards be worn by all participants. Every patient in your practice who isinvolved in any athletic activity where con-tact can be made or a fall can occur shouldbe using an athletic mouthguard. Someexamples are baseball, basketball, boxing,rugby, hockey, squash, soccer, racquetball,tennis, lacrosse, karate, judo, volleyball,touch and contact football, bicycling, andskating.

(Case Presented by Dr. Gary Baum)

In the case shown above, the patient’sinjuries occurred while riding a mountainbike. Although she was wearing a helmet,she was not wearing a mouthguard!

Custom formed mouthguards are fabricatedfrom a sheet of polyvinylacetate-polyethy-lene copolymer material and can be formedto fit either the upper or the lower arch byutilizing a vacuum forming machine. Theocclusal surface can be finished to positivelyintercuspate with the opposing arch if thelab is provided with an opposing model andan occlusal bite registration.

Customary Fee and Income Potential:

Average fees around the country range from$50.00 to $150.00 per arch. Just one mouth-guard per week at $150 each equals $7,800

in additional gross.

Many doctors make mouthguards for theirpatients at or below cost because of theireffectiveness as a marketing tool. Some mar-keting ideas I have found effective are to:offer this service to local gyms and sportsclubs; become a school dentist; give talks tocommunity service clubs i.e. P.T.A., Rotary;make the service available to neighborhoodsports teams i.e. soccer, Little League, PopWarner Football. A substantially higherreturn may be expected if the mouthguardservice is used as a method to generate newpatients.

V. Fluoride Delivery System

Fluoride is routinely used in most dental officeswhen a patient comes in for their regular pro-phylaxis. However, many patients need extrafluoride protection on a daily basis.

A typical example of someone who needsextra protection is shown here. This patienthas undergone extensive periodontal therapyand restorative work. To protect thispatient’s investment from the possibility ofrecurrent decay, daily fluoride treatment is amust. I have found that the best method ofdelivery is to use 1.1% neutral sodium fluo-ride in a custom tray for five minutes.2

This technique can effectively help:a) patients with a high caries index.b) patients undergoing periodontal

therapy.c) chemotherapy and radiation therapy

patients.d) patients with tissue recession,

exposed roots, and root caries. e) over denture patients.f) patients with extensive restorative work.g) orthodontic patients.h) patients with a high level of tooth

sensitivity.i) anyone who needs extra hygiene

motivation.

Customary Fee and Income Potential:

Average fees for this service range between$75 and $150. Many doctors regularlyinclude this procedure as part of a patient’streatment. It is estimated that delivering oneset of fluoride trays a week can add up to$7,800 a year to your income.

VI. Splint Therapy

Splints can be used to achieve a variety ofobjectives in the general practice. Bruxismsplints are used to prevent excessive toothwear, tooth mobility, and loss of tissueattachment.9 Stabilization splints are usedafter periodontal surgery to distributeforces, decrease trauma, and aid in the heal-ing process.10 They are also used inorthodontics as a form of final stabilization.10

Patients with TMJ dysfunction, i.e. patientswho suffer from local (neck, shoulder, orsinus) pain, clicking in the joints, pro-nounced malocclusion, impaired excursionin opening of the mouth or deviant motionsof the jaw are also regularly treated withsplint therapy.

Splints come in a variety of designs. Tradi-tionally, they have been made from a hardacrylic or a soft polyvinyl material. The hardacrylic splints provide the patient with anadjustable occlusal surface but usuallyrequire substantial chair time to make theappliance fit comfortably. The soft splints,although more comfortable for the patient,do not lend themselves to adjustment andrepair.

(Treatment by Dr. Rob Veis)

In this example, the patient is wearing thenew Talon Splinttm to protect his six anteriorveneers from any abnormal occlusal forcesduring sleep. The Talontm Splint’s internallayer is a soft, thermoplastic, resilient poly-mer while the outer layer forming theocclusal surface is made of hard acrylic.10

The Talontm Splint should be used when youneed:

1. A splint with a superior fit - the softnature of the retentive portion of theappliance completely eliminates pres-sure points and thus the patient adaptsimmediately. No longer will you haveto spend time trying to find “tightspots” on the appliance due to modelimperfections. You will find that yourdelivery appointments will be reducedgreatly over conventional hard splints.

2. Positive retention without the use ofmetal clasps.

3. The ultimate in comfort - a Talontm

Splint has the best features of a softsplint yet it allows for excursive move-ments free of the friction inherent inpolyvinyl splint designs.10

4. An appliance that can be made in amanner that will not interfere with yourpatient’s ability to speak normally.Because retention is superior, thisappliance can be designed withoutspeech inhibiting lingual extensions.This is greatly appreciated by your adultpatients.

Customary Fee and Income Potential:

Fees vary greatly depending upon the condi-tion being treated, i.e Bruxism splint - $400to $600, TMJ splints - $400 to $1,000 ormore depending on the diagnostic, thera-peutic, and restorative procedures required.Just one splint of any type per week will addover $20,000 to your practice by year’s end.If you choose to do TMJ therapy, one patientper month will add an additional $40,000 ormore.

VII. Sleep Apnea

Perhaps one in every 10 adults snores andfor most, snoring has no serious medicalconsequences. However, for an estimatedone in 100 persons, habitual snoring is thefirst indication of a potentially life threaten-ing disorder called “Obstructive SleepApnea.”11

In obstructive sleep apnea, the muscles ofthe oropharynx, hypopharynx, and tonguerelax and sag, obstructing the airway andmaking breathing labored and noisy.11 Col-lapse of the airway walls blocks breathingentirely. When breathing stops, a listenerhears the snoring broken by pauses. Aspressure to breathe builds, muscles of thediaphragm and chest work harder eventuallyuncorking the airway. The effort is akin tosipping a drink through a floppy straw. Witheach gasp, the sleeper awakens but so brieflyand incompletely that he/she usually doesnot remember doing so in the morning.11

Because the etiology of obstructive sleepapnea is multifactorial and the treatmentoptions are varied, proper diagnosis andtreatment are best handled by a team

approach. Members of this team mayinclude a Sleep Specialist, an ENT, aninternist, a speech pathologist, an orthodon-tist, an oral surgeon, and a general dentist.As a general dentist, you should play anactive role in all three stages of apnea thera-py: screening, diagnosis, and treatment.

Research has shown that many appliancesare quite effective in treating snoring andobstructive sleep apnea. In fact, sleep appli-ances offer several advantages over othertherapy choices. They are inexpensive, non-invasive, easy to fabricate, reversible, andquite well accepted by patients.

Sleep appliances seem to work in one or acombination of three ways. They eitherchange the position of the soft palate, repo-sition the tongue forward directly, or altermandibular position causing a change intongue position.

The appliances seen here are called the SnoreFree and the UCLA Modified Herbst. Bothappliances are designed to posture themandible forward and prevent it from retrud-ing during sleep. This mandibular resposi-tioning brings the tongue anteriorly andopens up the airway.11 These appliances canalso be used as a diagnostic tool to determinewhether orthognathic surgery is indicated.An excellent protocol for the use of dentalappliances has been established by the SleepDisorders Dental Society. We highly recom-mend that you follow their guidelines.12

The Snore Free Appliance

The UCLA Modified Herbst Appliance

Customary Fees and Income Potential:

Fees for treating obstructive sleep apnearange between $900 to $1,500 for the initialtreatment which includes the dental recordsand placement of an appliance. This does notcover out-of-office services such as sleepstudies, tomograms/ceph x-rays, and anymedical consultations or procedures.

This hidden source of income in your prac-tice is huge. Remember one in every tenpeople snore and one in every hundred peo-ple suffer from obstructive sleep apnea.

VIII. Temporary Partials

Temporary removable partial dentures servemany useful purposes and are an integralpart of any prosthodontic treatmentplan.13These appliances are classified accord-ing to the purpose for which they are used.The three types of temporary removable par-tial dentures are the interim, transitional,and treatment partial.13

An interim partial is used to:

1) maintain space.2) re-establish occlusion.3) replace visible missing teeth while

definitive restorative procedures arebeing accomplished.

4) serve the patient while he is undergo-ing periodontal or other prolongedtreatment.13

5) condition the patient to wearing aremovable prosthesis.

6) when healing is progressing after anextraction or a traumatic injury.

7) maintain function while accomplishingminor tooth movement.

The transitional partial denture is plannedwhen some or all of the remaining teeth arebeyond the point of restoration but immedi-ate extractions are not indicated for physio-logic or psychologic reasons.14

For example, this treatment plan can beused effectively on an elderly patient suffer-ing from a chronic debilitating diseasewhere multiple extractions could exacerbatethe basic illness.

Another example where a transitional partialis appropriate would be for those who arepsychologically unable to accept the loss oftheir teeth. In the mind of many people, thepresence of teeth is related to sex appeal,youth, and happiness. If the patient is trulyconcerned over the loss of his/her teeth, butthe loss is inevitable, treatment should becarried out over as long a period as possible.The use of a transitional denture will enableyou to accomplish this goal.14

The treatment partial denture may be usedas a vehicle to carry tissue treatment materi-al to abused oral tissue, as a splint followingsurgical corrections in the oral cavity and toincrease or restore the vertical dimension ofocclusion on a temporary basis while theresults of the increase can be observed.14

The example shown here is of a patient whohas extensive periodontal disease. A transi-tional partial has been designed which willallow the dentist to inexpensively add teethto it as it becomes necessary. At the sametime, this partial gives the patient the

esthetics and function he needs to be out inpublic.

(Treatment by Dr. Rob Veis)

Customary Fees and Income Potential:

$500 to $750 per appliance is a reasonablefee depending upon the type and length oftreatment. For example, a tissue treatmentpartial which is being used to treat papillaryhyperplasia may only be used for two tothree weeks. The fee for this would be farless than for an interim partial that is beingused to accomplish minor orthodonticmovement. Longer treatment time and peri-odic adjustments would command a muchhigher fee.

In most general practices, there is not aweek that goes by where an interim, transi-tional, or treatment partial would notenhance the quality of your patient care. Atthis conservative rate, you can expect to adda minimum of $34,000 to your yearly grossincome.

IX. Temporary Bridges

Simple space maintainers, which are morecommonly used after premature loss of pri-mary teeth, can also be used quite effectivelyas interim bridges for your adult patients.

Some common uses for interim bridges are:1) to maintain space when a patient can

not afford a traditional bridge.2) to re-establish the occlusion by prevent-

ing the super-eruption of the opposingdentition.

3) to replace visible missing teeth whiledefinitive restorative procedures arebeing accomplished.

4) to stabilize an area until periodontaltherapy is complete and a decision onthe best restorative technique can bemade.

5) to maintain space and protect a surgicalsite while healing is progressing after anextraction or a traumatic injury.

6) to maintain an implant site.

(Treatment by Dr. Rob Veis)In the example shown here, the patientexperienced a traumatic blow to the mouth.After a surgical extraction and a ridge aug-mentation were completed, an interimbonded bridge was placed to protect the sur-gical site. This technique was used for tworeasons. First, a bonded bridge will prevent

any pressure from being placed on the aug-mentation site. Second, the patient was anattorney and could not have an appliancethat would interfere with his ability to speak.

Customary Fees and Income Potential:

How many times do you encounter a patientthat for personal reasons cannot proceedwith the treatment that you have plannedfor them? Temporary bridges give you theflexibility to keep these patients actively inyour practice. Just two interim bridges amonth can produce up to $12,000 a year ingross revenue.

X. Forced Eruption

There are several common methods avail-able to manage a tooth which is severelybroken down or periodontally involved.These include extraction of the remainingroot followed by a prosthetic replacement,and techniques to expose sound tooth struc-ture such as an osseous surgery or a forcederuption.

Forced eruption is the use of gentle, contin-uous orthodontic forces in a coronal direc-tion. This movement can change the archi-tecture of both the hard and the soft tissuesallowing you to alter or eliminate an isolatedperiodontal defect. This coronal movementalso gives you the ability to restore a toothwith lost tooth structure at or below thebony crest.1

For example, after forced eruption, peri-odontal surgery can be performed exposingsound tooth structure without sacrificingbone on the adjacent teeth. The soft tissuecan then be sutured to blend with the gingi-val margins of the adjacent teeth to producean acceptable esthetic result.

There are several methods for eruptingteeth. The dentist can choose either a fixedor removable appliance depending upon theclinical situation.

Removable appliances are used when brack-eting teeth for anchorage is either inappro-priate or not possible. For example, placingbrackets on porcelain veneers or crowns iscontraindicated as the bonding process willdamage their finish.

Sometimes patients do not have enoughteeth to use as an anchor. This happensquite frequently in partially edentulouspatients where one of the remaining abut-ment teeth needs to be restored.

In both these cases, a removable applianceallows you to use the soft tissue, teeth, andthe appliance to form an anchor while anactivating spring can be used to engage thetooth to be erupted.

In our clinical example, a fixed approach wasused to erupt a cuspid. Using fixed direct bond

brackets and sectional arch wires, an otherwisenon-restorable tooth can be repositioned coro-nally. Because crestal bone comes along withit, osseous surgery can be accomplished with-out sacrificing the bone around the adjacentteeth. This decreases the chances of sensitivity,enhances the final esthetic results, and elimi-nates the need to prepare any other healthyteeth for the bridge.

(Treatment by Dr. David Levine)

Customary Fees and Income Potential:

Your fee for this procedure will depend uponthe type and number of appliances, and theestimated length of treatment time. Fees ofcourse will vary depending on your area.Remember that there will usually be a surgi-cal procedure needed as well. In talking withdoctors around the country, fees for thisprocedure range between $300 and $600.

Adding forced eruption to your restorativeskills will give you the flexibility to treatthose tough cases which would otherwise beunrestorable. General dentists usually findthe orthodontic eruption part of this proce-dure to be easy and predictable. However,most of us are uncomfortable performingesthetic periodontal surgeries. This offersyou a great opportunity to work closely withyour periodontist. What you will soon find isthat your periodontist will become one ofyour best referral sources.

Together, you will create esthetic resultsthat you just could not achieve on your own.The results will be beautiful smiles and hap-py patients who will spread the good wordabout your work.

XI. Molar Uprighting

The mesially inclined 2nd molar is one ofthe most common dental maladies in theadult population. This occurs because thefirst permanent molar is often extracted inchildhood due to decay. In the adult, thefirst molar is often lost because of endodon-tic failures, multiple restorative attempts,decay in the buccal and lingual furcation,and advanced periodontal disease. Withouttimely replacement or provisions for spacemaintenance, the second molars driftmesially and tip. When this occurs, archintegrity is lost and teeth begin to shift.

The typical clinical picture consists of extrusionand migration of teeth, accelerated mesial drift,uneven marginal ridges, angular bony crests,altered coronal to gingival form, foodimpaction, caries, periodontal disease, and ulti-mately posterior bite collapse with loss of theocclusal vertical dimension.15

Molar Uprighting Fixed Appliance

Molar uprighting can be accomplished usingeither a fixed or a removable appliance. Thefixed appliance shown above can successfullyupright a molar tipped up to sixty degrees,eliminate an isolated periodontal pocket andrealign the occlusal forces along the longaxis of the molar

Uprighting Partial

There are times when the fixed applianceapproach to molar uprighting is either inap-propriate or not possible. For example,when a patient does not have enough teethto act as an anchor unit, a removable partialwith an expansion screw like the one shownabove can be used.

Fixed Removable Molar Uprighter

Even when stabilizing teeth are present, moreanchorage is often needed to upright a severe-ly tipped molar. When this is the case, afixed/removable approach can be used. Here,an uprighting spring inserts into a fixed molarbracket which has a tube or slot; the springthen hooks onto the removable appliancewhich provides the needed extra anchorage.

All of us see mesially tipped molars on a dai-ly basis. Given the fact that most orthodon-tists prefer not to do these adult limitedtreatment cases and that they usually dothem only as a courtesy to you, perhaps it istime for you to consider learning how toupright a molar. It is the proper thing to dofor your patients’ dental health, it willenhance the final results of your restorativeprocedures, and it can be very financiallyrewarding.

Customary Fee and Income Potential:

Your fee for this procedure will depend uponthe type and number of appliances (fixed,removable, or combination) and the estimat-ed length of treatment time. Fees will alsovary from area to area. Some practitionersdiscount their fee if they are planning to dothe final restorative work. In talking withdoctors around the country, fees for this ser-vice range between $750 and $2,000.

I have never met a dentist that did not haveat least several patients that could benefitfrom molar uprighting. In most practices,there are dozens of candidates for molaruprighting and the income potential is con-siderable.

Integrating these simple techniques intoyour routine treatment will open up a wholenew world of restorative dentistry for you.Instead of leaving an area untreated or plac-ing a compromised bridge or partial, younow have the flexibility to offer your patientsideal prosthetic care. Happy patients refer.This is one of the best practice building pro-cedures in dentistry.

XII. Implant Appliances

Today, it is considered the standard of careto offer patients the option of having animplant when they have lost a tooth. In fact,implantology is one of the fastest growing

fields in dentistry. Placing and restoring animplant requires planning. You will need touse every diagnostic tool at your disposal tohave a successful result. Many appliances arenow available to help you have greater con-trol over your implant therapy.

a. Implant Stents

Implant stents can be used with CT scansand during surgical procedures to aid in theproper placement of implants. It is generallyaccepted that a CT scan, used in conjunctionwith special imaging, can produce invalu-able information for pre-surgical planning ofosseointegrated implants.

(Treatment by Dr. Monroe Sternlieb)

In our clinical example, the surgeon is usinga stent as a guide for implant placement.Remember this appliance is a representationof your desired prosthetic result. It is impor-tant to take the time to make sure that thisis correct.

Surgical stents are designed in the samemanner as a scanning appliance with theexception that radiopaque markers are notneeded. In fact, most surgeons simply modi-fy their CT stent and use it during surgery.Of course surgical stents can be modified tomeet the surgeons’ needs. For example,some surgeons prefer occlusal coverage overthe existing teeth, while others want theappliance to have full palatal coverage. SpaceMaintainers will construct your stent toyour exact specifications.

b. Interim Implant Appliances

Interim implant appliances have also beendesigned to give you flexibility in your treat-ment. Appliance selection will depend on thestage of treatment and the desires of thepatient.

(Treatment by Dr. Rob Veis)

The completely removable design shownabove is retained with wrought wire claspsand can be used through all the stages ofimplant therapy. This appliance affords thepatient the advantage of an excellent esthet-ic appliance with no speech impeding lin-gual acrylic as found in regular partials.

Customary Fee and Income Potential

Fees for surgical stents are generally kept toa minimum. However, when a stent is beingused for a CT scan to determine if there isenough bone for the proper placement of animplant, a separate charge is appropriate.Fees for this stent range between $300 and$500. Fees for interim implant appliancesrange between $500 and $1,000. Even if youare starting only one new implant case amonth, you can add up to $12,000 to yourgross production a year.

CARE FOR APPLIANCES

Both fixed and removable appliances needspecial care. All of our appliances are sentwith our patient instruction care booklet “APassport to a Healthy Smile.”

Fixed Appliances:

Whether your patient is undergoing com-plete fixed orthodontics, is having anteriors

splinted with a Maryland splint, or spacemaintained with an interim bridge, all fixedappliances will demand special oral hygienecare. We highly recommend the use of fluo-ride with a tray delivery system to help pre-vent caries activity.

Removable Appliances:

1. Never allow the appliance near hightemperatures or allow it to dehydratefor more than 24 hours.

2. All appliances should be kept moistwhen not in use. A retainer case worksnicely. The patient should simply placethe appliance in the case with a smallpiece of wet paper towel.

3. All appliances should be cleaned everyday. A soft brush and toothpaste, orsoaking in a cleaner, like Clean andFresh, is all that is needed.

4. Removal of the appliance is best accom-plished by using equal pressure on bothsides of the mouth. This will minimizethe chance of damage to the resilientportion of the appliance.

LAB REQUIREMENTS

Space Maintainers’ goal is to give you the bestservice possible. To help us get your lab workback to you on time, we need the following:

1. A detailed prescription. If you are hav-ing a problem designing an appliancehave a look at our Practice BuildingBulletin called The Appliance TherapyWorksheet. By using this worksheet,with a little practice, you'll have no dif-ficulty designing an appliance.

2. The date wanted and the patient’sappointment date. If there is a problemin meeting the due date the lab will call.We will then choose a delivery method,such as Airborne, that will get the workto you on time.

3. Accurate casts poured in stone that cap-ture all the teeth and land areas. Airbubbles or holes on tooth surfaces areunacceptable as they can negativelyeffect the fit of the appliance.

4. Provide a carefully taken construction bitethat represents the exact vertical and APposition that you desire in the finishedappliance. This is the single most impor-tant step to successful treatment aftermaking the correct diagnosis.10Check thecompleted construction bite by placing itback on the working models. Then care-fully wrap the bite separately for ship-ment.

LAB FEES

Lab fees range from $20 for a simple spacemaintainer to $200 for a UCLA Sleep appli-ance. The average cost for an upper and low-er appliance is $75 per arch.

SUPPLY LIST

Whether you have been practicing for one month or forty years, youwill find that you already have almost everything on this supply list. Besure to take a moment and review it. Is there a favorite instrument thatyou use that I have left out?

*available through Success Essentials catalog.

CONTRA INDICATIONS AND CONCERNS

1) Careful diagnosis and treatment planning are the key elements tosuccess. Before becoming involved in treatment, the patientshould be informed of the total treatment required including peri-odontal, orthodontic and prosthetic therapy.

2) For appliance therapy to work, all care givers must work closelytogether. This integrated method of treatment will help you deliv-er the best care possible.

3) Before beginning any appliance therapy, thorough root planingand curettage must be completed to eliminate all inflammation.If the inflammation is not controlled, tooth movement can resultin irreversible crestal bone loss. This will probably cause moreharm than benefit to the patient.

4) All new or recurrent caries should be treated prior to the fabrica-tion of an appliance. Generally the younger patient is even moresusceptible to caries when wearing an appliance. Adequate pro-phylactic measures must be taken such as fluoride treatments toprevent decalcification and caries in the teeth contacted.

5) Temporary bridges must not interfere with normal hygiene. Toassure this, we recommend that the bands for these appliances belab made. Only in this way can we assure that proper contoursand embrasure spaces will be respected in the appliance fabrica-tion.

6) Appliances can only be effective when they are properly designedto adhere to the principles of retention, force application andanchorage.4 Therefore, it is very important that some form ofretention be placed as near as possible to the active components ofthe appliance.

7) When using clasps for retention, care should be taken not to inter-fere with the patient’s normal occlusal pattern. Occlusal interfer-ences will usually cause the patient not to wear the appliance.4

8) A removable appliance must never be unilateral. A unilateralappliance offers a definitive hazard because the patient may swal-low or aspirate the prosthesis.

9) As with all appliances, patients should be checked on a regular basis tobe sure your treatment objectives are being met.

THE ECONOMICS OFAPPLIANCE THERAPY

Throughout this bulletin, I have tried to give you an idea of howadding appliance therapy to your practice can dramatically affect yourincome. Add the figures up yourself. Even being extremely conserva-tive, by doing just one of every procedure mentioned in this bulletin,each month you will increase your practice income by over $150,000a year!

By Rob Veis D.D.S.Director, Practice Development

REFERENCES:

1. Marks, Corn: Atlas of Adult Orthodontics, Philadelphia, Lea & Febiger, 1989. Chapter 19, pp413- 447.

2. Franzetti,J.J.: Periodontal Considerations and Guidelines for Therapy. Dental Clinics of NorthAmerica, Vol. 29, No.1, Jan 1985.pp 17-38.3. Graber, Orthodontics: Principals and Practice, Ch17, pp 833-847, Philadelphia: W.B. Saunders Co., 1972.

4. Major,Glover: Treatment of Anterior Crossbites in the Early Mixed Dentition, Journal ofPedodontics, July 1992,Vol.58, No 7, pp 574-579.

5. Payne, Mueller, Thomas: Anterior Crossbites in the Primary Dentition, The Journal ofPedodontics, Summer, 1981, pp281-291.

6. Croll, Fixed Incline Plane Correction of Anterior Crossbite of the Primary Dentition, The Jour-nal of Pedodontics, Vol 9: 84,1984, pp 84-94.

7. Chapman, P.J.: Mouthguards and the Role of the Sporting Team Dentists. Australian DentalJournal. Vol. 34, No. 1, pp 36-43, 1989.

8. McCarthy,M: Sports and Mouthguard Protection. General Dentistry, Vol. 38, No. 5, pp 343-346,Sept/Oct 1990.

9. Space Maintainers Laboratory: Manual of Orthodontic and Pedodontic Appliances, 1990. Tech-nical Bulletin- The Taking of a Proper Construction Bite.

10. Marks, Corn: Atlas of Adult Orthodontics, Philadelphia, Lea & Febiger, 1989. Chapter 5, pp147-159.

11. Lamberg, L.: Sleep Apnea Symptoms, Causes, Evaluation, Treatment. Rochester, MN, Ameri-can Sleep Apnea Disorders Association, 1988.

12. Clinical Protocol for Dental Appliance Therapy for Snoring and Obstructive Sleep Apnea, SleepDisorders Dental Society, 11676 Perry Hwy Bldg. Wexford PA 15090, 412- 935-0836.

13. Henderson, D.: McCracken's Removable Partial Prosthodontics, 6th Edition, C.V. Mosby Co.,St.Louis, 1981, pp 418-422.

14. Stewart, K.: Clinical Removable Partial Prosthodontics, C.V. Mosby Co., St. Louis,1993, pp 536-572.

15. Marks, Corn: Atlas of Adult Orthodontics, Philadelphia, Lea & Febiger, 1989. Chapter18, pp 391-412.

Appliance Type Fee Range/Treatment Estimated potential/yearSpace maintenance $150 - 400 $4,800Simple crossbite $300 - 800 12,000Adult minor tooth movement $500 - 1,500 39,000Bleaching splints $200 - 1,000 12,000Mouthguards $50 - 150 7,800Fluoride trays $75 - 150 7,800Bruxism splints $400 - 600 20,000TMJ splints $400 - 1,000 40,000Obstructive sleep apnea $900 - 1,500 24,000Temporary partials $500 - 750 34,000Temporary bridges $300 - 600 12,000Restorative enhancing $750 - 2,000 24,000Surgical stents $300 - 500 12,000

Total Potential $249,400(Yearly potential amounts are estimated based on my personal experi-ence in a solo practice using an average fee in US Dollars)

[ ] Appliance therapy design work-sheet*

[ ] Alginate*[ ] Mixing bowl and spatula*[ ] Dental stone[ ] Vibrator*[ ] Impression trays*[ ] Tray Tree*[ ] Bite registration material[ ] Bite sticks*[ ] Elastic separators*[ ] Articulation paper[ ] Diamond burs[ ] Acrylic burs*[ ] Acrylic repair kit*[ ] Pressure pot*[ ] 139 Bird beak pliers*[ ] Three prong pliers*[ ] Expansion screw key*[ ] Stiff Robinson brush*[ ] Micro-screw screwdriver*[ ] Boley gauge or diagnostic caliper*[ ] Cheek retractors*

[ ] Pumice[ ] Etchant*[ ] Fluoride releasing band cement*[ ] Pedo shade guide*[ ] Adult shade guide[ ] Posterior composite[ ] Composite resin for bonding fixed

brackets eg.one step*[ ] Emergency Bracket Kit (upper and

lower brackets with archwires)*

[ ] Cotton pliers or bracket placementtool*

[ ] Elastic ligatures*[ ] Needle nose hemostat or ligature tie

placement forceps*[ ] White utility comfort wax or brace

relief*[ ] Direct bond bracket removing plier*[ ] High speed finishing burs[ ] Abrasive polishing discs [ ] interproximal stripping tool*[ ] Clean and Fresh Appliance Cleanser*

The Practice Building Bulletin is a special service of Space Maintainers Laboratory pro-duced solely for the private use of our clients. It is designed to help expand and enhanceyour ability to provide comprehensive patient care. As an active client, you will continue toreceive all future editions at no charge. Subscriptions are available and includes a freethree-ring binder with all back issues to date. Information included is the opinion of theauthor and may not be reproduced in any form without written consent.

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Vol.II Number 6 • Chatsworth, California

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