CE: Expand Your Reality by Dr. Michael K. DeLuke

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Comparing expansion options for maxillary and mandibular arches

by Dr. Michael K. DeLuke

Short course description
Part 1 of this series described the need for a shift in our approach to the interceptive orthodontic treatment of preadolescent patients, in which we move from treating the patient’s symptoms to treating the etiology of the presenting malocclusion. In this installment, the traditional approach of using rapid maxillary expansion (RME) to address a transverse maxillary defficiency will be evaluated and contrasted with slow maxillary expansion (SME) using lighter, more physiologic forces. Expansion of the mandibular arch during interceptive treatment will also be explored, as will the use of braces and wires to predictably, safely and comfortably address deficient arch width in the early mixed dentition.

Synopsis
Rapid maxillary expansion (RME) is the traditional and most common method of correcting a transverse discrepancy in preadolescent patients, whereby heavy forces are delivered rapidly to the maxilla over a short period of time. Yet numerous studies have shown these heavy forces to be dangerous and destructive to the immature facial bones of younger patients. Slow maxillary expansion (SME), by contrast, delivers lighter, safer, more physiologic forces over a longer period of time. However, traditional methods of SME are often cumbersome, uncomfortable, imprecise and difficult to adjust and calibrate.

Additionally, while it’s extremely common for the mandibular arch to be constricted in younger patients, many providers don’t try to expand the mandibular arch during interceptive treatment. Those who do are likely to find mandibular expansion appliances clinically challenging for the provider and unpleasant for the patient.

Full-fixed appliances (braces and wires) are an often overlooked yet minimally invasive and well-tolerated way to expand constricted arches in preadolescent patients who present in the early mixed dentition. Cases will be presented to demonstrate the efficacy and stability of this technique, and the need for additional research into this approach will be discussed.

Learning objectives
At the end of this course, you should be able to:

Explain why slow maxillary expansion is preferable to rapid maxillary expansion in younger (i.e., preadolescent) patients.
Describe the biological differences between rapid and slow maxillary expansion.
Understand the importance of addressing a transverse discrepancy in the mandibular arch as part of interceptive treatment.
Determine which patients can benefit from interceptive treatment to expand the maxilla and the mandibular arch.
Recognize the advantages of using full-fixed appliances over traditional “expanders” when performing interceptive treatment on preadolescent patients in the early mixed dentition.

Introduction
Most orthodontists agree that a unilateral or bilateral posterior crossbite caused by a narrow maxilla should be addressed with interceptive treatment to expand the maxilla during the early or mid-mixed dentition. The typical treatment involves rapid maxillary expansion with a Hyrax-type appliance to apply very heavy forces to the patient’s midpalatal suture. However, it is important to consider both whether the application of this magnitude of force is necessary to expand the immature and patent palatal suture of a younger child and whether delivering lighter forces via slow maxillary expansion is a superior alternative.

Additionally, it is not uncommon for a preadolescent patient to present with a transverse deficiency in the mandibular arch. Yet many orthodontists do not believe that it’s practical, or even possible, to expand the mandibular arch, despite decades of research to substantiate its safety, efficacy and stability. Consequently, when the mandibular arch is allowed to remain narrow, the amount of maxillary expansion that can be achieved is significantly limited. This not only leaves insufficient space for the tongue and the erupting permanent teeth but also permits continued aberrant growth of the craniofacial complex.

The data are clear that the ideal time to address a transverse deficiency is when the patient is a preadolescent in the early mixed dentition, because it requires less force to achieve an orthopedic effect in younger patients and allows for arch development to occur before the eruption of a majority of the succedaneous teeth, including the permanent canines. Unfortunately, however, traditional expansion appliances are often uncomfortable for the patient and can be challenging for the clinician. As such, it is necessary to explore alternative treatment modalities that can both deliver light forces and allow the practitioner to predictably, effectively, comfortably and stably expand the arches of younger patients.

Rapid maxillary expansion
Rapid maxillary expansion (RME) involves delivering very heavy forces over a relatively short period of time. While such heavy forces are often necessary to achieve orthopedic expansion in a more skeletally mature adolescent, they can be damaging to the immature craniofacial complex of younger children. Isaacson and Ingram reported that single activations of a jackscrew-type appliance produce forces in the 3-to-10-pound range with accumulated loads of more than 19 pounds¹—a tremendous amount of force to deliver to a young face.

Storey concluded that from a histological perspective, RME is a “predominantly destructive process” whereby the sutural connective tissue becomes disrupted and edematous, and blood vessels hemorrhage into the extravascular tissue. He emphasized the importance of force control during expansion and added that less force is required to achieve palatal separation before the fusion of the palatal suture.²

Proffit took it a step further when he stated that using RME in young children is a “disadvantage” and can cause “facial distortion.” He added, “There is no evidence of any advantage of rapid movement and high forces in children and ample evidence that this can be dangerous.” He concluded that slow expansion is the preferred approach to maxillary constriction in children with primary and early mixed dentitions.³

Most orthodontists have observed first-hand the facial distortion referenced by Proffit. Interestingly, however, many providers continue to use RME to address a transverse maxillary deficiency in preadolescent patients despite the excessive force being delivered and the risk of negative clinical outcomes.

Slow maxillary expansion
Slow maxillary expansion (SME), by contrast, involves delivering lighter forces over a longer period of time and has been found to be an effective and less traumatic means of achieving orthopedic expansion of the maxilla when compared with RME.

In 1982, Bell reviewed the literature to determine the quantitative and qualitative changes of sutural, skeletal and dental tissues as demonstrated in human and animal studies of maxillary expansion procedures. He concluded that SME procedures compare favorably with the qualitative orthopedic/ orthodontic changes reported during RME procedures in prepubertal age groups. Further, the enhanced maintenance of tissue integrity in slowly expanded sutural elements has been associated with greater posttreatment stability and less relapse potential during reorganization of the maxillary complex.⁴

Isaacson and Ingram concluded that SME reduces the accumulation of residual stress loads within the expanded segments when compared with RME, thereby improving the physiologic adjustment at the maxillary articulations,¹ and Storey found that SME allows “physiologic sutural adjustments” with less traumatic disruption, greater reparatory reaction and greater sutural stability than RME.²

Hicks⁵ and Cleall et al.⁶ documented orthopedic separation of the maxillary segments as a component of slow maxillary expansion in patients with deciduous and/or mixed dentitions and found greater postexpansion stability with SME. Harberson and Myers⁷ and Bell and LeCompete⁸ demonstrated radiographic evidence of midpalatal suture separation with SME during the deciduous and mixed dentitions using a W-arch and quad-helix. And Martina et al. concluded that SME is as effective as RME in achieving orthopedic expansion of the maxilla of preadolescent patients.⁹

Nanda and Marzban looked at SME with a nickel-titanium (NiTi) expander and found that the light force and gradual rate of expansion maintain tissue integrity, elicit a physiologic response along the suture, avoid an “unsightly midline gap” and keep orthodontic tooth movement and buccal tipping to a minimum. They concluded that a NiTi expander provides a viable alternative to RME for orthopedic correction of transverse discrepancies.¹⁰

Kumar et al. used a finite element model to evaluate the orthopedic effect of both a quad-helix and NiTi palatal expander (NPE2).¹¹ They concluded that both methods can achieve orthopedic expansion of the maxilla but the amount of orthopedic change decreases as patient age increases. Sandikcioglu and Hazar compared slow (using a quad-helix), semirapid (using removable plates) and rapid (using a Hyrax) expansion in preadolescent patients and found that slow and rapid expansion achieved equal dental and skeletal effects at the end of treatment.¹²

Huynh et al. conducted a retrospective study of rapid versus slow expansion and concluded that Hass, Hyrax and quad-helix appliances are equally effective for posterior crossbite correction. Further, within the SME group they found no difference between bonded, banded, removable or quad-helix expanders, and determined that as age increased, so did the force required to achieve orthopedic expansion.¹³

It is evident that the data are abundantly clear regarding the ability of SME to produce orthopedic expansion in young patients. Further, it is essential to recognize the inverse relationship between skeletal maturity and the amount of orthopedic change one can achieve with the lighter forces delivered by SME. Therefore, to maximize orthopedic expansion and minimize dental tipping, SME should be performed in preadolescent patients in the early mixed dentition.

Force magnitude for orthopedic change with SME
It’s important to consider the amount of force needed to achieve orthopedic change with SME. Bell and LeCompete found 400 grams to be the ideal force for activation of the quad-helix,⁸ Ricketts demonstrated that it was possible to achieve orthopedic expansion with less than 400 g of force delivered with a palatal archwire,¹⁴ Nanda and Marzban recommended using approximately 350 g of force with a NiTi expander,¹⁰ Ladner and Muhl found that forces as low as 221 g using a quad-helix fabricated with 0.036-inch blue Elgiloy wire were sufficient to achieve orthopedic expansion in preadolescent patients,¹⁵ and Arndt stated that forces between 180 and 300 g with a nitanium palatal expander (NPE) were sufficient to achieve orthopedic expansion of the maxilla.¹⁶

Unfortunately, it can be difficult to determine the initial magnitude of force using traditional methods of SME (W-arch, quad-helix, NiTi expander). In addition, force magnitude decreases as the appliance deactivates, often requiring the clinician to remove, reactivate and reinsert the appliance midtreatment. Traditional SME appliances also present various clinical challenges, including irritation and ulceration of the palatal tissue and/or tongue, altered patient speech, food impaction and decalcification of banded anchor teeth. Therefore, we must explore more comfortable, predictable and efficient methods of achieving slow orthopedic expansion of the maxilla of preadolescent patients in early mixed dentition.

Expansion of the mandibular arch
Mandibular arch expansion is a controversial, polarizing and even taboo concept not suited for the faint of heart. It’s important to note that when we discuss “mandibular expansion” in this context, we aren’t discussing skeletal/orthopedic expansion, because the mandibular symphysis typically fuses in humans within the first year of life. Instead, we are referring to the use of light forces to upright lingually tipped molars and achieve dentoalveolar expansion in the anterior and middle thirds of the arch.

It has been known for decades that this type of mandibular expansion is safe, effective and stable. In 1962, Walter concluded that mandibular arch width could be expanded permanently.¹⁷ In 1966, Schwartz and Gratzinger presented the Schwartz appliance to expand the mandibular arch and recommended that the appliance be turned slowly (typically once every seven days) until the desired amount of dentoalveolar expansion is achieved.¹⁸ In 2010, Tai and colleagues used CBCT to evaluate dental and skeletal changes after slow expansion with a mandibular Schwartz appliance and concluded that dentoalveolar expansion of the mandibular arch is both possible and stable.¹⁹

O’Grady et al. also evaluated the Schwartz appliance and found that expanding the mandibular arch of preadolescent patients significantly increases both mandibular arch width and perimeter in the long term. Further, it allowed for additional expansion of the maxillary arch to correct moderate tooth size/arch size discrepancies.²⁰ This is a very important point that is frequently overlooked.

Maki and colleagues published a study in 2006 describing the use of a bihelix appliance to expand the mandibular arch of patients ages 7–11.²¹ They concluded that lateral expansion of the mandibular arch is both possible and stable and can greatly reduce the need to extract permanent teeth. McNamara and Brudon reported similar findings in 1993 and stated that increasing mandibular arch size at a young age is recommended so that dentoalveolar, skeletal and muscular adaptations can occur before the eruption of the permanent teeth.²²

In 2014, Kravitz proposed using an Arnold expander to expand the mandibular arch and, more specifically, the intercanine width in patients with moderate TSALD.²³ He stated that for maximum efficacy, expansion should begin before the eruption of the permanent canines, lending credence to the concept that we can use the primary teeth to achieve dentoalveolar expansion and thereby improve arch perimeter and decrease the crowding of the erupting permanent teeth.

However, as with traditional SME appliances, the traditional appliances used for mandibular expansion are often challenging for clinicians and uncomfortable for patients. Therefore, we must also explore superior methods of slowly expanding the mandibular arches of preadolescent patients in early mixed dentition.

Braces and wires
Full-fixed appliances have many advantages over removable and bonded palatal and lingual appliances. They are easy to place and use; are well tolerated by patients; eliminate the myriad clinical challenges associated with fabricating, placing and adjusting palatal/lingual appliances; require fewer visits and less chair time than banded or removable appliances; and produce superior and more predictable results. Archwires also allow for the creation of more ideal arch forms by improving incisor inclination and increasing the expansion of the anterior and middle thirds of the arch, resulting in greater increases in arch perimeter.²⁴

Further, archwires can easily produce the 250–500 g of force required to achieve orthopedic expansion of the maxilla in preadolescent patients. Therefore, while the use of full-fixed appliances to expand the arches of preadolescent patients has not been directly investigated in the literature, it is logical to infer that the application of a buccal force comparable to the force applied on the palatal using traditional SME and mandibular expansion appliances would have comparable biological and clinical effects.

The following cases demonstrate the amazing results that can be achieved when full-fixed appliances are used to expand the arches of preadolescent patients in the early-mixed dentition.

Case 1
This 7.10-year-old patient (Fig. 1) presented with the chief complaint of crowding. She has narrow, V-shaped arches, moderate crowding in both arches, retroclined incisors, insufficient space for the tongue and a vertical growth pattern with a steep MPA. The teeth are normal in size. She had her adenoids removed but is still a chronic mouth breather, snorer and bruxer. Dad is a physician and is concerned because he thought the removal of the lymphoid tissue would solve his daughter’s breathing problems. A developing transposition of the permanent maxillary canines and first premolars was also noted (Fig. 2).

Fig. 1

Fig. 2

Full braces were placed on all erupted maxillary and mandibular teeth along with bite ramps on the maxillary E’s to disocclude the arches. Our treatment objectives were to expand the maxilla and the mandibular arch, improve the interincisal angle and create space for the permanent teeth and the tongue. Treatment lasted 16 months and included nine total visits (bonding, six adjustments, one progress visit to bond the laterals, and debond) and the final Phase I records (Fig. 3) show that all objectives were achieved.

The before and after occlusal pictures (Fig. 4) demonstrate significant improvement in arch width, form and perimeter, as well as increased space for the tongue. Fig. 5 shows a 7.71 mm increase in arch width across the primary maxillary first molars and tremendous orthopedic expansion and remodeling of the palatal bone. This, along with the fact that the permanent maxillary first premolars are erupting much wider than they had been before expansion, further substantiates the orthopedic change that occurs with SME and, more specifically, archwire expansion.

Fig. 3

Fig. 4: Before (left), after (right).

Fig. 5: Before (left), after (right).
Initial: 27.99 mm
Final: 35.70 mm
Delta: +7.71 mm

The posttreatment CBCT slices (Figs. 6a and 6b) demonstrate the resolution of the crowding and the transposition, as the eruption of teeth #6 and #11 normalized without having to remove their primary predecessors. Fig. 7 shows the pre- and posttreatment volumetric analyses and demonstrates a significant change in patency of the posterior airway, especially in the oropharynx now that the tongue can assume a more normal position in the oral cavity and is not being forced posteriorly by the constricted arches.

Figs. 6a and 6b
Top: Right side before (left) and after (right).
Bottom:Left side before (left) and after (right).

Fig. 7: Before (top), after (bottom).

In addition, the patient’s mouth-breathing, snoring and bruxing all resolved within six months of the braces being placed. Dad was more than impressed.

But is it stable? Fig. 8 shows the patient three years later, after retention with only a maxillary and mandibular Essix C+. I let them know that the occlusion and aesthetics were quite good and we could perfect the alignment with approximately six months of treatment, but they were happy with the results and instead elected to have final retainers fabricated.

Fig. 8

Case 2
This 9-year-old patient (Fig. 9) presented with the chief complaint of crossbite. He had a narrow maxilla with a right CR/CO shift of the mandible, resulting in a unilateral posterior crossbite. His mandibular arch was constricted, especially in the middle and anterior thirds, resulting in insufficient space for the tongue. He had moderate maxillary and mild mandibular crowding, proclined mandibular incisors with insufficient attached gingiva on the mandibular central incisors, and was a mouth breather who occasionally snored. The pretreatment CBCT slice (Fig. 10) shows the significant constriction of the oropharyngeal airway.

Fig. 9

Fig. 10

The traditional approach would include the placement of an RPE that is turned once or twice a day to expand the maxilla. The new paradigm, however, addresses the entire etiology, which also includes the narrow mandibular arch and insufficient space for the tongue. Therefore, full upper and lower braces and asymmetrical bite ramps were placed. Treatment duration was 14 months and consisted of eight total appointments (bonding, five adjustments, progress bonding to bond tooth #10, debond).

Fig. 11 demonstrates that we accomplished our objectives of eliminating the posterior crossbite and CR/CO shift, increasing arch perimeter, aligning the incisors and increasing space for the tongue. In addition, expanding the mandibular arch allowed for the retroclination of the mandibular incisors, creating a more ideal interincisal angle and improving the attached gingiva on the mandibular central incisors. You can also notice ectopic tooth #6 in the posttreatment Panorex. I can almost assure you that had we treated this patient with RME alone, we would not have had sufficient space for this tooth to erupt and it would almost certainly have been impacted.

Fig. 11

The before and after occlusal pictures (Fig. 12) reveal significant expansion of the maxilla and the mandibular arches and tremendous improvement in arch form. You will notice that tooth #21 is erupting into the location of its expanded predecessor, proving that this approach does not simply tip primary teeth but instead uses the primary teeth to achieve dentoalveolar expansion.

Fig. 12: Before (left) and after (right).

Mom reported that the patient stopped snoring and mouth-breathing four to five months into treatment, which makes sense because the patient’s tongue now has sufficient space to rest more anteriorly in the oral cavity, decreasing the obstruction of the oropharynx (Fig. 13). Volumetric analysis reveals that the minimum area in the oropharyngeal region increased more than 100% from 45.4 mm2 to 97.6 mm2 (Fig. 14).

Fig. 13

Fig. 14: Before (top), after (bottom).

Regarding whether we tipped the maxillary teeth or achieved orthopedic expansion, you can see that the molars remained upright despite achieving 5.24 mm of expansion (Fig. 15, p. 60). I can assure you that more tipping and alveolar bending would have occurred had we used an RPE, and we would have had to overexpand the maxilla to allow for relapse. Such overcorrection is unnecessary when expanding slowly with archwires.

Fig. 15: Before (left), after (right).
Initial: 37.46 mm
Final: 42.70 mm
Delta: +5.24 mm

But is it stable? Let’s look at the patient two years later, when he was ready for Phase II (Fig. 16). You can see that the Phase I archwire expansion was extremely stable and the permanent teeth erupted nicely, including ectopic tooth #6. Fig. 17 demonstrates that intermolar width actually increased by 0.95 mm during Phase I retention.

Fig. 16

Fig. 17: Post-Phase I (left), pre-Phase II (right).
Initial: 42.70 mm
Final: 43.65 mm
Delta: +0.95 mm

Phase II was initiated and took just 12 months with only five adjustment visits to achieve an ideal result (Fig. 18). Further, the patient’s airway patency remained outstanding through the completion of treatment (Fig. 19).

Fig. 18

Fig. 19: Final.

Conclusion
The use of full-fixed appliances for the interceptive treatment of preadolescent patients is a viable alternative to traditional SME and mandibular expansion appliances, and allows the orthodontist to perform etiology-based interceptive treatment that can minimize, or even eliminate, the need for additional phases of treatment. It would be extremely beneficial for our patients and our profession if additional research was conducted to substantiate the orthopedic and dentoalveolar changes that occur when full-fixed appliances are used to expand and develop the arches of preadolescent patients in the early mixed dentition.

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References
1. Isaacson RJ, Wood JL, Ingram AH. “Forces Produced by Rapid Maxillary Expansion/Forces Present During
Treatment.” Angle Orthod 1964; 34:261–270. 2. Storey E. “Tissue Response to the Movement of Bone.” Am J Orthod 1973; 64:229–47.
3. Proffit W, Fields H, Larson B, Sarver D. Contemporary Orthodontics, 6th Edition (Mosby Elsevier, 2007).
4. Bell RA. “A Review of Maxillary Expansion in Relation to Rate of Expansion and Patient’s Age.” American Journal of Orthodontics 1982; 81:32–37.
5. Hicks EP. “Slow Maxillary Expansion: A Clinical Study of the Skeletal Versus Dental Response to Low-Magnitude Force.” Am J Orthod 1978; 73:121–41.
6. Cleall JF, Bayne DI, Posen JM, Subtelny JD. “Expansion of the Mid-Palatal Suture in the Monkey.” Angle Orthod 1965; 35:23–35.
7. Harberson VA, Myers DR. “Midpalatal Suture Opening During Functional Cross-Bite Correction.” Am J Orthod 1978; 74:310–313.
8. Bell RA, LeCompte EJ. “The Effects of Maxillary Expansion Using a Quad-Helix Appliance During the Deciduous and Mixed Dentitions.” Am J Orthod 1981; 79:152–61.
9. Martina R, Cioffi I, Farella M, Leone P, Manzo P, Matarese G, Portelli M, Nucera R, Cordasco G. “Transverse Changes Determined by Rapid and Slow Maxillary Expansion—A Low-Dose CT-Based Randomized Controlled Trial.” Orthod Craniofac Res 2012; 15:159–168.
10. Marzban R, Nanda R. “Slow Maxillary Expansion With Nickel Titanium.” J Clin Orthod 1999; 33(8):431–441.
11. Kumar A, Ghafoor H, Khanam A. “A Comparison of Three-Dimensional Stress Distribution and Displacement of Naso-Maxillary Complex on Application of Forces Using Quad-Helix and Nickel Titanium Palatal Expander (NPE2): A FEM Study.” Prog Orthod 2016 Dec; 17(1):17.
12. Sandikcioglu M, Hazar S. “Skeletal and Dental Changes After Maxillary Expansion in the Mixed Dentition.” Am J Orthod Dentofac Orthop 1997; 111:321–7.
13. Huynh T, Kennedy DB, Joondeph DR, Bollen AM. “Treatment Response and Stability of Slow Mx Expansion Using Haas, Hyrax, and QH Appliances: A Retrospective Study.” Am J Orthod Dentofac Orthop 2009; 136:331–9.
14. Ricketts, RM. “Features of the Bioprogressive Therapy.” Rocky Mt. Orthd. 14: 33–36, 1973.
15. Ladner PT, Muhl ZF. “Changes Concurrent With Orthodontic Treatment When Maxillary Expansion Is a Primary Goal.” Am J Orthod Dentofacial Orthop 1995; 108:184–193.
16. Arndt WY. “Nickel Titanium Palatal Expander.” J Clin Orthod 1993; 28:129–37.
17. Walter DC. “Comparative Changes in Mandibular Canine and First Molar Widths.” Angle Orthod. 1962; 32:232–41.
18. Schwarz AM, Gratzinger M. Removable Orthodontic Appliances. (Philadelphia: WB Saunders, 1966). p. 95–97.
19. Tai K, Hotokezaka H, Park JH, Tai H, Miyajima K, Choi M, et al. “Preliminary Cone-Beam Computed Tomography Study Evaluating Dental and Skeletal Changes After Treatment With a Mandibular Schwartz Appliance.” Am J Orthod Dentofacial Orthop 2010; 138: 262.e1–11: discussion 262–3.
20. O’Grady PW, McNamara JA, Baccetti T, Franchi L. “A Long-Term Evaluation of the Mandibular Schwartz Appliance and the Acrylic Splint Expander in Early Mixed Dentition Patients.” Am J Orthod Dentofacial Orthop 2006; 130:202–213.
21. Maki K, Sorada Y, Ansai T, Nishioka T, Braham RL, Konoo T. “Expansion of the Mandibular Arch in Children During the Mixed Dentition Period—A Clinical Study.” J Clin Pediatr Dent 2006; 30:329–32.
22. McNamara JA Jr, Brudon WL. Orthodontic and Orthopedic Treatment in the Mixed Dentition. Ann Arbor: Needham Press; 1993. pp. 171–8.
23. Kravitz ND. “Treatment With the Mandibular Arnold Expander.” J Clin Orthod 2014; 48:689–96.
24. Germane N, Lindauer, SJ, Rubenstein LK, Revere JH, Isaacson, RJ. “Increase in Arch Perimeter Due to Orthodontic Expansion.” Am J Orthod Dentofac Orthop 1991; 100:421–7.

Author Bio

Dr. Michael K. DeLuke is a board-certified orthodontist who received his specialty training at the University of Connecticut. DeLuke practiced for 18 years at DeLuke Orthodontics before retiring from private practice to teach full time. He has served as a faculty member at several hospitals and orthodontic residencies, including as the cleft-craniofacial orthodontist at Albany Medical Center in New York, and is an adjunct professor in the department of orthodontics at the Nova Southeastern University College of Dental Medicine..

DeLuke recently founded DeLuke Orthodontic Coaching (DOC), an ADA-CERP-recognized provider. He also created "The DOC Podcast" to help his colleagues attain the highest level of personal, professional and financial success.

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