Continuous research has given families, caregivers, and professionals a better understanding of how to help children with autism cope in loud, strange environments. As professionals who often work with children, orthodontists should also be doing their research into the tools and technique to help these special patients feel safe and comfortable while in the chair. This article first appeared on Orthodontic Products Online: http://bit.ly/2cqeX9H

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Technology’s Payoff
Using an intraoral scanner to minimize stress for patients with special needs
BY MARK CAUSEY, DMD
O
rthodontists face a unique challenge
in dealing with young patients. The
age of our patients affects how we
plan treatments, the technology we use, and
even how our office space is designed. This
is nothing new to an orthodontist; in fact,
many may have entered the profession with
the goal of changing the lives of children
for the better. As such, we’re prepared for
possible tears and tantrums from the children
we treat, but can be assured of eventually
revealing a beautiful smile to a more mature
teenager or young adult. But what about the
times when a young patient’s mental state
keeps them from ever moving beyond the
tears, from ever being able to fully under-
stand the payoff at the end?
Working with patients with developmental
disabilities, autism in particular, is a topic that
has become more prevalent as advancements
in research have given everyone—parents,
caregivers, teachers, doctors—insight into
how to better understand and work with
children with special needs. For example, it’s
been found that maintaining a strict routine
offers comfort and predictability that can
provide a child with autism with a way to
manage anxiety. However, nothing throws
off a routine like a trip to a doctor, or in
the instance of the following case, several
trips to two different doctors. However, with
patience, consideration of the patient’s needs,
and the right technology, my practice and
I were not only able to provide a superbly
fitting appliance, but change the course of
the treatment plan for one young patient
with special needs.
Clinical Case
In December 2015, a pediatric dentist
referred an 11-year-old female on the
autism spectrum with developmental delays,
and who also suffered from epilepsy, to my
practice. The referring dentist specialized
in treating patients with special needs and
had planned to remove the primary maxil-
lary canines and primary maxillary second
molars in the operating room in an attempt
to prevent impaction of several erupting
permanent teeth, followed by the place-
ment of a maintenance appliance. The
referring doctor requested that my practice
take the impression for the appliance; work
with a lab to have a Nance fabricated; and
then deliver the appliance to the referring
doctor to be placed during surgery while
the patient was under anesthesia.
In order to fabricate the space maintainer,
impressions would need to be taken. The
parents were informed of multiple appliances
(removable or fixed-Nance) that could be
fabricated in an orthodontic practice and the
means by which those appliances were made,
ie, taking an impression. Based on feedback
from the patient’s mother, it was determined
that traditional impressions with trays and
alginate would not be an option for several
reasons. First, due to sensory issues and a
history of epilepsy, the patient would be
unable to tolerate material in her mouth—
doing so would have possibly triggered an
epileptic fit. Second, using traditional trays
would have required fitting and removing
bands, which most likely would have hin-
dered us from even reaching the impression
step for appliance fabrication. Finally, accu-
racy could not be guaranteed with traditional
impression material, which would have
affected the final fit of the appliance and led
to possible retakes.
Ultimately, the use of Carestream Dental’s
CS 3600 intraoral scanner was deemed the
best course of action for obtaining digital
impressions. The impressions would not
only be much more accurate, thus avoiding
a possible retake, but would also eliminate
Using digital technology, like an intraoral scanner, makes things easier for patients with special needs,
their parents, staff, and the doctor.
MARK CAUSEY, DMD, is a board-certified orthodontist from Gainesville, Ga, and cur-
rently owns three practices throughout north Georgia. He received his orthodontic
certificate from the Medical College of Georgia Department of Orthodontics in
2012 and graduated from the Medical College of Georgia School of Dentistry
in 2010. Causey attended Duke University where he was a member of the
men’s basketball team under Coach Mike Krzyzewski and received the honors of
Academic All-ACC. After transferring to the University of North Georgia, he was
named to the basketball all-conference team and received many honors including
NCAA Academic All-American. He graduated magna cum laude. In 2015, he was
awarded the University of North Georgia Young Alumni Award for recognition of
his outstanding professional achievements, public service, and exemplary loyalty
to the University. He is a past president of the Georgia Orthodontists Foundation.

2. ORTHODONTIC PRODUCTS / September 2016 orthodonticproductsonline.com28
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the need for uncomfortable trays, trying in
bands, and gag-inducing PVS material.
First, an initial photo of the arch and a
panoramic radiograph were taken (Figures
1 and 2). The patient was prepared for the
digital impression. Whereas a typical scan
with the CS 3600 takes 3 to 4 minutes in my
practice, this case took 4 to 5 minutes—still
incredibly fast in this special situation. The
speed at which the impressions were able to
be taken certainly played a role in putting the
patient at ease (Figures 3 and 4).
Once the digital impressions were
acquired, the files were uploaded to my lab
of choice. A model was printed at the lab;
bands were digitally fitted; and the space
maintainer was fabricated and then delivered
to my practice.
In May of this year, upon the referring
pediatric dentist’s recommendation, I placed
the appliance at my practice, deviating from
the original treatment plan. The patient had
grown comfortable enough with my staff and
me that she allowed us to place the appliance
without the use of anesthesia or operating
room time. Not to mention the fit of the
appliance was exceptional.
Ultimately, using an intraoral scanner
instead of traditional impression trays and
material minimized stress for the patient, and
her parents were incredibly grateful for the
smooth procedure.
The patient was recalled in July to monitor
the eruption of the impacting teeth, as well
as to ensure she was able to keep the Nance
clean. Intraoral photographs and a pan-
oramic radiograph (Figures 5 and 6, page 30)
revealed that the appliance was successfully
preventing the mesial drift of the maxillary
first molars due to having primary teeth
extracted. I will continue to monitor the
eruption of the teeth.
Key Takeaways
There are several things that can be
learned from this case, both in dealing with
patients with special needs and in ensuring
you have the right technology to do the job.
1. Communicate with Parents: All
orthodontists understand what it’s like to
work through a patient’s parents, but with a
child with special needs, the parents become
true partners in the case. In this case, we
spent time in lengthy discussion with the
parents, explaining the different kinds of
orthodontic appliances and, more impor-
tantly, how the impressions to make them
were acquired. No one knows a patient
better than their parents, and the patient’s
mother provided valuable insight into what
the patient would and would not be able to
handle physically and emotionally and we
Figure 1: Initial photo of arch. Figure 2: Initial panoramic radiograph.
Figure 3: Digital impression prepared using the CS 3600.
Figure 4: Typical scan time with the CS 3600 takes 3 to 4 minutes. With this patient, scan time took 4 to
5 minutes—still fast given the patient’s special situation.

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T r e a t m e n t P l a n
adjusted our treatment plan accordingly.
2. Minimize Stress: Of course, the
comfort and mental state of the patient in
this case was our first priority; however, we
also wanted to take into consideration the
patient’s parents and other patients. It would
be difficult for any parent to stand by and
watch their child in distress. At the same
time, we knew that other young patients
being treated nearby would become anxious
if they were to see or hear the patient become
upset. As even some adults can’t handle tra-
ditional impression trays, it was clear that
going the traditional route would have caused
far too much stress to the patient—trying
in trays alone would have been frustrating
and time-consuming for both the patient and
staff. Thankfully, the interchangeable small
tip of the CS 3600 saved the patient the dis-
comfort of traditional impression trays. Also,
the speed at which the scanner allowed us to
acquire the impressions—within minutes—
meant the patient spent the minimum
amount of time in the chair.
3. Reduce the Chance of Retakes: As
previously mentioned, children with autism
find comfort in routine—therefore our goal
was to treat the patient with as few interrup-
tions to her day and with as few visits to my
practice as possible. The last thing we wanted
was to have to call her and her parents back to
the office for a retake. We were also working
on the referring doctor’s timeline leading
up to surgery, so extending turnaround for
the appliance from the lab wasn’t an option.
Unfortunately, accuracy is not always guar-
anteed with traditional impressions, as tech-
nique and skill vary from staff member to
staff member. Plus, there’s always the risk
of expansion, shrinkage, or breaking when
shipping models to a lab. As we determined
that digital impressions were the best route,
the result was highly accurate impressions
that were uploaded to the lab via secure web
portal. Using an intraoral scanner eliminated
the chance of a retake or damage to model
during shipping and ensured accuracy.
4. Build Trust: I have found the intraoral
scanner to be a unique trust-building tool
with all my patients. There’s no pain or dis-
comfort, and young patients find it “cool” to
watch their teeth begin to take shape in 3D
on the computer screen. A trip to the ortho-
dontist has suddenly become a high-tech,
almost futuristic, experience. In this specific
case, taking digital impressions instead of tra-
ditional impressions not only kept the patient
comfortable, but put her at ease enough that
she understood that we were truly trying to
help her. When we told the patient, “This is
so cool!” or “Just a few more seconds,” while
acquiring scans, it wasn’t just to placate her
or to cajole her to hold still, we meant every
word. In fact, it was a surprise and a delight
to hear from the referring doctor that the
patient had grown to trust my staff and me
enough to have us place the appliance. Using
the intraoral scanner completely changed the
course of the referring doctor’s treatment and
cut down operating room time.
Orthodontists have used intraoral scan-
ners for a few years now for record-keeping
purposes and to create digital impressions.
They eliminate impression materials, reduce
costs, produce more accurate impressions,
and cut down on turnaround from impres-
sion to appliance. However, while the “cool”
factor of the technology and the comfort it
provides young patients may be shrugged
off as “nice-to-haves,” I can’t stress enough
how important these little hidden benefits
were in this case involving a patient with
special needs. Another “little” benefit that
may be taken for granted is the fact that
my CS 3600 isn’t tethered to an awkward
trolley but is instead connected to a laptop
via USB. This made it easier to maneuver
around the patient while giving her the space
she needed to feel comfortable. In this case,
using the right technology reduced stress for
everyone (the patient, her parents, and my
staff) involved. The results were not only
an accurate, well-made appliance—that was
to be expected with an intraoral scanner—
but a trusting relationship between patient
and doctor that allowed the appliance to be
placed while in my practice rather than in the
operating room.
Continuous research has given families,
caregivers, and professionals a better under-
standing of how to help children with autism
cope in loud, strange environments. As
professionals who often work with children,
orthodontists should also be doing their
research into the tools and technique to help
these special patients feel safe and comfort-
able while in the chair. OP
Figure 5: Intraoral photographs taken 2 months after placing the Nance appliance show it is successfully
preventing the mesial drift of the maxillary first molars due to having the primary teeth extracted.
Figure 6: Panoramic radiograph taken 2 months after placement of the Nance appliance further shows
success of the appliance at preventing the mesial drift. Patient will continue to be monitored.