June 20, 2012

1. Connecticut Dental Health Partnership (CTDHP) Orthodontic Seminar June 20, 2012

2. Agenda Welcome! TimeTopic 6:00 - 6:30 Meet and Greet 6:30 - 7:00 Dinner 7:00 - 7:45Presentation - Introduction - Objectives - Salzmann scoring presentation - Case submission procedures 7:45 - 8:00 Question and Answer

3. Objectives • Introduce CTDHP staff • Develop a common understanding of the Salzmann scoring process • Clarify submission process • Answer general questions

4. Cases That Do Not Qualify • Fill out form with appropriate information • In Comments section write “patient does not qualify please deny” • Mail in with other Pre-authorization requests • Do not take x-rays or models for cases where they are not needed to diagnose

5. Objectives: Salzmann Scoring Process • 5,210 orthodontic cases submitted CY 2011 • Denied cases are an administrative burden to the practitioner and CTDHP

6. Definition:Handicapping malocclusion and handicapping dentofacial deformity are conditions that constitute a hazard to the maintenance of oral health and interfere with the well-being of the child by adversely affecting dentofacial esthetics, mandibular function, or speech.Materials courtesy of the American Association of Orthodontists Library, 1974 Salzmann Scoring

7. Salzmann Scoring • E. Intra-Arch Deviations: • Missing teeth: scored by actual count of teeth; remaining roots are scored as missing • Crowded teeth: insufficient space for alignment without moving other teeth in the arch. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when the space is insufficient for alignment. A tooth scored as crowded is not concomitantly scored as rotated • Rotated anterior teeth: insufficient space for alignment of teeth so malaligned as to interrupt the continuity of the arc of the dental arch

8. Salzmann Scoring • E. Intra-arch Deviations: Max & MandAnteriors • Maximum # of Maxillary or Mandibular Anterior teeth scored is 4 each • Maximum score for line one is 8 and for line three is 4 respectively • A tooth cannot be rotated and crowded • Count spaces not teeth 8

9. Salzmann Scoring • E.Intra-Arch Deviations: Max & Mand Posteriors • Missing tooth must be congenitally missing not just missing from arch. Remaining roots are scored as missing • Crowding: insufficient space for alignment without moving other teeth in the arch. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when the space is insufficient for alignment. A tooth scored as crowded is not concomitantly scored as rotated. A maximum of 2 teeth per side per arch can be counted • Rotation: Crown rotated buccally or lingually > 45° • Spacing must be evident on both sides of the tooth. A maximum of 2 teeth per side per arch

10. Salzmann Scoring • Max & Mand Posteriors: • Rotated posterior teeth: buccal or lingual surface wholly or partially faces proximal surface of adjacent teeth • Open spacing: crest of interdental papilla is visible. Score each papilla in incisor section; score posterior teeth when both adjacent crests of the interproximal papillae are visible • Closed spacing: space is insufficient for complete eruption of a tooth. Cannot have closed spacing and crowding for the same teeth

11. Salzmann Scoring Top:crowding, spacing, and missing teeth. Bottom: anterior spacing. Intra-arch Deviations:

12. Salzmann Scoring Intra-arch Deviations: (A) Method of placing casts for intra-arch assessment (B) Crowded anterior and posterior teeth

13. Salzmann Scoring • F. Inter-Arch Deviations: 1. Anterior Segment • Overjet: labioaxial inclination of maxillary incisor teeth with mandibular incisors occluding on or over palatal mucosa • For an incisor to be scored as excess overjet, any portion of the maxillary incisaledge must be at least 3mm ahead of the opposing lower incisor • Overbite: maxillary incisors occlude on or opposite labiogingival mucosa or mandibular incisors occlude DIRECTLY on palatal mucosa

14. Salzmann Scoring F. Inter-Arch Deviations: 1. Anteror Segment • Overbite is scored teeth 7, 8, 9, 10 in a ClassII Div 2 occlusion when these teeth touch lower labial gingiva. • Overjet and overbite: score both when mandibular incisors occlude directly on the palatal mucosa and maxillary incisors are in overjet • Openbite: the vertical separation between teeth in opposing dental arches when the rest of the teeth are in terminal occlusion. Edge-to-edge occlusion is not scored as openbite or crossbite.

15. Salzmann Scoring (A) Overjet- maxillary incisors labial, mandibular incisors over palatal mucosa. (B) Overbite-mandibular incisors on palatal mucosa. (C) Overjet and overbite maxillary incisors labial, mandibular incisors on palatal mucosa.

16. Salzmann Scoring Inter-arch Deviations: • Incisors crossbite: maxillary incisors are lingual to mandibular incisors when posterior teeth are in terminal occlusion. • Crossbite of posterior teeth: canines, premolars, and first molars are buccally or lingually placed out of the entire occlusal contact with their opposing teeth. Cusp tip is out of the fossa. End-on is NOT considered a crossbite 3. Open Bite: Erupting teeth cannot be counted as an open bite. Tooth must be fully erupted.

17. Salzmann Scoring F. Inter-Arch Deviation 2. Posterior Segments 1. Relate Man. To Max. Teeth • A. Distal Category is for Class II • B. Mesial Category is for Class III 2. Flush terminal plane not Class II or III 3. Opposing cusp must be over the tip of the opposing cusp

18. Not a Class II

19. This will qualify as Class II

20. Salzmann Scoring Inter-arch Deviations:

21. Salzmann Scoring • Anterior crossbite • (B) Crossbite of posterior teeth

22. Salzmann Scoring Mesiodistal Deviations:

23. Comments Section • Narrative only applies to clinical reasons to justify the case qualifying for treatment • Additional photos, x-rays, etc. that support the narrative must be included • Do not send treatment plan, mechanics to be employed, etc. as these do not alter the scoring of the case

24. Salzmann Scoring: Example Casts Overhead View Left Side View Bases of models are not parallel, backs are not even

25. Salzmann Scoring: Example Casts Frontal View Right Side View Bases of models are not parallel, backs are not trimmed

26. Salzmann Scoring: Example Casts Rear View Back needs to be trimmed to allow evaluation of overbite

27. Quality of Records • X-rays must be printed on PHOTO paper not copy paper • Panoramic radiograph must be relevant time-wise in relation to the models • Models must be of diagnostic quality and trimmed inocclusion, W/O wax bite, to ABO guidelines • Poorly trimmed models and models with broken teeth will be returned ungraded!

28. Study Model Packaging • The ideal way to ship models is with each model first placed in a blue fluoride tray, then bubble wrapped and secured with a rubber band • Do NOT ship the models with wax bite attached between upper and lower models. Models become difficult to separate and teeth break

29. Salzmann Scoring Sheet See attached document:

30. Returned Orthodontic Submission Form Member: __________________ ID#: ____________________ Claim #: ___________________ Date: ___________________ Dear Doctor, Your request for review of orthodontic services for your patient is incomplete as submitted or, in the opinion of the program’s dental consultant(s), does not appear to be consistent with the criteria of the Connecticut Medical Assistance Program. To allow proper processing of your request, we are returning your submission and supporting documentation for the following reasons: • Client’s name as it appears on their gray CONNECT card is required • Client’s Medicaid ID number as it appears on their gray CONNECT card is required • Dentist’s NPI, TIN and/or SSN identifiers are required on the accompanying claim form • Panoramic radiograph for full X-Ray series is required • Properly completed and scored Malocclusion Severity Assessment, including section “G” on Other Deviations (sample form enclosed) is required • Diagnostic Casts (models) must be properly trimmed • Radiographs and/or models must be of diagnostic quality • Other • Please resubmit this request with the missing or corrected information and/or materials for further consideration. • Interceptive treatment is not a Medicaid covered service: Patient has mixed dentition and no documentation from referring general dentists, behavioral health or mental health providers, or other severe deviations affecting the mouth and/or underlying structures are present as noted in section ‘G’ • Please discuss monitoring, future orthodontic therapy and alternative treatment options with your patient at this time

31. Thank you for coming!