Orthodontic Practice US March/April 2020 Vol 11 No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews March/April 2020 – Vol 11 No 2 • orthopracticeus.com

Intersecting areas of law and dentistry: part 2 Dr. Bruce H. Seidberg

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Corporate profile Safco Dental Supply

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MMG Fusion’s MMG Ortho — a suite of tools customized for the orthodontic practice

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“SmartArch… in the context of precise bracket positioning… is expected to decrease chair-time, improve outcomes, and decrease treatment time at least 50%.” 1 – Dr. Eugene Roberts et al.*

“Two SmartArch wires are more effective than 4-6 routine archwires for correcting malocclusions with a deepbite >3mm (… total sample of 50).” 2 – Dr. David Sarver et al.*

READ THE LATEST

1 2

Visit ormco.com/smartarch to learn how doctors are leveraging SmartArch.

Roberts, W.E. et al. SmartArch® Multi-Force, Super-Elastic Archwires: A New Paradigm in Orthodontic. JDO 55. July 1, 2019 Sarver, D. and Roberts, E. Orthodontic Practice. Volume 10 Number 6. Nov 2019

*The opinions expressed are those of the doctors. Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgement in treating their patients.

INTRODUCTION

Success or wonder?

March/April 2020 - Volume 11 Number 2

EDITORIAL ADVISORS

e live in the most technologically advanced, modern, fast-paced, and quickly changing world the human race has ever experienced. Our creature comforts are almost unreal and magical. We have smartphones, smart cars, smart homes; heck, we even have smart children! We have apps for everything — ones that will deliver food to our doorsteps or get anything you can imagine without leaving our homes. Our creature comforts have never been so good. If we need information, all we have to do is ask Siri, and if we wanted, we would never have to leave the couch; just ask Alexa to turn on the lights, play some music, or scratch your back. On the outside, it seems as though we are living in this futuristic, picture-perfect world, but in reality, many of us are cut off from “wonder and awe.” Dr. Arthur A. Dugoni, Dean of my dental school, gave me a simple piece of advice on my first day of dental school. He said, “Life is like a store; pay the price, and take what you want.” Many of us have paid the price and are taking what we want. We have amazing practices, nice cars, comfortable homes, and we go on trips that our parents only dreamed of taking. As I contemplate this dream life I live in, I feel as though I have conquered a mountain, but sometimes, I am left wanting something more. I didn’t realize what was missing until I came across this quote by Abraham Joshua Heschel. He said, “I don’t ask for success; I ask for wonder.” That quote struck me to my core. What is it in my life that brings me “wonder”? When I consider that question, I’m reminded of a trip I took with my wife a few months ago. I had the opportunity to take my wife with me to give a 2-day lecture in Tokyo, Japan. I was amazed by the people, their culture, and especially their language. While we were there, I learned a new word in Japanese that spoke to me: “Ikagi,” which has a profound meaning when translated. In English, it translates to “the reason for which you wake up in the morning.” In Japan, it is a fundamental part of the culture to have an ikagi, or something that gets you up in the morning. What is your ikagi? Whenever I ask orthodontists what their ikagi is, most say what I said when I started up my practice — success and money. As orthodontists, we are for the most part going to have success and money, but let us not forget that we have a craft that allows us to create beautiful artistic smiles that can change lives, build confidence, and enhance our patients’ self-esteem. This is my ikagi. Every day I go home, I consider the lives that I’ve impacted that day, and I say to myself, “I can’t believe I get to do this.” As my practice has grown, and as I’ve discovered my ikagi, my focus has shifted from just clinical excellence to creating an amazing overall experience for my patients. A good office culture, engaging patients in treatment, and a celebration at the end of treatment are all an integral part of creating an amazing experience during the patient journey. I have two favorite appointments during a patient’s transformation — the day I get to put the braces on, and the day I take them off. The smile reveal after braces come off is the ikagi for me. When I think of the word “wonder,” I think of the look on patients’ faces after I smooth and polish the teeth and then hand them a mirror to see their new smile. We surround them with as many team members as possible to celebrate with them when they see their new smile for the first time. Many patients just stare in the mirror and smile, some cry, and some even sob! It never gets old watching my patients see their lives change right in front of their eyes. If you are struggling to find your ikagi, or if you have strayed from the playbook that guided you into this profession in the first place, I invite you to re-evaluate your reason for getting up in the morning. Don’t get me wrong, success and money are good endeavors, but they will not allow you to really focus on what is most important. Success and money are not motivators that last. Wonder and awe bring lasting happiness. Joy is better! Sacrifice is better! Living beyond yourself is better! Dr. Stuart Frost Stuart L. Frost, DDS, received his dental degree at the University of the Pacific School of Dentistry. Following a 1-year fellowship in temporomandibular joint dysfunction (TMJ), he completed a 2-year residency in orthodontics and dentofacial orthopedics at the University of Rochester. Dr. Frost practices in Mesa, Arizona. He is currently a part-time associate clinical professor at the University of the Pacific orthodontic program and has lectured on the Damon System at several Damon Forums and other Ormco-sponsored events, including the national American Association of Orthodontists Annual Session, component meetings, and his own Damon in-office seminars.

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 Bradford N. Edgren, DDS, MS, FACD 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 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

© FMC 2020. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any 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.

ISSN number 2372-8396

2 Orthodontic practice

Volume 11 Number 2

AcceleDent is the only FDA-cleared vibratory device that has clinically proven its effectiveness with 3 RCTs. It increases the predictability of clinical outcomes and enables orthodontists to treat even complex cases with aligners. Furthermore, AcceleDent speeds up tooth movement by up to 50 %* and reduces pain and discomfort.

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Case presentation by Dr. Tommaso Castroflorio from Torino, Italy (Case ID: 042)

30 MONTHS ACTUAL TREATMENT TIME WITH ACCELEDENT

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40% less time Diagnosis: Dental & Skeletal Class II, Normodivergent, Overjet > 10mm, Transversal deficiency Aligner change routine: 14 days until maxillary second molars were fully distalised, then 10 days until first molars were in final position, then 7 days until end of treatment Mechanics: - Class II elastics Âźâ&#x20AC;? 4 oz - Severe maxillary overjet resolved with Class II aligner mechanics

Focus: significantly flared incisors and overjet

For more case presentations and information: acceledent.com

* Lobre et al.: Pain Control in Orthodontics Using a Micropulse Vibration Device: A Randomized Clinical Trial. The Angle Orthodontist, 2015.

ESTIMATED TREATMENT TIME

TABLE OF CONTENTS

Publisher’s perspective “It’s what you learn after you know it all that counts” Lisa Moler, Founder/CEO, MedMark Media................................8

Case study Nonsurgical correction of a maxillary hypoplastic/ mandibular hyperplastic patient

Orthodontic concepts The Tier V Practice Dr. Ron Roncone discusses the PhysioDynamicSystem (PDS)..........19

Question & answer MMG Fusion’s MMG Ortho — a suite of tools customized for the orthodontic practice

Drs. Jeffrey Silmon and Chris Cosse devise a treatment plan that avoided certain surgical disadvantages

.......................................................22

Orthodontic concepts The etiology of malocclusion and the “scientific method” Dr. John L. Hayes discusses the importance of discovering the why before treatment..............................26

Consumer research New consumer research validates the importance of orthodontists while also indicating the need to improve patient education

Corporate profile Safco Dental Supply

Jeff Summers, DMD, discusses patient perceptions that can impact orthodontic practices.......................32

What orthodontists should expect from their dental supply company

ON THE COVER Screen image on cover courtesy of MMG Fusion. Article begins on page 22.

4 Orthodontic practice

Volume 11 Number 2

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TABLE OF CONTENTS

Step-by-step Tie-On Rotation Wedge (TORW) for perfect orthodontic finishing: part 1

Continuing education

Vertical slot brackets — for increased treatment efficiency

Dr. Mark W. McDonough reviews several common uses of the vertical slot

Continuing education Intersecting areas of law and dentistry: part 2 Dr. Bruce H. Seidberg discusses various forms of harassment and substance abuse.............................42

Product profiles Boyd Industries — products tailored to the orthodontic market..........................................47

American Orthodontics introduces moisture-tolerant thermoplastic material............. 48 Active™ by OrthoGum To chew gum with orthodontics or NOT to chew gum with orthodontics?..... 50

Service profile Large Practice Sales Chip Fichtner explains that the value of part of your practice to a silent partner may surprise you.............................52

Dr. Lloyd Taylor presents a detailed technique using Tie-On Rotation Wedges on a finishing archwire to perfectly align contacts....................54

Practice development Soft skills for new technologies can create confidence for team members and patients JoAn Majors, RDA, CSP, shows how communication leads to higher value and acceptance of care...................57

Technology Agile aligner delivery Dr. Rooz Khosravi discusses bringing clear aligner fabrication in-house with new technologies............................59

Product profile 3Shape gives you options for clear aligner treatments...........63

www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

6 Orthodontic practice

Volume 11 Number 2

PUBLISHER’S PERSPECTIVE

“It’s what you learn after you know it all that counts”

“A

mentor is someone who allows you to see the hope inside yourself. A mentor is someone who allows you to know that no matter how dark the night, in the morning joy will come. A mentor is someone who allows you to see the higher part of yourself when sometimes it becomes hidden to your own view.” These words by talk show host, media executive, actress, and philanthropist Oprah Winfrey are meaningful to dentists as well as entrepreneurs. After being a part of the dental world for 20 years, I have had the opportunity to see firsthand the phenomenal benefits of having and being a mentor. Traveling on the journey to building a business can be frustrating and heartbreaking if you don’t have someone to offer advice on the Lisa Moler right paths to take and the hazards to avoid. Founder/Publisher, MedMark Media I recently read an article from Inc. magazine that described why mentors are integral to success. John Rampton, entrepreneur and investor, pointed out these top 10 reasons: 1. Mentors provide information and knowledge. 2. Mentors can point out where we need to improve. 3. Mentors stimulate our growth. 4. Mentors offer encouragement. 5. Mentors can help us develop self-discipline. 6. Mentors are open to listening to our ideas. 7. Mentors are trusted advisors. 8. Mentors can help with networking. 9. Mentors have experience you can learn from. 10. Mentors are free, but priceless. With publications that are read by general dentists and specialists alike, MedMark Media brings the expertise of mentors and innovators in the dental community to your houses, offices, and computers. Authors write for us because they believe in sharing their knowledge for better patient care, more efficient workflow, and more lucrative business methods. Over the years, dental mentors have helped our company grow from print magazines to digital formats, webinars, videos, and podcasts. If there is a way to reach you, we will be there! In this issue of Orthodontic Practice US, we bring you continuing education articles on uses of the vertical slot, which Dr. Mark McDonough calls the “Swiss army knife” of fixed orthodontic treatment, and Dr. Bruce Seidberg shares part 2 of his series on law and dentistry, discussing how to avoid the complications and challenges of harassment and substance abuse in the dental environment. Drs. Jeffrey Silmon and Chris Cosse illustrate a case that avoided surgical disadvantages for a maxillary hypoplastic/mandibular hyperplastic patient. Dr. Jeff Summers reports on consumer research regarding perceptions of the orthodontic office and how to keep the specialty relevant to consumers. Our issues also bring you product profiles, practice development and management, book reviews, corporate profiles — each full of ideas to keep your practices growing clinically, professionally, and financially. Mentors will help keep your protocols and knowledge fresh and exciting. So keep searching for those who can help you to achieve greatness. Of course, we want you to read our publications and listen to our digital offerings. But also, get out there to conferences and make connections with speakers and peers who can expand your horizons, no matter where you are on your career journey. It’s never too late to have a mentor or to become one, since learning and sharing knowledge should happen in all stages of life. As President Harry S. Truman said, “It’s what you learn after you know it all that counts.” To your best success! Lisa Moler Founder/Publisher MedMark Media

8 Orthodontic practice

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com www.medmarkmedia.com

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Volume 11 Number 2

Your peers are using Invisalign treatment with mandibular advancement to stand out from the competition. ®

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CASE STUDY

Nonsurgical correction of a maxillary hypoplastic/ mandibular hyperplastic patient Drs. Jeffrey Silmon and Chris Cosse devise a treatment plan that avoided certain surgical disadvantages Introduction Several years ago, a 14-year 10-monthold female named Caroline presented to our office with a hypoplastic maxilla, a hyperplastic mandible, and a complete crossbite of her entire arch except for the lower right first and second molars. She had retained deciduous upper cuspids, and her permanent cuspids had erupted facially. Caroline was having clicking and popping bilaterally with occasional pain. She also presented with narrow buccal corridors. She was being teased because of her prominent chin and prognathic mandible. Although she did have a slight CR/CO slide, we felt that due to the severity of her AP discrepancy that a surgical plan would be ideal. After a consultation with an oral surgeon, everyone agreed that a maxillary advancement and a mandibular setback was ideal. Then came the bill. The financial burden, required healing time, and potential surgical risks were too much to overcome, so her parents asked us to devise a nonsurgical plan. We used Braces Academy videos to educate her before treatment for informed consent and to explain different treatment plans. Braces Academy videos were used during treatment for compliance, turning the RPE, and brushing instructions; and after treatment they were used for Dr. Jeffery Silmon, DDS, is a graduate of Louisiana State University School of Dentistry, and he completed his orthodontic training there as well. He is the past president of the Northwest Louisiana Dental Association (NWLDA), and is a Damon Premier Provider and Educator. Dr. Silmon is married and has two children. He is in private practice in Shreveport, Louisiana.

Figure 1: Initial photos

Dr. Christopher Cosse, DDS, is a graduate of Louisiana State University School of Dentistry, and he completed his orthodontic training at Oregon Health Science in Portland. He is regularly invited to speak about orthodontics nationally and internationally. He is married and has four children. He is a Damon Premier Provider and Educator and is in private practice in Shreveport, Louisiana. Disclosure: Dr. Cosse is the founder of Braces Academy â&#x20AC;&#x201C; The prescriptive patient educationâ&#x201E;˘ system

Figures 2 and 3: 2. Initial panoramic radiograph. 3. Initial lateral cephalometric radiograph 10 Orthodontic practice

Volume 11 Number 2

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CASE STUDY retention instructions and for taking care of her retainers. These videos are unique because they are prescriptive, meaning they are sent from a library of content and sent to patients via email or text so that they receive exactly what they need, exactly when they need it, without having to search through vast amounts of extraneous information. The software also lets the orthodontist know if patients didn’t watch the content that the office sent.

Braces Academy videos are unique because they are prescriptive, meaning they are sent from a library of content and sent to the patient via email or text so that they receive exactly what they need, exactly when they need it, without having to search through vast amounts of extraneous information.

Treatment We elected to start with expansion using a Hyrax appliance to perform rapid palatal expansion due to her skeletal age, as determined by a hand/wrist radiograph. We determined one turn per day for a total of 6 weeks. As a result, we gained 8.5 mm of expansion at the maxillary first molars. At that point, we bonded the case using Ormco Damon® Q™ brackets. We used low torque for upper incisors and canines, standard torque for lower incisors, and high torque for lower canines. The torques were chosen to fight the inevitable upper incisor flaring and lower incisor retroclination that occurs with long term Class III elastic use. Her bite opened significantly with the expander due to the change in contacts of the incline planes and the inevitable flaring from the expander. Additionally, we used posterior bite turbos to disarticulate the bite, regain control of the torque on the upper first molars, and help close it back down. Early elastic protocol was used, and the patient was instructed to wear upper 4-6 to lower 3-4 Fox elastics for at least 20 hours per day, changing them regularly. She and her parents were told that her elastic wear was very important in the effort to avoid surgery. She was also warned that noncompliance would make her much more likely to need orthognathic surgery. The wire sequence we used was Ormco .014 Damon arch form

Figure 5: Final panoramic radiograph 12 Orthodontic practice

Figure 4: Final photos

Figure 6: Final lateral cephalometric radiograph Volume 11 Number 2

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CASE STUDY Copper NiTi U/L, Ormco .014 x .025 Damon arch form Copper NiTi U/L, Ormco .018 x .025 Damon arch form Copper NiTi U/L, and Ormco .019 x .025 Damon arch form stainless steel U and .017 x .025 Damon arch form stainless steel L. Our alternative plan, if the patient was noncompliant with elastics, was one of the Class III extraction patterns.

Outcome

Figure 7: Initial frontal extraoral smiling photo (left) and final (right)

After 6 months of treatment, Caroline appeared to be compliant with elastics, and the AP molar and canine relationships were improving. We were able to finish her case without extractions and with elastic compliance alone. She wore her elastic so well that her bite actually over-corrected at some point during treatment. Twenty-five months and 13 appointments after her initial bonding, we debonded and delivered U/L clear overlay retainers. We were surprised at her results. We felt confident that we could make her better, but the results turned out better than we expected. Looking back, our original surgical plan might not have turned out this successfully! We reached all of our goals for Caroline. We corrected her crossbite, filled her buccal corridors, and corrected her AP discrepancy, improved her smile arc, while improving her profile characteristics and overall esthetics. We guarantee that she isn’t being teased anymore. Her bite is stable, her clicking and popping has resolved, and she is compliant with her U/L clear overlay retainers. The final records are 2 years after debond. Caroline says, “I am much more confident with my new smile, and I’m happy with how nice my teeth look now.” OP

Figure 8: Initial lateral extraoral photo (left) and final (right)

Figure 9: Initial lateral cephalometric radiograph (left) and final (right) 14 Orthodontic practice

Volume 11 Number 2

Orthodontists are using Invisalign First treatment to stand out from the competition. ®

Learn how you can too. New clinical courses and Invisalign Pro modules available now! Enroll – Invisalign.com/treatingteens Visit us at Booth #1203 during the 2020 AAO Annual Session

CORPORATE PROFILE

Safco Dental Supply What orthodontists should expect from their dental supply company

hen Harold Saffir started Safco Dental Supply 75 years ago, he envisioned that the surest means to success would be the ability to delight customers in every way. Quality products at low straightforward prices, fast friendly service, and accurate, reliable order fulfillment would keep practices running smoothly. With all of the changes in the dental market and in technology since 1945, the means to fulfilling those goals have certainly changed, but thanks to Harold and his son, Ken, that business philosophy has been permanently embedded in Safco’s DNA. To this day, Safco’s success has indeed been dependent on its motivation to capitalize on new opportunities while remaining firmly rooted in the traditional core values that have propelled its growth for decades.

It all started with one product When Harold started Safco in 1945, it was a home-based mail-order business with just one product — dental anesthetic. Having earned his chemistry degree at the University of Chicago, Harold developed and manufactured the product himself. As more and more dentists came to recognize the quality and reliability of the product, Safco gained a loyal

Safco’s customer service representatives

following. Other manufacturers soon discovered that Safco could provide a new path to selling their products. Then in 1975, Harold’s youngest son, Ken, joined Safco at age 26, bringing with him a youthful flair for marketing and technology that would be the foundation for future growth. And grow they did. Safco branched out into a variety of private-label products and added more and more national brands. Ken recalls that “by the time Safco computerized its systems in

1986, we had about 650 inventory items, and a good customer was someone who ordered 3 times a year.”

Safco now offers over nearly 20,000 dental products Today Safco carries products from nearly every top manufacturer: 3M, Dentsply Sirona, KaVo Kerr, Septodont, Premier, Coltene, Young, Kulzer, and over 200 others. And every product is purchased directly from authorized sources, fully covered by manufacturer’s warranties. Safco also offers over 1,300 Safco private-label products that offer quality and reliability at economical prices. When Harold developed that first anesthetic product, he was committed to ensuring that it would meet all the standards that he would demand if used on his own family. That is the commitment Safco upholds to this day, and its selection continues to grow, with some exciting new additions coming in 2020.

Safco expands into orthodontic products

Harold Saffir shown with his wife, Joyce 16 Orthodontic practice

Ken Saffir when he joined Safco in 1975

Many orthodontists have long turned to Safco for their infection control, operatory, hygiene, and many other products. With Safco’s recent announcement of its new Volume 11 Number 2

Safco orthodontic product catalog

to a broad selection of orthodontic instruments from manufacturers like Hu-Friedy and Integra Miltex, cements from GC America, and 16 brands of alginate, including Safeco’s own private-label offering. All of these products and more can be found at safcodental. com/orthodontics. You can also request the new Safco Orthodontic Catalog at safcodental.com/catalogrequest or by calling 800-621-2178.

pricing philosophy — every practice, large or small, pays the same low price. And every price customers see on Safco’s website or current publication is the one they’ll see on their invoice. And on top of that, Safco offers free shipping for orders over $70, with no need to meet annual purchase levels or to join a special purchasing program.

Honest and transparent low prices

In 1999, Ken presented Harold with the idea that an organized, informative catalog would help dentists order products faster and more easily. As Ken tells it, “My dad was skeptical, but he let me try it anyway.” The idea was a huge success and remains a key customer resource, communicating the latest product features and benefits to customers with an easy-to-read design, large color photos, and third-party product reviews from The Dental Advisor and Reality. Safco’s proficiencies in product presentation and navigation proved to be the perfect springboard to developing what many of their customers tell them is the fastest, easiest dental product website in the industry. The first step was in 2005 with a simple “quick order pad” that made it easy for even the least tech-savvy customers to order from Safco. According to Steven Murovannyy, Safco’s Director of eCommerce, “Today safcodental.com features all of the helpful product information, photos,

Harold knew that by keeping overhead low, he could offer lower prices than most other distributors. Rather than hire an expensive sales force, he decided to sell only by direct marketing. He also felt that customers would appreciate the opportunity to order at their convenience without spending time with a sales rep. Harold and Ken also found that they could build greater trust with customers by ensuring that prices did not vary from customer to customer or vary from published prices. Safco today still adheres to this paramount

Safco remains dedicated to its tradition of treating customers, employees, and vendor partners with respect, friendliness, and a genuine commitment to do things right.

Making ordering easy and worryfree

Safco’s two school bus-sized carousels work like the retrieval system at your local dry cleaner, rotating to deliver exactly the right products for each customer order Volume 11 Number 2

Orthodontic practice 17

CORPORATE PROFILE

relationship with OC Orthodontics, orthodontists now have access to a wide assortment of respected, high-quality, competitively priced brackets, buccal tubes, ligature ties, elastomerics, and more. This is in addition

CORPORATE PROFILE

John Fuerst, Safco President and CEO Safco’s high-capacity refrigeration center assures that all temperature-sensitive products are delivered with the longest possible shelf life

and low prices Safco is known for. We’ve made it extremely easy for customers to quickly find and order exactly what they need, see the latest free offers, shop from their order history, create shopping lists, track orders, view invoices, and chat with our customer service team.” Over 75% of orders now come through Safco’s website, but many orders are still placed by phone. Whether calling Safco to place an order or just to ask a question, customer service representatives are trained to help customers quickly and efficiently, not to pressure or upsell. There are no commissions or incentives to promote anything other than excellent service. Many of Safco’s customer service representatives have dental office experience, and all receive ongoing training from vendors to stay knowledgeable on the latest products. Brad Joerger, Director of Customer Service and Vendor Relations, explains: “Quality service is what’s most important to us. We really are second to none in terms of how we bend over backwards to accommodate our customers.” All customer calls are answered quickly; if customer service is too busy to answer a call within 30 seconds, the phone rings on desks throughout the office. Safco offers a uniquely liberal 30-day guarantee, ensuring that any product can be returned for any reason for a complete refund and no shipping costs, even if it’s already been opened. “We also recently extended our hours to better accommodate our West Coast customers,” Joerger adds. 18 Orthodontic practice

Accurate, reliable order fulfillment Safco’s 162,000-square-foot facility near Chicago features state-of-the art technology and rigorous quality control to get orders out quickly and efficiently while ensuring that customers receive exactly what they order. Safco uses voice-picking technology and efficient barcode scanners to pick products and verify orders: “Our technology plus visual inspection of every order has enabled us to achieve over 99% accuracy, and we’re always striving for 100%,” stresses Paul Kearns, Director of Operations. “We want to make sure that our customers are always getting what they ordered.” And to make sure products are delivered in pristine condition, Safco’s entire warehouse is temperature and dust controlled. The high-capacity refrigeration center assures that all temperature-sensitive products are delivered with the longest possible shelf life. Safco even affixes a bright green label to every refrigerated product reminding customers to refrigerate it in their office. Safco’s two school bus-sized carousels work like the retrieval system at your local dry cleaner, rotating to deliver exactly the right products for each customer order. This allows Safco’s warehouse staff to get orders out with tremendous productivity. And nearly a mile of conveyer track with electric eyes, switches, and scanners guide their voyage from warehouse floor to delivery vehicle. Further investments Safco makes to ensure orders are delivered in pristine

condition include sealing and bagging bottled liquids, using the highest grade shipping boxes available (certified by UPS as meeting their Eco Responsible Packaging Program), and adding recyclable, biodegradable air pillows.

Safco’s people make it all happen Safco has always shown a high level of commitment and generosity toward its employees. John Fuerst, President and CEO since 2012, believes that providing them with opportunities to broaden their knowledge and to work with great teams contributes to a more satisfying work experience. “I was hired to develop Safco’s next generation of leaders and advance Safco’s technology. Creating a fun, supportive, and healthy workplace also matters,” Fuerst says. At Safco, this includes everything from providing a fullfeatured on-site fitness center, maintaining an outdoor garden and walking path, and providing company breakfasts and lunches throughout the year. Safco remains dedicated to its tradition of treating customers, employees, and vendor partners with respect, friendliness, and a genuine commitment to do things right as it continues its quest for innovative ways to improve operations, to ensure quality, and to offer its customers a full spectrum of the best product choices to meet their needs. Dedicated people checking every order. Proven processes that quickly move products from their shelves to your door. That’s what you should expect from your dental supply company. OP This information was provided by Safco Dental Supply.

Volume 11 Number 2

Dr. Ron Roncone discusses the PhysioDynamicSystem (PDS)

ith all of the changes occurring in the orthodontic profession, especially in the past 15 years, orthodontists have had to choose how they would like to practice. Disruption — one of the newer terms — is used both in a positive and negative manner. What disruptions have and continue to occur that impact the practice of orthodontics? We are all familiar with many negative disruptions such as DIY orthodontics. This brief article will focus on a positive disruption. This change, however, is not new to orthodontics, but it has not yet been embraced by the majority of the profession. It is the “three-legged stool” concept of using specific wires/brackets/prescription and its impact on the number of orthodontic appointments and the length of treatment time. The wires are titanium (NiTi, HANT, SE, and Beta), and the bracket is a self-ligating interactive (SLB). The prescription is the Roncone PhysioDynamicSystem (PDS). Heat-activated nickel-titanium (HANT) wires and superelastic (SE) NiTi wires have been used by the author since 1988. Then, as now, two .014 SE wires were used in tandem both within the SLB slot for a minimum of 6 months with no wire changes and patient visits at 10- and 12-week intervals during that time. The next titanium wire, beta titanium, is a finishing wire used again almost always in an active manner. This is different from what has become common. It is also critical to outcome! The PDS Prescription has evolved over the years from the most common pre-adjusted appliances. Philosophical descriptions of how this system

PDS Random samples over the past 10 years (June 2009 — June 2019)

works are available in courses, textbooks, etc. Over the years, studies were done in terms of 1) time required for each patient appointment and 2) total length of treatment time. In 2019, 89.6% of all patients finished full-functional treatment in seven or fewer appointments. Average treatment time in our practice is 14.1 months. A retrospective study was done in our practice to tabulate what was routinely being accomplished. This is by no means a truly “scientific” study. However, the sheer numbers of the sample are impressive. The following charts show not only my practice sample but also one from Dr. Anthony Patel, who was a new PDS user. He compared a sample versus one using the Damon® bracket.

• Full case starts only. • Surgical and severe Class III nonsurgical cases were removed and tabulated separately. • Extraction and non-extraction were included in the totals (26.7% were extraction). • Appointments included start and removal but not examinations, diagnostic records, or retention visits. • All brackets were all metal (3%) or all ceramic (88%), or a combination of upper ceramic and lower metal (9%). • Emergency appointments “counted” for an appointment.

Table 1: 2,622 — Full orthodontic patients Patient

Bond Date

Debond Total Tx Date Time (Mos.)

Wire Changes (upper)

Wire Changes (lower)

Total Appts

2,622 pts from June 2009 – June 2019 randomly chosen from 4,313 full orthodontic finishes 2,622

–

14.1

2.27

2.31

9.67

Table 2: Comparisons from Dr. Patel Total Sample

System

Total Tx Time (Mos.)

Wire Changes (upper)

Wire Changes Total Appts (lower)

Damon

19.18

6.88

5.28

16.92

PDS

16.02

3.16

12.03

Ronald Roncone, BA, DDS, MS, received his degrees in physiology from Marquette University and his postdoctoral Certificate in Orthodontics from Forsythe Dental Center and Harvard School of Dental Medicine. Dr. Roncone maintains a large practice in Vista, California, with 55% adult patients. Dr. Roncone has lectured extensively, presenting more than 1,000 seminars around the world, and is President and CEO of Roncone Orthodontics ® International , which offers practice management courses as well as in-office consulting and marketing services. Disclosure: Dr. Roncone is a key opinion leader for Forestadent.

Table 3: Patient treatment comparisons Damon vs. PDS Volume 11 Number 2

Orthodontic practice 19

ORTHODONTIC CONCEPTS

The Tier V Practice

ORTHODONTIC CONCEPTS • For TMD patients, splint, P.T., etc., were not counted — only the orthodontic portion of treatment if needed. • Dr. Patel also followed the PDS Wire sequence which starts with tandem PDS .014 Titanol® (Forestadent®) superelastic wires in the PDS archform. Dr. Roncone recommends those wires stay active for 6 months before going into any rectangular wire. In some patients, he uses a Thermal .018 Titanol. In those cases, Dr. Roncone recommends using a transitional .020 x .020 PDS Titanol. • The finishing wire recommend by Dr. Roncone is a .019 x .025 FMA betatitanium wire with P-Loops. • For the most part Dr. Patel followed this wire sequencing in the majority of his 31 PDS patients tabulated. • However, in six of those patients a .021 x .025 NiTi was used in finishing, which is contraindicated in the PDS System. These six patients were early patient tabulated in the PDS sample. So, what does this basic treatment look like? Twin .014 SE wires for 5½ months, which allows the following to occur: 1. Alignment of teeth 2. Archform 3. Full molar rotation 4. Correction of the Curve of Spee — (turbos are routinely used) 5. 3-6 mm of dental Class II correction where necessary 6. The turbos are kept in place for a minimum of 9-10 months. This allows for “bony apical fill” where posterior teeth have been extruded. 7. At 5½ months, it is easy to see if brackets were precisely placed. Since twin .014’s fill the slot in the horizontal and vertical, incisal edges and marginal ridges can be checked. 8. If one or more brackets need to be changed, the same twin wires can be loosened and replaced to make corrections. After about 4 weeks, the second and final wires can be placed: • Upper: 19 x 25 PDS Beta with “P” loops distal to the laterals for any space closure but, most importantly, to place final torque and overbite adjustments to achieve anterior guidance and esthetic “smile line.” • Lower: 19 x 25 PDS Beta with ideal archform coordinated with the upper. 20 Orthodontic practice

Example: PDS philosophy

Figures 1A and 1B: Deep impinging overbite, Class II. Division 1, Subdivision (left)

Figures 2A and 2B: Appointment No. 1: Two .014 SE in each arch. Buildup of lingual cusp upper second molars

Figures 3 and 4: 3. Appointment No. 4 — 26 weeks. Twin .014 SE removed and 19 x 25 PDS Beta with “P” loops in upper; significant compensating curve. 19 x 25 PDS Beta ideal arch in lower; slight reverse curve. 4. Elastic chain UL 6-3; short Class II elastics 6-4, 5, 3 left side. Worn for 4 months

Figures 5A and 5B: Removal at 54 weeks; immediate clear retainers. Positioner for final settling will be delivered in 2 weeks

Class II elastics can be worn if necessary (even early in treatment beginning with the second appointment at 12 weeks). Sling elastics can be worn to sock in occlusion; wires can be sectioned as necessary to combine with elastics. Figures 1-5 show an example of the simplicity and efficiency of the PDS philosopy. Due to space limitations for this paper, only eight photos can be shown. However, the major facial asymmetry was corrected by uncoupling the anteriors and allowing

the condyle on the left side to come slightly forward, accounting for one-half of the Class II molar correction. The 20/20 molar also gave full rotation of the upper left first molar. The second molar was not engaged to allow full rotation. Short Class II elastics on the left side corrected approximately 2 mm of dental Class II. The full case, including joint films, frontal, and lateral cephs, airway, pano, and placement of each tooth within cortical bone, has been shown in lectures. OP Volume 11 Number 2

Strategic Orthodontic Seminars The Tier V Practice Course Dates - Tier V June 3rd – June 7th, 2020 October 21st – October 25th, 2020 The Tier V Courses are held in Vista, CA at Dr. Roncone’s office.

Registration Fee Tier V Registration Fee: $5,000

“ After implementing the PDS System, we’ve seen faster leveling, alignment and an overall reduction in our treatment times. Dr Roncone’s Systems have helped us increase our efficiency and improve our clinical results. ” -Dr Aron Dellinger Fort Wayne, IN

To register: Call: 760-630-5914 or Visit: RonconeROI.com For more information, visit us at: www.forestadentusa.com or call us: 1-800-721-4940

www.forestadentusa.com

QUESTION & ANSWER

MMG Fusion’s MMG Ortho — a suite of tools customized for the orthodontic practice

MG Ortho is endeavoring to do more than the traditional software marketing solutions. MMG Fusion is set to release MMG Ortho in February 2020. For the past 4 years, MMG Fusion has been recognized as an award-winning suite of tools, each filling a different role in the marketing, management, and growth of a dental practice, including websites, SEO, reputation management, patient engagement and reminders, social media, patient portal app, HR management, unified communications, and more. While the MMG Fusion platform was originally designed to accommodate the general dentist’s workflow, the system and these tools have also been customized for the orthodontic community. MMG Fusion has spent the last year working closely with orthodontic key opinion leaders, orthodontic customers, and its internal development team to bring the first truly ortho-specific suite of tools to market. Paul Intlekofer, CEO of MMG Fusion, provided some details about this orthodontic platform.

Why did you feel the need to tailor these tools to orthodontic specialists? Paul Intlekofer: While the ortho space has some similarities to general dentistry or oral surgery, we know that there are also

dramatic differences in terminology and patient treatment flow that are not generally accounted for in other solutions available today. Orthos have been forced to put their “square peg in a round hole” since the inception of marketing management and growth software, and we want to be the ones to change that.

Regarding the wide variety of tools geared specifically toward orthodontists, can you highlight some of the major differences that make MMG Ortho more effective for orthodontists?

Paul Intlekofer, CEO of MMG Fusion 22 Orthodontic practice

Intlekofer: Certainly, we like to highlight seven major changes that make our suite of services the most ortho-specific of any other product on the market. 1. We have invested the time and resources to integrate with most of the major orthodontic practice management software (PMS) products. By developing these API connections ourselves, we can guarantee the smooth and secure

transfer of data, which allows for complex tracking and scheduling directly to and from the PMS. 2. Arguably, the most important is that we have made changes to adapt the orthodontic patient flow and their clinical goals. Many are transitioning from the construct of treatment plans to ongoing contracts, which require a focus on start dates and compliance. 3. Patient engagement reminders have been modified to fit the ortho patient flow. It is important that patients receive reminders and notifications prior to each appointment within a contract to ensure increased compliance. Volume 11 Number 2

QUESTION & ANSWER

4. We have focused on the timing of reviews, surveys, referrals, and social media requests. Perhaps a patient is not at his/her happiest in the middle of treatment, and we are better served requesting a review or survey at the end of a contract when there is a higher level of patient satisfaction. The same goes for the sharing of before-and-after photos and social media engagement. 5. ChairFill’s basic function of finding the best possible patient or lead to contact in order to fill an opening — last minute or in the future — remains the same. However, we have added a massive library of ortho content so that campaigns and messages within campaigns going out to prospective patients all contain ortho-specific content and copy — greatly increasing the probability of a patient scheduling. 6. Marketing Tracker has been updated similarly to the rest of the platform to display more relevant ortho statistics such as compliance, start dates, contracts, etc. Marketing Tracker has

also been adapted to put more focus on the tracking of referrals, which have shown to be more common and more valuable in an orthodontic practice. 7. Finally, Call Analysis listening algorithms have been updated with an exhaustive list of ortho terms that help it hear and report more accurately for an ortho practice. Some of these changes may seem minor, but I assure you they all make a major difference when deployed in an orthodontist’s practice. Even more so when a practice is utilizing a “full suite” of services.

Thank you for that interesting background on the purpose and functionality of MMG Ortho. Now, we would like to gain some insight from two of the orthodontists critically involved in its development: Dr. Lou Shuman, an advisor to the company, and Dr. Yan Kalika, a current user and consultant during the design process.

Dr. Lou Shuman, an advisor to MMG Fusion

Dr. Shuman, you have owned and operated a large ortho practice for many years. More recently, you’ve been an established leader on questions of technology and its application in dental and ortho practices. With your perspective as a clinician and expertise in evaluating innovation, what value does MMG Ortho bring to a modern orthodontic practice? Dr. Shuman: MMG Ortho is designed by orthodontists for orthodontists, which sets it apart from the beginning. The team involved understands the differences between how general and orthodontic practices are run and, more specifically, the differences between general and orthodontic patients. That attention to detail is felt throughout the product — in its flow, in the language — and leads to a tangible difference in results. For example, within their revolutionary ChairFill product, MMG Fusion has built an entirely new library of orthodonticspecific content. Now when ChairFill sends

Volume 11 Number 2

Orthodontic practice 23

QUESTION & ANSWER

It is important that patients receive reminders and notifications prior to each appointment within a contract to ensure increased compliance.

out a custom communication to a targeted orthodontic patient segment with the goal of filling empty schedule slots days, weeks, or months ahead, every message and graphic is tailored to the orthodontic service that patient needs. Patients are much more likely to respond to messaging that directly relates to them and the next steps in their treatment cycle, be it their treatment plan meeting or a missed appointment. All of this is based on a machine-learning software that literally works without staff involvement, providing the office great benefits on a daily basis. This is the first time a company has given the orthodontic space this level of customization.

Dr. Kalika, as an early user of MMG Ortho, what has your experience with this new product been like? What have you found most useful? Why would you recommend that other orthodontists adopt this product? Dr. Kalika: First of all, I am very thankful to have been a part of the creation and early implementation of this new product. As the owner and operator of 12 orthodontic practices, I am always looking for ways to increase efficiency and returns while also guaranteeing the best possible experience for my patients. In the past, I have been forced to meet these goals using solutions designed primarily for general dentists. Sometimes these tools are still effective, but they are never as effective as this purposebuilt solution has been. So far, the most useful features for me have been the Patient Engagement and Marketing Tracker tools. Patient Engagement functions much as 24 Orthodontic practice

other appointment reminder products, but the ability to send out re-care and re-activation campaigns with ortho-specific content has greatly improved the number of patients scheduled from each campaign. Also, the ability to contact patients ahead of each scheduled visit during their contract, not just at contract start, has increased our compliance numbers dramatically. Marketing Tracker has also been especially useful. Tracking all referrals as a unique marketing campaign and the focus on ortho-specific terms and reports â&#x20AC;&#x201D; such as appointments made, appointments kept, records, starts, and production â&#x20AC;&#x201D; have both been integral in gaining a deeper understanding of my practices. When I have better, more complete, and ortho-specific data, it is much easier to make informed business decisions for the month or year ahead. OP

Dr. Yan Kalika, a current MMG Ortho user and consultant

This information has been provided by MMG Ortho.

Volume 11 Number 2

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ORTHODONTIC CONCEPTS

The etiology of malocclusion and the “scientific method” Dr. John L. Hayes discusses the importance of discovering the why before treatment Abstract The “scientific method” was promoted by Francis Bacon (1561-1626) as a way to help move the society of his day away from old beliefs and superstitions. He believed that nothing was discovered without the scientific method and that scientists attempt to answer why. This article can serve as an example how the scientific method helped formulate a theory regarding the etiology of some malocclusions.

Introduction Physicians and dentists learn about the scientific method as part of their education. In the process of research, there is usually an attempt to follow the scientific method. Here is the regimen: 1. Formulate a hypothesis. 2. Gather data. 3. Analyze the data. 4. Determine whether the findings support the hypothesis or not. 5. Accept the hypothesis, or adjust the hypothesis, and repeat the process as necessary. Sometimes research does not call for a hypothesis. In that scenario, the initial steps become 1) gather data and 2) analyze the data — without adherence to the scientific method. Nevertheless, the gathered information can add to the understanding of some topic even if a theory is not proposed. Francis Bacon (1561-1626) is usually given credit for the development and promotion of the scientific method. He was a bright light of that age; he believed that if

conditions were to improve for the common good, there needed to be a methodical way to help discover those means. Bacon saw the scientific method as “the way.” Nothing got discovered without the scientific method, according to Bacon.1 Bacon also said that that “idols” [old beliefs and superstitions] needed to be purged in order for the “scientific method” to succeed. Albert Einstein said it differently 400 years later: “The only thing that interferes with my learning is my education.”1,2,3 Moreover, Bacon stated that a scientist is not like a spider. “A spider weaves his own web” (think armchair theorist). Bacon further stated that a scientist is also not like an ant. An ant collects facts but does not create theories that explain the facts. Bacon held that a scientist must be like a bee. A bee collects, digests, and makes something new — honey. A scientist attempts to answer why.1 About 200 years later, in the early 1800s, four students at Cambridge University studied Bacon’s ideas over their Sunday “breakfast meetings.” Those students — William Whewell, Charles Babbage, John Herschel, and Richard Jones — went on to promote Bacon’s scientific method and to change the world.4

Discussion The scientific method was invented in hope of improving the chances for the discovery of ideas that would benefit society. This method of discovery can be applied to any orthodontic malady in which the why (the etiology) is uncertain or unknown.

Exhibit 1 John L. Hayes, DMD, MBA, received his dental degree from the Boston University, H.M. Goldman School of Graduate Dentistry, and his orthodontic certificate from the University of Pennsylvania, School of Dental Medicine, Orthodontic Department, where he is a Clinical Associate. He continues to research and lecture on the advantages of early interceptive treatment and on the etiology of malocclusions. Dr. Hayes is in private practice in Williamsport, Pennsylvania, with his wife, Sharon, who is also an orthodontist. He can be reached at jhayesortho@comcast.net.

26 Orthodontic practice

A common perception is that the causes of the malocclusions are, for the most part, unknown. Etiology is a black box. Treatment plans that do not address etiologies necessarily address only the symptoms of malocclusions. If the scientific method were to be applied to our unknowns and their etiologies were to be discovered, our treatments would be more efficient and lasting.

Exhibit 1 • • • • • • • •

CL II CL III CL I crowding Impacted canines Anterior open bite (AOB) Crossbites Long face syndrome/high angle Causes of instability

Thirty years ago a new theory of malocclusion was imagined — the intervening years were necessary to gather enough data, consistent with the scientific method, to be sure that enough data had been gathered. When the theory was first proposed, a pilot study was performed; when the theory held true, a 10-year study was then undertaken, also patterned after the scientific method. Data was continued to be gathered from published anthropologic studies and natural history museum visits over the past three decades. Over 7,000 patients in one private practice were treated to the goals and carefully evaluated. (Charles Darwin — a strong proponent of the scientific method — published On the Origin of Species in 1859 after 23 years of data gathering subsequent to his voyage on the good ship, Beagle.) Axel Lundstrom (1875-1941) said that old and prehistoric arches exhibited “Harmony” that would be obvious when one saw it. However, Lundstrom admitted that he had no idea how to replicate the Harmony – he thought that the apical base was involved.5 Clinicians may be aware that old and prehistoric skeletal arches exhibit teeth that are well aligned and in a Class I relationship — with unquestioned stability throughout life. We were curious to discover the reason for the exceptional alignment and stability.5,6,7 The theory is based on skeletal measurements of the alveolar ridge crests and the constant differential of 5 mm that was found with hundreds of old and prehistoric arches that were examined. Volume 11 Number 2

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ORTHODONTIC CONCEPTS Exhibits 2 and 38,9,10,11,12 Consider the theory that malocclusions are primarily caused (proposed from experience, arguably, at 80%) by a transverse deficient maxillary arch when measured at the 6-year molars at the center of alveolar crests (CAC) technique. It is important to understand that the 80% estimate is an educated guess — it could be less; it could be a higher — but the exact percentage is not really the point. Etiology is the point. The other 20% of malocclusions are not related to a maxillary transverse deficiency but rather to causes such as premature loss of primary teeth, congenitally missing teeth, and untoward oral habits, etc. A typical orthodontic patient, in our experience, has some degree of transverse deficiency along with non-transverse related problems such as untoward oral habits along with premature loss of some primary teeth.

Exhibit 2

The etiology of many malocclusions — Exhibit 46,8,13,14 Exhibit 4 is a flow chart revealing that subsequent to a transverse deficiency, several different symptoms are possible. The theory defines an ideal maxillary arch when the mandibular CAC + 5 mm = maxillary arch CAC. The maxillary arch is transverse-deficient if it does not meet the 5 mm differential criteria. The measurement technique has been proven accurate. “Due to the diagnostic validity of the Penn analysis (CBCT based) and the CAC analysis (model based), they can be considered as the new gold standards for the precise diagnosis of transverse skeletal discrepancies.”8,15 After over 30 years of investigation and application, the theory can be considered to be a skeletal orthopedic law until proven otherwise. Because malocclusions have been deemed mostly “unknown,” so-called progress has led to the invention of new devices to help address the symptoms of malocclusions and not the root causes. New devices can even be touted as “cures.” Eventually, a short-term solution can lead to relapse. Accordingly, labeling malocclusions as unknowns has held back orthodontic progress with diagnosis and treatment. Think back to Francis Bacon’s warning over 400 years ago: idols (false beliefs) must be purged in order for discovery take place.

Exhibit 3

RCTs — Exhibit 5 RCT — an acronym for a randomized controlled trial — is a shortened version of 28 Orthodontic practice

Exhibit 4: Proposed etiology of malocclusions and relapse Volume 11 Number 2

ORTHODONTIC CONCEPTS RPDBCCT, or randomized, prospective, double-blind, controlled, clinical trial. Some research has been touted as a RCT when it was not. A famous Abraham Lincoln saying bears repeating: “Say a dog’s tail is a leg; now how many legs does a dog then have? Five! No, saying a dog’s tail is a leg does not make it so.”6 Saying that some research is a RCT does not necessarily make it so. It can be argued that a bona fide RCT is actually not fully feasible with orthodontic treatment for a few reasons: First, double blind is an obvious stumbling block. Second, it is not feasible to treat an orthodontic patient without normal, necessary orthodontic “adjustments” as needed —“adjustments” are simply not allowed with a RCT. Third, leaving one group behind (the untreated control group as part of the controlled design) can be a moral failure because of the lost opportunity for timely care.1 Most importantly, the root cause of a particular orthodontic malady (the confounding variable) needs to be controlled for a real RCT. No confounding variable? No real RCT. “Age” and “sex” are commonly controlled, however, age and sex are not the causes of a malocclusion.

Conclusions 1. The scientific method is used to discover the why of something (referred to as the prognostic factor or the etiology). 2. Not all research uses the scientific method; not all research attempts to discover the why of something. 3. Once the why is determined, further research can be performed (RCTs?). 4. To perform an RCT, the first priority would be to determine the prognostic factor (the etiology, found by way of the scientific method). 5. Once the prognostic factor of a malady is known, orthodontic treatment can be directed toward a patient’s malady. 6. Treating the etiology of a malady is more effective than treating the symptom of a malady. 7. In this article, the scientific method has been used to propose a theory of malocclusion. When skeletal arches are measured by the CAC technique, there is a 5 mm maxillary/mandibular differential that mimics the differential found with old and prehistoric skulls. Those old and prehistoric skulls deserve to be mimicked. OP 30 Orthodontic practice

The scientific method was invented in hope of improving the chances for the discovery of ideas that would benefit society. This method of discovery can be applied to any orthodontic malady in which the why (the etiology) is uncertain or unknown.

Exhibit 5 A randomized, prospective, double-blind, controlled clinical trial (RPDBCCT=RCT) requires: 1. Randomized control and treatment groups and likely “... stratified randomization ... for balanced treatment groups on the important prognostic factors of outcome.”18 2. For example, stratification would require: determination of the skeletal transverse morphology (CAC) and also the CL II skeletal severity (the prognostic factors) then randomization of both variables along with randomization by age and sex — at least. 3. Prospective not retrospective. Thus, subjects are chosen and grouped, and then treatment commences. This research design does not allow for any modification to treatment — say a patient starts to exhibit untoward CL III growth — technically, would have to let it express itself without intervention! 4. Double blind (neither the experimental groups nor the researcher knows what method is being applied). 5. The moral issue of non-treatment of the control group should be considered as missed treatment may not be recoverable.

REFERENCES 1. Klein J. Francis Bacon. The Stanford Encyclopedia of Philosophy Edward N. Zalta, ed. Winter 2016 Edition. https://stanford. library.sydney.edu.au/archives/win2016/entries/francis-bacon/. Accessed February 23, 2020. 2. Lightman A. The Discoveries: Great Breakthroughs in 20th Century Science. Vintage reprint edition: Canada; 2009. 3. Einstein A. Brainy Quote. https://www.brainyquote.com/quotes/albert_einstein_110208. Accessed February 23, 2020. 4. Snyder LJ. The Philosophical Breakfast Club: Four Remarkable Friends Who Transformed Science and Changed the World. Broadway Books, The Crown Publishing Group, a division of Random House: New York, NY; 2011. 5. Lundstrom AF. Malocclusion of the teeth regarded as a problem in connection with the apical base. International Journal of Orthodontia, Oral Surgery and Radiography. 1925;11(12):1109-1133. 6. Hayes JL. Orthodontics, chapter 10. In: Owsley DW, Jantz, RL, eds. Kennewick Man: The Scientific Investigation of an Ancient American Skeleton. College Station, TX: TAMU Press; 2014. 7. Johanson DC, Edgar B. From Lucy to Language. 1st ed. New York, NY: Simon & Schuster; 1996. 8. Hayes JL. In search of improved skeletal transverse diagnosis. Part 2: A new measurement technique used on 114 consecutive untreated patients. Orthodontic Practice US. 2010;1(4):34-39. 9. Hayes JL. A new regimen of phase I care applied to anterior open bite — 10 case studies: an etiology proposed by the strategy of triangulation. Orthodontic Practice US. 2012;3(3):18-26. 10. Hayes JL. A new regimen of Phase I care applied to potential canine impactions. Orthodontic Practice US. 2013;4(3):44-51. 11. Hayes JL. In search of the etiology of malocclusions — a common discovery technique is proposed. Orthodontic Practice US. 2018;9(5):60-64. 12. Hayes JL. In search of … [etiology of malocclusions]. Orthodontic Practice US. 2019;10(3):1. 13. Hayes JL. Williamsport Orthodontic Study. Penn Ortho Alumni database. 2009. 14. Price WA. Nutrition and Physical Degeneration. Price-Pottenger Nutrition Foundation, ed. 8th ed. Lemon Grove, CA: PricePottenger; 2007. 15. Gonzalez AG Gonzalez AG, López AF, Fernández ST, Ocampo AC, Valencia JE. Sensitivity and specificity of a radiographic, tomographic and digital model analysis for determining transverse discrepancies. Revista Mexicana de Ortodoncia. 2018;1(6):26-32. 16. Lincoln A. Quote Investigator. Quote attributed to Abraham Lincoln by 1862. Variants since 1825. https://quoteinvestigator. com/2015/11/15/legs/. Accessed February 23, 2020. 17. Hayes JL. Problems with RCT design. Am J Orthod Dentofacial Orthop. 2009;136:143-144. 18. Koletsi D, Pandis N, Polychronopoulou A, Eliades T. What’s in a title? An assessment of whether randomized controlled trial in a title means that it is one. Am J Orthod Dentofacial Orthop. 2012;141(6)679-685.

Volume 11 Number 2

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For more information, please stop by the Ormco/ AOA Booth #1933 at the AAO, or contact us at 800.262.5221. aoalab.com

CONSUMER RESEARCH

New consumer research validates the importance of orthodontists while also indicating the need to improve patient education Jeff Summers, DMD, discusses patient perceptions that can impact orthodontic practices

hile I take comfort in some of the findings of a recent national consumer study conducted by Ormco on the state of orthodontics from a consumer perspective, the results also underscore for me the need for orthodontists to be ever-committed to patient education, patient experience, and advocacy for our profession.

Note about the survey: Commissioned by Ormco, the national, online survey of 1,011 U.S. consumers, targeting adults (18-plus years) and parents, was conducted by Propeller Insights between Sept. 15 - Sept. 17, 2019. All participants self-identified as having purchased teeth-straightening products or services in the past 4 years or are considering purchasing teeth-straightening products or services within the next 2 years. Responses have a maximum margin sampling error of +/- 3 percentage points with a 95% level of confidence.

A smile is the No. 1 trait of a first impression In orthodontists’ favor, a smile ranked as the No. 1 physical trait of a first impression among adults and parents who rated it significantly higher than eyes, height, weight, hair, skin, or body type. In fact, when asked to prioritize physical issues parents and adults would fix, if an issue for them or their children, both adults and parents ranked straightening teeth as their No. 1 priority above addressing weight, skin, hair, fixing their nose, or swapping contacts for glasses. All of this validates the important role orthodontists have in not only functionally addressing oral health and proper bite and alignment, but also in the esthetic and emotional role we play in perfecting beautiful smiles. And we shouldn’t shy away from or be ashamed of that. We are changing lives.

Investing in a smile is perceived to pay many dividends Correlating with the importance parents place on having a great smile, 9 out of 10 parents ranked teeth straightening as the No. 1 financial investment they can make in their children’s long-term success and happiness. This ranks above tutors, sports programs, music lessons, weight loss, or acne/skin Jeff Summers, DMD, is currently a privatepracticing orthodontist, educator, lecturer, and industry key opinion leader, based in Greenville, South Carolina. He has degrees from Clemson University, the Medical University of South Carolina, and the Medical College of Georgia.

32 Orthodontic practice

treatments. Adults also rated it No. 1 over all other options, including cosmetic surgery. Maybe all of this desire for a great smile — and its lifelong benefits — is rooted in the fact that fewer than 1 in 2 (46%) adults feel confident with their own smile/teeth. At a minimum, everyone deserves a welcoming smile he/she loves. According to the study, parents who seek orthodontic treatment for their children do it almost equally to boost confidence (63%) as for health reasons (60%). But it’s notable that approximately 2 in 5 parents do it because they believe it will help their child be more

successful in life, improve attractiveness, or protect their child from potential bullying. Adults seek orthodontic treatment to boost confidence (59%), attractiveness (55%), health reasons (45%), reduce judgment from others (24%), and help with career success (20%). I am sure if you are like me, by the end of each patient’s treatment, you see a new sense of confidence that radiates, enough so that we can see it through a patient’s eyes, not just a new smile. But it’s equally gratifying if we may also help the elimination of needless bullying or unfair judgment — in a classroom or in the workplace. Volume 11 Number 2

Despite the significance attributed to orthodontic treatment in both the cost and lifelong importance, the study reports that more than two-thirds of treatment seekers do fewer than 3 hours of research to make treatment decisions for themselves or their children. In fact, more than 20% of parents and almost 40% of adults did less than 1 hour of research or no research at all. At the same time that people are not searching for the facts or learning about the newest treatment methods, they are being bombarded with marketing messages directly from aligner manufacturers promising great results at a fraction of the cost and time of traditional braces — all without the need for a doctor. As a result, 7 in 10 parents or adults cited they would consider an aligner sold directly by a manufacturer that did not involve any doctor visits. Yes, you read that startling number right: 7 in 10. We should all sit up straight and be nervous by that statistic. Equally concerning is that two-thirds of those polled do not find today’s treatment options straightforward, customized, or consumer friendly. We haven’t done as good of a job of getting the word out as well as the direct-to-consumer (DTC) manufacturers have. We have work to do. We have a responsibility to continually advance our own knowledge with continuing education, for sure, to be on top of the latest science, technology, and products for efficient, effective treatment with beautiful outcomes. But we need to share our knowledge with the public at large, not just prospective patients. Patients are hearing about DTC aligners, clear aligners through a doctor, more progressive braces like the Damon self-ligation system, lingual braces, advanced ceramic esthetic options, claims of fewer or no doctor visits, promises of reduced treatment time, and statements that extractions or palatal expanders are often not necessary. How are consumers to know what’s right for them, or what is fact versus myth? The onus lies on us to help our patients know their options and the pros/cons based on their treatment needs and goals. It’s also up to us to share with prospective patients and the public why our training and experience is key to the movement of teeth, bones, and jaws. We can also refer them to HealthySmileIQ.com for a wealth of information. Volume 11 Number 2

Correlating with the importance parents place on having a great smile, 9 out of 10 parents ranked teeth straightening as the No. 1 financial investment they can make in their children’s long-term success and happiness. This ranks above tutors, sports programs, music lessons, weight loss, or acne/skin treatments. Beautiful smiles are more than straight teeth Beyond becoming vocal advocates for our profession, we also need to help the public understand the variables that go into making a beautiful, natural-looking smile. We all know it is a lot more than just straight teeth. We know straight teeth can create a flat, dull appearance. It is about teaching people what a smile arc is, and how good treatment aligns the top teeth with the natural curve of the bottom lip for a full, natural smile. We need to show patients the difference between a narrow-arch smile versus a broad-arch smile, and how a broad-arch smile eliminates undesirable shadows in the buccal corridor, not to mention creates a better substructure for a more youthful appearance and more graceful aging. The study reports two-thirds of adults prefer a broad-arch smile that shows more teeth than a narrow-arch smile when shown images of the two. In fact, 77% of parents and 72% of adults preferred a broad-arch smile with more teeth showing over their or their child’s posttreatment smile when shown a picture of a broad smile. We also need to show our value in helping our patients achieve the best smile possible by explaining that beauty is in the details beyond desired straight teeth: gingival contouring, reshaping teeth, color correcting, and eliminating excessive and unsightly gum tissue in a smile, if that’s a concern.

A picture is more than a 1000 words With each consultation, I begin with understanding what the patient most wants treatment to fix. Once I know what he/she doesn’t like, I can customize and personalize our discussion and treatment recommendations around functional and esthetic goals that matter most to the patient. The best way to educate and also help the patient visualize his/her own transformation

is by showing professional before-and-after photos of similar cases that yielded beautiful results. I keep in mind that people want to see people like them, so I fill my office with professional images of remarkable smiles we have created with everyday people of all different ethnic backgrounds. People want to see themselves in your patient mix. Attainable beauty. Not everyone is a supermodel. But everyone deserves a big, beautiful, confidence-infused smile that lights up a room. Additionally, we can use these pictures to educate patients on the other esthetic benefits of their orthodontic treatment in addition to their chief concern. The Ormco study (noted on page 32) showed little public understanding that orthodontic treatment can improve facial symmetry and facial profiles, enhance appearance of the lips, reduce noticeable creasing on the sides of the mouth and exposed gum tissue, create a more youthful appearance as we bring down teeth that no longer show due to lost lip elasticity, and so much more. Again wellexecuted photography of similar patients’ before-and-after images go a long way in patient education. I have never been prouder to be an orthodontist. Every day my patients tell me and my team we have been a game changer. I hope all of you feel this way, too. Let’s make sure we use every opportunity to pass on our knowledge, and capture and share our patient transformations. There is no better advocate than a thrilled patient or parent who shares the video and photos you have taken and provided to them or posted to your social media channels with their consent. Let our happy patients get the good word out of the significant work we do. Let’s be advocates for our profession and educators of ourselves and the public on the latest treatment modalities and facts. Our future is depending on it. OP Orthodontic practice 33

CONSUMER RESEARCH

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Vertical slot brackets — for increased treatment efficiency Dr. Mark W. McDonough reviews several common uses of the vertical slot

re you interested in increased treatment efficiency? Do you like to treat challenging cases? Would you like a better bracket at no additional cost? If you answered “yes” to any of these questions, you should have a vertical slot in your bracket. The vertical slot or V-slot can be traced back to Dr. Raymond Begg in 19281 (Figure 1). As our profession progresses, we often lose sight of how we got here and disregard the past as we focus on the future. There have been relatively few articles published recently on the vertical slot, and this may be the reason it has fallen out of favor with the current generation of orthodontists.2 We all have preferences and often discuss the benefits of .018 versus .022 slots, standard versus self-ligating, Roth versus MBT prescription. However, the one constant should be that the bracket has a vertical slot. This article reviews several common uses of the vertical slot and will make the case that 100% of fixed appliances should have a vertical slot. If you review most bracket manufacturers’ websites, you will note that about 25% of braces manufactured today are offered with a vertical slot. Most vertical slots are .018 X .018, and TP Orthodontics has the widest variety of auxiliaries for the vertical slot. Many orthodontists indicate that they do not have a vertical slot due to the increased profile of the bracket, which will cause interference on lower incisors, and

Educational aims and objectives

This article aims to discuss the benefits and several common uses of the vertical slot.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify vertical slot ligation.

•

Realize the variety of uses of the T-Pin.

•

Recognize the function of rotation springs when placed in the vertical slots.

•

Realize the function of torquing auxiliaries.

•

Identify power arms and how, when inserted into the slot, they exert a force closer to the center of resistance of a tooth.

their patients do not like thicker brackets. This is a common misconception. Figure 2 reviews the Mini Diamond® Twin bracket from Ormco (Orange, California), which I use, and shows no significant difference in the base thickness of a lower incisor bracket with a vertical slot on the left (0.58) or without a vertical slot on the right (.060). This is due to improvements in manufacturing, which allow for a lower profile vertical slot bracket. Most other manufacturers show similar findings. In order to demonstrate why orthodontists need a vertical slot, the most common uses of the vertical slot will be reviewed. These cases represent the use of the vertical slot in our practice from most frequent to less frequent. This is not meant to be an exhaustive review of vertical slots, but a practical

Figure 1: The original Begg Bracket utilized insert pins in a vertical slot. (Courtesy of Rocky Mountain Metal Product Company)

Mark W. McDonough, DMD, is an orthodontist who has been practicing in Pennington, New Jersey, since 1994. He earned his dental degree from the University of Pennsylvania, completed a General Practice Residency at Lenox Hill Hospital, New York, New York, and his Certificate in Orthodontics from Albert Einstein Medical Center in Philadelphia, Pennsylvania. He has also been a part-time clinical instructor at Albert Einstein Medical Center in Philadelphia since 1995. He is a Diplomate of the American Board of Orthodontics and past President of The Greater Philadelphia Society of Orthodontics and the Mercer Dental Society. Disclosure: Dr. McDonough is in no way affiliated with any company, nor is he a paid speaker for any company mentioned in this article.

36 Orthodontic practice

Figure 2: Mini Twin vertical slot (VS) lower incisor bracket on left has a .058, and the Mini Twin without a vertical slot has a slightly higher profile at .060 Volume 11 Number 2

Vertical slot ligation The most common use of the vertical slot is to allow insertion of ligature wires through the vertical slot, which is tied to the archwire for severely displaced teeth at the initial bonding (Figure 3). We all acknowledge that low friction and wide inter-bracket distance are desirable for efficient tooth movement. When forces are directed through

Figure 3: The vertical slot is used on the lower left lateral and canine with a steel ligature to initiate tooth movement

the center of rotation, tooth movement is enhanced. Loosely tying a displaced or ectopic tooth through a vertical slot accomplishes all of these goals. It also decreases the force to the teeth involved, which increases patient comfort while increasing tooth movement by preventing excessive force to the periodontal ligament. For the following visit, the steel ligature can be tightened, and gradually the tooth is brought in the arch. This avoids additional archwire changes, which saves chair time and overhead expense. Figure 4 shows exactly 5 months later, and the bite is open, and the arches are aligned. Without a vertical slot, the displaced teeth would need to be ligated to the two tie wings closest to the archwire, which would exert an undesirable rotational force as the tooth moves toward the archwire. Later in treatment, this undesired rotation would have to be addressed, which increases treatment time. Also, with this method of tying only two tie wings, there is the chance the ligature loosens and falls off, which further lengthens

Figure 4: Five months after Figure 3, the arches have been leveled, and the bite is open

We all acknowledge that low friction and wide inter-bracket distance are desirable for efficient tooth movement. When forces are directed through the center of rotation, tooth movement is enhanced. treatment time. When you tie through the vertical slot, there is no chance the ligature falls off.

T-Pins T-Pins (Figure 5) can be inserted through vertical slots for a variety of uses. The most common is as hooks for elastic bands. Unlike ball hooks that many brackets have permanently attached to the bracket, which irritate the patient throughout treatment, T-Pins can be added and removed as needed. Since they are at the base of the bracket, they protrude less than ball hooks and are more comfortable for the patient. They have the added benefit that they ensure that the patient is wearing the elastics as prescribed, since the T-Pins are only placed in the brackets as needed. An additional benefit is that as the elastics change from Class II elastics to triangle elastics or vertical elastics, it becomes readily apparent to patients how they should wear their elastics. This is especially useful when patients have different types of elastics on each side (Figure 6). T-Pins are also an alternative for ball hooks crimped to the archwire for orthognathic surgical patients for the surgeon to use at the time of surgery to ligate the surgical splints (Figure 7). The T-Pins are

Figures 5A and 5B: T-Pins are inserted through the vertical slot, and the end is bent to prevent them from coming out. A. Insert power pin into vertical bracket slot from gingival with 15ยบ angle head tipping toward labial. B. Bend tail away from elastic force

Figure 6: T-Pins are used for vertical elastics. Note that the T-Pins are only on the teeth on which the elastics are worn. This method instructs the patient how to properly wear the elastics, which is useful if it is different on each side Volume 11 Number 2

Figure 7: T-Pins are placed on each tooth for orthognathic surgical patients. These are used during surgery to attach the surgical splints and post-surgery for elastic bands Orthodontic practice 37

CONTINUING EDUCATION

review of common situations we all face every day. The article will conclude with a difficult transposition patient who could not have been treated as efficiently or with fewer side effects without a vertical slot.

CONTINUING EDUCATION easily inserted, have a lower profile than ball hooks, and are less expensive. Unlike ball hooks, they do not slide on the wire, and the surgeon will not introduce torque on the wire, which can cause unwanted postsurgical tooth movement. Some surgeons request ball hooks, but are unaware that T-Pins are an alternative. Another use for T-Pins is to secure nitinol springs as shown in this indirect anchorage TAD-supported case for missing maxillary second premolars (Figure 8). The T-Pin is at the same height as the hook on the molar, and this keeps a more horizontal force for the nitinol spring and has the added benefit that the T-Pin can be bent buccally to prevent the nitinol spring from impinging on the gingiva.

Rotation springs Rotation springs are placed in the vertical slots and are used to correct individual tooth rotations. These are easy to place (Figure 9) and provide more control than a superelastic wire since they are able to be used with larger stainless-steel wires. They are particularly useful if a patient breaks a bracket and a tooth rotates near the end of treatment when larger diameter wires are in place. Typically, the bracket is rebonded, and a smaller flexible wire is used to unrotate the tooth. At a later visit, the larger wire is replaced, and valuable treatment time was wasted due to the broken bracket. With a rotation spring, the need to step back in wire size is negated, and treatment time is not affected. Another case where rotation springs proved useful is shown below when a patient was congenitally missing two lower incisors. The prosthodontist requested the incisors to be brought together so that implants could be used to restore the case, since implants with natural teeth on either side of the implant have a better restorative outcome than two implants next to each other. As the teeth were brought together, there was a mild rotation to the mesial. Correcting this with flexible wires would have been difficult, since pontics were attached to the 19 X 25 stainless steel wire and the case was near the end of treatment. The rotation springs aligned the teeth in only 6 weeks with no need to change the wire (Figures 10, 11, 12).

Figure 8: T-Pin used in a TAD-supported indirect anchorage patient to close the space for a congenitally missing second premolar. The T-Pin is placed through the eyelet on the nitinol spring, and the molar is brought mesial to close the space

Figure 9: Diagram of how to place the rotation spring through the vertical slot

Figure 10: Pretreatment photographs of patient congenitally missing lower incisors with retained primary incisors. Treatment planned to extract the primary incisors and to bring the lateral incisors together to create spaces for eventual implants

Figure 11: Rotation springs to rotate the lower incisors out on the mesial

Torquing auxiliaries Adding labial or lingual root torque to a tooth is often the most difficult tooth movement to do because the force is generated 38 Orthodontic practice

Figure 12: Patient ready for resin-bonded bridges for the missing incisors, which will eventually have implant restorations Volume 11 Number 2

Figure 14: Power arm used to help retract the anterior segment using TAD-supported nitinol coil spring. The diagram shows that the force is closer to the center of resistance which allows for better translation of the teeth. (Case treated by Dr. McDonough; diagram from Cozzani, et al.2)

Power arms Power arms inserted into the vertical slot are used to exert a force closer to the center of resistance of a tooth. They come in a short and long size depending on the desired place you want to exert a force. This can be especially useful if a temporary anchorage device (TAD) is placed in order to retract an anterior segment using maximum anchorage (Figure 14). The diagram shows the unfavorable rotation of the anterior segment if the force is directed from the TAD to the canine. When a power arm is used, a more favorable bodily movement is possible without the unwanted rotation of the anterior segment.

Transposition patient utilizing vertical slot mechanics

Figure 15: Pretreatment photographs of transposition of maxillary right canine with the lateral incisor

Figure 16: Power arm used to allow the direction of pull to be high as the canine is pulled past the lateral incisor Volume 11 Number 2

This 12-year-old presented with a transposition of the upper right canine between the lateral and central incisor (Figure 15). A transpalatal arch was used for anchorage, and a power arm was used to pull the tooth distal and keep it high in the buccal vestibule until it passed the root of the lateral incisor (Figure 16). Once the canine was brought into the arch, a Torquing Auxiliary was added to the maxillary lateral incisor to add buccal root torque (Figure 17). Toward the end of treatment, Class II check elastics were used to T-Pins in the Orthodontic practice 39

CONTINUING EDUCATION

Figure 13: Torquing auxiliary placed on maxillary right lateral incisor for labial root torque. The torquing auxiliary is steel-tied on the tooth to be torqued and the end of the overlay wire. This picture was taken prior to elastic tying all the teeth to show where the steel ties are placed. The diagram indicates that the direction of torque is determined by placing the auxiliary either from the gingival or the incisal.

in the slot of the bracket, which is .022 or .018 inches high. The archwire must exert the torquing moment over a very small distance, which is very inefficient. Fortunately, the Individual Root Torquing Auxiliary (Figure 13) from TP Orthodontics can exert either labial or lingual root torque by having a rectangular stainless-steel base arch, and it is inserted either from the incisal or gingival to exert the appropriate direction of torque. You can control the amount of torque by the selection of the appropriately sized rectangular wire. For example, if a 17 X 25 wire is used in a .022 bracket, there is .05 of play in the bracket. Each .01 of play allows ~4 degrees of rotation in the slot. If you multiply .05 by 4 degrees, this will allow for 20 degrees of torque. If the patient misses an appointment, no further torque is expressed. If you wanted only 12 degrees of torque, use a 19 X 25 base wire. TP recommends using round wires, but I do not feel this is wise, since unintended excessive torque can be expressed if the patient does not return at the appropriate time.

CONTINUING EDUCATION maxillary canines to achieve Class I canine and lock in the molar (Figure 18). The total treatment time up to this point is 18 months, and the patient is now in finishing. Without a vertical slot, this patient could not have had such efficient tooth movement in as short of time.

Conclusion The vertical slot is the “swiss army knife” of fixed orthodontic treatment. It is used on just about every patient we treat to make the treatment more efficient while increasing patient comfort. The vertical slot is most useful on the most challenging cases, and there is no additional cost for brackets with a vertical slot. I can easily understand the advantages and disadvantages of many of the brackets produced today, but there is no reason all brackets used should not have a vertical slot. It is always available and useful in so many ways, and it is free. OP

Figure 17: Torquing auxiliary added to the maxillary right lateral incisor for buccal root torque

RERERENCES 1. Kesling, PC. Begg theory and technique: Past, present and future, In: Johnston LE, ed. New Vistas in Orthodontics. Philadelphia, PA: Lea and Febiger; 1985. 2. Cozzana M, Mazzotta L, Bowman SJ, Rinchuse DJ. Use of the Vertical Slot in Orthodontic Brackets, J. Clin. Orthod. 2015;49(9):574-581.

Figure 18: T-Pin for Class II elastics to achieve Class I canine relationship

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40 Orthodontic practice

Volume 11 Number 2

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Vertical slot brackets — for increased treatment efficiency MCDONOUGH

1. The vertical slot or V-slot can be traced back to Dr. _______ in 1928. a. Norman Kingsley b. Raymond Begg c. Albert Ketcham d. Etienne Bourdet 2. If you review most bracket manufacturers’ websites, you will note that about ______ of braces manufactured today are offered with a vertical slot. a. 25% b. 45% c. 60% d. 75% 3. Most vertical slots are _______, and TP Orthodontics has the widest variety of auxiliaries for the vertical slot. a. .018 X .018 b. .022 X .022 c. .019 X .025 d. .022 X .030 4. The most common use of the vertical slot is to allow insertion of ligature wires through the vertical slot, which is tied to the archwire for _________.

Volume 11 Number 2

a. mildly displaced teeth at the initial bonding b. severely displaced teeth at the second visit c. severely displaced teeth at the initial bonding d. mildly displaced teeth at the second visit

c. T-Pins d. elastics

5. We all acknowledge that ________ is/are desirable for efficient tooth movement. a. low friction b. wide inter-bracket distance c. OrthoEasy® Pins d. both a and b

8. T-Pins are also an alternative for ball hooks crimped to the archwire for orthognathic surgical patients for the surgeon to use at the time of surgery to ligate the surgical splints. The T-Pins _______. a. are easily inserted b. have a lower profile than ball hooks c. are less expensive d. all of the above

6. When you tie through the vertical slot, there is _______ the ligature falls off. a. a slight chance b. no chance c. a great chance d. more of a chance

9. _______ are placed in the vertical slots and are used to correct individual tooth rotations. a. T-Pins b. Rotation springs c. Power torques d. Steel ligatures

7. Unlike ball hooks that many brackets have permanently attached to the bracket, which irritate the patient throughout treatment, ________ can be added and removed as needed. a. OrthoEasy® Pins b. crimped hooks

10. _______ inserted into the vertical slot are used to exert a force closer to the center of resistance of a tooth. a. Rotation springs b. T-Pins c. Power arms d. Class I elastics

Orthodontic practice 41

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ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Intersecting areas of law and dentistry: part 2 Dr. Bruce H. Seidberg discusses various forms of harassment and substance abuse Introduction Part 1 of this series focused primarily on the dentist-patient relationship, informed consent, and documentation of treatment. Part 2 focuses on two other areas of dental practice that intersect with the law. The first is harassment, which deals with the demeanor of those within the practice, including the dentist, employees, and patients. The second has been summarized from a very broad area that includes, but is not limited to, use of drugs, prescribing drugs, alcohol, vaping, and self-infliction — all of which can lead to the loss of license and/or family, and even death.

Educational aims and objectives

This article aims to discuss the various forms of harassment and substance abuse and how to avoid putting clinicians, staff, and patients in unlawful situations.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 46 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Define the conduct that constitutes harassment.

•

Identify some classifications of harassment and how to avoid them in the practice environment.

•

Define substance abuse.

•

Realize which drugs are most easily abused and how to avoid the pitfalls.

•

Realize the challenges that dentists face when patients “vape.”

•

Recognize the legal and ethical challenges when the clinician has substance abuse issues and possible measures if such abuse is noted in the office.

Harassment Harassment is the conduct of one individual directed to another that would cause a reasonable person’s interpretation that there is a credible threat to a person’s safety or to that of his/her family, or fear in his/her place in the workforce. The workforce is a universal situation involving any form of employment, but this article focuses on the health field environments of dentistry, medicine, and hospitals. Harassment occurs more often than is readily made known, primarily because of the fear of reporting it or the lack of action by those to whom it is reported. This is a source of frustration for victim advocates and members of the criminal justice system.1 The ADA absolutely prohibits sexual harassment and harassment on the basis Bruce H. Seidberg, DDS, MScD, JD, is a Board-certified endodontist with a private practice in Liverpool (Syracuse), New York, and a consultant for dental malpractice cases. He is a Past President of the American College of Legal Medicine, the NYS Onondaga County Dental Society, Past Chairman of the NYS Board for Dentistry, and currently Treasurer of the AADB. Dr. Seidberg received his MScD in Endodontics from Boston University School of Graduate Dentistry. He was awarded the AAE Presidential Award for his dedication to Endodontics and the ACLM Gold Medal for his work on behalf of law and dentistry. Dr. Seidberg lectures about Risk Management issues in the dental office and can be reached at bseidbergddsjd@me.com. Disclaimer: The materials presented in this manuscript are for general information to use as suggestions to reduce and manage various risks in the practice of dentistry, and not to be interpreted as legal advice. You should communicate with your personal attorney for actual legal advice pertaining to any legal dispute you may be involved in. Repetitive information is for emphasis purposes only.

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of race, color, religion, gender, national origin, age, disability, sexual orientation, status with respect to public assistance, or marital status. Certain discriminatory harassment is prohibited by state and federal laws, which may subject the ADA and/or the individual harasser to liability for any such unlawful conduct. With this policy, the ADA prohibits not only unlawful harassment, but also other unprofessional and discourteous actions. Derogatory racial, ethnic, religious, age, sexual orientation, sexual, or other inappropriate remarks, slurs, or jokes will not be tolerated. Sexual harassment includes

unwelcome sexual advances and requests for sexual favors, and all other verbal or physical conduct of a sexual nature. Harassment is against the law.2 Sexual harassment is a form of sex discrimination and, therefore, illegal under Title VII of the 1964 Civil Rights Act 31,32. Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on race, color, religion, sex, national origin, disability, or age in hiring, promoting, firing, setting wages, testing, training, apprenticeship, and all other terms and conditions of employment. Harassment claims, Volume 11 Number 2

Table 1: Classification of harassment

Table 2: Sexual harassment allegations

• • • • • • • •

• • • • • •

Sexual abuse Verbal abuse Physical abuse Hostile environment Menacing Bullying Cyberstalking Electronic

for refusing to be sexually cooperative. A female employee who accused a supervisor for forcing her into sex was then being fired after she refused.13 Verbal abuse is the second most common type of harassment reported. It includes any type of inappropriate communication such as a one to one, electronic, or telephonic. Typically, it involves lewd comments, off-color jokes, comments about appearance or body parts, being disciplined in front of patients or other staff, and use of harsh tones. The perception of patients is that of a non-caring, non-compassionate, and non-professional dentist. Verbal abuse is demeaning and embarrassing. Physical abuse is that of inappropriate unwanted touching or threatening whereby the individual feels threatened of being harmed. Physical harassment can be in the form of assault and battery. When a reasonable person fears that he/she is threatened to be touched in an unwanted manner, it is assault; and when reasonable person is actually restrained and touched, it is battery. Harassment has consequences such as a negative effect on an office and its personnel. Harassment makes the office atmosphere “stale” and unhappy, can cause a loss of patients, and create a rotating door for staff instability, can be a potential loss of jobs and/ or license, and tarnishes family relationships. Harassment of any type violates the law specifically because of its abusive nature to the person affected, and if severe and pervasive enough, it creates a work environment that a reasonable person would find hostile.

• • • • • • •

Inappropriate touching Making sexual advances Making sexual requests Pursuing after-hours relationship Using indirect sexual language Making demands for sexual compliance Repeated sexual jokes Quid pro quo: receive employer’s benefits for sexual behaviors Demands for sexual favors for favorable employment Graphic commentary about individual’s body Leering, pinching, gestures Sexually suggestive pictures or objects displayed in the office Flirtations

For protection, every office should have a “no tolerance” harassment policy that encourages employees to complain about sexual harassment, assure employees that their complaints will be handled in a confidential manner, and outline reporting channels and methods. Always have an assistant in an operatory when treating patients. Never scold, belittle, or raise your voice to an assistant. Use common sense, and offer constructive criticism in the appropriate setting, and remember that compliments should not contain sexual innuendos.

Substance abuse Occasional use of legal or illicit drugs usually used in a social setting and rarely causing harm or threat of harm to self or others is considered to be substance use. Occasional use in situations that can cause harm to self or others is considered substance misuse. Either category, use or misuse, can include the occasional drink at a party or meeting, but excessive alcoholic drinks are misuse that can lead to intoxication and a DWI.

Table 3: Substance use/abuse simply stated Use and Misuse =

Abuse =

Dependency =

Normal drinking, social drinking

Getting drunk or high

Addiction

Taking medications as prescribed

Driving under the "influence"

Alcoholism

Excessive drinking

Taking medications after needed

Drugs

Mixing alcohol with certain medications

Referral information

Volume 11 Number 2

Orthodontic practice 43

CONTINUING EDUCATION

allegations, and lawsuits are popular areas of compliance violations in employment law. There has been an increase of reported harassment of various types within the past 5 years.5 There are several classifications of “harassment”6 (Table 1). Each one has its own characteristics, and each one is punishable. The #MeToo movement that has been prevalent the past few years has focused on sexual abuse,7 the most common form of the harassment categories. It is the unwelcome verbal, visual, or physical conduct of a sexual nature that is severe or pervasive and can affect working conditions or create a hostile work environment. Sexual misconduct occurs more frequently than reported, and of those reported, most are not successfully prosecuted because of lack of sufficient evidence made available for the egregious allegations.8 Allegations for sexual harassment include, but are not limited to, those listed in Table 2.8 Allegations of being forced to work in an office environment filled with references, material, gestures, and discussions, which included being forced to endure pornographic materials in print, magazine, and digital form, and being subjected to unwelcomed touching by the dentist while making inappropriate sexual comments lead to a hostile harassment environment.9,10 The New York State Dental Association addressed this issue in 1995.11 One of the most egregious cases was in 2009 in which a dentist claimed that massaging women’s chest muscles was treatment to relieve TMD symptoms.12 Quid pro quo harassment is a request for “this” for a result for “that.” It generally results in a tangible employment decision based upon the employee’s acceptance or rejection of unwelcome sexual advances or requests for sexual favors, but it can also result from unwelcome conduct that is of a religious nature. This kind of harassment is generally committed by someone who can effectively make or recommend formal employment decisions (such as termination, demotion, or denial of promotion) that will affect the victim — i.e., a supervisor who fires or denies promotion to a subordinate

CONTINUING EDUCATION Misuse of prescription drugs means taking a medication in a manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria, i.e., to get high. The term “nonmedical use of prescription drugs” also refers to these categories of misuse.14 Substance abuse, a third classification, is a pattern of use leading to clinically significant impairment or distress. There is a capacity to control the use of substances in the aforementioned. When individuals are unable to stop using a substance, when they lack capacity to control use despite selfknowledge that the problems are caused by continued substance use, they are considered to be substance-dependent (Table 3). When those in dependency are asked why, they claim for the feeling of euphoria, to reduce perceived stress, or just to feel better. This type of individual can also be referred to as having an addiction. Addiction is characterized by the inability to consistently abstain, impairment in behavioral control and craving, diminished recognition of significant problems with one’s behavior and interpersonal relationships, and a dysfunctional emotional response.14 The health professions are now engaged in attempting to stop opioid addiction by educating those who prescribe drugs. Drugs include, but are not limited to, overuse and misuse of prescribed medications; all of the opioids, which are referred to daily in the media; nicotine (tobacco); and vaping substances, alcohol, and nitrous oxide. Use of nitrous oxide is easily available in dental offices and is most abused in the dental field.14 It is the leading cause of death in a dental office. Using prescription pain relievers with other prescription drugs (i.e., antidepressants) or over-the-counter medications (i.e., cough syrups and antihistamines) can lead to life-threatening respiratory failure. With some pain relievers, all it takes is one pill. The overprescribing and use and dangers of opioids have been widely publicized, and the tobacco industry has had its fair share of negative publicity.14 The opioid and tobacco industries have faced numerous product liability claims. Recently, the media have reported numerous cases of vaping that have caused respiratory issues from severe to fatal. What has not been reported in depth is the questionable use of recreational or illicit marijuana, CBD products, cannabis, and e-cigarettes.14 Issues now surfacing (that readers of this article are encouraged to seek out) are the 44 Orthodontic practice

Table 4: Red flags identifying substance abuse XX XX XX XX XX XX XX XX XX XX XX XX XX XX

Tremors or jitters Alcohol-like odor on breath Frequent mood swings Isolation and withdrawal from friends and colleagues Increased ordering of patient sample meds and nitrous oxide Loss of attention to patient care and staff management Disheveled appearance Handwriting changes throughout the day Memory difficulties Change in usual behavior Lack of reliability Frequent medical complaints Self-prescribing of mood altering medications Outbursts and intolerant of others

true issues that face children today, especially those of vaping. Vaping is getting out of control starting in middle school. Now there is VAPRWEAR, technology-developed clothing, and other means for vaping without being seen.14 The news media have reported on a number of deaths and other respiratory problems associated with vaping. Dental provider substance abusers are usually less productive, more likely to stop work earlier than normal, more likely to be late for work, and found to be more irritable and have frequent mood changes in and outside of the office. Red flags to help identify substance abusers are found in Table 4. The dental profession is cautioned to be diligent in prescribing habits when participating in the prevention of drug abuse by patients. Drugs should only be used as an adjunct to the dental treatment. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs) or opioids (i.e., narcotics). Opioid prescription pain medications are a type of medicine used to relieve pain. Some of the common names include oxycodone and acetaminophen (Percocet®), oxycodone (OxyContin®), and hydrocodone and acetaminophen (Vicodin®). The three most commonly abused prescribed drugs involved in overdose death are hydrocodone, oxycodone, and methadone. Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. Most painful problems that require analgesics will be due to inflammation.

Table 5: Avoiding lawsuits • Be professional and courteous. • Keep good and accurate records. • Provide adequate informed consent. • Predict appropriate prognosis. • Communicate with patients and colleagues, especially if confused or unsure. • Don’t exceed your level of competency. • Refer when appropriate. • Don’t guarantee or promise results. • Don’t be egotistical about secondopinion diagnoses. • Don’t be greedy and overbill. • Be accessible for patient’s complaints. • Meet the reasonable standard of care.

Table 6: In a malpractice case against the dentist • Don’t try to settle the matter on your own. • Don’t discuss the case with colleagues. • Don’t be shortchanged by your defense counsel. • Don’t be your own private detective. • Don’t rely on hold-harmless agreements. • Don’t alter records. • Treat need, not greed. • Learn from the experience.

It is unethical for a dentist to practice while abusing controlled substances, alcohol, or other chemical agents that impair the ability to practice.17 All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when so impaired have an ethical responsibility to report such evidence to the professional assistance committee of a dental society.18 Failure to adequately warn patients about morbidity or to have screenings for risk factors such as psychosis when prescribing high-potency pain medications could leave dentist vulnerable to malpractice litigation.19 Drug use by anyone is self-abuse, life abuse, and the potential destruction of life. Volume 11 Number 2

Every office should have a harassment policy with which all employees are familiar and comfortable. Always act professionally, and avoid the off-color humor with staff and patients. Attempt to never be alone in the operatory with a patient, especially one of the opposite gender. Prescribe only what is necessary when necessary and only to your patients of record. Prescribe minimally, and try to avoid the opioid crisis. Be aware of substance use, misuse, and abuse of alcohol and drugs. Take time to educate staff and patients about the dangers of vaping and the effects on dental health.

Conclusion A successful practitioner should adhere to Mickey Fallon 3A’s Doctrine of Affability, Availability, and Ability.20 Affability is to be easy to speak to, approachable, amicable, and gentle. Availability is to be accessible to anyone in need for whatever reason. Ability is to be able to think, to accomplish, and have the mental or physical power to do something and to do it well and all in that order. Following the principles of risk management

listed in Table 5 will help avoid lawsuits. In the event of being involved in a lawsuit, follow the criteria set forth in Table 6. Always act morally, ethically, professionally, and with integrity.21 OP

REFERENCES 1. Campbell R., Patterson D. Bybee Prosecution of adult sexual assault cases: a longitudinal analysis of the impact of a sexual assault. Violence Against Women. 2012;18(2):223-244. 2. American Dental Association (ADA). Sexual Harassment and the Dental Workplace. Unit 3. Appendix 3.2; 2017. Unit 3 Appendix 3_2_harassment.docx. Accessed February 25, 2020. 3. Equal Employment Opportunity Commission, Guidelines on Sexual Harassment, 29 C.F.R. Section 1604.11; 1980. https://www.law.cornell.edu/cfr/text/29/1604.11 Accessed February 25, 2020. 4. Weinstein BD. Sexual harassment: identifying it in dentistry. J Am Dent Assoc. 1994;125(7):1016-1021. 5. Twigg T, Crane R. Harassment: avoiding the nightmare. Dental Economics. 2010. https://www.dentaleconomics. com/practice/article/16392775/harassment-avoiding-thenightmare. Accessed February 25, 2020.

10. Campbell R, Patterson D, Bybee D. Prosecution of adult sexual assault cases. Violence Against Women. 2012;18(2):223-244 11. New York State Dental Association. Policy Statement: Sexual Harassment in the Professional Workplace. Albany, NY. 1995 12. Associated Press. Woodland Dentist Faces Sexual Harassment Charges. February 2009 13. Bradon C. Woman accuses supervisor of forcing her into sex, firing her after she refuses. Ferrell v Matthew. Kanawha County Circuit Court; Case No. 19-c-806, 2018. West Virginia Record. September 2019. https://wvrecord. com/stories/513840481-woman-accuses-supervisor-offorcing-her-into-sex-firing-her-after-she-refuses. Accessed February 25, 2020. 14. Bornstein E. Opioids and Marijuana: Managing the Nationwide Emergency. INR Seminars. September 2019. Syracuse, NY 15. Seidberg BH. Dentist’s Drug Use, Abuse and Dependency. Syllabus. American College of Legal Medicine. 2004 16. Arnold J. Knowing the Risks of Opioid Prescription Pain Medication https://www.deadiversion.usdoj.gov/mtgs/ pract_awareness/conf_2018/sept_2018/arnold.pdf. Accessed February 25, 2020. 17. American Dental Association (ADA). Principles of Ethics and Code of Professional Conduct. Section 2, 2.d. Personal Impairment. https://www.ada.org/~/media/ ADA/Member%20Center/Ethics/Code_Of_Ethics_Book_ With_Advisory_Opinions_Revised_to_November_2018. pdf?la=en. Accessed February 25, 2020.

6. Seidberg BH. Harassment — Crossing the Professional Line. Endodontic Practice US. 2013;6(5)42-45.

18. Seidberg BH. Ethics, Morals, the Law and Endodontics. In: Ingle JI, Bakland LK, Baumgartner JC, eds. Ingle’s Endodontics 6. 6th ed. Lewiston, NY: BC Decker; 2008.

7. Zener K. What’s A Dentist To Do? And Other Boundaries Issues. ACLM 12th Annual Ethics and Legal Aspects of Dentistry Conference. Los Angeles, CA. 2019.

19. Seidberg BH, Sullivan TH. Dentists’ use, misuse, abuse or dependence on mood-altering substances. N Y State Dent J. 2004;70(4):30-33.

Seidberg BH. Harassment — Crossing the Professional Line. Oral Health. 2014;10-14.

20. Fallon MW. Personal communication. Oral maxillo-facial surgeon. Syracuse, NY; 2002.

9. Ashbury K Stone v Howard & Howard DDS. Kanawha Circuit Court, case no. 09-C-2103. West Virginia Legal Journal.

21. Seidberg BH. Ethics, Morals, and Law in the Professional Office. Endodontic Practice US. 2014.

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Volume 11 Number 2

Orthodontic practice 45

CONTINUING EDUCATION

Summary

REF: OP V11.2 SEIDBERG

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Intersecting areas of law and dentistry: part 2 SEIDBERG

1. The ADA absolutely prohibits sexual harassment and harassment on the basis of race, color, religion, gender, national origin, _______, status with respect to public assistance, or marital status. a. age b. disability c. sexual orientation d. all of the above 2. _______ harassment is a request for “this” for a result for “that.” a. Quid pro quo b. A priori c. A quo d. Animus revertendi 3. ______ is the second most common type of harassment reported. a. Sexual abuse b. Cyberstalking c. Verbal abuse d. Menacing 4. For protection, every office should have a “no tolerance” harassment policy that encourages employees to ______.

46 Orthodontic practice

a. complain about sexual harassment b. assure employees that their complaints will be handled in a confidential manner c. outline reporting channels and methods d. all of the above

interpersonal relationships, and a/an ______. a. willingness to seek help b. obsessive focus on cleanliness c. dysfunctional emotional response d. heightened memory

5. _______ have an assistant in an operatory when treating patients. a. It is unnecessary to b. Always c. For certain patients d. For minors only

8. _______ provide(s) excellent pain relief due to its/their anti-inflammatory and analgesic action. a. Opioids b. Nonsteroidal anti-inflammatory drugs (NSAIDs) c. Nicotine d. Nitrous oxide

6. When individuals are unable to stop using a substance, when they lack capacity to control use despite self-knowledge that the problems are caused by continued substance use, they are considered to be _______. a. substance-dependent b. socially functional c. occasional-misusers d. euphorics

9. ________ should have a harassment policy with which all employees are familiar and comfortable. a. The front office employees b. Only the dentists c. Every office d. Offices that employ mostly millennials

7. Addiction is characterized by the inability to consistently abstain, impairment in behavioral control and craving, diminished recognition of significant problems with one’s behavior and

10. Always act professionally, and avoid the offcolor humor _______. a. with staff and patients b. with women only c. unless the patient likes it d. unless you cannot be heard by patients

Volume 11 Number 2

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT PROFILE

Boyd Industries — products tailored to the orthodontic market

“B

uilt to Last. Built for You. Built by Boyd” is more than a tagline — it signifies the commitment that the Boyd team makes to each and every one of our customers. Best known for the durability and reliability of our award-winning products — including treatment chairs, mobile storage, and custom cabinetry — we combine over 60 years of design and manufacturing expertise to perfectly fit your unique space and personal style. We take great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can take pride in your office for years to come.

Learn about our featured products: The M3000LC Exam and Treatment Chair is Boyd’s most popular option among orthodontists, combining affordability, function, and a wide variety of practical features including: all-steel frame construction, ergonomically designed winged-back, lowvoltage DC motor actuators, integrated fullfunction foot control, Snap-On upholstery, and choice of seven headrest styles. What makes the MC3000LC perfect for everyday use? Its motorized column base with 8" vertical lift allows the chair’s height to be adjusted for maximum ergonomic positioning, ensuring your comfort as well as your patients’. Perfect for orthodontic consultation rooms, the award-winning M3010 Series Exam and Treatment Chairs’ synchronized drop-toe design provides your patients with the most natural seated position during consultations or minor exams. Like the M300LC, these chairs come standard with all-steel frame construction, ergonomic winged backs, integrated full-function foot

BOS-279 Doctor/Assistant Seat Volume 11 Number 2

control, and more. Enhance these chairs with Ultraleather Pro™ upholstery and Memory Foam cushioning for maximum comfort. To complement your exam and treatment chairs, Boyd offers a series of standard Delivery Unit models for chairside, rear, or concealed delivery. With a nearly limitless selection of laminate colors and grains, these units combine functionality, efficiency, and style. Choose standard or square-back models to accommodate your storage and space requirements. The new CSU-456SQ has a comprehensive range of features: Corian™ work surface, ample storage with push-to-open top drawers, point-of-use countertop Sharps container, internal and external medical grade A/C power receptacles, easy-access self-contained water system, and more. The BOS-279, Boyd’s most popular Doctor/Assistant Seat, offers an ergonomic saddle seat, adjustable seat height and tilt, and a floating lumbar-support back. You’ll find a perfect fit with the seat’s wide range of possible adjustments. Like our patient chairs, Boyd’s doctor/assistant seats are designed with your long-term comfort and spinal health in mind. Once you’ve chosen your seating and storage solutions, complete the picture with Boyd’s LED Exam Lights, which provide

the latest in operatory light technology. Their cool, power-efficient, and reliable LEDs emit clear and natural white light for maximum visibility. Choose the C300 LED Exam Light for its clear and natural regeneration light technology, with an IR sensor with intensity up to 30,000 LUX and 95Ra rendering, three-axis head movement, and adjustable, sterilizer-safe hand grips. The C500 Camera Exam Light features built-in HD video camera, hands-free operation, selection of three different color temperatures, and more. The Boyd team has made every effort to create specialized products that are truly Built for You. These featured orthodontic products can be combined with Boyd’s custom clinical and office cabinetry — with nearly limitless combinations of color and print laminates — to create a fully cohesive office space. When you work with the Boyd team, we recognize your unique needs and offer the widest range of personalization options in the industry, so feel free to consult your sales representative about your new project. Start the conversation today! To learn more, visit us at www.boyd industries.com. You can also follow us on Instagram and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. OP This information was provided by Boyd Industries.

Orthodontic practice 47

PRODUCT PROFILE

American Orthodontics introduces moisturetolerant thermoplastic material

hen it comes to thermoforming plastics, orthodontists have many options to create quality results for their retainers or aligners. Their expertise combined with the right mix of quality, value, and convenience not only brings out the best treatment outcomes, but also can improve the efficiency of the office. A new product, Atmos Thermoforming plastic material from American Orthodontics, offers this winning blend as it has been tested and engineered for best-in-class formability, clarity, moisture tolerance, and extended inventory shelf life. “Atmos has an open-bag shelf life or storage time of more than 3 days in a

climate-controlled storage area,” says Kathryn Dinolfo, AO Product Manager. “That could equate to weeks in office or lab conditions, compared to the typical recommendation of using similar products within 15 minutes of exposure to the atmosphere.” Atmos Thermoforming plastic sheets can remain in open air for 10 to 14 days without warping during formation and also offer excellent stain and wear resistance. Not only will the moisture tolerance of Atmos create less waste in the lab, but a Visual Inventory Management color-coding system will allow orthodontists to easily identify the size of the plastic for intended usage and to manage overall inventory visually.

In addition to achieving lab-tested best-in-class moisture tolerance, Atmos provides patients with an excellent esthetic treatment experience due to its excellent performance, clarity, durability, and stain resistance.

Nancy Morales, Clinical Coordinator for Innovative Orthodontics in Sicklerville, New Jersey, has been using Atmos. “We actually did a little science experiment and left one of the pieces of plastic out on the countertop for a few weeks and heated it up, and it did not have any air bubbles,” says Morales. “We are all super excited about that, plus we have not had a single patient come back with a cracked or broken retainer.” The appearance of air bubbles during formation is indicative of moisture failure. Exposed to 90% humidity in an environmental chamber, Atmos Thermoforming plastic did not form air bubbles even after 3 days. While this could equate to much longer periods in dryer conditions, Atmos should be used within 3 days of opening for best results. Stored in an environment of no more than 75°F and 60% humidity, unopened bags of Atmos Thermoforming plastic could be stored for as long as 3 years. In addition to achieving lab-tested bestin-class moisture tolerance, Atmos provides patients with an excellent esthetic treatment experience due to its excellent performance, clarity, durability, and stain resistance. It can be formed on stone models or 3D-printed models. Dr. Nicole Jane of The Big Smile Orthodontics in Livonia, Michigan, considers formability and clarity to be the most important factors in choosing a plastic for aligners. “My lab team loves Atmos,” says Dr. Jane. “It’s been great for our in-house aligners because of its excellent formability and clarity.” Atmos Thermoforming Plastic is available in .030", .035", and .040" to accommodate most clinical needs and arrives in lab-friendly packaging, allowing you to easily select the proper material from your inventory. Atmos can be formed on equipment that requires 125 mm circles, 120 mm circles, or 5-inch squares. Atmos offers packaging options to accommodate small labs to large offices. Atmos is FDA registered and CE marked, and has passed all ISO 10993 biocompatibility testing. Atmos is available to purchase as of February 10, 2020. Please contact your AO Representative for more details. OP This information was provided by American Orthodontics.

48 Orthodontic practice

Volume 11 Number 2

WHEN THE ATMOSPHERE IS LESS THAN PERFECT Introducing Atmos Thermoformable Plastic from American Orthodontics. Atmos offers exceptional formability, clarity, durability, moisture tolerance, and stain resistance.

Labs of all sizes benefit from the ability of Atmos to produce high quality, bubble free parts up to three days after opening the mylar package.

Atmos is FDA registered, CE marked, and has passed all ISO 10993 biocompatibility testing and is certified to form with or without the protective film wrap.

PRODUCT PROFILE

Active™ by OrthoGum To chew gum with orthodontics or NOT to chew gum with orthodontics?

hewing gum with orthodontics has been debated for years! First, let us talk about why our patients are in orthodontics? • Optimal restorative outcome • Esthetics • Correcting occlusal trauma Old theories: Chewing gum bends wires … Chewing gum knocks off brackets … Chewing gum breaks clear aligners … Chewing gum sticks to braces and clear aligners.

Buckle up! It’s time for change! New technology and new research • Chewing gum decreases pain with orthodontic tooth movement. • Chewing gum increases healthy orthodontic tooth movement. • Chewing gum increases patients’ compliance with wearing clear aligners. • Chewing xylitol-based gum reduces caries, neutralizes pH, kills Streptococcus mutans. 50 Orthodontic practice

Xylitol is the main ingredient in Active™. Xylitol stops bacteria from living by starving it. Active™ balances your pH, neutralizing harmful acids that cause cavities. Using Active™ three times a day can reduce your risk of cavities up to 85%.

I know what you’re thinking — “My patients can just use various chewing devices and vibration appliances.” I’m thinking, “Why are you giving your patients a choking hazard that harbors bacteria?” Or “Why are you making your patients buy an expensive product that they won’t use?” Fortunately, there is a solution! Active® by OrthoGum Inc. Active® is a specifically engineered, ultra-low tack, sugar-free gum that will not stick to aligners or brackets. It is clinically

proven to kill bacteria and biofilm, reduce dry mouth symptoms, accelerate treatment, and freshen breath. Help your patients reach their goal of wearing their aligners 22 hours a day. Visit www.OrthoGum.com. OP REFEERENCES 1. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.16016343.2012.01546.x 2. https://www.sciencedirect.com/science/article/abs/pii/ S0889540616308745 3. https://www.orthogum.com/about

This information was provided by OrthoGum.

Volume 11 Number 2

SERVICE PROFILE

Large Practice Sales Chip Fichtner explains that the value of part of your practice to a silent partner may surprise you

ental Support Organizations (DSO) are a growing force in dentistry. They control up to 20% of the dentistry in the United States, and the number of doctors affiliated with a DSO is growing by 15% per year. Today’s graduates are entering the workplace with a record amount of debt, and many are choosing the safety of DSO employment versus private practice. These factors have a profound effect on the short- and long-term exit strategies of all doctors, but have a more immediate effect on orthodontists due to the typically higher values of their practices. A new graduate has little hope of buying a thriving orthodontic practice unless the selling doctor is willing to be the banker over an extended period of time. One exit option for orthodontists of all ages is to sell 100% to a branded DSO. There are several in the U.S. who eagerly buy orthodontic practices with the doctor remaining as an employee for some period. For doctors nearing the end of their career, this is an option. But for doctors who are not interested in a short-term exit, there are other strategies which could be far more lucrative both initially and long term. Invisible DSOs (IDSO) are groups that own interests in, but not all of, dozens or hundreds of practices across the country. Their model is to become an orthodontists’ “silent partner.” They purchase 60% to 90% of a practice for cash today with the doctor retaining an ownership interest in the practice, the new parent, or a combination of both. The doctor continues to operate the practice under the doctor’s brand, management, and team for years into the future. However, the doctor gains a partner with the resources to accelerate practice growth, profitability, and with decreased administrative headaches. Many doctors even under the age of 40 are attracted to this model as it enables Chip Fichtner is the founder of Large Practice Sales, which specializes in invisible DSO transactions for large practices of all specialties. The company has completed more than $100 million in transactions in the past 6 months. Learn more at largepracticesales.com.

52 Orthodontic practice

“I guess you DO get what you pay for. I was skeptical you could sell my practice at the number you projected. But you did and more. Thank you.” — Dr. B., Orthodontist, Western U.S. (age 60) them to secure their financial future with cash today, while continuing to benefit as an owner for 5, 10, 20 years, or more. They also may have the potential to create wealth through ownership in their new partner. Many orthodontists have made millions above the initial value of their practice over time. Offensively, the IDSO partner can help the practice market more effectively, purchase supplies and team benefits at lower cost, and potentially provide new patients to the doctor through synergies with other partner practices in the area. IDSOs are also eager to provide the capital necessary for complimentary acquisitions or new office starts. Their focus is growth, and it can occur with zero risk to the doctor, even though they are an owner in the growing group. IDSO partnership is also defensive; a real world example to consider. Our client, a very successful 50-year-old orthodontist in a town of 100,000 people, sold 70% of his practice to an IDSO that owned five pediatric practices near him. Previously, he received no referrals from this group. The pedo group was referring 1,500 orthodontic cases per

year to the other four orthodontists in town. Our client is now getting these referrals which justified the 3X-plus collections the IDSO paid for his practice. He still owns 30% of a practice that has more than doubled in value. The other orthodontists in town have seen their production drop precipitously and are now unsellable at almost any value. Orthodontists are unique in the world of dental specialists as many are now dependent upon direct-to-consumer marketing. The other specialists still rely upon referrals from other doctors as their primary source of new patients. The great IDSOs have mastered orthodontic marketing and can become a formidable foe in the marketplace, whether branded nationally or locally. Over time, you will either join a DSO or compete with many. The IDSO model achieves the highest value and can be attractive to doctors of all ages. You can learn the potential value of your practice to an IDSO through the confidential and no-obligation process provided by LPS. Many doctors are shocked at the high values of their practices in today’s bubble. OP Volume 11 Number 2

Silent Partners Invest in All Practice Specialties (Invisible DSOs)

Recent Orthodontic Practice Transactions One-Doctor Practices: 2.4X Collections 2.6X Collections 3.5X Collections

Two-Doctor Practices: 1.7X Collections 2.1X Collections 3.4X Collections

Three-Doctor Practices: 2.2X Collections 3.0X Collections

Every Transaction Customized

Gain Capital For Growth • Known Exit When You’re Ready • Remain as Practice Owner • Your Team, Your Brand Visit FindMyOrthodonticIDSO.com to register for the next webinar. Call 844-734-8533 or email OPUS@LargePracticeSales.com to arrange a confidential discussion with an LPS principal. You may be surprised...

STEP-BY-STEP

Tie-On Rotation Wedge (TORW) for perfect orthodontic finishing: part 1 Dr. Lloyd Taylor presents a detailed technique using Tie-On Rotation Wedges on a finishing archwire to perfectly align contacts

deal occlusion is the ultimate goal of orthodontic treatment. Patients expect perfectly aligned teeth and are aware of the slightest irregularities. Tie-On Rotation Wedges (TORW) are an easy, efficient, and painless way to correct rotations and achieve ideal proximal contacts in one or two office visits. This article presents the clinical steps for bending offsets in stainless-steel finishing archwires and the placement and application of TORW. Rotation wedges were invented by Dr. Cecil Steiner, an orthodontist famous for his Steiner cephalometric analysis. His rigid stainless-steel wedges were available in either a small or large size on a .010" stainless-steel wire. However, now with the TORW, both sizes of his rigid Steiner stainless-steel wedges are replaced with one flexible urethane wedge, which is easily pulled between the tooth and archwire. To produce the desired tooth rotation and perfect alignment of proximal contacts, an offset will need to be created in the finishing archwire. This offset, which is the exact height of the step between the tooth contacts, is driven into the bracket slot while the two wire legs of the TORW are cinched down to produce the perfect tooth alignment. Tied-On Rotation Wedge is composed of two parts: 1. Urethane wedge — body, seating groove, and two ridges

Lloyd R. Taylor, DDS, received his DDS degree from Fairleigh Dickinson Dental School. He first completed a 3-year residency in Oral and Maxillofacial Surgery and Anesthesiology and was Chief Resident at the Albert Einstein College of Medicine/Jacobi Hospital in New York City. Dr. Taylor then completed a 3-year Fellowship in Orthodontics at the Harvard School of Dental Medicine. Dr. Taylor also completed an additional 3-year Fellowship in Orthodontic Teaching and Research at the Forsyth (Harvard) Dental Center. He has practiced both Oral Surgery and Orthodontics in North Hollywood, California for more than 50 years. Disclosure: Dr. Taylor is both the founder and president of OrthoSource since 1985.

54 Orthodontic practice

2. The two legs are formed from a 14" length of .010" stainless-steel wire bent to form the two 7" lengths. Only four instruments are used in the placement of either clear or gray TORW: 1. Double Ended Ligature Director Large Tips (Cat. No. 878-205). The “V” straight end is larger than previous ligature directors for easy and secure placement while driving the finishing wire offset down into the bracket slot. This instrument is also ideal for the 90° bend and tucking in of the wire pigtail under the archwire at the end of placement. 2. Tweed Arch Plier (Cat. No. 871-131). For bending precise width and angle offsets in round or rectangular stainless-steel finishing archwires. 3. Wide 4 mm Mathieu Wire Twisting Hemostat (Cat. No. 878-540). The jaws of this hemostat have been specially designed to securely hold the twisted .010” legs of the TORW as the wire legs are cinched down. Narrower Mathieu plier tips such as Smaha Mathieu, used for placing

Figure 1: Tie-On Rotation Wedge

Figure 2: Instruments for TORW

elastic O-rings, are too fine for twisting steel wires. 4. Pin and Ligature Cutter (Cat. No. 871-173). For the precise cutoff of the twisted wire pigtail.

Tie-On Rotation Wedge (TORW) Technique (Figures 3A-3O):

Offset No. 9 Offset No. 10 Compensatory Bend

Figures 3A and 3B: A. Using a mouth mirror from an occlusal view, determine the exact distance in millimeters that the tooth to be rotated must be moved to perfectly align the contacts. Here the maxillary left central (tooth No. 9) requires a 1 mm step, and the maxillary left lateral (tooth No. 10) needs a 0.5 mm step. With an ultra-fine ink marker, precisely mark the mesial and distal contacts on the labial surface of the finishing archwire. The marker tips can be cleaned with an antiseptic wipe. B. With a Tweed Arch Plier, make a 1 mm offset bend on the mesial of tooth No. 9 and an 0.5 mm offset bend on the mesial of tooth No. 10. Note that a compensatory bend has been made on the distal of tooth No. 10. This compensatory bend, although quite small, is critical to maintain the symmetry of the finishing archwire Volume 11 Number 2

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STEP-BY-STEP

Figures 3C-3E: C. The finishing archwire with its two offsets is inserted in the first molar buccal tubes and then visually checked to assure that the offsets are in the correct position and bent to exact heights. It is critical for perfect tooth rotation that the offset bends on the mesials of tooth No. 9 and tooth No. 10 are precisely located interproximally and are the exactly the height of the needed correction. D. The gingival leg of the Tie-On Rotation Wedge (TORW) is placed first under the archwire. Putting a gentle curve in the end of the gingival leg allows the leg, after passing under the archwire, to turn back labially and thereby avoid sharply contacting the gingiva. E. The wire legs of the TORW are both pulled toward the side of the bracket with the offset. The two ridges on either side of the urethane wedge form a channel where the archwire now sits. As both wire legs are pulled toward the offset, the urethane wedge will be seated tightly against the bracket

Figures 3F-3H: F. The gingival and incisal legs of the TORW are seated under their respective bracket wings. The wire legs are crossed by hand, and a single twist is made in a clockwise direction. To be consistent, wires should always be tightened clockwise so that removal can easily be done in a counter-clockwise direction. G. The initial hand-twisted wire legs are clamped between the wide jaws of the Mathieu. The Mathieu is then used to gently twist the wire legs clockwise until the twist reaches the bracket. H. Gently unclamp the Mathieu, and then re-clamp the jaws around the second twist. Move the Mathieu and twisted wire toward the urethane wedge side of the bracket, opening access for the Double Ligature Director to seat the offset into the bracket slot

Figures 3I-3K: I. The straight end of the Double Ligature Director is used to drive and then hold the wire offset into the bracket slot. Then the Mathieu is rotated 180° clockwise to cinch down the wire offset in the bracket slot. You will see the tooth actually rotate! The patient will feel the pressure of the tooth rotating but no discomfort. J. The Mathieu is gently unclamped and the Ligature Director slowly and carefully released from the archwire, avoiding any sudden movement which might debond the bracket. K. The excess wire beyond the sixth twist is cut off by the Pin and Ligature Cutter leaving a wire pigtail to be placed interproximally under the finishing archwire

Figures 3L-3N: L. Using the straight end of the Double Ended Ligature Director, a 90° bend is made in the middle of the pigtail. M. The 90° bent wire pigtail is then tucked interproximally against the tooth under the archwire. The wedge on tooth No. 9 is placed in the same manner as in Figures 3A-3M as was done with tooth No. 10. N. Labial view showing completed placement of TORW on teeth Nos. 9 and 10

Figure 3O: This occlusal view shows the perfect alignment of both teeth No. 9 and No. 10 immediately after placement of both Tie-On Rotation Wedges. If any minute additional correction is needed, that can be done at the next visit 56 Orthodontic practice

5. Gray Wedges (Cat. No. 618-982) for stainless-steel brackets and Clear Wedges (Cat. No. 618-992) for clear brackets, each in packs of 10 TORW. There are 4 basic steps in the placement of TORW: 1. Marking and measuring (Figure 3A) 2. Wire bending and insertion (Figures 3B and 3C)

3. Wedge placement and cinching (Figures 3D-3L). 4. Wedge finishing (Figures 3J-3O). Tie-On Rotation Wedges are a specialized and unique tool for achieving the perfect tooth rotations sought by orthodontists and expected by patients. Part 2 in the future will explore the fine points and advanced techniques with TORW. OP Volume 11 Number 2

JoAn Majors, RDA, CSP, shows how communication leads to higher value and acceptance of care

oday’s technology onslaught can be overwhelming to learn and implement. It’s not just the acceptance of the technology and what it can provide the clinician; it’s always how we will get trained, who will “mother” the new technology in our practice, and how will we charge and be paid for it. Figuring out how to put soft skills around these technologies to create value and greater acceptance of care is the part I love. It builds confidence among the team and, ultimately, with the patients. Team members have such opportunities to offer benefits and clarity as long as a system is in place for them to do this. From the initial call to chairside and check out, we need soft skills systems in our practices. It’s no secret that the team and doctor often think differently when it comes to new technology. My late father-in-law was a wonderful man who practiced dentistry for 40 years. He did not do bonded dentistry. He did not wear gloves or own an autoclave. He did many amalgams, and so did everyone else. The overhead was dramatically different as well. This does not mean that he could practice dentistry today the way he did when he graduated from dental school in 1948. He did the best he could with what he had to work with at the time. More reason to understand everyone on the team needs to be able to JoAn Majors, RDA, CSP®, is a registered dental assistant and published author, and has earned the designation of certified speaking professional from the National Speakers Association. Her vast career in dentistry spans 3 decades. Her biggest block of business is speaking and training specialists and teams along with their referring practices and teams on the skills that matter. JoAn even developed an aftercare program that consists of online short video training that is executed through a monthly meeting with team leads. She is founder and content creation specialist for The Soft Skills Institute, LLC, a nationally recognized AGD PACE provider of seminars and workshops. JoAn’s happy place is at the front of the room inspiring today’s total team to appreciate the significance of soft skills to create greater value for all types of care and in every relationship, they want to keep. The time is now; the choice is yours! To learn more or see her in action visit: www.joanmajors.com

Volume 11 Number 2

communicate with confidence about new technologies. Otherwise, the doctor’s time educating will be doubled, even tripled, doing a non-revenue generating task. Many times when a recommendation for a product or service is made by the doctor, the patient will turn to the team member after the doctor leaves and say, “What would you do?” or “What did he/she say?”

Then the acceptance or rejection of treatment could lie in the (I would love to add capable here) hands of the team member. Often a team member may not have been trained in verbal skills that create value for a particular service or technology. Leaving your team to (as I often say) “wing it with the words” is a terrible idea! When so much time and money is spent learning the techniques Orthodontic practice 57

PRACTICE DEVELOPMENT

Soft skills for new technologies can create confidence for team members and patients

PRACTICE DEVELOPMENT and technology for care, why would one leave how we convey this to our patients to chance? It’s a roll of the dice in an industry built on predictability. A simple beginning to establish value for the CT scan, or any X-ray for that matter, is not to use terminology we have used in the dental practice for years. For example, we were trained to say, “cavity-detecting X-rays” or “necessary X-rays.” What about creating value by using the person who has the most perceived power in the practice? The doctor. Try offering a different approach simply by using information from the doctor, such as “When reviewing your chart this morning, the doctor ordered these X-rays (or this scan). Do I have permission to take the X-rays (or scan) the doctor ordered so it’s available when the doctor comes in, and you won’t have to wait?” Create value in both the service and the time involved by offering it this way. On a phone call with a potential new patient who is “shopping,” mention the technology to set your practice apart — assuming that you have already connected with the patient on that call, and that you’ve already taken the mom’s and son’s name. Team: “We would love to see Lukas for care. One thing that sets us apart is Dr. Ah-Mazing’s commitment to the best technology and techniques. Did anyone in your family wear braces?” Patient: “Yes, I have older children, and I wore them years ago too.” Team: “You might remember orthodontic records were made with a 2D or flat images and those ooey, gooey impressions to determine outcomes. Our practice is on the leading edge of today’s technology. You see, we now know the most predictable and safest way to determine how much tooth movement is possible for Lukas is with a 3D scan. It’s the only way to measure the thickness of the bone where the teeth are positioned. Our doctors love predictability, and so do our patients. Does this make sense?” Patient: “Yes, that sounds much better than when I had mine!” Team: “We even offer different types of treatment today. Sometimes we use digital scans for impressions and leave the old ooey, gooey stuff in the lab! When you and Lukas meet Dr. Ah-Mazing, he/she will be able to determine all these things. You’ll both love him/her. Would you be able to come in this week to meet Dr. and our team?” With CT scans, the conversation becomes more complicated. Creating value for what some patients and team members 58 Orthodontic practice

Team members have such opportunities to offer benefits and clarity as long as a system is in place for them to do this. From the initial call to chairside and check out, we need soft skills systems in our practices.

perceive as an expensive X-ray is not always easy. We encourage you to point out things that are not obvious. Where standard X-rays are 2D, these cone beam scans are 3D. The thickness of the bone can actually be measured, and the patients LOVE to see this very space-age image. In our practice, patients will often get out of the chair and move closer to the monitor to see the doctor measure specific landmarks. For a cuspid exposure, no more guessing which side of the alveolus it is on. It’s something you show a patient or parent, and it’s impactful (pun intended). Where the nerve is located is no longer a prediction, it’s now proven. It seems that implant dentistry was quickly receptive to CT scans as part of the routine regimen. Recently, an oral surgeon client who has practiced 30-plus years and placed implants, as well as many other quite complex surgeries over his career, said, “I know I can do it without the scan; I did for years. However, I do the scan today because it’s what’s right and best for patients. A lot of things are changing, and it doesn’t matter how good I was. It’s about how good I can be. If you close your mind, you’ll be left behind.” I love his answer; it makes sense. Today more orthodontic practices are embracing 3D technology as part of their routine. My husband, who is an experienced dentist, often says, “The more I know, the more I know that I don’t know.” The team needs to have an understanding and, most of all, a belief in the treatment options available today. If this is not the case, your patients will not receive the enthusiasm they deserve about these wonderful services. Most companies will offer at least some training for your team when you purchase this equipment. Unfortunately, many do not actually have experience in communicating about these new services to patients. We shouldn’t fall so deeply in love with the perfect product or service that we forget to fall in love with communicating

with the ideal patient. When you remember the patient is the one to serve, you won’t leave out the soft skills that allow you to connect with word pictures and questions that bring the confidence and trust for choosing care. It’s the reason I am blessed to be a speaker for some of the best technology companies in our industry. They are the companies that “get it” and understand the significance of having your team “get it.” Your team members can do remarkably well at “preheating” the possible services available with your care, skill, and judgment. If we offer patients an unparalleled reason or create real value for the CT scan (or current technology), they will choose the service. Whether a patient is in your office, referred to you or to someone else who has a CT scanner, much thought and discipline need to be devoted to the discussion about the scan. Remember no more “wing it with the words” is allowed. If you want your team to be enthusiastically sharing, set them up with the systems for success! In closing, we often tell patients that the only proven way to have 100% predictability on bone width or density, nerve location, or whatever relates to your patient’s situation is to do a CT scan. We follow this by asking the patient, “Does this make sense?” If you ask and wait, the person will answer in a positive way. Notice in our earlier phone call with the patient how we end most often with a question. Keep the patient engaged with questions and enthusiasm, and you will create value. Until next time, think about taking a trip somewhere you’ve never visited and hiring a guide. The more experienced guide has done this route for years but now depends on a driver because he lost his sight some years back. On the other hand, you can hire a guide who may be less experienced but can see the route clearly. Ask yourself, who you would choose, and why? See you on the road. OP Volume 11 Number 2

Dr. Rooz Khosravi discusses bringing clear aligner fabrication in-house with new technologies

oving teeth with clear aligners has been around since the 1970s.1 The invisible retainer was the term initially used to describe a clear tray moving a limited number of teeth. The first paradigm shift in aligner therapy was introduced in 1999, when computer-aided design and manufacturing (CAD/CAM) technology majorly improved the treatment planning and manufacturing of aligners. In the past two decades, orthodontists have slowly implemented aligner therapy in their daily practices. Additionally, advances in technology have accelerated improvements in both the components and the manufacturing of clear aligner systems. Examples of these improvements include the introduction of attachments of multiple shapes and forms, auxiliary components added to aligners (bite ramps, Class II corrector arms), and various types of plastic (single and multiple layers plastics).

The new wave of clear aligner therapy in 2020s In-house fabrication of clear aligners is becoming a popular protocol in orthodontic practices. Some opt to use this approach in combination with the existing third-party manufactured aligner systems, while some exclusively provide aligners made at their clinic. Multiple factors have contributed to the rapid expansion of in-house aligner fabrication in orthodontic clinics in recent years. 3D digital technology Digital technology — i.e., desktop 3D printers and intraoral scanners — are easier to operate as compared to a few years ago.

The cost of acquiring such systems is also relatively low now. Practitioners can purchase an intraoral scanner in the range of $14,000 to $40,000 and completely eliminate analog intraoral record acquisition. It is important to note that most of these scanners have advantages and disadvantages. Practitioners should consider the following costs: 1. initial investment 2. consumables to operate the scanner 3. storage of data 4. monthly or annual subscription for the pertinent software Factors such as versatility of software features (e.g., treatment simulation, or web-based model viewer) associated with a scanner and its compatibility with other software platforms in a practice should be considered in addition to the cost of operation to utilize an intraoral scanner. Adding desktop 3D printers to the digital workflow is trending in orthodontic offices. The majority of desktop vat photopolymerization printers used in dentistry fit in one of these 3D-printing protocols: • laser beam stereolithography (SLA) • digital light processing (DLP) • LCD three-dimensional printing (also referred to as mask SLA printing) (see Figure 1). Each of these approaches to 3D printing an object — namely, dental models — has pros and cons. DLP printers, such as SprintRay Pro (SprintRay Inc., Los Angeles, California) and Envision One (EnvisionTEC, Dearborn, Michigan), are among the most popular printers in orthodontics. Higher printing speed, accuracy, minimum training,

Rooz Khosravi, DMD, PhD, MSD, is a diplomate of the American Board of Orthodontics and a clinical assistant professor of orthodontics at the School of Dentistry, University of Washington. Dr. Rooz practices orthodontics at Porth | Personalized Orthodontics, boutique clinics located in Sammamish and Bellevue, Washington. His practice expertise includes clear aligner therapy for adults, teens, and children, using custom Porth aligners. He also provides lingual braces (placed behind the teeth), which are a highly specialized treatment option that are truly invisible. In addition to his academic and clinical excellence, he brings his knowledge of and passion for using technology to Porth, where he uses 3D scanning and printing in every treatment need plan. Dr. Rooz lectures nationally and internationally on digital technology, especially on implementation of in-house aligner systems. He is a leading expert in aligner therapy and is an orthodontist-scientist consultant at leading companies in this field. He also offers courses on how to implement the latest digital technology in daily practice of orthodontics. Disclosure: Dr. Khosravi is an orthodontist-scientist consultant at uLab Systems, Baymaterial | Straumann Group, and SprintRay with financial interest with some of these companies. He noted, “It is a challenge to dissect personal biases while discussing agile aligner delivery workflow, yet I seek to offer unbiased opinion delineating this process.”

Volume 11 Number 2

Figure 1: Three most common 3D-printing protocols for desktop printers. Each of these approaches to print an object layer-by-layer has pros and cons

calibration, and consistency seem to be driving the selection of these two printers. Fused Deposition Modeling (FDM) printers are also promising. Feasibility to print in high volume and limited post-printing processes are some of the strengths of FDM printers. However, further development of filament materials that match the needs of aligner manufacturing is required to further adapt this technology. Digital platforms to move teeth Digitally manipulating an STL model using open source software such as Meshmixer or Blender was part of the early phase of adopting digital technology in orthodontics — some clinics still use these software tools to move teeth. Multiple companies now provide complex digital platforms to modify digital models, move teeth, stage the treatment, add attachments, and optimize the models to be printed. Examples of these platforms are uLab systems, SureSmile® (Dentsply Sirona, York, Pennsylvania), ArchForm, 3Shape Clear Aligner Studio, and Maestro 3D. The mere existence of multiple platforms allows practitioners to choose one based upon their needs and expand in in-house aligner fabrication. Training courses offered by orthodontists or some companies on how to use these platforms aid in faster implementation of the software in the daily practice of orthodontics. New generation of orthodontic assistants Most assistants of a younger generation are very comfortable with acquiring skills to Orthodontic practice 59

TECHNOLOGY

Agile aligner delivery

TECHNOLOGY operate 3D intraoral scanners, to manipulate digital models, and to utilize 3D printers. A trend of transitioning to active (versus passive) treatment is on the rise in orthodontics. Specifically, digital orthodontics allows practitioners to create a therapeutic plan and fabricate appliances while the patient is not in the chair. Therefore, orthodontists are looking to a new workforce — namely, digital orthodontic assistants — who are accustomed to this relatively new daily operation. More flexibility in daily work schedules and possibility to work remotely are some of desirable attributes for such a position that could attract a new wave of orthodontic assistants. Needless to say, seasoned orthodontic assistants with a deeper knowledge and skill set in the orthodontic field who are interested in such positions may be more susceptible to digital training. Direct-to-consumer orthodontic care The new generation of remote clear aligner therapy — with the main premise of convenience at a lower treatment cost — has increased awareness of clear aligner therapy, especially in young professional adults. To some individuals, however, direct in-person interaction with the provider is a nonreplaceable choice while seeking orthodontic treatment. In the past few years, more orthodontists have been looking into offering treatment options that address this new wave of demands. One approach is to reduce the cost of aligner fabrication in order to offer this treatment at a lower price point. In-house aligner fabrication is one of the solutions to this end after the workflow is dialed down properly. The future direction of in-house aligners All of these factors collectively push the in-house aligner fabrication to be further optimized and grow in the coming years. In-house aligner fabrication also helps with 1) combining these appliances with fixed orthodontic appliances, or 2) programming the use of these aligners during certain stages of treatment in order to create a better experience for patients. Orthodontists are learning how to use digital technology to better communicate with the patient and their colleagues as well as to render a more convenient care plan while maintaining the high quality of treatment provided. Practitioners can reason that honing down on digital technology allows an orthodontic clinic to thrive in a market with an increasing number of direct-to-consumer companies and Dental Support Organizations (DSO) offering orthodontic treatment. 60 Orthodontic practice

Figure 2: SprintRay 3D-printing ecosystem together with the software and equipment offered by uLab systems offers a simple solution to establish a robust digital workflow in an orthodontic practice

Figure 3: Plug-and-play desktop 3D printers have fundamentally changed the daily practice of orthodontics in the last few years

Agile aligner delivery One of the advantages of fabricating aligners in-house is the higher speed of delivering care to patients. It is important to note that this agility comes with challenges associated with scaling aligner fabrication at a clinic. Agile aligner delivery workflow is an optimized protocol allowing practitioners delivering highquality aligner therapy at a fast pace. Agile aligner delivery workflow offers the choice of quickly starting the treatment for interested patients. Immediately rendering the care for such patients may increase the compliance with wearing aligners (a removable appliance) by relying on the higher motivation to correct orthodontic problems at the beginning of the treatment. It should be noted that speeding to start the treatment

should not jeopardize the proper diagnosis and treatment planning in order to maintain a high-quality standard of care. The implementation of agile aligner delivery workflow requires all parts of the in-house aligner manufacturing pipeline to work smoothly and in tandem. Ideally, a clinic should have a digital assistant in charge of this operation. Each segment of the aligner manufacturing pipeline has to follow certain requirements. Specifically, practitioners need a digital scanner providing high-quality 3D models. Best practices in scanning should be established in a clinic in order to acquire good quality records. The orthodontic team should have proper training on scanning techniques. Improper scanning techniques Volume 11 Number 2

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TECHNOLOGY could result in poor models, which turn into roadblocks in the aligner manufacturing pipeline. TRIOS® from 3Shape, 3M™ Tru-Definition, and iTero® from Align Technology seem to provide most of these requirements. It is vital to have back-up scanners at your clinic and opt to use one ecosystem to maintain simplicity in training as well as consumable ordering and inventory. A robust yet simple digital platform is the core component of agile aligner delivery workflow. Digitally segmenting the teeth, modifying the models (e.g., adjusting the bite, removing brackets or attachments, and filling holes), moving the teeth, staging the tooth movements, adding the auxiliary parts of clear aligner system (attachments, pressure areas, elastic and button cuts, pontics, and blockouts) and preparing the digital models for 3D printing are sequential blocks of such platforms, and all should be synergistically linked. Lack of efficiency in each of these parts will slow down the process and will introduce the inability to scale the operation. At this point, uDesign from uLab Systems (Redwood City, California) and partly SureSmile aligner software are the two common platforms in the United States that offer such abilities with a promise of improving their features in the future. In my clinic, we spent, on average, a range of 5 minutes to 1 hour from the importing of digital models to the software to exporting the ready-to-print staged models using uDesign from uLab Systems. I found myself reviewing some of the more complex digital setups multiple times over the course of a few days to optimize the staging of the movement and sometimes the position and shape of attachments or pressure areas. 3D-printing technology has been rapidly changing these days. Multiple desktop printers are on the market, which could

provide the requirements for agile aligner delivery workflow. DLP printers (e.g., SprintRay Pro 95, Envision One, or Juell 3D) offer the best balance of speed and quality of a print in orthodontics. Formlab printers, one of the most common laser beam vat photopolymerization also known as SLA, are a user-friendly and affordable option at the expense of printing speed. LCD masking (also known as masked stereolithography, or mSLA) printers are entering the orthodontic field as well. LCD printers offer reasonably accurate models when properly calibrated. The lack of customer support with most of these printers and steep learning curve are challenges when practitioners consider opting for these printers. Nonetheless, the minimum initial investment to acquire one of these LCD printers is appealing to some orthodontic clinics. Additionally, developing a print farm with multiple LCD printers is, in theory, interesting; however, the saturation point to operate multiple units is low, given that most of these printers allow two to three horizontal models per print load. Intuitively, users opt to print vertically on these small build plates, accepting the inaccuracy of unsupported vertical 3D printing. In summary, a 3D printer that can print six to eight models in approximately 30 minutes is a feasible option on the market in order to fulfill the requirements of the agile aligner delivery workflow. The final part of the agile aligner delivery workflow is fabricating and packaging the aligners. The common positive desktop thermoforming units follow: 1. MiniSTAR S® or BIOSTAR® from Scheu-Dental distributed by Great Lakes Dental Technologies (Tonawanda, New York) 2. Drufomat by Dentsply Sirona

Figure 4: In-house aligners allow orthodontists to provide a new array of unconventional orthodontic treatment such as hybrid treatment plans especially to professional young adults seeking personalized care 62 Orthodontic practice

Using these units, an assistant can fabricate one aligner in the range of 1-2 mins. Specifically, practitioners should use a tandem method where one aligner is trimmed and polished while another aligner is thermoformed to optimize the time. Appropriate instruments, including sharp scissors, hole punchers, teardrop cutters, and polishing burs, are essential for a swift operation. Beck Instruments (Santa Ana, California), Hu-Friedy (Chicago, Illinois), and Allure (Whitinsville, Massachusetts) offer most of these instruments. The type of plastic used in aligner fabrication determines the trimming time. Some plastics are hard to cut and create a burden to your team. At our agile aligner delivery workflow, my clinic opted to exclusively use Zendura™ FLX (Bay Materials LLC, Fremont, California), which provides a balance of easier trim, patient comfort, and efficient tooth movement at a higher cost per sheet. Desktop CNC (computer numerical control) aligner trimmer units are entering the orthodontic field. These robotic arms can trim aligners more consistently and with higher precision. Most of these units require further adjustment steps in the aligner manufacturing flow and are promising. uContour from uLab Systems (Redwood City, California) and 5AXISMAKER (5AXISWORKS LTD, London, United Kingdom) are a couple examples of these machines. To the best of my knowledge, uContour is the only unit that is fully integrated with the software (uDesign) to move teeth. Ideally, these units should have the ability to trim multiple models with minimal to no assistance from the user. In summary, it is possible to deliver a set of six to eight active aligners in a couple of hours using an optimized agile aligner delivery workflow. Adjusting and optimizing each part of this pipeline is the key to success on this protocol. I would encourage practitioners to start on a smaller scale and build up the workflow. The choice of certain brands, described earlier, is based on my experience in the past few years striving to optimize the agile aligner delivery workflow. Most parts of this relatively small operation are rapidly evolving, and practitioners may use alternatives based on all these changes. The agile aligner delivery workflow can be implemented in combination with the use of laboratories that offer aligner fabrication to offset some of the aligner manufacturing workload. Practitioners can imagine that the initial series of aligners for each sprint (new scan and new sets of aligners) could be quickly manufactured locally, while the remaining aligners are outsourced. OP REFERENCE 1. Ponitz, RJ. Invisible Retainers. Am J Orthod. 1971;59(3): 266-272.

Volume 11 Number 2

PRODUCT PROFILE

3Shape gives you options for clear aligner treatments

while back 3Shape shook up the clear aligner market by launching an open clear aligner workflow that enables laboratories and practices, no matter what size, to enter the booming clear aligner market. The open workflow, from scanning and treatment planning to setup and manufacturing, is powered by 3Shape technology and its Clear Aligner Studio software and award-winning 3Shape TRIOS® intraoral scanner. The workflow puts labs and doctors completely in charge of the clear aligner treatment and its budget. Any steps in the open workflow can be done in-house and/ or sent to 3Shape partners. Starting with an intraoral scan, Clear Aligner Studio software enables professionals to treatment plan and print models for clear aligner treatments. The printed models are then simply vacuum formed to create the clear aligner treatments. What is unique about 3Shape Clear Aligner Studio and 3Shape TRIOS is that they give professionals options. Professionals can choose to design and produce the treatment or outsource any steps along the way. The result is a clear aligner treatment that can be 500 – 1000 euros ($546.07

– $1,092.14 USD) cheaper than name-brand clear aligners.

Price does matter Dutch lab owner, Germen Versteeg, says that for his business, the decision to go with 3Shape was simple: “When patients come to us, we can offer them a choice for their clear aligners. They can choose the name brand, or they can have us make the clear aligners for five hundred to a thousand euro less. The huge difference in price usually helps them come to a decision.” In Versteeg’s workflow, he has chosen to outsource the clear aligner planning to

3Shape design service partner, FullContour, which uses 3Shape Clear Aligner Studio for its setup and staging. Versteeg takes intraoral scans of the patients at his practice and sends the files to the FullContour portal; within 1 or 2 days, he gets the proposal back from them. Once cleared by the doctor, Versteeg simply downloads the STL files from FullContour and prints the models with his NextDent printer. From there it’s just a matter of vacuum-forming the aligners. Versteeg says that his lab carefully packages the aligners “very nicely just like a name brand would. And the customers go home happy and a thousand euro richer.”

Getting started with clear aligners When getting started with clear aligners, U.S. Orthodontist, Dr. Christian Groth, says the process can be as simple or as advanced as you want to make it. Groth says, “If you want to go full on with bringing the design and production of aligners in-house, you can do that with 3Shape Clear Aligner Studio. You can do it by bringing a 3D printer online, and you can fabricate in-house. “However, if you want to go a little bit slower, you can simply outsource the design portion of this, and you can outsource the manufacturing portion, just to deliver the treatment portion to your office. You can mix and match, whichever you want to do it, depending on you and your staff’s skill set, and what your space requirements are. You may not have space in your office to do all this, but you are still going to want to offer these products to your patients.” Volume 11 Number 2

Orthodontic practice 63

PRODUCT PROFILE

“There’s a lot of people who want to have orthodontics, but they don’t want to have metal braces, and so we have options now to offer treatment in a much more esthetic and streamlined fashion. Clear aligners are the primary way we do that.” — Dr. Christian Groth

Bring simpler cases in-house for control and profitability Having software like 3Shape Clear Aligner Studio enables you to work seamlessly in one integrated workflow. The software’s guided workflow bar walks you through the planning and production steps. With enhanced setup and staging, Clear Aligner Studio gives you more control over tooth movements and improved visualization with intuitive setup and staging features, such as per-aligner tooth-specific movement constraints, and timeline and waypoint adjustments. The software’s automated features, such as automatic attachment placing and sizing, ID tagging, number of aligners, and generated reports, save you time and increase workflow efficiency. In a testament to the software’s usability, U.S. Orthodontist, Dr. Ignacio Blasi, says, “Getting into Clear Aligner Studio and clear aligners in-house is not that difficult. You just have to have good staff that’s trained, the whole office onboard for digital itself, and then you can make things happen.”

Make your practice stand out With the opportunity to offer clear aligner 64 Orthodontic practice

treatments made from your practice, you can pass the cost savings on to your patients. For simple movement cases, relapses, or patients who have already been through treatment, there is really no reason for them to spend so much money on big-name brands. Patients can literally get scanned in the morning and have the aligners designed, models printed, and aligners fabricated by the afternoon. The turnaround time is unheard of. Dr. Groth also adds that another benefit of making clear aligners in-house is when it comes to debanding brackets. He says, “Everyone has had patients where you have small spaces or small rotations that you want to take care of, but you don’t want to do that with brackets and wires, either because hygiene is an issue, they are overtime, or the patients simply want to get their braces off. You can easily design and manufacture a small number of aligners to get these movements taken care of, and they are not done in fixed appliances. These are services that we could not offer before. “Clear aligners are changing what we do because it’s bringing a whole new segment

of patients to our office. There’s a lot of people who want to have orthodontics, but they don’t want to have metal braces, and so we have options now to offer treatment in a much more esthetic and streamlined fashion. Clear aligners are the primary way we do that.”

There’s more to being open than just your choice of solution partner While Clear Aligner Studio and 3Shape TRIOS enable you to instantly send your cases to more than 50 different clear aligner makers around the world, it’s the open workflow that really drives savings for you and your patients. From integrations with all major 3D printers to seamless connections with design and manufacturing services, you are in full control over your budget. You keep everything in the office so that your overhead can be diminished dramatically. Even though you may still have to invest in a printer and whatever other equipment you might need, you end up saving. Dr. Groth sums up the clear aligner workflow powered by 3Shape technology: “When you have clear aligner design and production in-house, you can do whatever you want to do. You can do it in the time frame you want. You control the costs. You control the whole process, which is something that we have not been able to do in the past. In my practice, moving aligner design and production in-house has been one of the greatest things we’ve done.” OP This information was provided by 3Shape.

Volume 11 Number 2

Go Beyond SCANNING

“The beauty of having options.” Dr. Christian Groth, USA

Your open clear aligner workflow With 3Shape’s open clear aligner workflow, you decide whether to send your 3Shape TRIOS® scans to the industry’s widest selection of integrated clear aligner providers or to design and produce clear aligners in-house. From timeframe to costs, take control of your clear aligner cases with the award-winning TRIOS intraoral scanner, 3Shape Clear Aligner Studio® software, and your choice of printer.

Scan-and-send

Produce in-house

1. Scan

2. Simulate & send

3. Plan & design in-house

4. Produce in-house

Take digital impressions with the award-winning TRIOS intraoral scanner for superior scanning

Increase case acceptance with the TRIOS Treatment Simulator and send to aligner providers

Plan and design your treatment in-house with Clear Aligner Studio software

Designs created with Clear Aligner Studio can be manufactured on your choice of 3D printer

Book a demo today!

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