Orthodontic Practice US July 2012 Vol. 3 No.3

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!"#$%&%'#()* July 2012 – Vol 3 No 3

PRACTICE US

Dr. RK Tamburrino and KD Tamburrino A method for accurate recording of the Axis-Horizontal reference plane: part 3

Dr. John Hayes A new regimen of phase I care applied to anterior open bite–10 case studies: an etiology proposed by the strategy of triangulation

Dr. David Seligman Keeping pace with orthodontics

3D imaging straight talk Understanding CBCT dosimetry

Dr. Eric J. Ploumis Coverage groups: don’t be caught dead without one

Also inside: Industry News Practice Development

s e l tic e! r A sid E C In

Memo from the Publisher July 2012 – Vol 3 No 3 Mission Statement To be a practical journal promoting excellence in orthodontics by providing a full range of clinical, continuing education, practice management, and technology articles written by leading specialists.

Orthodontic Practice US Editorial Advisory Board Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD S. Jay Bowman, DMD, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth 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 Margherita Santoro, DDS Gerald S. Samson, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD

Dear Readers: Summertime is finally here (as the Kenny Chesney song goes)! While school is out, and your younger orthodontic patients are happily involved with their summer vacations, we know that you are still hard at work, determined to provide them with the best orthodontic treatment all year round.

As always, Orthodontic Practice US is dedicated to helping you reach your treatment goals by providing new information about every aspect of the orthodontic experience. In this issue, Dr. Ryan Tamburrino ends his three-part CE series about an innovative way to accurately record the Axis-Horizontal reference plane. This series proved to be a great learning opportunity and also yielded a possible six credits, for those who took all three tests. The CE from Dr. John Hayes evaluates a new regimen of phase I care applied to the anterior open-bite.

In our Orthodontic Concepts column, Dr. Rohit Sachdeva shares some philosophy related to our profession as Dr. Larry White concludes his three-part conversation with the cofounder and chief clinical officer of Orametrix. In 3D Dialogue, Dr. Sean Carlson discusses very interesting new details about radiation exposure safety related to the use of 3D imaging.

Knowing these facts will help our readers make informed decisions about this imaging method for diagnosis, treatment, and implementation of orthodontic treatment. In the Legal Matters column, we are happy to welcome Dr. Eric Ploumis, an attorney and orthodontist, who shows how preparing for the worst can result in the best outcome for the dentist and his family. For practice management, we welcome back Dr. Lou Shuman and Diana Friedman, who illustrate the whys and hows of staying connected to patients on the Internet. Knowing that 97% of dental patients would rather click their mouse than call the practice for information, this article can provide insights to boost your practice’s profitability.

Staying connected and building a relationship with patients is becoming increasingly more important. Just as patients want to know that their orthodontist cares about them in between appointments, the MedMark team wants to keep you involved in between issues! Please look for us on Facebook, Twitter, LinkedIn, and our website: www.medmarkaz.com/web/.

PUBLISHER Lisa Moler lmoler@medmarkaz.com

(480) 403-1505

MANAGING EDITOR Mali Schantz-Feld mali@medmarkaz.com

(727) 515-5118

ASSISTANT EDITOR Kay Harwell Fernández kay@medmarkaz.com PRODUCTION MANAGER/CLIENT RELATIONS Kim Murphy kmurphy@medmarkaz.com (480) 580-8008 NATIONAL SALES/MARKETING MANAGER Drew Thornley drew@medmarkaz.com (619) 459-9595 E-MEDIA MANAGER/GRAPHIC DESIGNER Deidra Cole dcole@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton lauren@medmarkaz.com

The MedMark editorial team is always interested in orthodontist/authors for our clinical and CE articles, practice profiles, practice management and development, or technology columns.

Please feel free to contact us for more details or writers’ guidelines for submitting an article.

We are all grateful to our authors, peer reviewers, editorial advisory board, advertisers, and columnists, for helping Orthodontic Practice US to evolve into the enriching, thoughtprovoking, engaging publication it is today. As I say on our website: “The success of our business is achieved as a direct result of helping others succeed in their business.”

I hope that your business continues to thrive and grow, and while you’re at it, remember to save room for some summer fun!

All the best,

MedMark, LLC 15720 N. Greenway Hayden Lp. #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Fax: (480) 629-4002 SUBSCRIPTION RATES: One year: $99 Three years: $239 Tel: 1(866) 579-9496 Web: www.medmarkaz.com © FMC Ltd 2012. All rights reserved.

FMC is part of the specialist publishing group Springer Science+Business Media. 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.

Volume 3 Number 3

Lisa Moler Publisher

!"#$%&%'#()*practice 1

Contents 6

Orthodontic concepts Transforming orthodontics

Part 3 of a conversation with Dr. Rohit Sachdeva, cofounder and chief clinical officer of OraMetrix Inc., by Dr. Larry White

Practice profile

10 Through the keyhole Dr. David Seligman: Keeping pace with orthodontics

10

Corporate profile

14 OrthoBanc

Marla Merritt, director of sales and marketing, discusses how OrthoBanc helps orthodontic practices become more profitable and efficient

Continuing education

18 A new regimen of phase I care applied to anterior open bite–10 case studies: an etiology proposed by the strategy of triangulation Dr. John Hayes outlines a study of anterior open bite to evaluate a regimen of phase I care

18

27 A method for accurate recording of the Axis-Horizontal reference plane–part 3 In the last of the series, Dr. Ryan K. Tamburrino and Kenneth D. Tamburrino illustrate how to implement their method for precision mounting to an articulator system

3D imaging straight talk

34 Understanding CBCT dosimetry Dr. Sean K. Carlson presents the facts about radiation exposure as it relates to CBCT scans and everyday living

27 2 !"#$%&%'#()*practice

Volume 3 Number 3

Uniting Knowledge with Those Who Seek It The Clinical Alliance for Research and Education is at the root of the GCARE name and at the heart of what we do.

More than an acronym, it’s our commitment to an idea that defines who we are. It’s about a dedication to pure science, the company we keep, the knowledge we uncover and the way we share it. Founded on clinical integrity and shaped by your input—GCARE is focused on your needs. From implementing and integrating the latest technology, to enhancing clinical outcomes to practice-growth solutions.

If you’re looking for a deeper understanding of not just what, but also how and why, look to scientists, teachers and leaders of GCARE. Because knowledge is nothing more than trivia…until you care.

Part Inspiration. Part Exploration. All Education.

800.645.5530 | www.gcare-edu.org

Contents Industry news

36 TAD user forum offers an exciting weekend of learning

38 Carestream Dental announces six solutions

at Ontario Dental Association Annual Spring Meeting New product offerings provide benefits for dental practitioners, streamline workflow, and improve doctorto-patient communication

Technology

40 Improved patient care, quality, and practice

38

efficiencies using SureSmile technology

Dr. Steven Moravec tells how this technology changed the orthodontic experience for him, his staff, and his patients

Product profile 42 Ortho FlexTech

Lingual retention in stainless steel and good as gold

Legal matters

44 Coverage groups: don’t be caught dead without one

Dr. Eric J. Ploumis outlines the steps to keeping a practice thriving even in the face of adversity

Practice management

44

48 Tackling the technology HIPPO, er HIPAA!

Toby Buckalew outlines technology-related ways to take the stress out of protecting patient data

50 Stay connected // the engine driving practice efficiency and patient satisfaction

Dr. Lou Shuman and Diana P. Friedman, MA, MBA, show how patients can keep in touch with your practice 24/7

Practice development 52 Why a career in orthodontics is still a smart choice

Chris Bentson and Doug Copple, AVA, discuss the statistics that drive orthodontic opportunities

48 4 !"#$%&%'#()*practice

Volume 3 Number 3

SureSmile now provides the unprecedented ability to plan treatment by positioning teeth and roots within supporting bone.

This capability is just one of the many advances in SureSmile digital orthodontic technology.

ISN’T IT TIME YOU

LEARNED MORE ABOUT SURESMILE? To schedule a meeting with a SureSmile representative or register for one of our upcoming events, visit info.suresmile.com/learnmore

Proven Technology Two peer-reviewed studies comparing the quality and efficiency of SureSmile to conventional treatment were published. Both studies show that SureSmile enables doctors to provide better quality care in a shorter time.

“The SureSmile process results in a lower mean ABO OGS score and a reduced treatment time than conventional approaches.”

World Journal of Orthodontics 2010

© 2012 OraMetrix, Inc. All rights reserved. SureSmile is a registered trademark of OraMetrix.

Orthodontic concepts

Transforming orthodontics Part 3 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of OraMetrix Inc., by Dr. Larry White White: The idea of the preadjusted appliance was to have an ideal arch wire with no bends. Based on SureSmile’s experience, is this a reasonable expectation?

Sachdeva: No, the idea of treating a patient without a single bend in the arch wire is fool’s gold. As I mentioned earlier, many factors combine to affect the final positions of the dentition. It is certainly a complex system, and no simple appliance solution can provide precision control of all tooth movements. Claude Matasa, owner of Ortho-Cycle Co., says that he almost never receives brackets for recycling attached to arch wires without bends. Thomas Huxley once averred, “The great tragedy of science—the slaying of a beautiful hypothesis by an ugly fact.” The ugly fact is that the straight-wire concept was always deeply flawed.

minimum of interaction with other professionals. How do you see the digital age changing this?

Sachdeva: The digital age is providing new vistas for interprofessional collaboration that has the potential to break down the barriers between various disciplines in terms of mindshare that allows patient care from a unified systems-wide perspective. If this great experiment succeeds,

White: CBCT imaging has literally added a new dimension to orthodontic diagnosis, but for the large part has not translated into significant therapeutic value for patients.

Why is that?

Sachdeva: Yes, you are absolutely right. CBCT images provide enhanced 3D visualization and have expanded the horizons of orthodontic diagnosis, and yet this has not translated significantly into therapeutic value for several reasons.

First and foremost, SureSmile provides the only product in the marketplace that has completely integrated the CBCT into the design and fabrication of targeted precision appliances (Figure 1). Although our user base continues to grow, it is still relatively small, and we haven’t reached a point large enough to affect a new standard of care. Also, the ABO has not encouraged its use in diagnosis even though the CBCT has established its diagnostic superiority in assessing root position and localization of impacted and unerupted teeth. A third reason is that our treatment goals have generally been limited to crown positioning. Now we have the new reality of seeing bone and roots in 3D and slowly realizing that the placement of roots perfectly in bone requires meticulous planning and requires additional skills and may not always be possible (Figures 2, 3 C-E). This means that we may need to reconcile with root size to bone discrepancies that may dictate leaving crowns misaligned in order not to harm the bone and/or the roots.

The bottom line is that we can now see so much more than we ever could before, but that we have a deficit in our research and clinical experiences that requires unusual professional and academic conduct to develop appropriate clinical guidelines.

White: Dentistry generally and orthodontics specifically have been pretty much a cottage industry that relied on a 6 !"#$%&%'#()*practice

Figure 1: Demonstrates the various steps in the SureSmile process. (a) is a 3D scan of the physical model using the SureSmile OraScanner. This model is called the Diagnostic or Decision Support Model. Its use is optional and provides the orthodontist the capability to strategize various treatment scenarios and choose the optimal course of action; (b) shows a proactive strategic treatment plan designed in 3D by a doctor using the Decision Support Model. It is accompanied with targeted measures as shown in the tables to the right of the images. Figure (c) is a therapeutic scan, which is generally taken immediately post-alignment.This scan helps localize the bracket positions on the teeth. In this situation, the scan has been taken with a CBCT. The therapeutic scan is used to design a setup; (d) whose boundary conditions are defined from the doctor’s prescription based upon the principles of MACROS. The setup is constructed at the OraMetrix Digital Lab in Richardson, Texas by skilled Digital Orthodontic Technicians. Along with the setup, a virtual targeted prescription arch wire is designed. The virtual setup and its accompanying virtual arch wire are “shipped” to the doctor electronically for review. Once accepted by the doctor, the arch wire is sent to the doctor within 10 business days. The entire process from the time the therapeutic scan is taken to the doctor receiving the arch wire takes 4 business weeks. E and f show the insertion of the initial wire and the initial outcome 3 months post-SureSmile arch wire insertion.

Volume 3 Number 3

Orthodontic concepts interoperability.

SureSmile has the only system currently designed to provide a common platform that enables software that can assist in planning orthodontics, surgery, restorative, periodontal, and esthetic needs of patients. This allows the interprofessional team to provide a total care solution for patients (Figures 3-8). Other obstacles could arise such as resolving conflicts in treatment design, how to incorporate the patient’s voice, and how to make such interactive treatment cost effective for patients. These illustrate the mind shift and cultural shift that orthodontists will have to accommodate to make this a reality.

Figure 2: SureSmile’s Virtual Integrated Patient (VIP) is a surrogate representation of the physical attributes of the craniofacial skeleton of the patient: soft tissue, hard tissue, and dentition. It is the only Decision Support System that allows comprehensive care planning and targeted therapeutics

then patients will gain the most, which is what a welldesigned healthcare system should do.

An interactive virtual environment overcomes the deficits of a fragmented piecemeal approach to patient care. Of course, this new approach has challenges, e.g., who will take overall responsibility of coordinating patient care? What are the roles and responsibilities of each team member? Can the team share a common patient health record?

Many doctors have software tools for planning unique to their own specialty, and these tools don’t have

White: Technology seems to run much faster than human adaptation. Is this because we keep trying to layer our analog 2D processes on to newer digital 3D models?

Sachdeva: Two-dimensional imaging does not provide us with a comprehensive and accurate picture of the in situ condition, and, in fact, gives a projection fraught with error. After all, we can only treat what we can see. Threedimensional orthodontics gives orthodontists appliances that truly control teeth in three dimensions very early in the care cycle, which avoids vagrancies associated with the serial mechanics approach. But one has to recognize that most 3D-driven appliances only offer partial 3D control.

Their inability to assess the roots and bone and coordinate that with the crowns limits their 3D applications. As of now, only SureSmile allows orthodontic clinicians to fully integrate 3D imaging with therapeutics for both labial and lingual treatment (Figures 1 and 9).

White: Just about everyone, including state licensing agencies, pay lip service to continuing education for professionals, and, in fact, have yearly requirements for CE. How does this differ from what you see as lifelong learning, which digital coaching can achieve?

Sachdeva: State licensing agencies provide social instruments to protect the public’s interests. The current paradigm operates on a once-a-year fulfillment of CE requirements that supposedly insures that caregivers have the basic knowledge and skills to provide a minimum standard of care. This concept has some obvious flaws. First, it presumes that all practitioners have the same abilities

Figure 3: Illustrates further deficiencies of the straight-wire appliance and philosophy. (a) demonstrates a simulation of the crown position of the upper right canine, with the bracket prescription fully expressed. Since the appliance has been designed only about a local crown position, one cannot judge where the root will end up; (b) shows the full expression of the same bracket position with the roots displayed. From the vertex view, root discrepancies are clearly visible; (c-e) show the root position relative to the bone. It is obvious that if this appliance was allowed to express itself fully, the root may perforate the palatal cortex. SureSmile provides the only technological solution that allows both the doctor and patient to visualize the boundary conditions of the teeth in 3D. The doctor then designs an appliance system that produces a consistent force system to achieve harmonious treatment goals. The practice of SureSmile emphasizes patient safety, high reliability, and participatory care Volume 3 Number 3

Figure 4: SureSmile’s Software Suite allows for planning surgery in a collaborative environment. The appropriate preand post-surgical arch wires can be designed. The application for designing surgical splints is well under way and should be released sometime in the near future. STL files can be generated to print SLA models !"#$%&%'#()*practice 7

Orthodontic concepts

Figure 5: SureSmile can be used to work interactively with the dentist to plan the restorative needs of the patient. (a) demonstrates the simulation of a buildup for a peg lateral incisor.

Restorations, including veneers, can be planned in all three planes of space; (b) shows the tools available in SureSmile to plan for the smile line. The 3-D model, which has moveable tooth objects, can be superimposed over the facial images to plan for the smile curve

Figure 6: The SureSmile software can also be used to plan the space requirements for implants with both the periodontist and surgeon at both the crown and root levels

Figure 7: The impact of orthodontic treatment on the gingival architecture can also be simulated with SureSmile. Note that the result of the black triangle was predicted in advance using this tool. The patient elected not to proceed with further interproximal reduction to approximate the incisors to close the triangle

and skills, and secondly, it presumes that by brushing up with new techniques, they will implement them to provide improved care for patients.

I propose a different approach. Doctors should assess their professional performance regularly and measure themselves against published best practices. These best practices should be formulated in concert with the clinical community, academia, and professional organizations and regularly updated. This encourages personal accountability and professional strengthening by encouraging doctors to seek expert coaching to help fill any voids in their experience or expertise. Digital technology can facilitate this model, but it will only succeed if we can transform our practices into continuous learning organizations. SureSmile has already embarked on such a model of professional development.

White: I understand that product innovations bring value to the consumer. What else does?

Sachdeva: This is a great question. Process innovation is the other side of product innovation. Process innovation greatly improves product reliability, which improves scalability resulting in affordable goods for services.

Henry Ford is a great example. He did not invent the motorcar or the assembly line. However, he was the first to “mass produce� a car, a phrase he coined. According to Leunig and Voth, process innovations developed by Ford decreased the time for assembling a car chassis from 12.5 hours in the spring of 1913 to 93 minutes a year later.

Greater efficiency dramatically affected the price of the Model T Ford from $959 in 1909 to $360 in 1916. Ford caused other car manufacturers to follow and transformed 8 !"#$%&%'#()*practice

Figure 8: SureSmile software may also be used to include the impact of functional movements on the planned tooth positions

the industry making automobiles affordable to the masses.

Between 1908 when the Model T-Ford was first introduced at a price of $2,126 to 1923, the average price of a car sold in the U.S. dropped to $317 in real terms. This resulted in a drastic increase in the number of car sales from 64,000 in 1908 to 3.6 million in 1923.

White: Is mass production possible in health care?

Sachdeva: Well, in a sense, yes. After all, vaccines are mass-produced drugs and have dramatically improved the health of humanity. Today, we have the ability to mass customize and provide personalized care. The product innovations are in place. The next big thing is to bring process innovation with the view of democratizing health care, which will allow every human to have a beautiful smile. In fact, in the healthcare industry, Dr. Devi Shetty, who is often called the Henry Ford of heart surgery in India, has already proven the viability of this model in the provision of care for heart patients. At his hospital, Narayana Hrudayalaya, the average price for a coronary bypass graft surgery is $2,000, while in the U.S. it ranges from $20,000 to $42,000. His hospital is equipped with state-of-the-art technology, which he has coupled with process and business innovations to bring affordable and high quality care to the masses with less morbidity and mortality than the best hospitals in the U.S. White: Do you have any closing remarks for our readership?

Sachdeva:

I am reminded of Diane Vaughn’s Volume 3 Number 3

Orthodontic concepts

Figure 9: SureSmile integrates 3D imaging with therapeutics for lingual treatment

Figure 10: Shows the evolutionary trend in orthodontics. The path to sustainability lies in placing value in professional skills and demonstrating patient empathy

investigation on the reasons for the Challenger disaster.

A major deficit resided in NASA’s acceptance of a culture of Normalization of Deviance, which she described as “...

Over multiple recurrences of error (variation), we shift our thinking to believe that these flaws are acceptable.”

Orthodontics is unfortunately a victim of the same malaise.

Commonly, during the early part of treatment, we are accepting of both diagnostic and therapeutic errors. We attempt to correct their clinical manifestations towards the end of treatment. This error-correction stage of treatment we call “finishing,” which adds substantial costs to care and unfortunately burdens the patient with the penalty of extended treatment as well. Our professional responsibility is to cure orthodontics of such practices!

We need to establish practices of distinction where we overtly seek a share of the patient’s heart and embed the silent engines of proactive and high performance care technologies and processes. We need to reverse our evolutionary path from a consumption and a provider-consumer relationship to compassionate and creative orthodontics with a focus on the doctor-patient relationship to achieve sustainability (Figure 10). As Hartzband and Groopman remind us, the words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship – the aspects that traditionally made medicine a “calling” in which altruism overshadowed personal gain. This mandates that we rediscover our True North, and reaffirm our values of empathy and authenticity in our relationships with both our patients and colleagues.

We must also embrace failure, and harvest the knowledge from it incessantly within a framework of a system that encourages both transparency and continuous quality improvement. In fact, I wholeheartedly agree with Atul Gawande, who believes that professional betterment can only be achieved by acculturating the discipline of measuring, learning and sharing all the time. Our specialty’s sustainability is at stake. It is time for change! Change not for the sake of change but for the sake of improvement!

Thank you, Dr. White, for giving me the opportunity to have an extended conversation on my viewpoints on transforming orthodontics with you. I have really enjoyed it!

Volume 3 Number 3

White: Dr. Sachdeva, thank you for sharing your knowledge, expertise, and experience in digital orthodontics with readers of Orthodontic Practice US.

Acknowledgements from Dr. Sachdeva: Many of the thoughts I have discussed with you in this interview represent a compilation of ideas from writings of thought leaders in a multiplicity of fields ranging from academic medicine, orthodontics, reliability science, change management, public policy, and automation to marketing, and to them, I am thankful. I would be remiss if I did not name those who have sharpened my cognitive lens.

Chuck Abraham, the SureSmile family, Dr. John Lohse, Dr. Peter Kierl, Dr. Jeff Johnson, Dr. Darrel Schmidt, Dr. Larry White, and Karen Moawad–thank you for sharing a belief system that recognizes the existence of a single truth, although the paths to it may be many.

To my wife, Benu, and my children, Maya, Nikki, and Arjun: you are the best, and thank you for sharing your belief that every moment in life offers an opportunity to better oneself. Also, thank you for nourishing my moral compass every day through your actions—they do not go unnoticed. Your encouragement provides me the jet fuel to seek ways to improve care for orthodontic patients and better my profession.

My heartfelt thanks go to Maya, Nikki, Arjun, and Dr. Sharan Aranha for their help in preparing the figures for this manuscript and helping me to meet the deadline for submission for this interview.

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Practice profile

Photo courtesy of: www.jensencarter.com

Dr. David Seligman

Keeping pace with orthodontics What can you tell us about your background?

I am from Connecticut and am the youngest of three siblings.

My father was a general dentist in the town where I grew up, and my mother was a trainer hygienist who was actually busy raising us kids and didn’t practice hygiene for long.

It was a very “toothy” household. I always had a passion for math and science and was drawn to problem solving. I used to take the city bus home from school and go to my father’s office where I would watch him practice dentistry. I liked being in his lab as well, and his lab tech, Roy, taught me so much. I think it was his mission to have me fully prepared for dental school before I got there! He used to test me about the names of all the teeth. I feel that the best part about my background centers around the educational opportunities that my parents gave me. I’m sure that I threw a bit of fun in there as well!

Why did you decide to specialize in orthodontics?

I chose orthodontics because I loved the mechanical aspect of what we do. Orthodontics is the best of being an architect and designer and requires a creative edge that makes the difference between a good case and a great case finish. I feel that I am at my best when I am caring for others, and orthodontics gives me the opportunity to do that every day at the office.

How long have you been practicing, and what systems do you use?

I have been practicing for 15 years now—hard to believe!

I am a Damon® System purist. I also use Insignia™ Damon, the custom-milled version.

10 !"#$%&%'#()*practice

What training have you undertaken?

Continuing education is key to staying up on the latest in appliances, techniques, and technology. I take as many CE courses in varied subjects as I can get to. My passion is to share information so that others can excel in their practices as well, and have enjoyed recent speaking engagements.

This year’s Damon Forum in Arizona was a true career high for me! I was able to speak about building a referral network. I hope to continue speaking as I find it just the ultimate way to round out a career.

Who has inspired you?

My father served as the greatest role model of hard work. I have been inspired by Dr. Damon from the moment that I heard him speak 10+ years ago. I feel so fortunate to know Dr. Alan Bagden, Dr. Stuart Frost, and so many others. I feel like the orthodontic community is so strong and is the best network to throw questions to when in need. I am surrounded by so many amazing dentists and colleagues here in New York City as well. There’s never a shortage of tooth talk to be had.

What is the most satisfying aspect of your practice?

The most satisfying aspect is certainly helping people. I am my very best when helping others.

Professionally, what are you most proud of?

Wow, tough question. I am very proud to be in New York City and at a place in my career where I am challenged.

I thrive on this. I look forward to watching this practice morph and evolve. I look forward to more speaking engagements as well. I love it.

Volume 3 Number 3

Practice profile

(Right) Dr. Seligman’s system of choice is Damon Clear braces (Bottom left) Records room: PaxReve CBCT (E-WOO), iTero™ scanner (Cadent™), CliniPix photo backdrop in BLUE, Dexta dental chair (Center) Dr. Seligman in the ortho bay (Bottom right) Waiting room, chairs are from Design Within Reach

Photo courtesy of: www.jensencarter.com

Photo courtesy of: www.jensencarter.com

What do you think is unique about your practice?

What makes my practice unique is from the moment that the patients walk in the door, they are treated with the ultimate customer/patient service. I have tried my very best to foster an environment that is unique and personalized.

It is relaxed and peaceful. I strive to be the best part of that patient’s day!

What has been your biggest challenge?

TIME!! Sometimes there just isn’t enough of this! Time management is a big part of being successful in many aspects of life, and this definitely carries over to the office.

What would you have become if you had not become a dentist?

I couldn’t even answer this question because this is not a “career.” Orthodontics is a way of thinking and a lifestyle. I really couldn’t imagine anything else!

What is the future of orthodontics and dentistry?

The future of orthodontics, I believe, will lie in customization.

Braces will all be made specifically for you and you only.

Insignia has set the curve for this. I also believe that all dentists will be using 3D imaging and photography. I truly believe that we are coming into the “Golden Age” as we speak. I have so much respect for dentistry and believe that we will become greater colleagues with our physician Volume 3 Number 3

What advice would you give to budding orthodontists?

I would first let them know that they are so lucky to be a part of the best profession, and that it is so important to align yourself with colleagues who have the same treatment philosophy as you. Many of these colleagues will become amazing friends before you know it.

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Practice profile

(Above) Office views; (Right) Central hallway with cove lighting Office interior photos courtesy of www.jensencarter.com

(Above) Consult room set up with Damon typodont and Invisalign® aligners (Left) Consult room

counterparts as the relationship between oral health and systemic diseases becomes more related. I look forward to this!

What are your top tips for maintaining a successful practice?

When I started in private practice, I was told two things to be successful. First, take great care of people. Second, do the right thing. I try my best to do both every day.

What are your hobbies, and what do you do in your spare time?

I am a runner and like to train for a race here and there. I’m certainly not setting any world records, but a run down to the Freedom Tower and around the tip of Manhattan is the best way to end a day! I love dining and am a total foodie. I think I have a varsity letter in NYC restaurants.

12 !"#$%&%'#()*practice

Top Ten List: 1. I am most thankful that I get to go to work every day and do something I love and am passionate about.

2. My running shoes. They keep me sane.

3. Damon® Clear braces. They have changed the face of orthodontics.

4. The crab crostini at Locanda Verde in Tribeca.

5. My team, which is the true backbone of the practice. I am one; they are many!

6. My patients because they inspire me to be the best that I can be every day.

7. My amazing family and friends.

8. Central Park.

9. The veggie burger at Candle 79 by my office. It’s a life saver!

10. My cone-beam CT scanner; I can’t imagine life without it.

Volume 3 Number 3

Dolphin Management 5 scan Finger ent Treatm

Security U Full Patient Database U Schedu ling U Sequence Planning U Correspondenc Patien e U t Compr ehens ive F

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Patient Information Charlene White's SOS Dolphin Interactive Report Tools Zuelke Financial Expert™ Light Bar Analysis Ledger Scheduling Tooth Chart

Customize!

Organize!

Take control.

Dolphin Management is a powerful yet flexible, full-featured orthodontic practice management system that accommodates your practice’s unique processes. You choose the options you need to help you efficiently manage and organize your practice flow. Customize reports, treatment cards, tooth chart, questionnaire integration, scheduling and much, much more.

Dolphin is the only system that allows this degree of flexibility, so you’re always in control.

Dolphin Management is perfect for any sized practice: from a new practice to an existing practice with high-volume patients, multiple locations and multiple practitioners. To learn more, visit www.dolphinimaging.com/management.

© 2012 Patterson Dental Supply, Inc. All rights reserved.

Corporate profile

Marla Merritt, Director of Sales and Marketing, discusses how OrthoBanc helps orthodontic practices become more profitable and efficient Tell us a little about the history of OrthoBanc.

Before it delved into the orthodontic industry, the company that started OrthoBanc was a credit reporting agency that provided risk assessment and payment management. In those early years, we provided credit reports and risk assessment to banks and finance companies in southeast Tennessee and were an affiliate on the Equifax credit reporting system. In 2000, an orthodontist who used our services needed help deciphering a credit report and deciding whether to offer a payment plan to his patient.

He met with our president, Bill Holt, for advice. Their discussions led to the discovery that orthodontists need access to credit information and recommendations but are very often unprepared to determine this on their own. Their specialty is creating beautiful smiles, and they are typically not trained to be bankers and collection agents.

Out of that initial discussion, OrthoBanc was born.

We quickly expanded the concept of offering credit and payment plan recommendations by adding a product that would help orthodontists collect monthly patient payments. This was at a time when electronic payments were just becoming accepted, and we saw a great need for this in orthodontic offices. In those early days, Bill met with several orthodontic practices and learned that drafting was only part of the equation. Practices needed a company that would completely manage their monthly payments, making sure that failed drafts were handled in a timely manner, and conducting the majority of the patient communication regarding payments. This discovery gave us the vision to create a complete solution that can transform a practice’s financial health while eliminating a great deal of work for the office staff.

What is OrthoBanc’s philosophy?

Our philosophy is to make every payment a priority. In an orthodontic practice, it is very easy to get busy with patient care often at the expense of chasing down the money.

Missed payments can go unnoticed until the responsible party owes for 2 or 3 months plus fees. Doctors who use our services essentially gain a whole new set of employees to manage their monthly payments. We typically recognize problems much more quickly and have a trained staff who begin working with the patient immediately. We know that it is our job to represent our customers in the same way that they would treat their patients, by demonstrating the same integrity, sensitivity and exceptional customer service that they would want their staff to provide. We want our customers to be proud of the way that we represent them, and to be confident that they will get paid because we make every payment a priority.

14 !"#$%&%'#()*practice

OrthoBanc’s Sales Team, led by Marla Merritt

How has your company evolved over the years?

When we first started selling OrthoBanc services in 2001, we had five employees and a set of five Beta customers.

As we achieved success with these initial practices and began marketing to others, word of our company began to spread. Several consultants contacted us and ultimately began recommending us to their clients. Referrals from consultants and practices that use OrthoBanc have enabled us to enjoy steady growth for the last 11 years.

Several years after starting OrthoBanc LLC, we made our services available to general dentists via DentalBanc.

Most recently, we have added another division, PaymentBanc, which provides the same services to any company that offers payment plans. Our greatest success so far with PaymentBanc has occurred with veterinary practices. By offering alternative payment plans for high dollar pet procedures and emergencies, we have helped our clients increase their case acceptance. We see tremendous potential in this market.

OrthoBanc LLC now has 39 employees. We serve orthodontists, dentists, veterinarians and other medical specialties in all 50 states. For the past 3 years, we have made Inc. Magazine’s list of the 5000 Fastest Growing Companies in the United States, and we are on task to make that list for a fourth time this year.

To what do you owe such success?

When the economy plummeted several years ago, many practices were forced to reassess the way they collect their monthly payments. OrthoBanc stepped in and filled the gap. In recent months, we have seen some orthodontists experiencing growth again. Many of these practices had Volume 3 Number 3

Corporate profile

information available via colorful charts and graphs so a practice can see where improvement is possible.

OrthoBanc’s Customer Support Team, led by Tina Mead

downsized their staff to make up for the lack of new starts and associated income. Once again, OrthoBanc has stepped in. Our products can help a practice be much more efficient because we eliminate many office staff tasks.

Of course, our greatest source of new customers is referrals by existing customers. We have done well because our customers love what we do for them and want to share this great news with their colleagues.

What are your flagship products, and how do they serve this niche of dentistry?

As I mentioned, we manage office payment plans by electronically drafting the monthly payment from the responsible party’s checking account or credit card. What differentiates us from our competitors is that we also manage those payments. If a payment fails for any reason, we contact the responsible party and set up the next draft.

If a credit card is about to expire, we contact the responsible party and get the new expiration date. We give patients an ID and password so they can check balances and print receipts directly from our website. By providing these extra services, we help a practice eliminate those calls about missed or failed payments. We also eliminate the mailing of statements or providing coupon books.

In addition to payment management, we offer credit recommendations. In seconds, we can provide a letter grade and a payment plan recommendation. Practices can use these recommendations to reduce risk by charging a higher down payment or shorter payment terms for patients who present a high credit risk. Practices can also increase case acceptance by offering more flexible payment terms to patients who represent a low credit risk. Our credit recommendation product has been available since we first started working with orthodontists, but a few years ago we acquired the use of Paul Zuelke’s algorithm as the basis for our Zuelke Automated Credit Coach (ZACC). We were excited to add his depth of credit reporting knowledge to our existing suite of products. Paul is a well-known and respected consultant in this industry.

Most recently, we introduced a brand new product called OrthoMetrics. This practice analysis tool gathers practice statistics about financials, treatment efficiency, and other important factors. OrthoMetrics then makes this Volume 3 Number 3

How do your company and products differ from your competitors?

OrthoBanc provides a great product at a very reasonable price. We are the only company that provides payment management in addition to electronic drafting. This management truly sets us apart.

OrthoBanc handles all the patient follow-up regarding payments, and we do that for one low price per account. We are the only company that offers credit recommendations along with payment drafting, and we also have the lowest credit card rate that you will find for non-swipe credit card transactions.

How do you cater to the changing needs of the market and keep your finger on the pulse of the industry?

There is so much legislation in the works regarding payment plans. I can’t imagine that a doctor has time to study up on this new legislation to make sure that the practice is compliant with new laws and standards. We recently added a Director of Compliance to do just that. We are equipped to handle the changing legislation that orthodontists don’t have time to research.

We also attend many of the national and regional orthodontic meetings and very much participate in the industry by supporting these events. Attendance at these events gives us the opportunity to talk to many doctors and industry leaders. Our team leaders take this knowledge and meet regularly to determine what else orthodontists need from OrthoBanc.

What feedback do you hear from your clients?

Our customers often tell us that using OrthoBanc has been one of the best decisions they ever made for their practice.

OrthoBanc’s Management Team (left to right): Patrick Wu, Director of Information Technology; Marla Merritt, Director of Sales and Marketing; Tina Mead, Director of Operations; Bill Holt, President, and Joe Gordon, Director of Compliance

!"#$%&%'#()*practice 15

Corporate profile We hear that our services take work off of their staff, and that they love our customer service, southern hospitality, and kindness to their patients. Here are a few quotes from some of our customers:

OrthoBanc – a valuable financial tool. We have had nothing but positive experiences from the very beginning. Our patients love the idea of automatic withdrawal – it is time saving, efficient, and they never forget a payment. The reports are concise and easy to read. As the financial coordinator of our office, I am extremely pleased with the over-all service, tech support and accuracy of their system. Being a paperless office, this system is perfect for us. Thank you, OrthoBanc, for making my life easier!

— Jo Flint, Veil Orthodontics, Bloomington, MN

We LOVE OrthoBanc at Dr. Collazo’s office! This company has made life so much easier for myself and for all of our patients! Setting everything up is so easy.

I wish I could talk about the great help I’ve had when calling OrthoBanc for assistance, but the truth is...it’s so easy and organized that I never have to call them!

How’s THAT for great service!

— Stephanie Washburn, Dr. Mel Collazo, DDS, MS, PA, Little Rock, AR

What is OrthoBanc’s goal for the future?

Of course, we want to continue to grow our OrthoBanc, DentalBanc, and PaymentBanc customer base. We have a large and very capable Information Technology staff who is constantly working to make our systems more efficient and to assure security. We are keeping an eye on industry needs and government regulations to make sure we constantly adapt to the ever-changing world of payment processing.

Our goal is to continue to make orthodontic practices more efficient and profitable by offering products that meet these goals while staying within government guidelines.

OrthoBanc’s Sales Team at the AAO 2012 in Hawaii

Everyone, without exception, I have dealt with at OrthoBanc has been extremely nice and helpful. Some of our patients had doubts about auto-drafts because of problems they had encountered in the past. They are now convinced that auto-draft can work with the right company. That company is OrthoBanc.

— Jackie King, Dr. Michael J. Mahaffey, Peachtree City, GA

Chris Bentson of Bentson, Clark & Copple, a firm that works with practices as they transition from one doctor to another says, “We’re in the business of valuing orthodontic practices. Our experience with practices that effectively present and use OrthoBanc automated payment products is that they are characterized by having little or no past due AR, a happy administrative staff that has more time to focus on the patient’s clinical experience rather than asking for payments and working past due accounts, and a happy doctor. Generally an office that utilizes OrthoBanc is financially strong and often will yield a higher value than other comparable practices.”

Marla Merritt is the Director of Sales and Marketing for OrthoBanc, LLC. She has more than 22 years of experience in financial services and credit reporting.

Ms. Merritt has worked with OrthoBanc since 2001.

The highlights of her career include leading her sales team in the efforts that landed OrthoBanc on Inc. 5000’s list of Fastest Growing Companies for 3 years in a row. She also received Exhibitor Magazine’s All Star Award for OrthoBanc’s marketing efforts at the 2009 American Association of Orthodontists (AAO) Annual Session in Boston and Exhibitor Magazine’s Sizzle Award for her marketing efforts at the AAO 2011 in Chicago. Ms. Merritt has four daughters and enjoys singing, sports and traveling.

OrthoBanc, LLC provides payment management services to over 3,800 practices nationwide and currently operates as OrthoBanc, DentalBanc, and PaymentBanc. OrthoBanc is located in Chattanooga, Tennessee.

16 !"#$%&%'#()*practice

Volume 3 Number 3

Continuing education $ QHZ UHJLPHQ RI SKDVH , FDUH DSSOLHG ĘžR DQĘžHULRU RSHQ ELĘžH FDVH VWXGLHV DQ HWLRORJ\ SURSRVHG E\ WKH VWUDĘžHJ\ RI WULDQJXODWLRQ Dr. John Hayes outlines a study of anterior open bite to evaluate a regimen of phase I care Abstract Objective: The purpose of this study was to evaluate a new regimen of Phase I care applied to anterior open bite (AOB) and to theorize one possible etiology for AOB. Materials and Methods: The data were drawn from the Williamsport Orthodontic Study, which is part of the University of Pennsylvania, School of Dental Medicine, Orthodontic Department’s practice based research network (PBRN). Ten AOB cases were evaluated, all of which underwent a new regimen of “Phase I onlyâ€? care. All patients were diagnosed as maxillary deficient based on Harmony criteria and also based on the center of alveolar crest (CAC) measurement technique, both of which were previously reported.

Results: Based on the strategy of triangulation, one possible etiology of AOB is proposed.

Conclusions: Early Phase I diagnosis and RPE correction of maxillary transverse deficiency, by way of Harmony criteria and the CAC measurement technique may be helpful for mouth breathing/low tongue posture and AOB correction.

More study is recommended with control and treatment groups matched for maxillary deficiency determined by Harmony criteria and measured by the CAC technique.

Introduction Anterior open bite (AOB) is an occlusal condition where no vertical overlap of incisors is present. Previous research papers have documented the hallmark cephalometric characteristics of AOB–the typical deviations from the norms are well known.1-7 Studies have also noted the fortuitous self-correction of some AOB cases.1,8,9 However, it is not known why those patients self-correct and why others do not.

Possible etiologies for AOB have been suggested with some reports proposing that AOB may have several causes.1,8,10-18 AOB correction has usually been attempted by way of orthodontic care alone or by orthodontic care in combination with orthognathic surgery(s). Unfortunately, at the present time, promises of correction are problematical.19 All this suggests that we really do not understand the cause(s) of anterior open bite; the need to know more about the etiology is clear. It has been said that one may learn more from failures than from successes. Accordingly, it should be fair to say that we have learned: UĂŠ ,i}>Ă€`ˆ˜}ĂŠ Ă€iÂ?>ÂŤĂƒi\ĂŠ ĂŒÂ…iĂŠ ˆ˜`iÂŤi˜`iÂ˜ĂŒĂŠ Ă›>Ă€Âˆ>LÂ?iĂƒĂŠ ĂŒÂ…>ĂŒĂŠ >Ă€iĂŠ at fault for persistent AOB may not be importantly related to factors influenced by either orthodontics or surgery.

Although well-performed orthodontic treatment and surgeries have moved patients closer to improved occlusions and improved cephalometric norms, relapse following 18 !"#$%&%'#()*practice

Educational aims and objectives

The aims and objectives of this article are to evaluate a new regimen of anterior open bite (AOB) correction and to theorize on one possible etiology.

Expected outcomes

Reading this article and correctly answering the questions on page 31, worth 2 hours of verified CE, will demonstrate to you that: r :\JJLZZM\S HU[LYPVY VWLU IP[L (6)

correction requires early diagnosis of its likely cause followed by treatment directed at the cause. This may be most effective during ages 6 thru 10 years. r ( �KLÊJPLU[ TH_PSSHŽ PUHKLX\H[L UHZHS HPY^H` PZ one likely cause of AOB. A skeletal transverse deficient TH_PSSH JHU SLHK [V TV\[O IYLH[OPUN HUK H TV\[O VWLU WVZ[\YL HSVUN with other dental and medical health problems. r 4V\[O IYLH[OPUN SLHKZ [V H SV^ [VUN\L YLZ[PUN WVZP[PVU ^OPJO PU [\YU can lead to AOB. r ;OL KLÊUP[PVU VM H �KLÊJPLU[ TH_PSSHŽ TH` ]HY` KLWLUKPUN VU H JSPUPJPHU�Z L_WLYPLUJL HUK [YHPUPUN >L OH]L \ZLK H UL^ KLÊUP[PVU of deficiency and new treatment regimen based on skeletal [YHUZ]LYZL TLHZ\YLTLU[‹\ZPUN [OL �JLU[LY VM HS]LVSHY JYLZ[Ž

measurement technique (CAC) and Harmony criteria –both previously reported. r ( WH[PLU[ ZSV^ [V YLZWVUK [V [OL UL^ YLNPTLU VM (6) JVYYLJ[PVU may need an ENT evaluation to rule out any other possible nasal airway problem(s).

routine AOB treatment is common. This is likely due to the independent variables continuing to assert themselves.

UĂŠ ,i}>Ă€`ˆ˜}ĂŠĂƒiÂ?v‡VÂœĂ€Ă€iVĂŒÂˆÂœÂ˜\ĂŠĂƒÂœÂ“iĂŠÂˆÂ˜`iÂŤi˜`iÂ˜ĂŒĂŠĂ›>Ă€Âˆ>LÂ?iÂ­ĂƒÂŽĂŠ is(are) acting with growth/maturity to self-cure the problem.

Two possibilities come to mind: 1. Normal vertical facial growth, with maturity, and the concomitant increase in the nasal airway volume could be responsible for less mouth breathing and help jump-start self-correction (more study is needed). 2. Additionally, shrinkage of lymphoid tissue with maturity could also lead to less mouth breathing and also help jump-start self correction.20 Volume 3 Number 3

Continuing education

The purpose of this study was twofold: to evaluate a new regimen of Phase I care applied to anterior open bite (AOB) and to theorize one possible etiology for AOB. Materials and methods For the “Phase I only treatment–no braces” Williamsport Orthodontic Study (WOS) provided the patients. The WOS is part of the University of Pennsylvania School of Dental Medicine, Orthodontic Department’s practice based research network (PBRN).21 The WOS was a 10-year retrospective and longitudinal study; it used before and after dental casts and films from one private practice.

Patients in the WOS were diagnosed with maxillary deficiency. Patients were then treated with a new regimen of Phase I care with RPE to eliminate the maxillary deficiency; all cases started in mixed dentition; after Phase I care, the cases that were judged to require 9 months or less care in a future Phase II of braces were retained in the data base.

Volume 3 Number 3

The present AOB study used 10 anterior open bite (AOB) case studies (three male and seven female) from the WOS. All the patients exhibited maxillary deficiency as defined by harmony criteria. Harmony was defined: when the skeletal transverse maxilla was at least as wide as the skeletal transverse mandible (measured by center of alveolar crest [CAC]) and up to 5-mm wider. Thus, there was a range of harmony. For example, a maxilla that was narrower than the mandible (measured by CAC) would be considered maxillary deficient and not in harmony. The studies undertaken to propose new harmony criteria have been previously reported. It was evident from the studies that maxillary deficiency was more common than previously thought.21-24 The new center of the alveolar crest (CAC) measurement technique may be the most reliable and meaningful transverse skeletal measurement available at this time as it does not rely on less reliable dental landmarks.21-24 !"#$%&%'#()*practice 19

Continuing education

Each patient in the study also showed variable signs of habitual mouth breathing; tongue thrusting; CL II and CL III developing skeletal patterns; low tongue rest position (as noted by cephalometric radiograph); impacted maxillary cuspids among other crowding issues, and some snoring symptoms. Two patients presented with a posterior crossbite (Table 2, item 2).

Dolphin cephalometric software was used with the cephalometric analysis. OrthoCad™ (Cadent, Inc.) software was used for analysis of the dental casts and for measurements. Vertical incisor overlap was determined, in part, by OrthoCad (Figure 1).

Appliances were constructed by Great Lakes 20 !"#$%&%'#()*practice

Orthodontics, Ltd.: RPE (Great Lakes SD1017 turnbuckle)-Haas style (modified with the classic buccal wire struts removed for improved appliance flexibility); lower lingual holding arch–for lower leeway space maintenance; Hawley retainer–also for Phase I space maintenance, and modified Hawley retainers (with habit loops for two patients, Table 1, item 15).

To be included in the present AOB study, an AOB at T1 (presentation) of at least negative 1.5 mm was required, as measured by the OrthoCad bite analysis. Additional criteria were used to ensure that a true AOB was present: 1. Maxillary incisors were fully erupted.

2. Mandibular incisors featured a step-down from the Volume 3 Number 3

Continuing education

occlusal plane–a classic skeletal open bite characteristic (Figure 2).

3. The anterior portion of the maxillary ridge alveolar ridge featured a vertical warp–also a classic characteristic of skeletal open bite (Figure 2).

4. And, as noted above, all patients were diagnosed with maxillary deficiency defined by harmony criteria and CAC measurements.24 UÊ,iV À`ÃÊÜiÀiÊÌ> i Ê>ÌÊ/£­«ÀiÃi Ì>Ì ®ÆÊ>}iÃÊÀ> }i`ÊvÀ Ê 6 years 3 months to 9 years 6 months, Table 1, item 4.

UÊ,iV À`ÃÊÜiÀiÊÌ> i Ê>}> Ê>ÌÊ/ÓÊ­Ü V Ê >À i`ÊÌ iÊÃÌ>ÀÌÊ of eruption of 12-year molars); ages ranged from 10 years, 1 month to 14 years, 1 month, Table 1, item 5. T2 post Phase I (delta) ranged from 1year, 11 months to 5 years, 1 month.

The T2 dental casts comprised a portion of the orthodontic progress records.

UÊ,iV À`ÃÊÜiÀiÊÌ i ÊÌ> i Ê>}> Ê>ÌÊ/ÎÊ­ }iÀ ÌiÀ Êv Ü up) for five patients who were able to be located (case Nos. 3, 5, 6, 7 and 10). T3 years post T2 (delta) ranged from 4 years to 11 years, 2 months, Table 1, item 7.

The new regimen of phase I orthopedic care consisted of: 21,22 1. Diagnosis and treatment to address any maxillary deficiency by ages 6 to 10 years. For example, Case No. 1, a 7-year-old, featured a maxillary deficiency of 3 to 8 mm, based on the Harmony criteria range and CAC measurements. Actual expansion was 7 mm, which was close to “ideal harmony,” Table 1, items 2 and 3.

2. Very slow RPE expansion (one turn/every other day) was used to gain the skeletal harmony. The amount of recommended skeletal expansion varied, depending on individual patient needs (Table 1, item 2).

3. An expanded and torqued lower lingual holding arch was also used to simultaneously upright posterior mandibular molars as the maxillary deformity was normalized.

4. Adequate maxillary midline suture maturation was achieved, prior to removal of RPE–as determined by prior research (no turnbuckle activation for 6 weeks after completing very slow expansion).21,22 5. The RPE was then removed.

6. Unhampered dental “settling relapse” of the posterior dentition was allowed to take place by waiting at least 6 weeks after RPE removal, as determined by prior research.21 Volume 3 Number 3

7. A Hawley retainer was used, as necessary, for maintenance of maxillary leeway space and for tongue habit loops, as necessary, Table 1, item 15.

8. Phase I active care duration was 12 months or less.

9. Post Phase I, periodic (6 to 9 month) follow-up visits were planned until eruption of some 12-year molars, or as necessary.

10. Progress records were taken at T2.

Disclaimer: These steps are presented to help distinguish the newly proposed orthopedic regimen of Phase I care, used in this research, from the typical definition of “Phase I care.” The above information is not designed to take the place of a seminar course given to certified orthodontists.

Due to the severity of maxillary deficiency (defined

by CAC and new Harmony criteria) at presentation, four patients (case Nos. 3, 5, 8 and 10) required a second, sequential RPE to gain the needed skeletal CAC expansion to move within the range of acceptable to “ideal” harmony (Table 1, item 13). Although the turnbuckle featured a maximum of 12-mm turnbuckle expansion, actual skeletal expansion attainable was typically 6 mm with the remaining 6 mm seen in unwanted increased posterior inclinations.

The unwanted additional inclinations were allowed to relapse back to pretreatment inclinations after removal of the RPE, as discussed above.21 It is important to note that the expansion was not measured by turnbuckle or by dental landmarks but rather by CAC measurements as skeletal improvement was the objective.

One patient, case No. 6, wore a Phase I Hawley retainer occasionally, Table 1, item 16. And one patient, case No. 5, used a Hawley retainer, intermittently following a short course of Phase II treatment (braces for less than 9-months duration) when evaluated at T3, Table 1, item 17. The remaining eight patients were unretained at T2 and T3.

Results The new regimen of Phase I care helped address maxillary deficiency and was helpful to gain AOB correction. Results of this study are shown in Figures 3 thru 17 and in Tables I and II. An advantage of case studies is apparent: the cases can be visually evaluated by way of before and after dental casts, panoramic films and cephalometric data. Accordingly, individual case results were not lost in averages or statistical inferences.25 !"#$%&%'#()*practice 21

Continuing education

At T1 (initial presentation), all 10 patients presented with AOB that ranged from negative 1.5 mm to negative 4.8 mm, Table 1, item 8; two patients presented with posterior crossbite, Table 2, item 2: five patients were CL III; two patients were CL II; 3 patients were CL I, Table 2, item 1.

At the end of the 12 months of Phase I care, full correction of AOB had occurred for 6 of the 10 cases. Four remaining case Nos. 6, 7, 8, and 10 were not fully corrected after the 12 months of Phase I. Accordingly, Hawley retainers with habit loops were used (case Nos. 6 and 8) along with oral habit therapy (case Nos. 6, 7, 8, and 10) to further help with the complete correction of any remaining open bite, Table 1, item 14.

At T2 (the start of eruption of 12-year molars), all cases including case Nos. 6, 7, 8, and 10, were fully corrected, Table 1, item 9. Open bite improvement (delta) T1 versus T2 ranged from 6.9 mm to 3.6 mm for the 10 cases; at T2, bites ranged from positive 1.6 mm to positive 3.5 mm.

Importantly, mouth breathing/low tongue posture was resolved for all these patients by T2, as evidenced by their stable AOB correction and by observation.

At T3 (longer-term follow-up), all five long-term follow22 !"#$%&%'#()*practice

up cases maintained positive correction of bite, ranging from a positive 1.8 mm to 2.8 mm. Long-term open bite changes, T2 through T3, continued to improve for two patients: case Nos. 3 and 7, (delta) 0.5 mm and 0.3 mm, respectively. Case No. 5 relapsed slightly (delta), negative 0.1 mm; however, it maintained a positive bite of 1.8 mm. Case Nos. 6 and 10 (delta) remained unchanged in the long-term follow-up, T2 through T3. Thus, open bite correction remained stable at T2 and at T3 without retention in all five cases, Table 1, item 11.

Actual skeletal RPE expansion (for all cases, ranged from 4 mm to 10 mm, as measured by CAC, Table 1, item 3.

Non-surgical maxillary skeletal expansion with RPE beyond 6 mm has not been previously reported in the literature based on PubMed and hand-searching of the literature.

Given that AOB was resolved for these 10 cases by way of addressing their maxillary deficiency/mouth breathing, referral to an otolaryngologist was not necessary (Figure 18). Had an intractable open bite remained at T2, an airway evaluation would have been recommended to rule out adenoid hypertrophy, deviated septum, hypertrophic turbinates, allergies, etc.

Volume 3 Number 3

Continuing education

Reciprocal results of the new regimen of Phase I care were also notable: UÊ*> À> VÊw ÃÊÀiÛi> i`ÊÌ >ÌÊ«ÀiÛ Õà ÞÊ «>VÌi`ÊVÕë `ÃÊ at T1 had spontaneously de-impacted by T2.

UÊ i Ì> Ê V>ÃÌÃÊ Ã Üi`Ê Ài >À >L i]Ê Ã« Ì> i ÕÃÊ improvement in dental alignments from T1 to T2 (and maintained at T3).

UÊ >Ý >ÀÞÊ >ÀV Ê v À ÃÊ >ÃÃÕ i`Ê Ì iÊ V >ÃÃ VÊ >À ÞÊ morphology (horseshoe shaped) of normal non-orthodontic subjects, as described by Lundstrom.26 UÊ/ iÊ ,* Ê > Üi`Ê Ài`ÕVi`Ê V >Ì Ê vÊ « ÃÌiÀ ÀÊ teeth for improved periodontal stability—more study is recommended.

UÊ `` Ì > Þ]Ê > `Ê > iV` Ì> Þ]Ê Ì iÊ «>Ài ÌÃÊ Ìi`Ê improvements in their children’s overall health by way of improved nasal respiration—more study is recommended.

UÊ Ê Ê > `Ê Ê Ê «>ÌÌiÀ ÃÊ V > }i`Ê Ü Ì ÕÌÊ ÀÌ ` Ì VÊ care to a CL I pattern and remained stable–more study is recommended.

UÊ ÌÊÃ Õ `ÊLiÊv> ÀÊÌ ÊÃ>ÞÊÌ >ÌÊÌ iÊ iÜÊÀi} i Ê vÊ* >ÃiÊ ÊV>ÀiÊ would have been an advantage for these patients whether or not the anterior open bite had been corrected.

Discussion One possible etiology for anterior open bite—a theory based on the strategy of triangulation: Simply put, triangulation is the use of three different methods to arrive at a conclusion.

Volume 3 Number 3

Method No. 1: Gain insight from highly respected experimental research and experience.

1. Harvold et al, showed, by way of animal research, that mouth breathing/low tongue posture can cause AOB–and other malocclusions.27 2. Linder-Aronson et al, wrote: “The important point proven by animal experimentation is that alteration in mandibular and tongue posture in the presence or relief of nasal obstruction appears to be more important than whether the air flows through the mouth or the nose.”28 3. Mason and Proffit wrote: “It is quite possible, though it has never been demonstrated directly, that light forces produced by an anteriorly positioned tongue tip can impede eruption of incisors.”11 4. Mason and Proffit also wrote: “Excessive adenoid proliferation before puberty is one cause of nasal respiratory obstruction in children. Chronic allergic conditions, nasal infections and mechanical blockage by turbinates or a deviated septum also can lead to mouth breathing. The resulting respiratory obstruction syndrome (Ricketts, 1968) includes tongue thrusting and malocclusion. To open the oral airway, it is necessary to carry the tongue low and forward and the mandible at a lower-than-normal rest position.”10,11 5. Ricketts wrote: “It would seem that during the 1940s and 1950s, the role of heredity had its day [re: etiology of malocclusions].10 6. Ricketts also wrote: “If 20 years of orthodontic experience !"#$%&%'#()*practice 23

Continuing education

means anything, I can say with no reservation whatsoever that open-bite tongue problems constitute the most annoying situation that I have experienced in a clinical level in pre-orthodontic, orthodontic, post-orthodontic, and non-orthodontic patients. It is also my suspicion that many tongue problems are in some way basically related to respiratory problems, either at present or in the past history of persons with problems.”10 7. Ricketts noted that, in addition to adenoid and turbinate tissue size as a cause of mouth breathing: “There are other local factors however. Chronic rhinitis, recurrent upper respiratory infections, allergies, asthmas, polyps, foreign bodies, deviated septa, unreduced fractures, and ambitious surgical treatment of cleft palate conditions can produce varieties of obstruction to natural flow of air through the nasal cavity.”10 8. Theories since the 1960s have suggested that a deficient nasal airway can lead to an anterior open bite. And since it has also been known since the 1960s that a deficient nasal airway can frequently be caused by a maxilla deficient in the transverse dimension,29 it may seem unusual that little attention has been focused on the morphology of the maxilla as it may relate to AOB. The possible reasons for this oversight will be discussed later in this paper.

9. A common thread runs through the findings of AOB research: UÊ Ê ÜÊ > `Ê v ÀÜ>À`Ê Ì }ÕiÊ « ÃÌÕÀi]Ê Ü V Ê VVÕÀÃÊ Ü Ì Ê mouth breathing.

24 !"#$%&%'#()*practice

UÊ Ê }Ê ÜiÀÊ v>ViÊ i } Ì]Ê Ü V Ê V> Ê ÀiÃÕ ÌÊ vÀ Ê ÕÌ Ê breathing.

UÊ Ê } Ê } > Ê > } iÊ > `Ê Ì iÀÊ Vi« > iÌÀ VÊ ` V>Ì ÀÃ]Ê which are common with mouth breathing.

UÊ «Ê V «iÌi Vi]Ê Ü V Ê ÃÊ V Ê Ü Ì Ê « ÀÊ }À ÜÌ Ê resulting from prolonged mouth breathing.

UÊ Ê `iwV i ÌÊ >Ý >]Ê Ü V Ê ÃÊ V Ê Ü Ì Ê ÕÌ Ê breathing.

UÊ Ê > ÌiÀ ÀÊ «i Ê L Ìi]Ê Ü V Ê ÃÊ V Ê Ü Ì Ê ÕÌ Ê breathing.

UÊ/ iÀiÊ>ÀiÊ Ì iÀʺÃÕëiVÌûÊv Õ `Ê ÊÌ iÊÛ V ÌÞÊ vÊ ÕÌ Ê breathing.

Method No. 2: Gain insight from unsuccessful AOB treatment reports. The failed correction of AOB, as seen in orthodontic or orthodontic/surgical case studies, may be linked to disregard for the diagnosis/treatment of an inadequate nasal airway. Consider: a low and forward tongue posture–an impediment to incisor eruption–can be secondary to mouth breathing, which can be secondary to an inadequate nasal airway or which can be secondary to a deficient maxilla and other possible airway problems.

Method No. 3: Gain insight from successful AOB treatment. The present AOB study improved maxillary deficiency for 10 patients that also, coincidentally, improved nasal respiration enough to apparently allow correction of tongue posture enough for the AOB to resolve by itself with stable long-term results. Results of the present case study help confirm that improvement in maxillary deficiency, as Volume 3 Number 3

Continuing education diagnosed by Harmony criteria and CAC measurements, is importantly related to AOB correction and may be recommended as a first step in AOB correction.

Accordingly, based on triangulation, it was theorized that deficient maxilla/mouth breathing/low tongue posture were root causes for AOB, with deficient maxilla being the most likely precursor (Figure 18).

These are not new ideas.5,14, 29-32 However, a new definition of maxillary deficiency and a new center of alveolar crest (CAC) skeletal measurement technique helped to reveal more clearly what constituted maxillary deficiency.21,22,24 Could self-correction be responsible for any or all of the 10 case study results in this manuscript? AOB improvements were noticeable 4 or 5 months into the 12 months of Phase I. The four patients who required additional time for full correction also showed early improvement. On the other hand, the self-correction apparently occurs over several years’ time—if it occurs at all.8 Regardless, in the unlikely situation that some cases would have cured themselves, the important reciprocal changes previously discussed above would not have occurred if it had not been for Phase I care.

This study’s simple design helped minimize research biases. No braces or active retainers were used for AOB correction. No retention of any type was used to hold AOB correction. Treatment involved: 1. The elimination of maxillary deficiency by way of RPE; new skeletal transverse criteria were used to help define maxillary deficiency.

2. Preservation of leeway space.

3. Orthodontic treatment, surgical treatment and artificial retention were not used, thus, treatment biases were minimized. A treatment plan flow diagram is proposed (Figure 19).

In our experience, the 10 case studies and the AOB treatment results presented in this manuscript were not exceptional—they were, in fact, representative of hundreds of other similar AOB cases that received the new regimen of Phase I care.

It may be interesting to speculate on the reasons for the frustrating lack of historical clinical success with AOB correction. It has not been for lack of research efforts. Five popular approaches to treatment may be partly responsible: I. Waiting for self-correction of AOB may be problematic. Given that some self-correction has been noted with growth, there have been suggestions that a “waitand-see” approach should be taken regarding AOB care.8,33 The questions that need to be asked regarding “laissez faire care” are: why do some patients self-correct while others do not correct?

Those patients who do not self-correct are in a tough spot. Orthodontics combined with surgery of one or two jaws may be recommended and, unfortunately, the surgery has not been fully effective.19 Surgery has not been a reliable cure for AOB Volume 3 Number 3

because the root causes of AOB likely continued to assert themselves. When enough is known regarding the selfcuring patients, they could be let alone to cure themselves.

However, with the over-eruption of posterior teeth and loss of lip competence, AOB may become intractable. Studies are needed to help develop new criteria to determine when waiting could cause problems, and when waiting would not cause problems. When we know more, “wait- and-see” will make more sense.

On the other hand, other authors have suggested that we should not wait to treat AOB.5,34 II. Randomized controlled trials (RCTs), at this time, may be problematic. It may be that little is known about AOB correction because the valid authority of a RCT research study is not yet available to help shine some light on this dark subject.17,18,35 Most orthodontists would likely agree that RCTs are desirable and should be performed, if they are feasible.

Problems with RCTs are well documented, and they can easily be researched. One problem among many: the moral dilemma of not treating a group of patients (the control) that eventually needs treatment—and treatment delayed may adversely affect their outcome.

Consider a brief hypothetical scenario: an author was interested in the incomes of different ethnic groups and concluded that incomes varied significantly by ethnicity.

However, when the author ran the data again, this time “controlling for” the independent variable, educational level—the same research concluded that the educational level attained was more important for incomes that ethnicity.

Further, it is a given that simply increasing the sample size of the original study, without “controlling for” education would not change the invalid conclusion.

Consider another brief hypothetical scenario: an author, wishing to discover the secrets of AOB planned a RCT. The author started with patients matched by age, sex, severity of AOB and then randomized them into a control group and a treatment group. The particular treatment applied to the treatment group was decided upon: braces were tried. Then, surgery was tried. The treatments were all unsuccessful. Why did the RCT not reveal the secrets for AOB correction?

RCTs do not figure such things out. The problem with the above RCT design was that some important steps were left out. There was no causal theory for the AOB –therefore, the causal independent variable(s) could not be “controlled for” and could not be treated. What if the proposed cause were to be deficient maxilla/mouth breathing/low tongue posture. No appropriate action was taken to improve mouth breathing (or any other problem) for any of the members of the treatment group.

“Controlling for” the causal independent variable is critical for valid conclusions as discussed above. For a future RCT, maxillary deficiency could be “controlled for,” and the maxillary arch could be treated to harmony within the treatment group.

III. The use of posterior crossbite as the sole criteria for maxillary deficiency may be problematic. “… the presence or absence of clinical posterior crossbite does not indicate the absence of a transverse discrepancy.”36 !"#$%&%'#()*practice 25

Continuing education Additionally: UĂŠ ĂŠVĂ€ÂœĂƒĂƒLÂˆĂŒiĂŠÂˆĂƒĂŠÂ˜ÂœĂŒĂŠĂƒiÂ˜ĂƒÂˆĂŒÂˆĂ›iĂŠiÂ˜ÂœĂ•}Â…ĂŠĂŒÂœĂŠ`ˆ>}Â˜ÂœĂƒiĂŠ>Â?Â?ʓ>Ă?ˆÂ?Â?>ÀÞÊ deficiencies for many reasons previously reported. New, more sensitive criteria based on skeletal measurements have been proposed.24 UĂŠ ĂŒĂŠÂˆĂƒĂŠÂ?ˆŽiÂ?ĂžĂŠĂŒÂ…>ĂŒĂŠÂ“>Ă?ˆÂ?Â?>ÀÞÊ`iwVˆi˜VĂžĂŠÂˆĂƒĂŠÂ“ÂœĂ€iĂŠÂŤĂ€iĂ›>Â?iÂ˜ĂŒĂŠĂŒÂ…>Â˜ĂŠ previously thought, based on the data from prior research.

And many patients who would otherwise not be diagnosed with maxillary deficiency can now be corrected.22-24 UĂŠ vĂŠÂˆĂŒĂŠĂœiĂ€iĂŠĂŒÂœĂŠLiĂŠĂŒĂ€Ă•iĂŠĂŒÂ…>ĂŒ]ĂŠ>ĂŒĂŠÂœÂ˜iĂŠĂŒÂˆÂ“i]ĂŠVĂ€ÂœĂƒĂƒLÂˆĂŒiĂŠ`iĂŒiĂ€Â“ÂˆÂ˜i`ĂŠ maxillary deficiency, as was likely the case in the 1960s, then it would be easy to overlook a narrow maxilla or high palate as a normal morphologic variation. However, it is now apparent that a skeletal disharmonious maxilla is a deformity.22,26,29 IV. Waiting to treat AOB patients in one phase of care may be problematic. Waiting to treat AOB later, in one phase of care, may increase the risk for less successful correction as poor skeletal growth compensations reduce treatment options. The early recognition and treatment of deficient maxilla/mouth breathing may help patients avoid complicated treatment.

V. Conventional AOB treatments that do not address etiology may be problematic. It may be difficult to correct an orthodontic problem, with reliability, without first addressing the cause of the problem. One should not expect successful results by repeating failed AOB treatments.

It should be reasonable to propose that more research is needed to help increase knowledge about the causes of malocclusions.

References

:\I[LSU` 1+ :HR\KH 4 6WLU IP[L! +PHNUVZPZ HUK ;YLH[TLU[ Am J Orthod !

358.

5LTL[O 9) 0ZHHJZVU 91 =LY[PJHS anterior relapse. Am J Orthod ! ,SSPZ , 4J5HTHYH 1( 1Y *VTWVULU[Z VM HK\S[ *3 00 VWLU IP[L THSVJJS\ZPVU Am J Orthod !

3VWLa .H]P[V . >HSSLU ;9 3P[[SL 94 1VVUKLWO +9 (U[LYPVY VWLU IP[L THSVJJS\ZPVU! ( SVUNP[\KPUHS `LHY WVZ[ YL[LU[PVU evaluation of orthodontically treated patients. Am J Orthod ! ;HUPTV[V 2 :\a\RP ( 5HRH[HUP @ @HUHNPKH ; ;HUUL @ ;HUHRH , ;HUUL 2 ( JHZL VM HU[LYPVY VWLU IP[L ^P[O ZL]LYLS` UHYYV^LK TH_PSSHY` dental arch and hypertrophic palatine tonsils. J Orthod ! )LHUL 9( 1Y 5VUZ\YNPJHS THUHNLTLU[ of the anterior open bite: a review of the options.

Semin in Orthod !

2SVJRL ( 5HUKH 9: 2HOS 5PLRL ) Anterior open bite in the deciduous dentition: SVUNP[\KPUHS MVSSV^ \W HUK JYHUPVMHJPHS NYV^[O considerations. Am J Orthod Dentofacial Orthop, ! >VYTZ -> 4LZRPU 3/ 0ZHHJZVU 91 6WLU IP[L Am J Orthod !

(UKLYZLU >: ;OL YLSH[PVUZOPW VM [OL [VUN\L [OY\Z[ Z`UKYVTL [V TH[\YH[PVU HUK V[OLY factors. Am J Orthod !

9PJRL[[Z 94 9LZWPYH[VY` VIZ[Y\J[PVU syndrome. Am J Orthod " 4HZVU 94 7YVMĂŠ[ >9 ;OL tongue thrust controversy: background and recommendations. J Speech Hear Disord !

132.

5NHU 7 -PLSKZ /> 6WLU IP[L! H YL]PL^ of etiology and management. Pediatr Dent !

26 !"#$%&%'#()*practice

Acknowledgement The author would like to express particular thanks to Michael J. Hayes, research assistant, for help in the preparation of this manuscript.

Conclusions 1. One etiology of anterior open bite is speculated to be maxillary deficiency, which, in turn, can lead to mouth breathing and a low tongue posture. There are other causes of mouth breathing, less amenable to treatment by an orthodontist.

2. Early Phase I diagnosis and RPE correction of maxillary transverse deficiency, by way of Harmony criteria, and the CAC measurement technique may be helpful for mouth breathing/low tongue posture and AOB correction.

3. A deficient maxilla may be more prevalent than previously thought.

4. More study is recommended with control and treatment groups matched for maxillary deficiency determined by Harmony criteria and measured by the CAC technique.

1VOU 3 /H`LZ +4+ 4)( YLJLP]LK HU () HUK 4)( MYVT [OL <UP]LYZP[` VM 4PJOPNHU (M[LY NYHK\H[PUN MYVT [OL )VZ[VU <UP]LYZP[` / 4 .VSKTHU :JOVVS VM +LU[HS 4LKPJPUL OL JVTWSL[LK OPZ VY[OVKVU[PJ YLZPKLUJ` H[ [OL <UP]LYZP[` VM 7LUUZ`S]HUPH ^OLYL OL PZ H *SPUPJHS (ZZVJPH[L PU [OL +LWHY[TLU[ VM 6Y[OVKVU[PJZ +Y /H`LZ PZ VU [OL Editorial Review Board of the Journal of Orthodontics and Dentofacial Orthopedics, as well as Orthodontic Practice US. He continues to research and lecture on the advantages of LHYS` PU[LYJLW[P]L [YLH[TLU[ HUK VU [OL L[PVSVN` VM THSVJJS\ZPVUZ +Y /H`LZ PZ PU WYP]H[L WYHJ[PJL PU 7LUUZ`S]HUPH ^P[O OPZ ^PML :OHYVU ^OV PZ HSZV HU orthodontist.

)\MVYK + 5VHY 1/ ;OL JH\ZLZ diagnosis and treatment of anterior open bite. Dent Update !

4L^ 19* ;OL WVZ[\YHS IHZPZ VM malocclusion: a philosophical overview. Am J Orthod Dentofacial Orthop ! *VaaH 7 4\JLKLYV 4 )HJJL[[P ; -YHUJOP 3 ;YLH[TLU[ HUK WVZ[ [YLH[TLU[ LMMLJ[Z VM X\HK OLSP_ [OLYHW` VM KLU[VZRLSL[HS VWLU IP[L Angle Orthod !

5N *:; >VUN 9>2 /HNN ,<6 Orthodontic treatment of anterior open bite. Inter J of Paediatr Dent !

3LU[PUP 6SP]LPYH + *HY]HSOV -9 @L 8 3\V 1 :HJVUH[V / 4HJOHKV 4(* 7YHKV 3)- 7YHKV .- (2008). Orthodontic and orthopaedic treatment for anterior open bite in children (Review). Cochrane +H[HIHZL :`Z[ 9L] (WY " !*+ .YLLUSLL .4 /\HUN .1 *OLU :: / *OLU 1 2VLWZLSS ; /\QVLS 7 :[HIPSP[` VM [YLH[TLU[ MVY HU[LYPVY VWLU IP[L THSVJJS\ZPVU! H TL[H HUHS`ZPZ Am J Orthod Dentofacial Orthop, ! ;\YWPU +3 ,KP[VYÂ?Z JVTTLU[ Am J Orthod Dentofacial Orthop PP ! :JHTTVU 9, ;OL TLHZ\YLTLU[ VM [OL IVK` PU JOPSKOVVK ;OL 4LHZ\YLTLU[ VM 4HU 1 ( /HYYPZ 4PUULHWVSPZ! <UP] 6M 4PUULZV[H /H`LZ 13 ;OL >PSSPHTZWVY[ 6Y[OVKVU[PJ :[\K` 7YHJ[PJL )HZLK 9LZLHYJO 5L[^VYR <UP] VM 7LUUZ`S]HUPH :JOVVS VM +LU[HS 4LKPJPUL 6Y[OVKVU[PJ +LWHY[TLU[ /H`LZ 13 4HYJO ( JSPUPJHS HWWYVHJO [V PKLU[PM` [YHUZ]LYZL KPZJYLWHUJPLZ 7YLZLU[H[PVU [V [OL 7LUUZ`S]HUPH (ZZVJPH[PVU VM 6Y[OVKVU[PZ[Z 7OPSHKLSWOPH /H`LZ 13 0U ZLHYJO VM PTWYV]LK ZRLSL[HS [YHUZ]LYZL KPHNUVZPZ 7HY[ ! [YHKP[PVUHS measurement techniques. Orthodontic Practice US,

" /H`LZ 13 0U ZLHYJO VM PTWYV]LK ZRLSL[HS [YHUZ]LYZL KPHNUVZPZ 7HY[ ! ( UL^ TLHZ\YLTLU[ [LJOUPX\L \ZLK VU JVUZLJ\[P]L \U[YLH[LK patients. Orthodontic Practice US !

2LPT 9. 3PLZ KHTULK SPLZ HUK statistics. J Clin Orthod !

3\UKZ[YVT (- 4HSVJJS\ZPVU VM [OL [LL[O regarded as a problem in the connection with the HWPJHS IHZL :]LUZR ;HUKSHRHYL ;PKZRYPM[ /HY]VSK ,7 ;VTLY ): =HYNLY]PR 2 *OPLYPJP . 7YPTH[L L_WLYPTLU[Z VU VYHS YLZWPYH[PVU Am J Orthod !

3PUKLY (YVUZVU : >VVKZPKL +. /LSSZPUN , ,TLYZVU > 5VYTHSPaH[PVU VM PUJPZVY position after adenoidectomy. Am J Orthod Dentofacial Orthop ! /HHZ (1 ;OL [YLH[TLU[ VM TH_PSSHY` deficiency by opening the midpalatal suture. Angle Orthod ! /HYHSHIHRPZ 5 7HWHKHRPZ . 9LSHWZL after orthodontics and orthognathic surgery. World J Orthod ! /Z\ ): ;OL UH[\YL VM HYJO ^PK[O difference and palatal depth of anterior open bite.

Am J Orthod Dentofacial Orthop ! :HZZV\UP = ( JSHZZPĂ&#x160;JH[PVU VM ZRLSL[HS facial types. Am J Orthod ! ;\SS` >1 ( JYP[PJHS HWWYHPZHS VM [VUN\L thrusting. Am J Orthod ! ,UNSPZO 1+ ,HYS` [YLH[TLU[ VM ZRLSL[HS VWLU IP[L THSVJJS\ZPVUZ (T 1 6Y[OVK +LU[VMHJPHS 6Y[OVW ! )VUKLTHYR 3 /VST (2 /HUZLU 2 (_LSZZVU : 4VOSPU ) )YH[[Z[YVT = 7H\SPU . 7PL[PSH ; 3VUN [LYT Z[HIPSP[` VM VY[OVKVU[PJ [YLH[TLU[ HUK patient satisfaction. Angle Orthod ! =HUHYZKHSS 93 1Y ;YHUZ]LYZL KPTLUZPVU HUK SVUN [LYT Z[HIPSP[` Semin Orthod !

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Volume 3 Number 3

Continuing education

$ PHWKRG IRU DFFXUDʞH UHFRUGLQJ RI WKH $[LV +RUL]RQʞDO UHIHUHQFH SODQH SDUW In the last of the series, Dr. Ryan K. Tamburrino and Kenneth D. Tamburrino illustrate how to implement their method for precision mounting to an articulator system Introduction Part 1 and part 2 of this series introduced the concepts of the Axis-Horizontal reference line1 and the Axis-Horizontal reference plane2 for treatment planning to adjusted natural head position (ANHP). In this third and final article, a methodology will be introduced for recording and transferring ANHP and the Axis-Horizontal reference plane to an articulator system for a precision mounting.

The head positioning instrument (HPI) As shown below in Figure 1, the ultimate goal when treatment planning for optimal esthetics and function is to have seamless integration and positioning of the patient’s photographs, head film, and mounted casts. The head positioning instrument3 (Steel City Dental Concepts, Ardmore, PA), shown in Figure 2, is an innovative device/ technique to efficiently and accurately measure, orient, and transfer head and jaw position to radiographs and mounted dental casts.

Use of the instrument will be described in two components—one for proper three-dimensional orientation of the head and head films, and the other for relating the three-dimensional spatial positioning of the patient’s maxilla to the articulator mounting.

While the technique described herein with the HPI applies to cone-beam computed tomography (CBCT), it may also be applied to traditional film cephalograms.

However, use of a CBCT will provide an image with minimal distortion.

Head orientation in the sagittal plane For optimal treatment planning and diagnosis, the head must be oriented in ANHP on the head film in both the sagittal and frontal planes. The HPI orients the head in the sagittal plane via establishing a horizontal reference distance between two reproducible points of the operator’s choosing. For convenience, the authors recommend using one point located on the forehead and one on the tip of the maxillary incisor. However, any two points may be used as long as they are easily identifiable on both the patient and radiograph.

A digital sliding rule is used to determine the reproducible horizontal distance between the two points.

Therefore, prior to using the device, the slider and headrest pointer must be calibrated to zero, as shown in Figure 3.

To prepare the patient, barium paste or a radiopaque marker is arbitrarily placed on the forehead (or the first reference point). The patient is placed into the HPI, and the head is oriented to ANHP. Next, the headrest assembly is adjusted so that the pointer is coincident with the first reference point and the patient is supported by the headrest, Volume 3 Number 3

Educational aims and objectives

This article describes a specific methodology for recording and transferring ANHP and the AxisHorizontal reference plane to an articulator system for a precision mounting.

Expected outcomes

Correctly answering the questions on page 31, worth 2 hours of CE, will demonstrate the reader can: r <UKLYZ[HUK [OL \ZL VM [OL OLHK WVZP[PVUPUN instrument (HPI). r 9LHSPaL WYVWLY [OYLL KPTLUZPVUHS VYPLU[H[PVU of the head and head films. r 9LJVNUPaL [OL LSLTLU[Z [OH[ YLSH[L [OL [OYLL dimensional spatial positioning of the patient’s maxilla to the articulator mounting. r )L HISL [V KPZJ\ZZ HJJ\YH[L YLJVYKPUN VM [OL [OYLL KPTLUZPVUHS ZWH[PHS positioning of the maxilla. r ;YHUZMLY [OL (_PZ /VYPaVU[HS YLNPZ[YH[PVU [V TV\U[ [OL TH_PSSHY` JHZ[

Figure 1: The ideal superimposition of lateral photograph, lateral head film, and mounted models for patient diagnosis and treatment planning

as seen in Figure 4.

With the patient comfortable and the head properly positioned, the slide is slowly advanced until it touches the tip of the maxillary central incisor (or the second reference point if the tooth is not used), as shown in Figure 5. This information can then be taken to the CBCT software or 2UWKRGRQWLF practice 27

Continuing education

Figure 2: The Head Positioning Instrument shown with head orientation and facebow transfer accessories

Figure 3: The calibration device to correlate the slider and headrest pointer to zero

Figure 4: Proper positioning of the patient on the headrest assembly in ANHP

-PN\YL ! <ZPUN [OL ZSPKLY [V determine the horizontal distance between the chosen reference points

Figure 6: Example of how the radiograph is oriented to ANHP using the HPI measurement

lateral head film in order to reproduce the distance and, ultimately, the head orientation. The sequence illustrating this process is shown in Figure 6. The software illustrated is Dolphin Imaging 3D (Dolphin Imaging, Chatsworth, CA), but any cephalometric software with the ability to measure a distance (or using a ruler if hand tracing) can be used.

oriented to true horizontal, as shown in Figure 8.

Additionally, by locating the true or palpated hinge axis prior to orienting the head in the HPI, the frontal markings (if at the same vertical position) now will add the second and third reference points for easy construction of the AxisHorizontal plane2, seen in Figure 9.

Head orientation in the transverse (coronal) plane After the patient is oriented in the sagittal view, the operator adjusts the patient from the front. This allows the patient to be oriented in ANHP in all three planes of space. To record this frontal position for reproduction on the CBCT or PA cephalometric film, the axis pointers are used. By sliding the facebow sidearms forward, as shown in Figure 7, the axis pointers now can denote the true transverse plane of the patient. Barium paste or other radiographic markers can then be placed at the location of the points for ease of identification on the film.

While it is not necessary to mark the actual or estimated rotational axis of the mandible prior to using the HPI for transverse head orientation, this feature can provide a double check for lateral head-film orientation. Since the Axis-Horizontal line will be demarcated when the lateral head film is oriented according to the distance measured on the slider, the Axis-Horizontal line should subsequently be

Axis-Horizontal facebow recording The HPI provides for accurate recording of the threedimensional spatial positioning of the maxilla. Using the concepts described in part 2 of this series, and illustrated with Figure 10, the side arms of the facebow are oriented to true horizontal, and the crossarm is oriented perpendicular to true vertical. Thus, when the bite-fork stem is placed into the apparatus, it will be oriented to true vertical as well.

Any variations in cants of the maxilla then will be accurately recorded and represented with the bite fork.

A mark denoting the midline of the apparatus is scribed onto the crossarm of the facebow (Figure 11). Prior to recording the facebow, the operator should ensure that the patientâ&#x20AC;&#x2122;s facial midline corresponds to this mark. This allows for proper centering of the patient prior to recording the maxillary orientation with the bite fork, and will be important for understanding the concepts contained in the subsequent section.

28 2UWKRGRQWLF practice

Volume 3 Number 3

Continuing education

Figure 7: Demarcation of the transverse component of the Axis-Horizontal plane using the axis pointers

Figure 8: Illustration of how the AxisHorizontal line is perpendicular to true vertical in a properly adjusted head film

-PN\YL ! 9HKPVNYHWOPJ markers denoting the Axis-Horizontal reference plane

Figure 11: The centerline of the facebow, which correlates to the midline of the patientâ&#x20AC;&#x2122;s face and is the reference position for the bite-fork assembly Figure 10: Orientation of the bite fork to the facebow of the HPI

Figure 14: Example of how the centerline of the mounting stand crossarm correlates with the center of the mounting stand, and, therefore, the midline of the patient Figure 12: The facebow sidearms with embedded ruler to measure the distance from the axis pointer to the base of the sidearm block

Figure 15: Illustration of the adjustability of the axis transfer arms to replicate the axis-crossarm distance of the facebow

Figure 13: An axis mounting stand with the HPI Axis transfer arms and bite fork in place

Figure 16: Illustration showing identical anatomical arc of closure representation with an HPI mounted maxillary cast

Additionally, when the Axis-Horizontal facebow is recorded, the operator should note the millimetric distance of the axis pointer to the base of the block on the facebow crossarm, as seen in Figure 12. The apparatus used in the mounting stand contains the identical calibration and markings, and, therefore, will be adjusted to represent the same distance. The rationale for this feature will be described below.

Axis-Horizontal facebow transfer Transferring the Axis-Horizontal registration to mount the maxillary cast is accomplished via any commercially available articulator system and corresponding hinge axis mounting stand. If using the HPI, the existing rods for Volume 3 Number 3

accommodating the hinge axis facebow are replaced with the HPI axis transfer arms shown in Figure 13. Unlike traditional methods of transfer that required the entire facebow and bite fork assembly to be transferred as one unit, the axis transfer arms require only the bite fork.

Use of this apparatus eliminates errors in centering or side-side positioning of the jaws following the axis facebow transfer. This is due to correspondence of the bite-fork stem to the midline of the axis mounting stand and the facebow (Figure 14). Therefore, there is a consistent relationship of the bite fork to the operator determined facial midline of the patient.

Also, by adjusting the axis transfer arm distance (Figure 15) to correlate with the axis crossarm distance on 2UWKRGRQWLF practice 29

Continuing education

Figure 17: Correlation of the ANHP head film with an HPI mounted maxillary cast

the facebow, variations in patient anatomy and axial arc of mandibular closure can be accurately represented, as shown in Figure 16.

Once the bite fork is placed and secured in the axis mounting stand, the maxillary model can be mounted and the upper member of the articulator will represent true horizontal. The Axis-Horizontal line will now pass through the axis of the articulator, and the vertical, transverse, and horizontal spatial relationships of the maxilla and the maxillary dentition will be identical to the way they appear on the patient (Figure 17). The mandibular model can then be mounted using any CR bite registration technique of the practitionerâ&#x20AC;&#x2122;s choosing. The final result will then be a complete and accurate functional and anatomical representation of the patientâ&#x20AC;&#x2122;s jaw position and function.

Conclusion This three-part article focuses on the rationale for establishing true horizontal, vertical, and transverse reference positions to use as a starting point for diagnosis and treatment planning. Additionally, methodology for accurate recording of head position and transfer of the Axis- Horizontal plane is discussed in via use of the HPI. While the HPI is not the only methodology that can be used for synchronizing patient records, the objective of this series is to stress the importance of the photographs, radiographs, and articulator-mounted models having the same spatial orientation for diagnostic purposes. This allows for the most accurate representation of the patient, and, therefore, improves the ability of the dental team to provide the best esthetic and functional treatment outcomes for the patient.

Disclosure The authors are co-founders of Steel City Dental Concepts, LLC and developers of the Head Positioning Instrument (HPI) described in this article. U.S. patents on the design and use of the instrumentation are pending.

References

;HTI\YYPUV 92 3PU[VU 13 ;OL (_PZ /VYPaVU[HS YLMLYLUJL SPUL MVY WYLJPZPVU KPHNUVZPZ! 7HY[ Orthodontic Practice US. 3(1): 25-28. ;HTI\YYPUV 92 3PU[VU 13 :OHO :9 ;OL (_PZ /VYPaVU[HS YLMLYLUJL WSHUL MVY WYLJPZPVU KPHNUVZPZ! 7HY[ Orthodontic Practice US; 3(2): 25-28. ;HTI\YYPUV 92 ;HTI\YYPUV 2+ /LHK 7VZP[PVUPUN 0UZ[Y\TLU[ /70 0UZ[Y\J[PVU 4HU\HS :[LLS *P[` +LU[HS *VUJLW[Z 33* < : 7H[LU[Z 7LUKPUN

9`HU 2 ;HTI\YYPUV +4+ H UH[P]L VM 7P[[ZI\YNO HUK co-founder of the Center for Orthodontic Excellence, NYHK\H[LK MYVT +\RL <UP]LYZP[` ^P[O H KV\ISL THQVY PU biomedical engineering and mechanical engineering/ TH[LYPHSZ ZJPLUJL /L [OLU H[[LUKLK [OL <UP]LYZP[` VM Pennsylvania for dental school and stayed an additional 2 years for specialty training in orthodontics.

During his orthodontic training, Dr. Tamburrino concurrently completed additional training in advanced orthodontic diagnosis, M\UJ[PVUHS VJJS\ZPVU HUK ;41 OLHS[O ^P[O [OL (,6 9V[O >PSSPHTZ .YV\W HUK (UKYL^ZÂ? :P_ ,SLTLU[Z JV\YZLZ Dr. Tamburrino is on faculty as an attending clinician in the graduate VY[OVKVU[PJ JSPUPJ H[ [OL <UP]LYZP[` VM 7LUUZ`S]HUPH (KKP[PVUHSS` OL PZ VU MHJ\S[` HUK SLJ[\YLZ PU[LYUH[PVUHSS` UH[PVUHSS` ^P[O [OL 9V[O >PSSPHTZ Center for Functional Occlusion and Complete Clinical Orthodontics (CCO) courses. He also routinely speaks at various local study groups. >P[O PU]VS]LTLU[ PU ZL]LYHS VUNVPUN JSPUPJHS YLZLHYJO WYVQLJ[Z IV[O privately and in conjunction with the Department of Orthodontics at [OL <UP]LYZP[` VM 7LUUZ`S]HUPH +Y ;HTI\YYPUVÂ?Z THPU PU[LYLZ[Z SPL PU [OL HYLHZ VM ;41 PTHNPUN HUK KPHNUVZPZ HJOPL]PUN ZRLSL[HS HUK LZ[OL[PJ harmony in three planes of space, the science of functional occlusion, and early orthodontic intervention.

Clarification: This is the correct order for the illustration as shown in Figure 6, Part 2 of this series. The jig will always represent true vertical and horizontal.

Errors in transverse facebow orientation will alter the representation of the maxillary cast

30 2UWKRGRQWLF practice

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Volume 3 Number 3

Orthodontic Practice US CE Certificate details Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231 Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

!"#$%&'()* REF: OP V3.3/HAYES/TAMBURRINO

+,-%$)./01$'1/"2%2"* </=)20)%2"* +33$)00*

Q Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260

>/1?@%A1'1)%'23%B/7%>"3)*

Q Fax to (480) 629-4002.

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Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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

A new regimen of phase I care applied to anterior open bite–10 case studies: an etiology proposed by the strategy of triangulation Dr. John Hayes

A method for accurate recording of the AxisHorizontal reference plane – part 3

1. Anterior open bite (AOB) is an occlusal condition where ____vertical overlap of incisors is present. a. some b. no c. a considerable amount of d. moderate

1. The ultimate goal when treatment planning for optimal esthetics and function is to have seamless integration and positioning of _______. a. the patient’s photographs b. the head film c. mounted casts d. all of the above

2. It is important to note that the expansion was not measured by turnbuckle or by dental landmarks but rather by CAC measurements as _______ was the objective. a. patient comfort b. more precise measurements c. skeletal improvement d. a quicker arch expansion 3. The new center of the alveolar crest (CAC) measurement technique may be the ______transverse skeletal measurement available at this time as it does not rely on less reliable dental landmarks. a. least predictable b. most reliable c. most meaningful d. both b and c

6. It should be fair to say that the new regimen of Phase I care would have been an advantage for these patients whether or not the anterior open bite ______. a. had been ignored b. had been corrected c. had been postponed d. had been studied for a longer period of time 7. Chronic allergic conditions, nasal infections and mechanical blockage by turbinates or a deviated septum also can lead to ______. a. chronic sinus infections b. caries c. mouth breathing d. tooth sensitivity 8. It is likely that maxillary deficiency is ______ previously thought based on the data from prior research. a. more damaging b. about the same frequency as c. less prevalent than d. more prevalent than

4. (Within the new regimen of phase I orthopedic care) very slow RPE expansion (one turn/every other day) was used to gain the _______. a. skeletal harmony b. patient’s trust c. low tongue rest position d. space maintenance

9. Waiting to treat AOB later, in one phase of care, may _____ the risk for less successful correction as poor skeletal growth compensations reduce treatment options. a. decrease b. neutralize c. increase d. limit

5. Had an intractable open bite remained at T2, _______ would have been recommended to rule out adenoid hypertrophy, deviated septum, hypertrophic turbinates, allergies, etc. a. a 2D X-ray b. pediatric evaluation c. an airway evaluation d. short waiting period

10. Early Phase I diagnosis and RPE correction of maxillary transverse deficiency, by way of Harmony criteria, and the CAC measurement technique may be helpful for _____. a. mouth breathing b. low tongue posture c. AOB correction d. all of the above

Dr. Ryan Tamburrino and Kenneth Tamburrino

2. While the technique described herein with the HPI applies to conebeam computed tomography (CBCT), it may also be applied to traditional film cephalograms. However, use of a CBCT will provide an image with ________. a. additional colorization b. reproducible points c. minimal distortion d. radiopaque markings 3. A digital sliding rule is used to determine the reproducible horizontal distance between the two points.

Therefore, prior to using the device, the slider and headrest pointer must be calibrated to _____. a. 0 b. 1 c. 2 d. 3 4. To prepare the patient, barium paste or a radiopaque marker is arbitrarily placed on the _______ (or the first reference point). a. central incisors b. forehead c. mandibular incisor d. lips 5. After the patient is oriented in the sagittal view, the operator adjusts the patient from the ____. a. front b. side c. back d. none of the above

6. ______ provides for accurate recording of the three-dimensional spatial positioning of the maxilla. a. A panoramic image b. The HPI c. A digital recorder d. The millimetric distance 7. A mark denoting the ______ of the apparatus is scribed onto the crossarm of the facebow (Figure 11). a. radius b. calibration c. midline d. cant 8. Additionally, when the Axis-Horizontal facebow is recorded, the operator should note _______ of the axis pointer to the base of the block on the facebow crossarm, as seen in Figure 12. a. the approximate position b. the stability c. the calibration d. the millimetric distance 9. Use of this apparatus eliminates errors in ________ of the jaws following the axis facebow transfer. a. correspondence b. centering c. side-side positioning d. either b or c 10. The final result will then be a complete and accurate functional and anatomical representation of the patient’s _______. a. body posture b. jaw position c. jaw function d. both b and c

!"#$%"&'()#*))(+,-.#"/#01'2#,%0'-3)#,/(#456#$3),2)#-"/0,-0#7%01"("/0'-#8%,-0'-)#9: ;<=>?#@A#B%))/C,D#E,D()/#F""$#GH6#:-"002(,3)6#IJ6#K<>L?###M###*,NO#PQK?R#L>HSQ??>###M###)T,'3O#)(U-,0'"/VT)(T,%.,WA-"T Volume 3 Number 3

!"#$%&%'#()*practice 31

Establish a Smile for a Lifetime (S4L) chapter and change the lives of deserving children in your community. Through this national non-profit organization, you can create self-confidence, inspire hope and change the lives of children and teens in a dramatic way.

Your affiliation with Smile for a Lifetime allows you to: s Manage your pro bono work s Adopt a proven structure for creating a local board and select S4L patients s Gain publicity and exposure for your practice s Promote your S4L chapter through scholarship awards, local media and schools s Use Ormco products free-of-charge to treat your S4L patients

Gift of a Smile Winner Dr. Robert Gire with his new S4L patient, Eby

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3D imaging

Dialogue STRAIGHT TALK

Imaging 8QGHUVʞDQGLQJ &%&7 GRVLPHWU\ Dr. Sean K. Carlson presents the facts about radiation exposure as it relates to CBCT scans and everyday living

X

-ray dosimetry is the calculation of the absorbed dose new i-CAT “Quick Scan” imaging technique and revealed in human tissue resulting from the exposure to ionizing significantly reduced effective dose values (Figure 1).

X-ray radiation. It can be a confusing subject for even These updated values for CBCT dosimetry put the savviest of orthodontists. Unknown to many, recent it remarkably close to conventional two-dimensional advances in CBCT technology have reduced X-ray exposure orthodontic imaging. In fact, when compared with the to patients considerably. And although there is a common ICRP dose limit of 1000µSv per year and to our ever-present misconception that CBCT imaging dramatically increases background radiation exposure of 8µSv per day (2920µSv the exposure risk when compared to conventional two- per year), the values of all current orthodontic imaging dimensional orthodontic imaging, recent data shows there protocols are extremely low (Figure 2). can be minimal difference. In fact, when the truth about risk Of course, when it comes to X-rays, most people quantification is added to the equation, both orthodontists and dentists alike should be put at ease when it comes to their exposure liability.

Before beginning any discussion on dosimetry, it is important to be familiarized with the International Committee of Radiological Protection (ICRP). The ICRP is a group that is designed to protect and inform the public regarding the harmful effects of ionizing radiation. They set guidelines for the medical and dental communities to help minimize the risks to their patients. In 2007, the ICRP released a set of updated guidelines on the limits of Figure 1: Effective dose in µSv for three different fields of view X-ray exposure. (J:2007kt) The two most important take- using i-CAT’s “Quick Scan” technology home messages from this publication are the following: 1) Non-occupational exposure to ionizing radiation should be limited to 1000µSv per year. 2) A revised set of tissue weightings was released that should be used when calculating effective dose of ionizing radiation. Using these ICRP guidelines, as practitioners, if we limit our patient X-ray exposure to below 1000µSv per year, we will stay well within the “tolerable dose” as judged by the ICRP. Recent publications by Ludlow and colleagues report current X-ray exposure dosimetry (using 2007 tissue weightings) of the most common dental imaging procedures (Ludlow:2008wv, Ludlow:2008vz).

Recent technical advances in the Next-Generation i-CAT® machine have resulted in even lower doses for CBCT scans. Using Ludlow’s 2: Effective dose in µSv for various orthodontic imaging protocols (blue materials and methods, more recent Figure columns) compared with our ever-present annual background ionizing radiation dosimetry studies were repeated for the exposure (green column) 34 2UWKRGRQWLF practice

Volume 3 Number 3

3D imaging

Figure 3: Common life risks in days of LLE compared with the associated risk of CBCT scan

simply want to know how big are the risks they face when getting dental or orthodontic X-rays. Using the statistical methods of nuclear physicists, a calculation known as Loss of Life Expectancy (LLE) can be used to put risks of X-rays in perspective with other life risks (Cohen:1990us).

Figure 3 shows the relative risks of some common everyday experiences. Notice how the risk associated with a dental arch “Quick Scan” CBCT falls well below that of many more common risks that we take everyday. In fact, it is only 13 times more risky than crossing the street.

Of course, basic human nature tells us that people tend to accept risks that they impose on themselves, but will often refuse risks that are imposed on them by others.

When it comes to 3-D X-rays, we simply must explain that the increased exposure is miniscule, but the diagnostic benefits are extraordinary.

Due to recent advances in technology, it is clear that the exposure risk of current CBCT X-rays (like those taken using i-CAT “Quick Scan” technology) is comparable to that of two-dimensional X-rays (pan and ceph). Of course, the media will continue to sensationalize any increased risk, no matter how small. But we must use the scientific research data to help separate emotional responses from rational ones. As professionals, we have the facts at our fingertips.

And as professionals, we must present these facts to our patients in an easy-to-understand way that puts dental X-ray risks in perspective with those risks of their everyday living.

References available upon request.

Dr. Sean Carlson is a Board-Certified orthodontist who received his dental degree from Harvard University in 1994, where he was awarded the American Association of Orthodontists Award. He received his orthodontic specialty training and his Master of Science degree in Oral Biology from the University of California at San Francisco. He is currently an associate professor of orthodontics at the University of the Pacific School of Dentistry, senior investigator in the Craniofacial Research and Instrumentation Laboratory at the University of the Pacific School of Dentistry, and maintains a private practice in Mill Valley, California.

STRAIGHT TALK

Imaging

If you have a question regarding 3D imaging that you want Drs. Carlson and Quintero to address in a future column, please email: 3DImaging@orthopracticeus.com.

For more information on how 3D imaging can improve your practice, please fax this information to (480) 629-4002, visit www.orthopracticeus.com/web/imagingsciences.html to submit this form online, or mail this form to: Orthodontic Practice US | 15720 N. Greenway Hayden Loop #9 | Scottsdale, AZ 85260.

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Volume 3 Number 3

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2UWKRGRQWLF practice 35

Industry news

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EXPERT LECTURES ROUND TABLE DISCUSSION LIVE TAD PLACEMENT IN CLINICAL SETTING

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s the TAD User Forum enters its 4th year, it is exciting to see the growth and development of this Forum into one of the true “can’t miss” meetings of the year. The attendance has grown to an expected 350+ attendees this year, and it is easy to see why this meeting has quickly become so popular.

Las Vegas in November offers a perfect weekend getaway with beautiful weather, incredible dining, endless options for nightlife and accommodations at the 5-Star Wynn/ Encore resort at $195 per night.

However, this meeting is much more than 5-Star Hotels, beautiful weather and Vegas nightlife.

This meeting has grown because it is the only meeting of its kind that offers the wide variety of exciting, new information on TADs for everyone from a first-time TAD user all the way up to the expert who has been placing TADs for many years.

On tap for the November 2-4, 2012 Forum are 12 top TAD experts including such names as Dr. Sebastian Baumgaertel, Dr. Jason Cope, Dr. Bob Smith and many more who will all be lecturing in a very fast-paced and exciting 4-Track lecture program. The meeting is broken down into segments of 1.5 hours, and each segment offers four different topics and lecturers to choose from. This format ensures that every attendee with any level of experience can choose the most interesting topic of interest for their specific skill level. The lectures cover a diverse range of topics and offer tips on everything including: Patient Consultation, Implementing TADs into Daily Practice, Placement Protocols, Improving Success Rates, Treatment Planning with TADs, Molar Intrusion and Open Bite Correction, Gummy Smiles, Opening and Closing Spaces, Class III Correction without Surgery, Forced Eruption of Canines, 36 !"#$%&%'#()*practice

En-Masse Arch Retraction, Using TADs with Aligner Trays, Using TADs as Temporary Implants, Uprighting Molars and much more. These are all topics that might only be briefly discussed with 1-2 cases at the typical 1-day TAD lectures, while this meeting offers 1.5 hours on each topic with a great deal of insight on the pitfalls to avoid, while also providing tips for achieving maximum success.

In addition to lectures, this meeting offers hands-on workshops, round-table discussion groups and several other social networking opportunities to simply share frustrations and successes with other TAD users. Many attendees have found it very rewarding to attend a meeting with 300 other TAD users and simply brainstorm together on how to treat the same case three to four different ways with TADs. Another exciting option for a limited number of new TAD users is the ability to physically place a TAD in a live volunteer patient in a monitored setting. This is limited to the first 40 doctors who register for this upgrade, and it truly gives doctors the live experience and confidence level needed to begin placing TADs successfully in their office when they return from the meeting. If you are a doctor who would love to begin using TADs in your office, but you are a little skeptical on how and where to start, then this LIVE Clinic upgrade is definitely for you.

For brand new TAD users, or even for those who have been placing TADs as an expert for many years, this meeting offers an exciting, rewarding weekend of learning and fun in Las Vegas. The meeting offers an impressive 13 CE credit hours at a reasonable tuition rate of only $599. The tuition includes a cocktail reception at the famous TRYST nightclub in the Wynn, and the room rate of $195 per night is about ½ the normal rate for a weekend room at the Encore resort in November.

Register by July 31st at www.tomasforum.com and mention the code “OPBLAST” to receive a $100 “early registration” discount on tuition. Call 800-523-3946 or visit www.tomasforum.com for more information.

This information was provided by Dentaurum.

Volume 3 Number 3

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Dr. Neil Warshawsky

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Industry news

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arestream Dental introduced six of the newest additions to its extraoral imaging system, intraoral imaging system, intraoral camera, and software suites–all geared towards streamlining workflow and improving doctor-topatient communication. The products debuted at the 2012 Ontario Dental Association (ODA) Annual Spring Meeting, held in May at the Metro Toronto Convention Centre.

During the ODA Annual Spring Meeting, the Carestream Dental team showcased new solutions, which included: UÊ / iÊ -Ê ÎääÊ vi>ÌÕÀiÃÊ Õ Ì « iÊ wi `ÃÊ vÊ Û iÜÊ v ÀÊ Î Ê >}iÃ]Ê À> } }Ê vÀ Ê xÊ V Ê ÝÊ xÊ V Ê Ì Ê £ÇÊ V Ê ÝÊ £Î°xÊ V °Ê / iÃiÊ Õ Ì « iÊwi `ÃÊ vÊÛ iÜÊi >L iÊ«À>VÌ Ì iÀÃÊÌ Êv VÕÃÊ Ê >Ê Ã«iV wVÊ Ài} Ê vÊ ÌiÀiÃÌÊ LÞÊ V >Ì }Ê Ì iÊ wi `Ê of view, giving clinicians the ability to limit radiation iÝ« ÃÕÀiÊ Ì Ê «>Ì i ÌÃ°Ê `` Ì > Þ]Ê Ì iÊ -Ê ÎääÊ vviÀÃÊ practitioners 2D digital panoramic imaging with variable v V> ÊÌÀ Õ} ÊÌiV }Þ°Ê/ iÊ -Ê ÎääÊ ÃÊ> à Ê>Û> >L iÊÜ Ì Ê a cephalometric option.

UÊÊ i ÛiÀ }ÊÌ iÊ } iÃÌÊÀià ÕÌ Ê >}iÃÊ vÊ> ÞÊ ÌÀ> À> Ê sensor in the industry (> 20 line pairs/mm), the RVG 6500 System uses Wi-Fi technology to completely eliminate the need for a wired connection to a computer. In 5 seconds, images can be transferred to an operatory’s computer with no workflow interruptions. Available in three sizes, these waterproof and shock-resistant sensors are perfectly sized for any examination, including a size 0 sensor that is ideal for pediatric applications.

UÊ } V Ê >À iÃÊ iÌiVÌ À™ Software, the only FDAapproved caries detection software, is now available in an automatic version. This software serves as a computer-aided detection tool that is clinically proven1 to help dentists w `Ê ÀiÊ ÌiÀ«À Ý > Ê V>À iÃÊ Ê ÌÀ> À> Ê À>` }À>« Ã°Ê / ÃÊ iÜÊ ÛiÀÃ Ê vÊ } V Ê - vÌÜ>ÀiÊ «À ÛiÃÊ «À>VÌ ViÊ ivwV i VÞÊÜ Ì ÊÌ iÊ>L ÌÞÊÌ Ê>ÕÌ >Ì V> ÞÊÀÕ ÊÌ iÊ`iÌiVÌ Ê algorithm on all applicable tooth surfaces within a bitewing radiograph and immediately display the results with a single click.

UÊ / iÊ V «>VÌÊ -Ê ÇÈääÊ ` } Ì> Ê ÌÀ> À> Ê À>` }À>« ÞÊ system reinvents imaging plate technology by improving usability, productivity, and security. This cost-effective system’s patented intelligent workflow technology prevents plate mix-up and reduces operation time. The CS 7600 is vÕ ÞÊ >ÕÌ >Ìi`Ê > `Ê ÃÊ >ÃÊ i>ÃÞÊ Ì Ê ÕÃiÊ >ÃÊ w qÜ Ì Ê > Ê Ì iÊ Li iwÌÃÊ vÊ` } Ì> Ê >} }° UÊ / iÊ -Ê £ÈääÊ ÃÊ >Ê Õ Ì ÕÃiÊ ÌÀ> À> Ê V> iÀ>Ê Ì >ÌÊ combines exclusive, patented caries detection technology with Carestream Dental’s industry-leading image quality.

With the widest focus range on the market (1 mm to 38 !"#$%&%'#()*practice

w ÌÞ®]Ê Ì ÃÊ i>ÃÞ Ì ÕÃiÊ V> iÀ>Ê >À ÃÊ >Ê i>«Ê v ÀÜ>À`Ê Ê dental care, as dentists typically must rely upon traditional, more subjective methods of caries detection. This camera features the same unique liquid-lens autofocus technology as Carestream Dental’s 1500 Intraoral Camera as well as a à « ÃÌ V>Ìi`Ê£n Ê Õ >Ì ÊÃÞÃÌi Ê> `Ê> Ê «Ì > Ê « >À âiÀÊw ÌiÀÊÌ ÊÀi`ÕViÊ} >Ài° UÊ Ê>`` Ì > Ê iÜÊ ÌÀ> À> ÊV> iÀ>]ÊÌ iÊ -Ê£Óää]Ê ÃÊi>ÃÞÊ to use and provides practitioners with an affordable entry point into digital imaging. The CS 1200 captures crisp, clear images. The camera’s wide focus range captures a variety of images including macro, single teeth, arches and smiles, > `Ê ÌÊ >ÃÊÌ iÊ>L ÌÞÊÌ ÊÃÌ ÀiÊÕ«ÊÌ ÊÎääÊ >}iÃÊÜ Ì ÊÌ iÊ camera itself.

“Carestream is dedicated to developing and producing solutions that help–not hinder–workflows and optimize «>Ì i ÌÊV>Ài]»ÊÃ> `Ê `Ü>À`Ê- i >À`]Ê

]ÊV ivÊ >À iÌ }Ê vwViÀÊ> `Ê` ÀiVÌ ÀÊ vÊLÕÃ iÃÃÊ`iÛi « i ÌÊv ÀÊ >ÀiÃÌÀi> Ê Dental. “We’re excited for practitioners to experience our new solutions and the time savings they provide.”

For more information or to contact a Carestream

i Ì> ÊÀi«ÀiÃi Ì>Ì Ûi]ÊV> Ê£ nää {{ ÈÎÈxÊ­v ÀÊÌ iÊ1 Ìi`Ê -Ì>ÌiÃ®Ê ÀÊ £ nää ÎÎ näÎ£Ê ­v ÀÊ > >`>®Ê ÀÊ Û Ã ÌÊ ÜÜÜ° carestreamdental.com.

This information was provided by Carestream Dental.

Reference 1. Gakenheimer, David C. “The Efficacy of a Computerized Caries Detector in Intraoral Digital Radiography.” Journal of the American Dental Association 133 (2002): 883-890.

Volume 3 Number 3

Technology +,-"%./&* -0#(/'#* )0"/1* 2304(#51* 0'&* -"0)#()/* HʨFLHQFLHV XVLQJ 6XUH6PLOH ʞHFKQRORJ\ Dr. Steven Moravec tells how this technology changed the orthodontic experience for him, his staff, and his patients

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brought SureSmile into my practice after attending a seminar given by SureSmile® (OraMetrix) co-founder Dr. Rohit Sachdeva in October of 2007. I already knew about SureSmile through two orthodontists whom I respected— Dr. Barry Booth and Dr. William Petty—who were early adopters of SureSmile. I had been practicing orthodontics for 20 years and knew finishing cases well can be very challenging. I was seeking a better, more efficient way, and SureSmile seemed like a versatile and logical approach. I also thought SureSmile would reinvigorate my professional curiosity.

Once I signed on with SureSmile, the clinical benefits became clear to me very quickly. Our first SureSmile patients were current patients converted to SureSmile mid-treatment, and they were finishing better and quicker than my conventionally treated patients. I could also see that once the office was fully up to speed, there would be many practice management advantages to treating all fully bonded patients with SureSmile.

SureSmile gives me the tools to analyze and visualize clinical outcomes before starting treatment. This is especially helpful in borderline extraction cases, orthognathic surgery cases, and planning spacing scenarios with missing teeth and Bolton discrepancies. I can model multiple options in just minutes. Additionally, with CBCT imaging and recent SureSmile software advances in root and bone modeling, I can virtually plan root movement in the patient’s supporting bone.

SureSmile not only allows me to start finishing sooner but also shortens this phase of treatment. The robot used to make the SureSmile customized wires can make bends in the heat-activated CuNiTi wire to within 1/10th of a millimeter, and to within a degree for rotational, angulation, and torquing movements. This is much more precise than I could ever do by hand. Since the wire adjusts to the position of the brackets, we have virtually eliminated the “bracketing repositioning” appointment. I typically put my patients into a SureSmile wire early in treatment. For Class I mild to moderate crowding cases, patients are scanned for their SureSmile wires the day the brackets are placed, and the SureSmile wire is ready at the next appointment. This allows a passive SureSmile wire to be placed in the posterior segments and eliminates the iatrogenic disturbance of a solid occlusion we sometimes see with conventional straight-wire treatment. I am also able to avoid typical hazards of the trade, like round-tripping and overcorrection.

Once I started to see the clinical benefits of SureSmile, I decided that I no longer wanted to offer conventional treatment to my patients. I had to think about how to scale the office to be 100% SureSmile.

With additional training and the revamping of work flow, my staff came up to speed very quickly. I designated 40 !"#$%&%'#()*practice

a SureSmile coordinator who became the point person for managing SureSmile cases. The position’s responsibilities include tracking scans, evaluating diagnostic SureSmile models, tracking patient wires, and communicating with the SureSmile digital lab. My staff now has become involved in setting up diagnostic models and has a better understanding of the dynamics of tooth movement and what a high-quality finish looks like.

Since we truly believe SureSmile does a better job in less time, we adopted the motto: “If you have a better treatment to offer, why would you want to use anything else.” I did not want to run a two-tier office with two levels of treatment quality and two fee structures. We wanted consistency in the clinic, in scheduling, and in marketing. The question became, “How do we cover the cost of SureSmile?”

We cover the cost of SureSmile several ways. First is clinical efficiency. We see about 10% more patients than several years ago, and my doctor chair time has been reduced about 20%. Second, we are able to significantly reduce supply costs for wire and brackets. I used to use a well-known and rather costly self-ligating bracket. Since SureSmile wires are doing all the work, I decided this bracket’s advantage was minimal. We now use a more costeffective twin bracket for most cases. Third is the increase in new patients because we are a 100% SureSmile practice.

We promote the benefits of SureSmile in our internal marketing and in communications with referring dentists.

Each patient who completes SureSmile treatment is given a “SureSmile Success Story” post-treatment report highlighting his/her finished treatment and the time savings.

Only by being 100% SureSmile are we able to openly and honestly explain its benefits to current and future patients.

We are the only SureSmile practice in the immediate referral area, and we use that fact to distinguish ourselves.

I have completed more than 1,000 SureSmile cases and started nearly 2,000. Our average treatment time is just under 15 months with SureSmile compared to my preSureSmile average of more than 23 months. We have also seen similar reductions in number of appointments and logically the number of wire changes. Most importantly, my finishes are more precise, and my patients look and feel great. As we say to referring dentists and their staff, we will “never go back to practicing orthodontics the old-fashioned way again.”

Steven Moravec, DDS, MS, received his DDS from the University of Michigan School of Dentistry and MS in Orthodontics from the University of Illinois in Chicago in 1983. He now practices orthodontics in Plainfield, Illinois.

He began offering SureSmile to his patients in 2007. To date he has completed more than 1,000 SureSmile cases and started nearly 2,000 cases. Dr. Moravec lives in Chicago and is married with two daughters ages 10 and 12.

Volume 3 Number 3

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Product profile

!"#$%*+,-./-)$ Lingual retention in stainless steel and good as gold

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or over a decade, Ortho FlexTech™ from Reliance Orthodontics has been an extremely popular lingual retention product both here in North America and in Europe. Developed and patented by orthodontist Dr. David Musich, it is a unique “flat linked chain” that is completely dead soft. The dimensions are 1.0 x .35 mm, and the flat design allows for closer adaptation to the lingual tooth surface for enhanced patient comfort. The advantage of the design provides esthetic lingual retention without the concerns of accidental wire activation that can cause relapse, tooth movement or “kick out” of the incisors.

History Ortho FlexTech’s original design was manufactured of 14 kt. yellow gold. Later on in its evolution, the chain was changed to 14 kt. white gold, which slightly improved the chain’s strength. In the last several years, as we all know, the cost of gold has increased exponentially, and this directly affected the retail cost of Ortho FlexTech. As these costs became prohibitive, a new solution had to be found. Despite the higher cost, Ortho FlexTech continued to be a popular and excellent selling product.

New Stainless Steel Ortho FlexTech™ In 2011, research created a solution to the high cost and increased the strength even further. At the AAO Annual Session in Hawaii, Stainless Steel Ortho FlexTech was introduced to the orthodontic profession. Stainless Steel Ortho FlexTech is the same design and dimension as the original but is now 30% stronger in tensile strength and 300% stronger in torsional strength.* Best of all, the retail price was half of the original gold Ortho FlexTech! It is the best scenario possible – stronger, half the cost and the same ease-of-use for predictable, superior results. As a note, white gold Ortho FlexTech is still available, if preferred.

Easy to Bond Stainless Steel Ortho FlexTech can be bonded directly or indirectly. If bonded directly, cut the chain to the proper length. Prepare the enamel as normal with a proper prophylaxis, and etch with phosphoric acid. Rinse and dry thoroughly. Once dry and isolated, place a light cure bonding primer on the etched tooth surface. Assure® Universal Bonding Resin is a popular choice. Place a small dot of a flowable composite such as FlowTain™ to the primed enamel surface. Place the chain on the paste undercoat “dot” and position for best alignment. Take up any “slack” in the chain. You do not want any “slack” in the chain interproximally. Light cure for 10 seconds to hold the chain in place. Apply a flowable composite overcoat to the enamel and chain, making sure of adequate coverage of the paste over the chain and onto the enamel surface.

Perform a final light cure of the paste for 20 seconds on 42 !"#$%&%'#()*practice

each tooth. Bonding the cuspid first and then working your way around the incisors to the opposing cuspid, tooth by tooth, works well.

We hope this information provides a concise picture and understanding of the Reliance Ortho FlexTech products.

If you have questions on this or any of the Reliance product line, please visit: www.relianceorthodontics.com or call direct at 800-323-4348. *Independent laboratory test available upon request.

This information was provided by Reliance Orthodontics.

Volume 3 Number 3

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Legal matters

+%,-"./-* /"%0123* &%'4#* 5-* ).0/$#*&-.&*6(#$%0#*%'Dr. Eric J. Ploumis outlines the steps to keeping a practice thriving even in the face of adversity

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rthodontists, by nature, are solitary beings and most practice alone. The latest statistics from the AAO report that 75 percent of practicing orthodontists are solo. Many have no arrangement to keep their practices running in the event they are unable to be in the office. The thinking often goes, “I have life/disability/ overhead/malpractice insurance. What else is there to worry about?” An often overlooked “insurance” is the crosscoverage group—an agreement among like-minded practitioners to fill-in for one another in the event a member is disabled or dies.

As an attorney who specializes in practice transitions, I have seen a number of instances where the death or disability of a sole practitioner has resulted in a significant decrease in the value of his/her practice. The dramatic drop-off in productivity and income rapidly erodes the attractiveness of the practice to a potential buyer. Even if the doctor is able to return to work, the disruption the practice endured can have a long-lasting impact on growth and profitability. If the doctor had a cross-coverage agreement in place, he/she could have helped preserve the ongoing value of the practice, made it more appealing to a potential buyer, and maintained the new patient flow essential to every practice.

The cross-coverage agreement is a contract among willing participants. Unlike many contracts, its enforceability rests more on the moral compact the parties bring to the agreement rather than something they can bring before a judge to enforce. One of the key elements in an enforceable contract, consideration, is not present in a tangible form.

Asking a judge to compel a member to cover for another member or to award monetary damages for a failure to cover is an argument grounded more in theory than in fact. The lesson, then, is to choose your coverage group colleagues wisely and make sure they are professionals you can count on to come to your aid in the event you need them. When you are lying in your hospital bed, the last thing you want is to find out is that a member of your coverage group does not plan to fulfill the solemn obligation.

Let’s look at what a typical cross-coverage agreement in the event of disability or death should consist of: 1. Parties: The agreement should list the members of 44 !"#$%&%'#()*practice

the cross-coverage group. No member can substitute or assign his/her obligation to the group to anyone else. You don’t want casual or oral commitments; you want willing participants who will solemnly agree, in writing, to step up if and when needed. This is not a loose collection of dentists you happen to see on occasion at a meeting. This is an essential part of your practice security, as important as any other insurance coverage you have. It is usually advisable to have at least six members in the group but no more than 12. No member should have to assist more than once a week. With six members, every day of the week is covered; with 12, a member only has to cover once every two weeks. Covering for another member means a day you cannot be in your office. You want to minimize the impact on your practice while being able to assist your coverage group member to retain the value of his/her own.

Another option to consider is for the group to keep a file of recently-retired local orthodontists. Having one doctor covering the practice will provide greater continuity of care for the patients. The local dental society or ortho program often has data on recently-retired practioners who might want to help out on a short-term basis.

2. Purpose: An introductory section that defines the mission of the group and its stated purpose, concluding with words like, “The parties seek to provide for the orderly functioning or transition of their practices in the event of a member’s disability or death.”

3. Definitions: In this section, you clearly define when members are obligated to step up and assist the member in need. Death is easy to define; disability is a little trickier.

As a member of the group, you want to make sure that if you suffer a disability, the group is obligated to come to your aid. However, there are a number of events that may technically constitute a disability that you might want to consider excluding from the definition of disability, such as: UÊ iVÌ ÛiÊ i` V> Ê«À Vi`ÕÀià UÊ-i v y VÌi`Ê` Ã>L Ì ià UÊ Ã>L Ì iÃÊ>ÃÊ>ÊÀiÃÕ ÌÊ vÊ >â>À` ÕÃÊ>VÌ Û Ì ià Volume 3 Number 3

Legal matters UÊ ÀiÃii>L iÊ` Ã>L Ì iÃÊÌ >ÌÊ> ÜÊÌ iÊv ÀÊÌ iÊÊ Ê procurement of a substitute Ê > }ÊÌ Ê>VVÕÀ>Ìi ÞÊ> `Ê«ÀiV Ãi ÞÊ`iw iÊÜ >ÌÊÌÀ }}iÀÃÊ a disability is often the source of friction and resentment within the coverage group. The decision should rest with objective facts, not on the subjective opinion of the majority of the members.

4. Triggering mechanism: The agreement should clearly state how the cross-coverage is put into play. One member should be appointed chair of the coverage group. This should be done on a rotating basis with the subsequent chair already established, either by seniority or alphabetically, in the event the presiding chair is the one in need of assistance.

If coverage is required, the member or representative of the member in need of assistance will know immediately who to call to arrange for coverage. There needs to be a clear chain of command and a specific way members should communicate with each other in the event they are needed to assist.

Members should not automatically assume that if they hear of another member’s illness or death, they will be required to serve. The practice may have a buy-sell agreement already in place that obviates the need for coverage. It is even possible that the representative of the practice prefers not to have the coverage group spring into action, opting to make other arrangements with someone not in the coverage group.

5. Schedule: Each member should know what day he/ she is expected to be available. When the call comes in from a member in need that is not the time for everyone to decide the day he/she can give. Each member should state a specific day of the week he/she will be available. Members should also discuss the hours their office is open. If a member likes to work three 12-hour days each week, that may not be acceptable to a covering doctor who prefers a shorter day.

6. Duration: The group needs to agree on how long they will cover for a doctor in need. The customary time is no more than 6 months. Most of the time, group members are very happy to step in and assist a colleague in need, but the obligation must have an end. The rationale behind the coverage group is to buy time for the doctor in need to make appropriate arrangements for a more permanent solution. This means that if a doctor is disabled, the group’s obligation is to fill in while the disabled member actively looks for a substitute doctor to keep things going until he/ she can recover. In the event of the death of a member, the group’s obligation is to maintain the value of the practice while the designated representative actively seeks to transition the practice.

Especially in the event of the death of a doctor, there is often a grieving period that prevents the immediate ability to put a transition in play. The group is there to keep things going. What the coverage group is not obligated to do is provide perpetual coverage while the representative shops the practice around looking for the perfect buyer.

7. Compensation: The group must decide whether the covering members are entitled to any compensation. The customary way this is handled is that for a period of a few months, usually no more than 3, the members fulfill their obligation to the member in need with no compensation. In Volume 3 Number 3

most cases, this will mean the covering doctor is out of his/ her office for no more than 12 days over a 3-month period, helping out a colleague in need. If coverage is needed after 3 months, members should receive per diem compensation.

Taking time out of one’s own office is a costly commitment.

Even when the covering doctor is compensated, the compensation rarely exceeds the lost income the covering doctor experiences.

8. Patient records: The covering doctor must make concise and accurate records of all procedures and income generated. Ideally, a trusted staff member will be there to assist. In addition, the member must agree that none of those records can be duplicated or removed from the office under normal circumstances. The disabled doctor or the spouse of the deceased doctor does not want to worry that the confidential records of the office are leaving the premises.

It also needs to be clearly stated that in the event any of the covering doctors require any of the records to defend against a judicial or administrative action, he/she is entitled to any access necessary to assist in the defense of such action. There should also be a clause in the cross-coverage agreement that all records need to be maintained for the required statutory period. The agreement should clearly state that in the event the practice is sold or otherwise disposed of, these provisions shall be binding on any subsequent buyer.

9. Office records: Each member of the coverage group should be required to keep a “transition file” in an accessible but secure location, ideally with a trusted accountant or lawyer. Much like a will, this file will be opened only upon a triggering event. The file should contain vital practice documents such as financial information, payroll reports, staff roster, passwords for office accounting and data information, and the names of trusted advisors including the doctor’s accountant, attorney, and investment advisor.

In an urgent situation, it is imperative not to lose time locating these records and advisors.

10. Transition letter: Members of the group should prepare several different template letters, to be sent as the appropriate situation arises. One letter should be in the event a member suffers a short-term disability, another is the disability appears to be of a more permanent nature, and a third in the event of a member’s death. The letter should be directed at both referring dentists and patients and should seek to assure recipients that it is “business-as-usual” in the office. Agreeing on and composing a letter under the stress of an urgent situation leads either to a costly delay or a poorly-drafted letter. A letter for each scenario should be attached to the cross-coverage agreement as an exhibit.

11. Non-solicitation: The parties to the agreement should promise not to solicit any of the patients or staff of the doctor in need. Concern by the disabled doctor or the family of the deceased doctor that the covering doctors will poach patients or staff is the primary reason coverage groups are not utilized. Without this peace of mind, the coverage group will be of little value.

12. Term and termination: The agreement should selfrenew on an annual basis unless a member withdraws or the group decides to disband. The agreement should !"#$%&%'#()*practice 45

Legal matters have a mechanism to allow a member to withdraw from the coverage group. Members should agree on how much advance notice is required to withdraw. Ninety days is the suggested notice. A method of delivery for the notice of withdrawal should be stated, usually a certified letter to the group’s chair with an obligation by the chair to immediately notify all other members so that a replacement member can be brought into the group. The agreement should have a provision that no member may withdraw if an active coverage situation is in effect or if there is deficiency in the number of members in the group. Coverage groups work best if there is a critical mass of doctors who are available to cover. The untimely withdrawal of a member in an active coverage situation can negatively impact the entire dynamic of the group.

13. Transition plan: In the event of a catastrophic illness or the death of the practice owner, it is imperative that a transition occur rapidly. The coverage group should form a relationship with a reputable practice broker and name that broker in the agreement. The broker can advise the coverage group before there is an emergency and be ready to spring into action in the event one occurs.

14. Indemnification: Under the heading of “no good deed goes unpunished,” the last thing any member of the coverage group wants is to be liable for the actions of another. The cross-coverage agreement must have a clause that states that each of the parties promises to indemnify and hold harmless all others from their independent acts, errors and omissions.

15. Relationship of parties: Your cross-coverage agreement should unequivocally state that there is no “privity” or business relationship between the members of the coverage group. No member, by virtue of being part of the group, has any claim on or responsibility for any of the assets or liabilities of the other members.

16. Dispute resolution: The agreement should address where and how any dispute between the members will be resolved. The logical venue for any dispute resolution is the state and county where most of the members have their offices. The best dispute resolution mechanism is arbitration rather than litigation in the court system.

General Issues The composition of the group should be age-balanced. As members age, younger members should be asked to join.

Although death and disability can strike anyone at any time, older members are actuarially more likely to require the group’s services. Younger members must acknowledge that the old guard has provided coverage for others for years and appreciate that fact if asked to come to the aid of a senior member. Coverage groups don’t work as well if all members are the same age.

Members must be clear about what constitutes a disability. A source of friction within a group, and occasionally the cause of a group’s collapse, is when some members feel that a disability is one that could have been foreseen and provided for. The purpose of a coverage group is to provide short-term support for unexpected illness or death. A member who expects the group to cover for him while he/she is out for a month recovering from a hair 46 !"#$%&%'#()*practice

transplant or maternity leave creates resentment among the other group members. Expecting group members to take time out of their offices when there was ample time to procure a substitute dentist is not within the spirit of the agreement.

When forming a coverage group or asking new members to join, vet each potential member to be sure everyone shares similar treatment philosophies. If you have a member who is adamantly opposed, say, to premolar extractions, he/she might not be a good fit in a group that believes in the virtues of Tweed incisor position. In addition to similar philosophy and techniques, all members of the group must be licensed in the same state. It makes no sense to have someone in your coverage group who cannot legally practice in your office. In the case of doctors with multiple offices, the group should determine which of the offices members are obligated to cover.

By establishing a pre-existing relationship with a reputable practice broker, the group can use its leverage to negotiate a discounted brokerage fee in the event a practice needs to be sold due to the death or disability of a member.

Using those same economies of scale, a coverage group can also negotiate a lower fee with a practice appraiser and get annual or biennial appraisals of their practices to insure that there is a current valuation in the event a rapid sale is required. The broker should be invited to speak to the group on a periodic basis to update the group on the current valuation methods for orthodontic practices and the current “state-of-the-market” for transitioning practices. Having a broker in place who knows the practice and the prevailing market will improve the transition value of the practice. In addition, a knowledgeable broker can also provide a “reality check” on the presumed value of the members’ practices and help a disabled doctor realize that the time to sell is before the practice starts to decline significantly.

In many jurisdictions, a nonprofessional cannot own a dental practice. Most state boards provide only a brief window where the spouse of a deceased dentist can own and run the practice as it is transitioned. If a coverage group is not in place, and the practice has not had a recent valuation, critical time is wasted putting together the necessary transition team. Often, the grieving spouse is too distracted to focus on the importance of acting decisively to transition the practice. Grief, coupled with lack of preparation, can cause a delay that severely impacts the ability of the practice to be effectively transitioned. The delay creates a significant drop in the value of the practice at a time when the surviving spouse may most need the income the sale would produce.

A successful coverage group has like-minded members who know each other and get along with each other. As a practical matter, when advising coverage groups I always suggest that they meet twice a year to reaffirm their legal, moral and ethical bond to each other. One of the meetings is a business meeting where the agreement is reviewed, and each member is made aware of his/her solemn obligation to the other members of the group. The group roster is updated with the names of each of the member’s office manager, accountant, and lawyer. On occasion, a speaker can be invited in to discuss issues that might arise in the event of a doctor’s death or disability such as taxation or Volume 3 Number 3

Legal matters

estate planning.

The second meeting is more of a social gathering where spouses are invited. It is important that spouses meet the members of the group and each other. In the event of the death or disability of the dentists, the surviving spouse will need to rely upon the members of the group to step in and assist in preserving the practice value while it is transitioned. Meeting with each other, even if it is once a year, serves to allay any fears the surviving spouse may have that members of the group would “poach” patients and staff from the deceased doctor’s practice.

In the past year, I have worked with six dental-practice transitions that were the result of the death or disability of the selling doctor. In four of the transactions, I represented the seller. Regrettably, not one of the deceased or disabled doctors had a coverage group in place. The spouses all had similar stories: we talked about it, but he never got around to joining one; she was in great health and never thought she’d get sick; he thought it would never happen to him; she knew she was sick but was in denial. Had the practice owners been part of a cross-coverage group, the practice value would have been preserved. The absence of a coverage group and lack of advance planning resulted in a significant reduction in the selling price of the practice. Even where

I represented the buyer, and we were able to pick up the practice at a significant discount, neither party benefited.

The seller got a lower price, the buyer a lesser practice.

Besides life insurance, disability insurance, office overhead insurance and malpractice insurance, add one more thing to your list of insurances: membership in a cross-coverage group.

This information is not intended as a substitute for legal advice.

You should familiarize yourself with the laws of your local jurisdiction and seek legal advice from a local attorney who specializes in such matters.

Eric Ploumis, DMD, JD, is an attorney, an orthodontist, and Associate Clinical Professor of Orthodontics and Risk Management at New York University. He limits his legal practice to issues surrounding the practice of dentistry with an emphasis on practice transitions, employment issues, leases, and defense of allegations of professional misconduct before the Office of Professional Discipline. He can be reached at EricPloumis@aol. com or www.dentalpracticelawyers.com.

Orthodontic Practice US is an exciting specialty journal that brings a new perspective to the orthodontic literature.

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April 2012 – Vol 3 No 2

• 100% Ortho-focused publication • Articles by world-renowned orthodontic specialists • Peer-reviewed clinical case studies • Unique blend of editorial content to include continuing education, technology features, practice management articles, and new product information • CE course listings

Drs. RK Tamburrino, JL Linton, and SH Shah The Axis-Horizontal reference plane for precision diagnosis: part 2

Dr. Larry White A cephalometric search for the ideal African-American softtissue profile

Dr. Derek Mahoney Treatment of white spot lesions after removal of fixed orthodontic applicances

3D imaging straight talk CBCT–changing the face of orthodontics

OrthoSynetics Practice management helping to accelerate your practice

Also inside: CE Articles Laboratory Link Practice Management

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3 EASY WAYS TO SUBSCRIBE Visit orthopracticeus.com Call 1.866.579.9496 Email kmurphy@medmarkaz.com Volume 3 Number 3

1 YEAR $99 3 YEARS $239 !"#$%&%'#()*practice 47

Practice management

7DFNOLQJ WKH ʞHFKQRORJ\ +,--!.*/"*+,-001 Toby Buckalew outlines technologyrelated ways to take the stress out of protecting patient data

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ention HIPAA and people scramble, run, hide, stare blankly into space, or run screaming into the void! Simply put, HIPAA is about taking steps to implement controls and safeguards, insuring only those with the need can view patient information. How technology works into your practice and how HIPAA affects your use of technology does not need to be a frightful experience. Understanding the basic technology categories of HIPAA is a good place to start.

HIPAA’s structure is general in nature. It does not list specific steps to secure electronic charts– neither does it dictate how to use technology in an office. Rather, it paints general guidelines to insure it always covers changing technology. While HIPAA is vague, there are well-documented and accepted best practices for securing your data.

HIPAA mandates specific control categories, each designed to insure the security of personal health information (PHI): data encryption/integrity systems, audit controls, authorization/authentication controls, and physical/logical access controls.

Data encryption/integrity systems: Data encryption helps insure only those with permission to view data can access that data, even if the data resides on a stolen computer.

Data falls into two general categories: data in motion and data at rest. Data at rest refers to data not moving, for example, sitting in your medical software or on a computer.

Many of the medical applications encrypt or secure their data.

The more difficult of the two data categories is data in motion, or data moving from point A to point B, and this is where the HIPAA “gotchas” come into play. Examples of this would be information burned to a CD, copied to a USB thumb drive, on a laptop being taken between offices, or in email—normally not encrypted. As such, sending PHI via email, or storing it in a mail system, would not be acceptable. If your data is accessed via the Internet, or some other public means, is your connection to that data secured (look for the ‘S’ in the prefix of the web address – https rather than http)? There is a simple way to test your data encryption. If you can hand something electronic (or send it) to your neighbor’s kid, and they can open and look at the information without any password or special tool, the data is not encrypted.

48 !"#$%&%'#()*practice

What is the best way to handle patient data “in motion?”

Limit it to a handful of secured methods proven to work, and never use email, Facebook, Twitter or other unsecured online methods to send or store patient health information.

Audit controls: Audit controls refer to an electronic mechanism for tracking who accesses and changes information on your systems. If you use any modern electronic medical software, there is a good chance these audit controls are built-in. A good test to see if adequate audit controls exist in your software is to look and see if you can answer some basic questions: Who created the chart?

Who entered those visit notes? Who made that change? If you cannot answer, then your controls may be inadequate.

Authorization/authentication controls: Authentication controls refer to how you can determine who is accessing information. This is normally in the form of a username and password (user credentials). As audit tracking uses credentials for logging, each user should have his/her own credentials that are kept secured—meaning not written on a note and taped to a monitor. Former staff members should have their credentials deactivated. Additionally, the password should be strong and changed on a regular basis. A quick Internet search for strong password yields a number of articles, tutorials, and information on creating strong passwords.

Volume 3 Number 3

Practice management

...never use email, Facebook, Twitter or other unsecured online methods to send or store patient health information.

Authorization controls work closely with authentication. They determine how much access a user’s credentials provide. A good example would be the front desk worker. He/she normally has permission to view general patient demographics, insurance information, and patient schedules to perform his/her job functions. However, these workers have no need to access charting details, whereas a physician would need access to all information.

Authentication controls insure credentials used to access PHI can only access needed information. Audit controls track when credentials access specific information and when inappropriate attempts to access information occur.

Logical/physical access controls: Logical and physical access controls are the front-line of defense when it comes to HIPAA and technology. Logical access controls consist of the computer policies for accessing information on a computer or network. Physical controls refer to the physical security of computers, servers, and network equipment.

Before anyone can get to PHI on a computer, they must have some method of physically getting there–through a computer at the front desk, a computer in the back office, by attaching to a secured wireless network, or by physically walking up to the server holding the PHI. The basics of physically securing PHI: - Secure servers so only those with a need have physical access to them do (think of a locked room) - Securing your workstations so the general public (and curious patients) do not have access to them - Insuring you encrypt and secure your wireless network so people in the parking lot cannot connect to your network Volume 3 Number 3

- You know and control all the physical network jacks in your office.

Logical access controls work in a similar, but electronic, manner. They are system controls to provide protection of the data. Do your computers require a login before they can be used? If not, are there other electronic security elements in place to insure the cleaning crew cannot use the computer to gain access to your store of PHI? Does your medical software automatically lock the session or log out the user after a certain period of inactivity? These are all examples of logical access controls to protect against PHI. Other types of logical controls are important, but often overlooked. How many times have you heard, “computer x never gets viruses,” or “my computer works, so I do not need to upgrade it?” If you operate with either of these mindsets, you may be shocked to find your logical access controls are not HIPAA compliant! All computers are susceptible to viruses, and all computers require security updates: - Insure you have anti-virus/anti-malware software installed and updated - Insure the operating system is up-to-date and patched for any known security vulnerabilities Making sure that the system is up-to-date is often the most overlooked aspect. All operating systems have a finite life (it does not matter whether the system is Mac, Windows, or Linux). There also comes a time when the publisher decides the software is past its usable life and will no longer develop, test, and release security updates for it— even when a known flaw exists. To keep your old, no longer supported, software compliant, you have two choices: develop the fix, test, and certify it yourself, or upgrade your operating system to a supported version. Each manufacturer lists an end-of-life and end-of-support date for its operating systems, and some support them for longer than others.

Entire volumes exist to delve into the detail of HIPAA compliance regarding the use of technology. You do not need to be an expert, but some basic understanding of the broad categories and following some best practices will take you a long way to being technology-compliant.

Toby Buckalew, CIO of OrthoSynetics, is an experienced technology and operations executive with over 24 years of experience in military retail, financial, and healthcare markets.

Starting his technology and operations career servicing U.S. military facilities in Europe, Mr. Buckalew returned to the U.S. to continue his work after the end of the cold war. Working and consulting in the healthcare field in both Cardiovascular Practice Management and Convenient Care industries, Mr. Buckalew specialized in the evaluation and implementation of technology, designing staffing and technology solutions for unique business needs. Serving as the previous CIO of GET Marketing, a military retail broker, and as the Vice President of HealthStop in the convenient care industry, Mr. Buckalew brings a strategic and varied view of technology and its focus on healthcare to OrthoSynetics. Mr. Buckalew studied Technical Management with a minor in Logistics at Embry Riddle Aeronautical University. !"#$%&%'#()*practice 49

Practice management

Stay connected the engine GULYLQJ SUDFWLFH HIÀFLHQF\ and patient satisfaction Dr. Lou Shuman and Diana P. Friedman, MA, MBA, show how patients can keep in touch with your practice 24/7

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he Internet affords us, as consumers, incredible benefits such as making it easy to research information quickly and seamlessly transact with service providers online.

From online banking to ordering books through Amazon, increasingly the Internet plays a bigger role in our lives. In fact, 98% of those with a household income of $75,000 or above use the Internet.

Put yourself in a patient’s shoes for a minute. What would the impact be if you had access to your account and records, whenever you want, wherever you want it?

Download an appointment reminder to your calendar; fill out health history forms from the privacy of your home, with clear access to your medication cabinet; print an insurance form without having to request the practice generate this form for you; look up and confirm your upcoming appointments at your convenience, and/or pay your balance using a credit card, all from the comfort of your home.

Sounds perfect and convenient, right?

There is something to be said when your patients can perform tasks such as filling out forms, accessing dental records and insurance balances, paying their bill, and sending you communications online, any time of day.

In fact, 97% of dental patients would rather click than call the practice for information. Simply put, it is a huge convenience factor.

More than 90 percent of dental patients surveyed report that online access is “much more convenient” than calling the office. The fact is, with our modern fast-paced, activitypacked lifestyle, your patients are extremely busy and appreciate service providers that facilitate their interactions.

When you can make their experience with your practice hassle-free and accommodate their preferences and convenience, they are going to respond by increasing their loyalty and commitment to the practice.

Just as important is the fact that automating certain administrative functions like past due accounts/receivable collections and appointment reminders gives your team the opportunity to leverage their time more efficiently.

Their time can be focused on more important tasks such as establishing great relationships with your patients, tracking treatment acceptance and completion, reactivating patients, and other tasks critical to ensure your office runs like a welloiled machine.

In this article, we will examine specific benefits of portals associated with automated patient reminders, email financial reminders, and patient-engagement tools.

50 !"#$%&%'#()*practice

Automated appointment reminders – keep your schedule full How much time would your staff save every day if they weren’t making calls to remind patients about upcoming appointments? What could they be accomplishing if they had that valuable time back in their day?

According to Medical Group Management Association data, in dental practices the average missed appointment rate is between 18 and 22 percent, which translates into an average loss in revenue of $138,000 per practice, annually, due to missed appointments alone. With appointment reminders, you are not just reminding your patients of their appointments, you are reminding them of how crucial dentistry is to their overall health. In fact, 100% of surveyed practices agree that patients perceive their doctors as hightech with superior customer service when appointment reminders are customized. An effective, automated appointment reminder system decreases your no-show rate, helps staff be more efficient, and strengthens patient commitment.

The most significant patient benefit of an automated communication system is the patient’s ability to customize communications to their preferences, specifically email, text, or voicemail appointment reminders. In a 2010 survey, it was found that 79.5% of Sesame Members’ patients preferred text and email reminders over phone reminders.

What’s more, 85% of surveyed Sesame Members agreed that using reminders reduced outbound calls from their team.

Unlike manual systems, which require daily scheduling, an effective online patient portal requires that your staff only set up the reminder once—the system takes care of the rest.

Appointment reminders are automatically sent when you want, including one-hour pre-appointment text messages to gently remind patients about their appointments. By using an automated process, doctors have the peace of mind in knowing all reminders were executed properly and on time, every time.

The result? Fewer patients telling you, “I got so busy I forgot,” not to mention more productive days with filled chairs. Without an online portal to communicate with your patients about their upcoming appointments, remaining insurance benefits, treatment images, and financial data, your office staff must spend time manually responding to each and every request for information.

Financial reminders – improve collections What would you be more likely to do on time–go to the Volume 3 Number 3

Practice management post office to mail a check to a business, or pay online with a credit card from the comfort of your home or office?

Online bill pay is becoming more of an expectation in today’s digital world, with the total number of households transacting online growing by 53% in the past 10 years, and check payment volume dropping by 57%.

The convenience of being able to pay online not only means a quicker turnaround for payments, but the ability to collect payment outside of office hours. Sesame Members receive more than 46% of payments outside of normal business hours, meaning the money is in their account and waiting for them by morning. More significantly, 90.5% of Sesame Member patients surveyed stated they are comfortable paying their dental bill online. Clearly, emailed financial reminders and the ability to discreetly pay balances via credit card 24/7 is a convenience patients both expect and endorse.

Automated past-due financial reminders also present an opportunity for increased effectiveness and efficiency on the part of the practice. In 2010, a comprehensive study by TransFirst found that 32% of online payments to practices were made the day the patient received their past-due financial reminder. An impressive 50% of payments were made by the end of the second day (within 48 hours).

Past-due balances dramatically impact the practice cash flow and profitability. Implementing a system that seamlessly and effortlessly collects half of those outstanding balances without administrative time required to manage collection calls is an important benefit. More significantly, collection calls are not only time-consuming, but can damage the relationship between the practice and the patient. Automated effective online collection systems reduce the need for that activity and minimize such a risk.

Patient digital communications – build brand trust Regular communication with your patients not only builds a sense of familiarity with your practice, but over time it builds brand trust as well. E-newsletters, customized personal emails, e-birthday cards, and holiday greetings are an effective way to deliver practice information, engage with your patients, or share news and promotions relevant to your patients’ treatment plans.

The average dentist has 1,871 active patients, making the ability to have one-to-many conversations crucial to patient retention and the success of their practice.

It’s difficult to make a personal connection with each one of your patients on a regular basis, but by reaching them electronically, you can close the time gap between conversations and increase patient recognition and awareness of your practice’s brand. Furthermore, consistent communication not only saves administrative time and cost, but further affords your practice the opportunity to educate patients about new services they may be interested in like adult Align orthodontics, implants, or teeth whitening.

Patient portals – gain new patients through referrals and measure to ensure satisfaction Practices are hectic and busy environments, and you may fail to ask your most valued patients for feedback and Volume 3 Number 3

guidance on how you may better serve them. It is imperative to regularly keep tabs on your patients’ level of satisfaction.

A complete online patient portal functionality needs to include post-appointment feedback surveys that can easily be filled out online after every appointment while the patients’ visit is still fresh in their minds. In addition, it should include a survey form any visitor may complete to provide feedback to the practice. Use this valuable information to continually improve the experience of patients in your practice and keep them returning. Take it one step further and post positive testimonials and reviews to your practice blog, Facebook™, Twitter™ and Google+pages™ to attract new patients.

Lastly, the continued success of your practice requires happy patients who refer their friends and family. Allowing your patients to conveniently input this information online and send your practice information directly to their referral, means you will have the contact data on hand to reach out directly to prospective patients right away, and that referral will have already received a positive evaluation of your practice.

Conclusion With the right online patient portal, your practice can elevate the patient experience and quality of care while effectively staying in touch with them at all the crucial moments in their lifecycle with the practice. From ensuring they remember to show up to an appointment, to reminding them to pay their bill, automated systems drive consistent, reliable execution of otherwise time-consuming administrative duties. In an economy where limited budgets and resources have become the norm, it’s imperative to make the most of what you have, and to discover ways to consistently achieve your practice’s production and collection goals through more efficient methods.

Lou Shuman, DMD, CAGS, in Orthodontics, is the President of Pride Institute. He is a member of the Key Opinion Leader Board at DENTSPLY GAC, is a personal consultant to DENTSPLY GAC, as well as to SomnoMed Inc., the country’s leading sleep apnea company. He currently serves as Chairman of the Sesame Communications Technology Advisory Board, is a member of the Clinical Advisory Board at Dentistry Today, as well as the Advisory Boards of The Progressive Orthodontist and The Progressive Dentist. He is also the only dentist who has been selected both as a Top CE Leader and a Leader in Dental Consulting by Dentistry Today magazine. Previously, Dr. Shuman served as Vice President of Clinical Education and Strategic Relations at Align Technology for 7 years. During that time he was responsible for the creation of Orthodontic and GP clinical programs, was the professional lead on multiple concept development projects, including the creation of Vivera retainers, and integrated the Invisalign® technique into orthodontic and dental school curriculums throughout North America.

Diana P. Friedman, MA, MBA, is President and Chief Executive Officer of Sesame Communications.

She has a 20-year success track record in marketing innovative technologies and fortifying brand positioning for dental companies in the professional and consumer markets. Throughout her career, Ms. Friedman has served as a recognized practice management consultant, speaker, and author.

Ms. Friedman holds an MBA in Management and Marketing as well as an MA in Sociology from Arizona State University. !"#$%&%'#()*practice 51

Practice development

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Chris Bentson and Doug Copple, AVA, discuss the statistics that drive orthodontic opportunities

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f you spend much time speaking to either very young or very, shall we say, mature orthodontists, you can get the feeling that the luster of the profession is somehow less bright now than it once was. For those in the middle years of practice life, the reviews are mixed on whether orthodontics still has the sheen of yesteryear. Our observation is that a career in orthodontics is indeed changing but offers doctors more choices of how to practice today than ever before with financial and lifestyle opportunities that are still the envy of dentistry and medicine.

It is true that complaints of increased competition, price wars, and rising technology costs are often coffee break fodder at alumni meetings. Lectures on new topics like marketing, social media, and why and how to blog and Twitter fill the lecture halls at meetings. On the clinical side, a myriad of new treatment modalities typically centered around more esthetic appliances or aligners, shorter treatment times, and touting more perceived value to orthodontic consumers are finding a foothold in “standard orthodontic care.” The business and clinical options of the profession are indeed evolving. However, amidst this cacophony of new information requiring new skills from orthodontists, the financial rewards of practice ownership or employment have placed the profession in very rarified air at the top of income earners (America’s Best-Paying Jobs, Forbes Magazine, July 12, 2010)—a position which shows no signs of materially abating.

This article will take a look at the current opportunities for young orthodontists and how the numbers work for the newly minted orthodontic graduate as he/she enters into the profession. Perhaps you will agree, orthodontics still offers the allure and rewards both in lifestyle and income of years past.

There is a meeting of residents across the U. S. that occurs each summer; it’s called the Graduate Orthodontic Resident Program, commonly referred to as GORP. GORP rocked out of the cradle at the University of Michigan program as the brainchild of Dr. Jim McNamara and then resident Dr. Gary Starr. The idea was to bring residents together from across the country once per year to hear a top-tier slate of lecturers and to have some fun. Several years ago, Dr. Robert Scholz presented a lecture at GORP titled: “Do You Want a Job When You Graduate?” It’s no secret that the recession that began in December of 2007 and ended in May of 2009 caused many practicing orthodontists to reevaluate their planned retirement date. Since late 2007, the job market for young orthodontists seeking to purchase a practice has been fiercely competitive. The current market has roughly three candidates vying for each practice available for sale. Additionally, the profession is aging. The 52 !"#$%&%'#()*practice

Chart 1

Chart 2

most recent Journal of Clinical Orthodontics (JCO) biannual Orthodontic Practice Study (2011) reports the mean age of orthodontists in the U.S. is 54 years, and he/she has been practicing for 23 years (2011 JCO Orthodontic Practice Study. Journal of Clinical Orthodontics, Vol. XLV, No. 10).

In his GORP lecture, Dr. Scholz outlined nine possible landing zones for orthodontic residents to consider after graduation. They are, in no particular order: UÊ -Ì>ÀÌÕ« UÊ Ãà V >Ìià « UÊ Ãà V >Ìià «]Ê i>` }ÊÌ ÊLÕÞ ÕÌ UÊ Ãà V >Ìià «]Ê i>` }ÊÌ Ê«>ÀÌ iÀà « UÊ - Ê }À Õ«Ê «À>VÌ ViÊ ­Ã«>ViÊ Ã >À }Ê Ü Ì Ê Ì iÀÊ `i Ì> Ê professionals) UÊ « ÞiiÊ vÊV À« À>ÌiÊi Ì ÌÞ Volume 3 Number 3

YOU COULD GET THERE ON YOUR OWN...

...BUT WEâ&#x20AC;&#x2122;LL GET YOU FURTHER, FASTER.

How do you plan to accelerate your practice? Itâ&#x20AC;&#x2122;s a big world with lots of possibilities. The challenge is you can only do so much at one time. Youâ&#x20AC;&#x2122;re lacking time in some areas and expertise in others. You want to keep control without getting bogged down in the details.

OrthoSynetics is the company youâ&#x20AC;&#x2122;ve been looking for. We assist orthodontic and dental practices with business, marketing and administrative functions.

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OrthoVOICE2012 'RQ·W PLVV LW

Featuring Dr. Lysle Johnston Indecision is the Key to Flexibility: The Role of Controversy in Contemporary Orthodontic Practice

Held at Paris/Ballys Resort and Casino Charity Golf Tournament at Desert Pines 12 hours of C.E. eligible lectures offered

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V OICE O RTHO Vegas Orthodontic International Conference & Exposition

October 11-13, 2012

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Doctor & Team Registration: $299 until July 31 then $399 unti Sept. 30 then $450 on site Resident Registration: $49 until July 31 then $99 unti Sept. 30 then $450 on site

Practice development and for the last 2 years, the number of residents who desire to work as employees as they exit their residency was reported at 26% in 2010 and 25% in 2011. Residents desiring to start a practice from scratch have remained constant at 11% in our surveys of the last 2 years. However, the majority of residents in our 2010 and 2011 surveys responded that they wanted to purchase a practice—51% in our 2010 survey and 54% in our 2011 survey. To analyze the cash flow opportunity for residents wanting to purchase a practice, Chart No. 3 provides a cash flow pro forma representing the mean practice opportunity available to potential purchasers.

This cash flow model makes the following assumptions: UÊ i> Ê«À>VÌ ViÊV iVÌ ÃÊ vÊf xä]äääÊ­Ài« ÀÌi`Ê ÊÌ iÊ 2011 JCO Orthodontic Practice Study) UÊ i> Ê «À>VÌ ViÊ ÛiÀ i>`Ê vÊ x ¯Ê ­Ài« ÀÌi`Ê Ê Ì iÊ Óä££Ê JCO Orthodontic Practice Study) UÊ Ê «À>VÌ ViÊ Ã> iÃÊ «À ViÊ vÊ ÇÈ¯Ê vÊ i> Ê V iVÌ ÃÊ ÀÊ fÇÓÓ]äääÊ v ÀÊ Ì iÊ i> Ê «À>VÌ ViÊ `iÃVÀ Li`Ê >L ÛiÊ ­ÇÈ¯Ê ÃÊ the average price of practices analyzed by Bentson Clark &

«« iÊ ÊÓ䣣ʭBentson Clark reSource, Vol. VII, Issue II) UÊ Ê V ÃiÀÛ>Ì ÛiÊ >ÃÃiÌÊ > V>Ì Ê Ê Ì iÊ «ÕÀV >ÃiÊ «À ViÊ ­Çä¯Ê Ì> } L iÊ> `ÊÎä¯ÊÌ> } L i® UÊ *ÕÀV >ÃiÀÊ L ÀÀ ÜÃÊ £ää¯Ê vÊ Ì iÊ «ÕÀV >ÃiÊ «À ViÊ > `Ê w > ViÃÊ Ì iÊ «ÕÀV >ÃiÊ v ÀÊ ÇÊ Þi>ÀÃÊ >ÌÊ Ç¯Ê ÌiÀiÃÌÊ Ü Ì Ê Ì iÊ i `iÀÊ­ i ÌÃ Ê >À ÊEÊ «« i½ÃÊiÝ«iÀ i ViÊ ` V>ÌiÃÊÌ ÃÊ ÃÊ>ÊV Ê ÌiÀiÃÌÊÀ>ÌiÊ> `ÊÌ >ÌÊÇÊÞi>ÀÃÊ ÃÊ>ÊÀi>à >L iÊ repayment period, although purchasers may finance the loan over a longer period) UÊ `ÕV>Ì > Ê`iLÌÊ vÊfÓÎä]äääÊ­>ÛiÀ>}iÊi`ÕV>Ì > Ê`iLÌÊ «iÀÊ Ì iÊ i ÌÃ Ê >À Ê EÊ «« iÊ Óä£äÊ > `Ê Óä££Ê Õ> Ê Resident Survey) UÊ Ê ÌiÀiÃÌÊÀ>ÌiÊ vÊÈ°n¯Ê Êi`ÕV>Ì > Ê`iLÌÊ> ÀÌ âi`Ê ÛiÀÊ £xÊ Þi>ÀÃÊ ­VÕÀÀi ÌÊ Õ ÃÕLà ` âi`Ê -Ì>vv À`Ê > Ê ÌiÀiÃÌÊ À>ÌiÊ ÃÊ È°n¯®]Ê Q-Ì>vv À`Ê > Ê ÌiÀiÃÌÊ ,>ÌiÃ]Ê StaffordLoan. com] UÊ Ê Ü À Ê L>V Ê vÊ Ì iÊ Ãi }Ê ` VÌ ÀÊ >vÌiÀÊ Ì iÊ Ã> iÊ vÊ Ì iÊ practice for 32 weeks, 3 days a week for 16 weeks, and 2 days a week for another 16 weeks, with a per diem fee of f£]äääÊ«> `ÊÌ ÊÌ iÊÃi }Ê` VÌ ÀÊv ÀÊV V> ÊÃiÀÛ ViÊ>vÌiÀÊÌ iÊ sale UÊ } ÌiÀ Ê> Õ> Ê«À>VÌ ViÊ}À ÜÌ ÊÀ>ÌiÊ vÊ£°x¯Ê«iÀÊÞi>À The cash flow pro forma in Chart No. 3 reveals that after debt service for the practice purchase loan, educational `iLÌÊ Ài«>Þ i ÌÃ]Ê > Ü }Ê £°n¯Ê > Õ> ÞÊ v ÀÊ V>« Ì> Ê expenditures and a reasonable allowance for benefits and deductible discretionary or personal business expenses ­fÓä]äääÊ ÊÞi>ÀÊ iÊ> `Ê VÀi>à }ÊίÊ>ÊÞi>À®]ÊÌ iÊLÕÞiÀ]Ê Õ `iÀÊÌ iÃiÊ>ÃÃÕ «Ì Ã]ÊÜ Ê >ÛiÊ>Ê«Ài Ì>ÝÊ}À ÃÃÊ V iÊ vÊ>««À Ý >Ìi ÞÊf££x]äääÊ ÊÞi>ÀÊ iÊÜ iÊÃÌ Ê«>Þ }ÊÌ iÊ Ãi ÀÊ` VÌ À]Ê> `Êf£Çx]äääÊ ÊÞi>ÀÃÊÓÊÌ À Õ} ÊÇ°Ê vÌiÀÊÌ iÊ ÃiÛi Ì ÊÞi>À]ÊÌ iÊLÕÞiÀÊÜ ÊLiÊi>À }Ê>Ê«Ài Ì>ÝÊiµÕ Û> i ÌÊ vÊ>««À Ý >Ìi ÞÊfÎÈ ]äääÊ«iÀÊÞi>À°Ê,i i LiÀ]ÊÌ ÃÊV>Ã Ê y ÜÊ«À Êv À >Ê >ÃÊ>ÊV ÃiÀÛ>Ì ÛiÊ } ÌiÀ Ê}À ÜÌ ÊÀ>ÌiÊ vÊ only 1.5% per year.

The cash flow illustration given shows that young ÀÌ ` Ì ÃÌÃÊ V> Ê «ÕÀV >ÃiÊ Ì iÊ i> Ã âi`Ê ÀÌ ` Ì VÊ practice in the country, cover the debt service obligations on both the practice purchase and educational debt while maintaining a lifestyle that still places them near the top of income earners in any profession.

56 !"#$%&%'#()*practice

Has the luster or sheen of the profession diminished?

Our opinion is there are more opportunities for employment for orthodontists than ever before, and there are lenders willing to partner with young orthodontists for practice startups or purchases. Without regard to the personal satisfaction of rendering orthodontic care, the profession continues to offer a lifestyle that is attractive with regards to earning potential and personal time off. The future of the profession is bright, even with the need for analysis and continued learning as a constant in these times—just as in times before. Young doctors can choose many directions in which to practice, all of which make a career in orthodontics still one of the most coveted and smartest choices in all of dentistry.

Chris Bentson has been working with orthodontists regarding the business aspects of their practices for more than 23 years. He is currently President of Bentson Clark & Copple, LLC based in Greensboro, North Carolina. He also serves as editor-in-chief of the Bentson Clark reSource, a quarterly newsletter focused on the business aspects of running a successful orthodontic practice. He is a frequent guest lecturer, most recently presenting at the invitation of the AAO at the 2011 AAO Transition Seminar in Chicago. He has personally visited over 1,000 orthodontic practices in the United States, Canada, and Australia. He can be reached at 1-800-6214664 or via email at Chris@bentsonclark.com.

Doug Copple is a partner with Bentson Clark & Copple, LLC. He is an Accredited Valuation Analyst (AVA), and has excellent knowledge in both valuation methodology and tax allocation/ negotiations in the transition process. He can be reached via email at Doug@bentsonclark.com.

Volume 3 Number 3