Orthodontic Practice US October 2012 Vol. 3 No.4

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Dr. Benedito Freitas Orthodontic treatment of a Class II division 1 malocclusion with severe maxillary gingival display by using mini-‐implants as anchorage

Dr. Derek Mahony Refining occlusion with muscle balance to enhance long-‐term orthodontic stability

3D imaging straight talk CBCT in the mixed dentition: a crystal ball

Dr. Rick Steedle Hiring the right people

Also inside: Product Profile Service Profile Technology

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Editorial October 2012 – Vol 3 No 4 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

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

The habitual vision of greatness

O

ne of my friends had the good fortune to study for a while with the prestigious Alfred North Whitehead when he emigrated from England to America in 1924. One of the most enduring lessons my friend learned from that great philosopher and mathematician was, “Moral education is impossible apart from the habitual vision of greatness.”

I don’t think it would be taking too much liberty to say education of any sort is impossible apart from the habitual vision of greatness. Behaviorists have told us for some time that most of what we learn comes from imitating role models. My friend said he often thought about Whitehead’s remark when he recalled his own educational experiences in the one-room schoolhouse where one teacher taught all grades. He told me how seeing the older children perform their mysterious and difficult tasks at the blackboard stimulated his own learning.

Those older students were a constant inspiration to my friend, and he was always grateful for that early educational experience.

Obviously, not everyone can be great. Only occasionally do really great people appear. A Socrates appears only rarely; a da Vinci comes on the scene only from time to time; a Sir Isaac Newton comes around once every 200 or 300 years; a genius of the rank of Amadeus Mozart is a rarity; and an Einstein is a welcome but scarce presence.

Individual orthodontists may humbly realize they are not great, but this should not prevent them from intellectually walking with the great. In fact, the more modest and realistic people are, the more they need contact with professional greatness. And that remains one of the important tasks of this journal because the published word makes it possible to share quality thoughts with its readers.

In short, I am not, and very few others, are Mozarts of orthodontics, but by reading first-rate articles, we have a chance to walk with some of the talented people of our profession and learn how to augment our own meager resources. I am grateful to be part of a profession that is open and eager to share its collective information. Not all of the professions dedicate themselves to this kind of sharing of information, and not all of them devote themselves to the nurturing of young colleagues. But my personal and professional life have been shaped by the habitual vision of greatness many of my mentors have had and so generously shared, and I am the better for it.

One of my friends was a successful junior high teacher, and he taught me an old expression that I dearly cherish. “If you lie down with the dogs, you’re gonna get up with the fleas.” If that aphorism is true in its pejorative sense, it is equally true in it positive application; to wit, we become like those with whom we habitually associate, i.e., what we watch, read, study, believe, and imitate have their effects.

Orthodontic Practice US tries to expose readers to some of the brighter lights of orthodontics.

They want you to receive something of value in every publication. Its editors are open to new submissions, and look forward to your ideas and suggestions for future issues.

PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton lauren@medmarkaz.com 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 4

Larry W. White, DDS, MSD

Orthodontic practice 1

Contents 6

Practice profile

Through the keyhole Dr. David Alpan: Orthodontics in the fast lane

Clinical

10 Orthodontic treatment of a Class II division 1 malocclusion with severe maxillary gingival display by using miniimplants as anchorage

6

Dr. Benedito Freitas discusses treatment of a Class II division 1 adult patient

16 Severely displaced teeth Dr. John Scholey presents a challenging case, treating severely displaced teeth combined with an overbite by using a number of different techniques

Continuing education

22 Refining occlusion with muscle balance to enhance long-term orthodontic stability Dr. Derek Mahony presents a technological breakthrough that represents a new opportunity for orthodontists

16

28 Iatrogenic effects of orthodontic treatment Dr. Shivani Patel discusses how to identify and avoid the potential risks of orthodontics

Education exploration

34 GCARE webinars: inspiration, exploration, and education

22 2 Orthodontic practice

Volume 3 Number 4

Contents Abstracts

36 The latest in orthodontic research from around the world

Dr. Shalin R. Shah presents the current literature, keeping you in touch with the latest studies and evolving technologies

3D imaging straight talk

38 CBCT in the mixed dentition: a crystal ball

Dr. Juan-Carlos Quintero explores the optimal management of common developmental problems in the mixed dentition

44

Service profile 44 Low price, online payroll services now available

OrthoBanc has leveraged its buying power to offer low cost payroll services to orthodontic offices

Product profile 46 Ormco

Insignia™ Advanced Smile Design™

Technology 48 3 smart ways to upgrade your radiography in today’s economy

52

Bryan Delano, co-founder of Renew Digital, discusses creative techniques for investing in innovative technologies

Practice management 50 Gary Johnson explains the elements of the “Wow” experience

52 The dangers of being a pirate!

Toby Buckalew shows that there “arrrrrr” ways to avoid pirating software licenses

54 Hiring the right people

For practices that want to hire great employees, Dr. Rick Steedle suggests why you may not have been successful in the past and offers sound advice on how to hire better staff in the future

54 4 Orthodontic practice

Volume 3 Number 4

Practice profile

Dr. David Alpan

Orthodontics in the fast lane

What can you tell us about your background?

I was born and raised in Los Angeles, California. I am a third generation dentist, with DDS stranded in my DNA. I cut my first tooth when I was 6 yrs old, and I started working in my dad’s office as early as age 10. I worked for an orthodontist when I was attending Pepperdine University, learned orthodontic assisting and some lab work. My father and grandfather were both dentists, and each practiced for 30 years respectively.

I earned my Doctor of Dental Surgery (DDS) degree from the University of the Pacific (UOP) School of Dentistry in San Francisco and became licensed to practice dentistry in California and Nevada in 1996. After completing the orthodontic training program at UOP in 1998, I received my Orthodontic Specialty certificate. I was awarded a Master of Science in Dentistry (MSD) degree for my master’s thesis written on the results of a 2-year TMJ research project that I completed during my orthodontic specialty training.

I founded Aesthetic Orthodontics in Los Angeles, Beverly Hills and Las Vegas in 1999. Every year, I and every member of my team take continuing education courses to keep current with the most modern orthodontic and TMJ treatment methods available today.

Why did you decide to focus on orthodontics?

I made my decision when I was 15 years old visiting an orthodontic office with a friend of mine that had braces. I saw the orthodontist tell five very good looking assistants 6 Orthodontic practice

what to do, and then he supervised their work. One of the patients got his braces off and was so happy. If I could make people happy every day, that would make my life amazing.

I decided to specialize in orthodontics because I love the challenges and rewards of improving a person’s smile along with his/her self-esteem. Every patient leaves our office with a bigger, brighter smile with more self-confidence. Our team strives to make every patient feel like he or she is a member of our family.

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

I have been in private practice since 1998. I opened all three offices in the first year of completing my training.

In 1999, I became certified as an Invisalign® provider. I have been an Elite premier provider since 2001. I worked on behalf of Align Technology in 2001 to teach orthodontists and general dentists how to become certified Invisalign providers. Since then, I have taught over 10,000 dentists and over 1,000 orthodontists how to use Invisalign to its full potential. Align Technology also asked me to lead Invisalign study clubs in Los Angeles, Las Vegas, Beverly Hills, and Orange County to help general dentists and orthodontists feel more comfortable about using the Invisalign system after their initial training. The company then invited me to train the sales forces at Discus Dental and Align Technology.

I served as a consultant and was an integral part of the clinical education department for Align Technology for over Volume 3 Number 4

Practice profile 6 years. With this extensive knowledge, I decided to then focus solely on my practice and have treated over 1,400 patients with Invisalign.

In 1996, I started treating patients with lingual braces as an orthodontic resident. After many years of working with various lingual bracket systems (3M Unitek, Creekmore, Ormco™, AOA Lingual, Lingualcare, and iBraces™), I became the number one provider for Incognito lingual braces in Los Angeles, Beverly Hills, and Las Vegas and have continued to hold that position. I work closely with 3M Unitek, the manufacturer of Incognito™ lingual braces, and I have been invited to be a clinical/technical consultant to help improve the Incognito system. I am currently working with 3M on new brackets designs.

I also started using self-ligating braces in 1996, and I am now the number one provider in Los Angeles, Beverly Hills, and Las Vegas for the Damon self-ligating braces. I am a member of the Ormco Insiders group, a select group of orthodontists from around the world that meets biannually to make suggestions and discuss improvements for products manufactured by Ormco.

What training have you undertaken?

I completed three externships at Massachusetts General Hospital in Boston, Parkland Hospital in Dallas, and Charity Hospital in New Orleans. I decided after all these externships that I would make a better orthodontist than an oral surgeon. This preliminary training has helped me understand how to plan and incorporate surgical approaches and techniques to help create the most ideal results. I was trained as an orthodontist and am certified as a specialist in both California and Nevada. I completed my masters in dentistry for a TMJ project in 1998. I subspecialize in treating TMD. I incorporate my TMD philosophies into my orthodontic treatment. I was trained to do Invisalign in 1999.

I go to continuing education courses every year, averaging 50 hours per year. I was trained to place TADs in 2006 and have been placing them myself ever since. Gingival laser surgeries have been part of my armamentarium for more than 10 years.

Who has inspired you?

I have been inspired by many people, but mainly my father Dr. Jack Alpan who practiced dentistry for 30+ yrs. During my dental school training, my father would come to the lab with me and sit there for hours with me, showing me how to carve wax teeth and amalgam. He showed me how to cut teeth, shape teeth, and restore them. My father was my mentor, teacher, and best friend. Unfortunately, he passed away September 22, 2010. I learned more from him than anyone in my life. I have had many who have inspired me in my profession: Drs. Ricketts, Jacobson, Poulton, Rutter, Baumrind, Boyd, Brody, Griffin, Shuman and Dugoni.

These doctors taught me about the world of orthodontics, and I owe much of my skills, techniques, and success to these people.

What is the most satisfying aspect of your practice?

The most satisfying part of my practice is creating incredible Volume 3 Number 4

Aesthetic Orthodontics team, Los Angeles and Beverly Hills

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Professionally, what are you most proud of?

Professionally, I am most proud of my practice. Building three successful practices from scratch has been a huge reward. The daily challenges and rewards are all worth it. I am also proud of my accomplishments with teaching. I am also most proud about the part where I get to pass on my knowledge and allow another doctor to treat his/her patients better. I feel like I am compounding my effect on the world. It is not just about my treatment outcomes but now all my students.

Orthodontic practice 7

Practice profile

$ERYH /DV 9HJDV RIÀFH WUHDWPHQW ED\ (Left) Dr. Alpan checking bite for a TMJ patient

and amazing finished results. Changing a person’s smile is like changing the disposition of his/her soul. The subconscious impact on a person’s self-confidence and self-esteem is paramount and many times life changing.

Watching a person transition from low confidence to a heightened level of confidence, just from improving his/her smile is my favorite part of orthodontics. It isn’t the thank you or the money. It is knowing I have changed the world, one smile at a time.

What do you think is unique about your practice?

We have the largest collection of dental animated art on the West Coast, with nearly 40 pieces of orthodontic and dental art from the 1960s to present time. We have calculated nearly 200 years of combined experience in our team of 25 at AO. The artwork is displayed in the office for all the patients and team to enjoy. We offer free Sonicare toothbrushes to help promote oral hygiene. We offer 1 year of free retention visits and always free Wi-Fi. I think the attention to customer care is unique. Social media through Facebook®, Twitter®, Yelp® and Google+™ has helped to build our reputation in our community. We really go out of our way to make the experience in the office pleasant, fun, and painless. We offer the highest quality of orthodontic care at an affordable price. Smile creation is not just straightening people’s teeth.

Gingival recontouring is done with our newest cordless laser. We use Philips Zoom bleaching to brighten and whiten every smile we finish, TADs to prevent implants, and some orthognathic surgery. We also offer TMJ therapy for patients with TMD. I take a comprehensive approach to treating every patient that comes to Aesthetic Orthodontics.

What has been your biggest challenge?

Orthodontics is fun and challenging, but practice management is the biggest challenge. Creating a cohesive team where all of the players understand the goals and objectives is the key to success. It all starts with a vision.

If the team understands the policies and procedures, our days work out great. If players participate in the process, 8 Orthodontic practice

Dr. Alpan’s Las Vegas team

it can be a very rewarding day, month, and year. This does not happen on its own. We have meetings to discuss the issues, and we create policies that we revise as we improve our systems. Reminding and chasing after everyone seems to still be part of my job that I am not sure I will ever relieve myself from.

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

I would have become a race car driver. My passion for driving fast started at age 6, probably unfortunately for my parents. Street racing is dangerous and illegal, so racing on a track is way more fun and safer. The cars are all going in the same direction, no traffic lights, no police, and no speed limit. Nothing about racing cars is safe, but I am very cautious and take all safety precautions available. The skill level with racing has some similarities to orthodontics.

I have to be very focused, or someone will get hurt. The attention to detail is paramount. The focus of attention and determination to win is similar to my education. It’s funny to me; all my patients seem to be in a race to complete treatment, and my best analogy is the turtle and hare. All orthodontic patients need to act like the turtle, even though they want me to act like the rabbit.

Volume 3 Number 4

Practice profile

2011 Pirelli Cup Race at Las Vegas Motor Speedway; Dr. Alpan’s 2007 Porsche 997 GT3 Cup car What is the future of orthodontics and dentistry?

The future of orthodontics and dentistry is very exciting.

Since everyone has teeth, we will always be busy helping others. New technologies make our lives seem easier, yet we deal with way more complexities than ever before. We have become so efficient, and effective. The future will have less caries, less bone loss, less tooth loss, but a lot more orthodontics. As the world becomes more educated about oral hygiene and lifelong improvements from improved oral health, more and more people will seek orthodontic care.

We are in the greatest profession this world has to offer.

We are in the top 1% of earners on the planet. I have been told that I have a fancy title and a cool job, but there is nothing better than changing a person’s life. Many of my patients don’t even know exactly how I am truly changing their interactions with life. I have patients who start with depression, anxiety, and horrible self-esteem, and leave with their chin up, an incredible smile, and whole new outlook on life. The career won’t afford a G5 or a 200-foot yacht, but at the end of the day, I know I improved my patients’ lives. It is not how much money one makes, but how much they can improve the world. Our profession is the first to advocate prevention of disease and will always be on the cutting edge of technology. I believe we are role models to our patients, team, and community.

Alpan family, June 2012

direction. Your team will make you or break you. Don’t ever think things are going to just be OK because you think it so.

Your environment is what you create it to be. The results are a direct effect of your efforts, so when you point the finger at others, you are really pointing the other four fingers at yourself. Tell all patients that things get worse before they get better. There is no “I” in team, which includes you, the doctor.

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

When I’m not working, I spend time with my wife Mary and my son Zephyr. I like to read about racing, finance, and leadership. I enjoy working out, going mountain biking, skeet shooting, researching on the Internet, traveling, and watching movies. My childhood dream of becoming a race car driver is realized every time I race my Porsche GT3 Cup Car with Porsche Owners Club, NASA, BMW CCA, and Pirelli Cup Competent Motors now called Trophy Cup West.

I also enjoy spending time with my family and friends.

Top Ten List: 1. Damon® System and Häagen-Dazs® ice cream 2. TADs and preventing implants and orthognathic surgery

What are your top tips for maintaining a successful practice?

1. Number one concern is the patient, not my pocket.

2. Finish treatment on time.

3. Finish like every case is for the ABO or your mother.

4. Team = together everyone achieves more.

5. Incentivize your team, so they are in the game with you.

6. The patient is the boss.

7. Always keep patients’ best interests in mind.

What advice would you give to budding orthodontists?

Look out for number 1, so you don’t step in number 2.

Don’t be the first, and don’t be the last one to try the new technology. Always accept that you can be wrong. The patients and team are looking to you for guidance and Volume 3 Number 4

3. Half Hollenback for positioning brackets 4. Bite adjustments and incisal edge recontouring for all cases 5. TENS machine for TMD patients 6. Any Porsche or BMW racing stuff 7. Knight Armaments Company, Browning, Leupold and L-3 Eotech 8. My team at Aesthetic Orthodontics 9. My son’s new bouncer and watching him smile when he bounces up and down 10. Buying my wife jewelry and watching her face light up

Orthodontic practice 9

Clinical Orthodontic treatment of a Class II division 1 malocclusion with severe maxillary gingival display E\ XVLQJ PLQL LPSODQʞV DV DQFKRUDJH Dr. Benedito Freitas discusses treatment of a Class II division 1 adult patient Abstract A 21-year-old woman presented for consultation with chief complaints of “protrusive lips and a gummy smile.” The clinical examination showed a convex profile, a protrusive maxilla, excessively proclined and extruded maxillary incisors, and a pronounced Class II division 1 malocclusion.

Temporary Anchorage Devices (TADs) in the maxillary posterior and anterior dental region were used as anchorage for retraction and intrusion of her maxillary anterior teeth.

The treatment eliminated her excessive maxillary gingival display and her protrusive profile, and corrected the overjet, overbite, and canine relationships. The patient ended up with a satisfactory occlusion and an attractive smile.

Introduction Class II malocclusion is characterized by anteroposterior imbalance of the jaws, caused by bone dysplasia or by a combination of skeletal and dental factors. In Class II division 1 malocclusion, the overjet is excessive, and is usually associated with a deep bite, causing esthetic and functional problems that require orthodontic treatment.

Proffit and Ackerman1 described three primary treatment approaches for correcting a Class II malocclusion associated with mandibular deficiency: growth modification to eliminate the jaw discrepancies, dental compensation, and surgical correction. Cohen2 says that all Class II treatments fall in these categories. Class II therapies depend upon the skeletal disharmony, the patient’s growth potential, and the necessity for extractions.

Mihalic, et al,3 suggest that for adult Class II patients, there are only two possible treatment approaches: camouflage orthodontics, consisting of extracting two maxillary premolars and retracting the maxillary anterior teeth to improve the occlusion and facial esthetics or to perform orthognathic surgery to correct the skeletal discrepancy.

Excessive maxillary gingival displays can be due to skeletal, dentoalveolar, or soft tissue imbalances. The skeletal type is caused by excessive vertical maxillary growth and is usually found in vertical growing patients.4 The use of mini-implants as temporary anchorage devices has been of great value in the treatment of these Class II patients.5,6,7,8 The purpose of this article is to present the treatment of a Class II division 1 adult patient with excessive maxillary gingival display associated with a skeletal malocclusion that was treated with maxillary first premolar extractions and TADs to reinforce anchorage of the posterior segments and to intrude the maxillary anterior teeth.

Diagnosis and etiology A 21-year-old woman presented for an orthodontic 10 Orthodontic practice

Figure 1: Pretreatment photographs

consultation with chief complaints of “protrusive lips and a gummy smile.” The extraoral clinical examination showed good facial symmetry, lack of lip seal, convex profile, excessively proclined and extruded maxillary incisors, excessive maxillary gingival display, and a retruded mandible. Intraorally, there was a severe Class II division 1 malocclusion, deep overbite (6 mm), an overjet of 8 mm, and good oral hygiene. She had no relevant medical history or previous orthodontic intervention. The patient’s speech was normal (Figure 1).

During opening and closing mandibular movements, there was no mandibular deviation. No sign of temporomandibular derangement such as clicking or crackling, or pain in the temporomandibular joints was evident.

Cephalometrically, there was maxillary protrusion and mandibular retrusion associated with excessive vertical growth. The maxillary incisors were labially inclined and extruded, and the mandibular incisors were proclined (Figure 2, Table I).

Treatment objectives The treatment objectives consisted of correcting the protracted maxilla, the occlusal anteroposterior relationship, i.e., the overjet and overbite, the excessive maxillary gingival display, and obtaining a passive lip seal, which would improve the patient’s facial esthetics.

Treatment alternatives An orthodontic-surgical approach, consisting of mandibular and chin advancement associated with superior repositioning of the maxilla, was proposed as a first Volume 3 Number 4

Clinical treatment option. This treatment option would fulfill all the treatment objectives. As a second option, extraction of two maxillary first premolars to allow retraction of the anterior maxillary teeth associated with intrusion of these teeth to correct the excessive maxillary gingival display, using miniimplants as anchorage, was proposed. This option would allow correction of most of the problems, but would not correct the mandibular retrusion. The patient did not elect the surgical procedures and chose the second option.

Treatment progress The malocclusion was treated with preadjusted 0.022 inch slot edgewise appliances (Roth prescription). Leveling and alignment began with 0.014 inch followed by 0.016 inch nickel-titanium arch wires and progressed to 0.018, 0.020 and 0.019 x 0.025-inch stainless steel arch wires.

After leveling and alignment (10 months), the maxillary first premolars were extracted and mini-implants (1.8 mm x 8 mm C-implant) were inserted bilaterally between the maxillary first molars and second premolars to provide skeletal anchorage. Another mini-implant (1.4 mm x 6 mm – Dentos, Daegu, South Korea) was inserted between the roots of the maxillary central incisors to intrude the anterior maxillary teeth. The anterior segmental retraction was accomplished with rectangular stainless steel arch wires (0.019 x 0.025 inch), with nickel-titanium closed coil springs activated from the hooks soldered distally to the canines directly to the mini-implants, with a force of 150g. Concurrently, a nickel-titanium coil spring was also activated between the arch wire midline and the anterior mini-implant to intrude the maxillary anterior teeth. After 20 months, the posterior mini-implants were removed to allow maxillary posterior teeth protraction and interdigitation, which lasted 4 months. Multiloop edgewise arch wires were used with vertical intermaxillary elastics for 2 months (Figure 5). Active treatment time was 26 months.

The patient was retained with a maxillary Hawley retainer and a mandibular bonded canine-to-canine retainer.

Results The extraoral photographs show good lip sealing, decreased maxillary gingival display, and improved facial profile, although with a retrognathic mandible and convex profile.

The intraoral photographs and dental models show Class I canines and Class II molars on both sides, and normal overbite and overjet (Figure 6). Good root parallelism was obtained (Figure 7). Cephalometrically, there was palatal tipping and intrusion of the maxillary incisors and labial tipping of the mandibular incisors (Table I). There was lower lip retrusion and an increase in the nasolabial angle. The patient was satisfied with her occlusion and facial esthetics, and 1 year later, she displays good stability (Figures 8, 9, and 10).

Discussion Mini-implants used as orthodontic anchorage offer high potential for favorable results and many treatment options, because they reduce the need for patient compliance.

TADs are well indicated for intrusion of teeth, because it is possible to apply continuous and light forces, which can 12 Orthodontic practice

Figure 2: Pretreatment study casts, cephalogram, cephalometric tracing, and panoramic radiograph

Figure 3: Photographs before extraction of maxillary first premolars

Volume 3 Number 4

Clinical

Figure 4: Photographs after premolar extractions, during anterior intrusion and en masse retraction

Figure 5: Photographs after spaces closed and finishing with MEAW technique

Figure 6: Post-treatment photographs

Volume 3 Number 4

reduce apical root resorption often associated with intrusive movements.5,6,7,8 Excessive gingival display associated with severe Class II division 1 malocclusion compromises facial esthetics, especially when associated with mandibular retrognathism and vertical maxillary excess. Orthognathic surgery is considered a preferred modality of treatment for this type of patient with mandibular advancement, superior repositioning of the maxilla or a combination of both, which will improve the patient’s facial harmony.9 However, many patients are unwilling to undergo surgery, and in these cases, orthodontic camouflage is the best alternative, as in the current case. Lately, TADs have been used for treating Class II, division 2 malocclusions with deep overbite.

This procedure is simple and requires minimal patient compliance. Although the profession still lacks concrete evidence that this type of incisor intrusion remains stable over time, we can now intrude anterior teeth free from the past restrictions when molar extrusion was the only option for treating deep overbite.5,6 Camouflage orthodontic therapy consists of dental compensations through extractions of premolars and en masse retraction followed with incisor intrusion in order to reestablish better horizontal and vertical dental occlusion and facial esthetics, without correcting the skeletal problem.10,11 In these patients, it is considered important that the orthodontist explain to the patient the possibilities of treatment, taking into consideration the esthetic and functional expectations that it features.12 Correction of the excessive maxillary gingival display cannot be performed with a high pull headgear in adult patients because these appliances have disadvantages, such as their unesthetic appearance, undesirable intermittent forces, lack of growth, and dependence on patient cooperation. Nor could Burstone´s segmented technique be used to perform anterior intrusion, because the side effects of extrusion of the posterior region would worsen the patient´s vertical pattern. This patient’s maxillary incisors were palatally tipped and retruded (Table I). Others have previously demonstrated this technique.7 Excessive gingival displays due to a skeletal discrepancy can be treated with a combination of TADs and periodontal surgery13, and in growing patients, high pull headgears associated with periodontal surgery have been reported.14 The method of incisor intrusion with skeletal anchorage was first introduced by Creekmore and Eklund15 and was recently reported by Ohnishi, et al.16 To ensure maximal retraction and prevent excessive lingual tipping of the anterior teeth, Shu, et al,7 placed a compensatory curve in the maxillary arch wire, which could counteract the deformation of arch wire, provide torque control on the anterior teeth, and assist in correcting the deep overbite. Kaku, et al,17 inserted the miniscrews in the maxillary bone above the lateral incisors root apices because the patient had sufficient space for miniscrew placement superior to the apices.

Our decision to insert a mini-implant between the roots of the maxillary central incisors was to control the torque, avoid contact of the roots with the lingual cortical bone during the anterior en masse retraction, and achieve enough intrusion to correct the excessive gingival display.

Orthodontic practice 13

Clinical

A

B

C Figure 10: (A) cephalogram after 1 year, (B) superimposition, and (C) panoramic radiograph after 1 year

Figure 7: (A) post-treatment cephalogram, (B) cephalometric tracing, and (C) panoramic radiograph

A

B

Figure 11: Maxillary incisors periapical (A) before intrusion; (B) after treatment

Figure 8: Study casts after 1 year

We consider this procedure as easier and more effective.

Our patient had an excessive maxillary anterior gingival display, and the posterior teeth were in vertical positions.

With this type of patient, an excessive gingival display can be corrected efficiently by intrusion of maxillary incisors with minimum root resorption (Figure 11). Therefore, we planned to intrude the maxillary incisors with miniscrews, which could provide a desirable improvement of the smile and facial profile without correcting the mandibular retrusion.

Our patient had a slight decrease in SNB; however, there was only a small change in FMA and in the lower facial height (LFH), which demonstrated little clockwise rotation of the jaw (Table I). The records after 12 months of the end of treatment show occlusal stability, correction of the excessive gingival display, good canine relationships, and satisfactory facial appearance (Figures 9 and 10).

Conclusion Mini-implants can provide stable skeletal anchorage during maxillary anterior teeth retraction concomitantly with intrusion of these teeth. Therefore, this approach offers an excellent treatment alternative to an orthodontic-surgical technique for patients unwilling to undergo surgery to correct a Class II maxillary dentoalveolar protrusion with an excessive gingival display.

References available upon request.

Figure 9: Photographs after 1 year

14 Orthodontic practice

Dr. Benedito Freitas practices in S達o Luis, Maranhao, Brazil. He can be reached at: beneditovfreitas@uol.com.br.

Volume 3 Number 4

Clinical

6HYHUHO\ GLVSODFHG ʞHHWK Dr. John Scholey presents a challenging case, treating severely displaced teeth combined with an overbite by using a number of different techniques Case presentation Diagnosis: MH presented at the age of 14 years complaining of “awful teeth.” There was a vague history of previous trauma to the upper labial segment at 8 years of age. He presented with a Class III incisor relationship on a Class III skeletal base, complicated by an impacted UL3, buccal displacement and 90º rotation of the UR1, a 2 mm anterior open bite, bilateral crossbites, asymmetric molar relationship, and uneven wear of the incisal edges and molars (Figures 1A and 1B).

Treatment: In line with the current evidence of interceptive canine alignment arch expansion, together with removal of the ULc and space, creation within the arch led to spontaneous eruption of the impacted UR3. The upper arch was started first on a non-extraction basis with a self-ligating appliance and quad helix to expand and allow for further growth and assessment of the prognosis for correction of the open bite and Class III (Figures 2A and 2B). A year into treatment, the lower arch was added and treated also on a non-extraction basis but with interproximal reduction.

The lower canine brackets were reversed and -6o of torque used with Class III mechanics to facilitate correction of the incisors to Class I and deepening of the overbite. The orthodontist carried out gingival and composite detailing to improve the final smile and fit of the teeth.

Current status: MH is now 8 months postoperative and continuing with night-only retention with removable Essix retainers and upper and lower bonded retainers. The occlusion and alignment remains excellent.

Assessment MH presented with a straight facial profile with a mild Class III skeletal base and mildly increased vertical proportions.

The Frankfort Mandibular planes angles and lower face height were both mildly increased.

He had competent lips with excess gingival show on smiling. The smile arc was flat and distorted by the UR1 and UR3 poor positions. Both the upper and lower centerlines were 1 mm to the left of the midfacial axis. The nasolabial angle was average at 95°, and the lips lay just behind the esthetic plane.

Teeth present 7654c321 12c4567 7654 321 1234567 Incisor relationship: Class III Overbite: reduced -2 mm (open bite extending 4-4) Overjet: 6 mm (to mesial of buccally placed and rotated UR1 but otherwise zero to all other incisors) Molars Right: three/quarter Class II Left: Class I

16 Orthodontic practice

Figures 1A and 1B: Preoperative

Canines Right: Class II Left: unclassifiable as impacted Provisional treatment options 1. Upper space creation with expansion and loss of ULc and URc, continuing to lower non-extraction treatment with lower interproximal reduction if there is no unfavorable growth. Exposure and bonding of gold chain to UL3 if fails to erupt within 9 months 2. If growth is unfavorable, review additional space creation to camouflage the malocclusion with upper and lower arch extractions. If there is severe growth, then review possibility of joint orthognathic care.

Definitive treatment plan 1. Maintain optimum oral hygiene 2. Begin with an upper quad helix for arch expansion 3. Posterior upper sectional fixed appliance and extract ULc and URc 4. Progress to full upper preadjusted fixed appliances 0.022 by 0.028 slot MBT prescription self-ligating brackets 5. Review changes to occlusion with continued growth

Volume 3 Number 4

Clinical

Figure 3: UR1 is aligned with a 012 nickel-titanium wire for careful control of the rotation

Figures 2A and 2B: Fixing of a self-ligating appliance and quad helix to expand the upper arch Figure 4: Periapical radiograph of UR1

6. Progress to full lower arch conventional ligated brackets with reverse canines brackets for distal tip. Space creation with interproximal reduction LL3 - LR3 7. Finishing and detailing 8. Long-term retention with upper and lower Essix retainers and bonded retainers.

Treatment rationale In view of the Class III skeletal and incisal tendency and open-bite tendency in a growing male teenager, there was clearly potential for further detrimental growth that could undermine successful camouflage. This was, however, the preferred treatment option, as the patient has a pleasing profile, and sufficient space could be created within the upper arch by both transverse and anteroposterior expansion.

Treating the upper arch first allowed prioritization of alignment of the UL3 and poor esthetics of the UR1, and also allowed a period of review of peak growth to ensure that a final occlusion was readily achievable.

The use of early expansion and space creation for the UL3 was very successful in allowing spontaneous eruption from a palatal position negating the need for surgical exposure. Initial alignment aimed to correct the crossbites and set an arch form so that auxiliary arch mechanics could then be used to bring the high and rotated teeth into line without worsening of the overbite. Gentle alignment with a 012 nickel-titanium wire to the UR1 provided careful control of the rotation (Figure 3). As there was a history of previous trauma to this tooth and lack of radiographic clarity, there was a high risk of root resorption. As soon as Volume 3 Number 4

Figure 5: Upper alignment space creation for UR2

this tooth was aligned, a periapical radiograph was taken to review root length, and the patient was prewarned about potential resorption (Figure 4). The radiograph showed a lateral dilaceration of the root, but no further problems were encountered. However, achieving completely idealized alignment of this tooth was difficult due to the very buccal position of the root and the dilaceration. The final position reflects brackets repositioning, arch wire bends, and additional torque placement, but all had to be carried out with gradual gentle forces to reduce the risk of resorption (Figures 5-7).

Once it was clear that rapid growth was declining and the tooth positions had not significantly deteriorated, the lower arch was bonded with reversed canine brackets to Orthodontic practice 17

Clinical

Figure 6: Alignment of UR2 with sling catapult

Figure 7: Final space closure, upper arch

Figure 8: The lower arch was bonded after a decline in growth rate

Figure 9: Interproximal reduction and Class III elastics bring the lower incisors back to establish a positive overjet and overbite

Figure 10: After debonding, the gingival contour of UL1 was adjusted slightly

Figure 11: Six months postoperative

Figure 12A: Ceph tracing, preoperative

tip the lower segment distally (Figure 8). Interproximal reduction and use of Class III elastics helped bring the lower incisors back and establish a positive overjet and overbite (Figure 9).

At debond and after gingival settling, small improvements were made to the incisal edge morphology and gingival contour of UL1 (Figure 10) with cusp buildup of the UL6 mesiobuccal cusp. This small degree of finishing complemented the orthodontic treatment in maximizing smile esthetics and fit of the teeth (Figure 11).

Ceph summary Figure 12A shows the ceph tracing at the start of treatment.

The reduced ANB and negative Wits confirmed the mild underlying skeletal Class III base. Both the MM of 29 and face height of 58% were the higher end of normal. While the lower incisors were compensated at 77, the upper incisors were also upright, giving some scope for orthodontic 18 Orthodontic practice

camouflage.

The postoperative ceph tracing (Figure 12B) shows there was deterioration in both the vertical and horizontal growth during treatment with increases to the Class III tendency with greater negative ANB and Wits and further increase in face height to 59%.

Despite this growth, appropriate torque control to the upper labial segment of 113 has allowed successful camouflage and an idealized interincisal angle.

Postoperative analysis By treating non-extraction, the result has supported the profile, although this made correcting the severely displaced teeth and, particularly, the overbite quite challenging.

Anchorage was supported initially by the quad helix as it derotated the molars and corrected the bilateral crossbite.

Crossbite correction allowed some improvement to the open-bite tendency, which was partially caused by the Volume 3 Number 4

Clinical

Figure 12B: Ceph tracing, postoperative

Figure 13A: Preoperative smile

propping open from the cusp-to-cusp relationship. The use of self-ligating appliances in the upper arch allowed efficient alignment using twin wire mechanics to pick up the displaced teeth, while maintaining continued alignment and arch form control in the buccal segments.

Great care had to be taken to derotate the UR1 and review the potential for root resorption as a result of previous trauma. The final position of UR1 is slightly compromised in view of the dilaceration mesiodistally of the root. However, by providing buildups and some discing of the incisal edges, the final alignment of the incisors looks great in the smile.

The relapse potential of this correction is great due to the initial severe displacement of the canines and laterals and severe rotation of the UR1. Placement of both bonded and removable retainers and close supervision will help maintain tooth positions long term.

The finished occlusion has produced a fantastic improvement for a patient who thought he was beyond help. The presenting malocclusion had many problems and complicating features that were overcome by efficient, thoughtful, and careful orthodontic mechanics. In addition to the orthodontic treatment, small detailing carried out by the orthodontist, such as restoration of worn and damaged central incisor edges, worn molar cusps, and minor gingival recontouring of UL1 has helped finalize the smile. Total

20 Orthodontic practice

Figure 13B: Postoperative smile

treatment time was 2 years and 9 months; Figures 13A and 13B show before and after smiles.

The author wishes to thank: Tim Malins (maxillofacial surgeon); Julie Strzala (maxillofacial technician); Mark Emms, Priors Dental Practice (referring dentist).

This case was the winning entry in the “Orthodontic Smile - fixed appliances� category at the 2012 Smile Awards. For 2013, the event is being renamed the Aesthetic Dentistry Awards, and will take place on Friday, March 22 at the Landmark Hotel, London.

Please visit www.aestheticdentistrytoday.co.uk/awards to find out more.

John Scholey, BDS, FDS, RCS (Edin), FDS (Orth) RCS (Edin), RCS (Edin), MOrth RCS (Eng), MDentSci, qualified in 1992, and after time, in general practice and as a senior house officer, he started specialist training in Liverpool, England in 1998. He is a consultant orthodontist at the University Hospital of North Staffordshire and Mid Staffordshire Foundation Trust, where he treats complex multidisciplinary cases.

Dr. Scholey also works at Albert Place Dental Referral Centre in Cheshire, England and has a successful private practice in South Staffordshire, England, as well as numerous teaching roles.

Volume 3 Number 4

Continuing education

5HʦQLQJ RFFOXVLRQ ZLWK PXVFOH EDODQFH ʞR HQKDQFH ORQJ ʞHUP RUWKRGRQWLF VʞDELOLW\ Dr. Derek Mahony presents a technological breakthrough that represents a new opportunity for orthodontists

T

he primary objective of orthodontic treatment is the movement of teeth into a more ideal relationship, not only for esthetic, but also for functional considerations.

Another very important objective, often not given enough consideration, is the need to finish the case with the muscles of mastication in equilibrium. If muscle balance is not achieved, an endless procession of retainers is required for retention. In simple terms, if the occlusal forces in maximum intercuspation are unevenly distributed around the arch, tooth movement will most likely occur. However, today it is possible to precisely measure the relative force of each occlusal contact, the timing of the occlusal contacts and specific muscle contraction levels, all simultaneously. This technological breakthrough represents a new opportunity for orthodontists everywhere.

Muscle balance and occlusion Many well-respected orthodontists agree that there is more to occlusion than just “teeth.” Temporomandibular joint function and the maxillomandibular relation are as much a part of occlusion as are the teeth. Consequently, when a malfunction occurs within the TM joints or a maxillomandibular malrelation exists, a compensatory response is elicited from the stomatognathic musculature.

Most often that response can be measured through electromyography (EMG).

Over 50 years ago, one orthodontist began to record muscle activity through surface electromyography in an effort to better understand the functions of the muscles of mastication.1 In the intervening years since, surface EMG has revealed several key facts about the relationship between the muscles and a patient’s occlusion. Today we can routinely record up to eight channels of EMG data, right in the clinic. And, data interpretation can lead us to a better understanding of our patient’s specific condition.

In Figure 2, we see muscles that are; a) relaxed at rest (the normal condition), b) hyperactive at rest (indicating a maxillomandibular malrelation), or c) exhibiting a neurological abnormality (large motor-unit firing). While these factors routinely go unmeasured, their contribution to a precise diagnosis can be highly significant, even to the long-term outcome of a particular case.2-5 Determining muscle balance in function is an easy task for EMG.6-13 Typically, the patient is asked to clench in maximum intercuspation and then swallow. The clench will appear balanced (Figure 3A) or unbalanced (Figure 3B). The swallow will either be with the teeth together (Figure 3C) or 22 Orthodontic practice

Educational aims and objectives

The aim of this article is to discuss the possibility of precisely measuring the relative force of each occlusal contact, the timing of the occlusal contacts and specific muscle contraction levels, all simultaneously.

Expected outcomes

Correctly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader can: r <UKLYZ[HUK JLY[HPU HZWLJ[Z VM T\ZJSL

balance and occlusion. r 3LHYU OV^ [V L]HS\H[L [OL [PTPUN HUK MVYJL VM occlusal contacts by using the T-Scan II. r 9LHSPaL [OL Z`ULYN` IL[^LLU ; :JHU 00 )PV,4. 00 r 9LJVNUPaL OV^ [V JYLH[L HU LU]PYVUTLU[ ^OLYL [OL T\ZJSLZ JHU function in harmony with each other.

Figure 1: An eight-channel electromyograph

with a tongue-thrust (Figure 3D). Then, if an appliance is utilized, muscle activity can be recorded before, during, and after adjustment of the appliance. This will immediately demonstrate the effectiveness of the appliance.14-20 If we see that the muscles are balanced, we know we have a result that will remain stable. But, if the muscles are not in balance, we can’t tell from the EMG recordings alone exactly what to do about it. While much has been learned about muscle hyperactivity and the various conditions of imbalance that can exist within the masticatory musculature, EMG is not, nor will it likely ever be, adequate to the task of directing case treatment by itself. While surface EMG is a fast, easy, and reliable way to record the relative contraction levels of the muscles at rest or in function, it has a low Volume 3 Number 4

Continuing education

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sensitivity to occlusal force locations and the timing of tooth contacts.

T-Scan II The simplest solution to the problem of evaluating the timing and force of occlusal contacts is the T-Scan II.21-23 It provides a very sensitive measure of contact force and a moving picture of the order in which the contacts occur.24-32 It is the only technology available to the clinician that can show precisely the order in which contacts occur and, simultaneously, the relative force of each distinct contact.

The new high density sensors are flexible, more precise, and very durable (usable for up to 30 registrations).

A bite-force recording is taken by having the patient bite down several times on the T-Scan wafer to condition it.

This allows it to conform to the shape of the arch. Then a recording is taken with the patient closing from rest position into the intercuspal position, followed by a clench. Other recordings can also be taken in centric relation, lateral excursions and protrusion.

In the recording in Figure 5, the initial contact points occur only on the incisors. As the patient continues to close, a contact appears on the right area of the second molar.

Eventually a contact appears on the left second molar creating a tripod effect.

When the recording is replayed as a “force movie,” a three-dimensional graph is displayed showing the relative force at each point of contact. Again we see that the initial contacts are on the incisors, then the right posterior, and finally the left second molars. What is also evident is that in full closure, the highest contact force is actually on the left second molar (indicated by the tallest spike), despite the lateness of the contact. Further inspection clearly suggests that the reason the excessive force is being born by the left second molar is due to a lack of solid contacts on the left Volume 3 Number 4

Figure 4: The T-Scan II

first molar and bicuspids. In spite of the large number of contact points around the arch, this is an occlusion badly in need of adjustment.

However, as we analyze the tracing above, as clear as the picture of occlusion of this case is, we realize that we do not and cannot from this information understand what the musculature is doing to accommodate. But there is a way to do both.

T-Scan II – BioEMG II Previous studies have attempted to correlate T-Scan data with EMG data.33,34 Recently the two companies who separately manufacture the T-Scan II and the BioEMG II have created a milestone by making their programs talk to each other.35 This is not something that happens often in dentistry, but the synergy created now offers a unique opportunity for dentists to more clearly understand their patients’ occlusal conditions comprehensively. The reason that the programs needed to talk to each other was to synchronize their respective data streams. This is accomplished by having either program act as a “master,” while the other program acts as a “slave” to it. That is, a dentist can “run” the T-Scan Orthodontic practice 23

Continuing education A map of the sequence from Initial Anterior Contact to Bilateral Contact

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program, and the BioEMG II program will dutifully “follow” it. Or, he/she can “run” the BioEMG II program, and the T-Scan II program will follow it. This is true in recording as well as in playback analysis.

Analyzing the combined traces When we see that the highest force of contact is on the left, can we assume that the greatest muscle activity will be the same? Not at all. Figure 7 shows an example of a patient with a higher force level on the left side (63% of total), focused in the bicuspid area. At the same time, we clearly see that the right anterior temporalis is firing at nearly twice the level of the left one. It is also apparent that the combined activities of the right masseter and temporalis are far greater than the same muscles on the left. How is this possible?

Not one of the muscles of mastication that elevates the mandible is positioned such that there is a straight vertical relationship between the origin and the insertion.

Each elevator muscle has a horizontal component to its direction of applied force. Due to the ginglymo-arthroidial structure of the temporomandibular joints, the mandible is able to move freely forward and back, left and right. The same “elevator muscles” that apply vertical forces can and do apply horizontal forces to the mandible as needed for function. In Figure 7 then, we can see that while the left side muscles are applying more force in the vertical direction, the right side temporalis must be applying a significant amount of its force in a nonvertical (horizontal) direction. However, 24 Orthodontic practice

Why the T-Scan wafer at 85 microns is not too thick.

According to the latest research on mandibular function (Gallo, et al), we now know that the sagittal path of closure is more complicated than a simple hinge movement. In fact, the “helical axis of rotation” moves from the vicinity of the angle of the mandible (early in opening) to about midramus (late in opening) in close proximity to where the inferior alveolar nerve enters the mandibular foramen. For a voluntary closure between rest and occlusion (2 - 3 mm), the average amount of rotation has been measured at 0.7 degrees (Lewin A, and Moss C). For an 85 micron change, that’s about 0.02 degrees of rotation (about 1.5 minutes of arc). If the A/P distance between the incisors and the second molars is 40 mm, 1.5 minutes of arc translates to an 18 micron difference in vertical change (more in the anterior, less posterior) between “wafer in” and “wafer out.”

This is a very small difference in comparison to the size of an occlusal adjustment being made and well within the adaptive capacity of the system. Another benefit of placing the T-Scan wafer between the arches — is that it reduces the acuity of proprioception, which reduces, but doesn’t eliminate, the ability of the central nervous system to avoid any existing prematurities.

Volume 3 Number 4

Continuing education The simultaneous recording of occlusal force, timing and muscle activity

Figure 7: One high force point on the left bicuspids, right anterior temporalis hyperactivity

A force and muscle activity balanced occlusion

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Orthodontic practice 25

Continuing education

with some extra effort, it is possible to achieve a muscle and force balanced occlusion. See Figure 8.

Balanced forces do not guarantee balanced muscles Sometimes we can record a relatively even balance of forces between the right and left sides, but the patient is still not comfortable. Even with adequate stable contacts on both sides, some patients still complain. The patient in Figure 9 had regular temporal headaches. The left-right force balance was rather good at 56% right to 44% left. It is evident that the initial contact is on the left side (see the center of force vector), which during the closure, the force passes to the right side before reaching its balanced force condition at maximum intercuspation. However, notice that the temporalis muscles are contracting two-and-a-half times greater levels than the masseter muscles. Soon after a

References ;OVTWZVU 19 *VUJLW[Z YLNHYKPUN [OL M\UJ[PVU VM the stomatognathic system. JADA 1954 Jun; 48:626637 .LY]HPZ 96 -P[aZPTTVUZ .> ;OVTHZ 59 4HZZL[LY HUK [LTWVYHSPZ LSLJ[YVT`VNYHWOPJ HJ[P]P[` in asymptomatic, subclinical, and temporomandibular joint dysfunction patients. Cranio. 1989 Jan;7(1):52-7. .SHYVZ (. 4J.S`UU -+ 2HWLS 3 :LUZP[P]P[` specificity, and the predictive value of facial electromyographic data in diagnosing myofascial pain dysfunction. Crania. 1989 Jul;7(3):189-93. .SHYVZ (. .SHZZ ,. )YVJRTHU + ,SLJ[YVT`VNYHWOPJ KH[H MYVT ;4+ WH[PLU[Z ^P[O myofascial pain and from matched control subjects: evidence for statistical, not clinical, significance. J Orofac Pain. 1997 Spring;11(2):125-9.

2HT`ZaLR . 2L[JOHT 9 .HYJPH 9 1Y 9HKRL 1 Electromyographic evidence of reduced muscle activity ^OLU <3- ;,5: PZ HWWSPLK [V [OL =[O HUK =00[O JYHUPHS nerves. Cranio. 2001 Jul;19(3):162-8. )LSZLY <* /HUUHT (. ;OL PUĂ&#x2030;\LUJL VM HS[LYLK ^VYRPUN ZPKL VJJS\ZHS N\PKHUJL VU THZ[PJH[VY` muscles and related jaw movement. J Prosthet Dent.

4HY" !

4J*HYYVSS 9: 5HLPQL 4 /HUZZVU ;3 )HSHUJL PU masticatory muscle activity during natural chewing HUK Z\ITH_PTHS JSLUJOPUN J Oral Rehabil. 1989 Sep;16(5):441-6. =PZZLY ( 4J*HYYVSS 9: 6VZ[PUN 1 5HLPQL 4 4HZ[PJH[VY` LSLJ[YVT`VNYHWOPJ HJ[P]P[` PU OLHS[O` young adults and myogenous craniomandibular disorder patients. J Oral Rehabil. 1994 Jan;21(1):6776. *OYPZ[LUZLU 3= 9HZZV\SP 54 ,_WLYPTLU[HS occlusal interferences. Part I. A review. J Oral Rehabil.

1995 Jul;22(7):515-20. *OYPZ[LUZLU 3= 9HZZV\SP 54 ,_WLYPTLU[HS VJJS\ZHS PU[LYMLYLUJLZ 7HY[ 00 4HZZL[LYPJ ,4. responses to an intercuspal interference. J Oral Rehabil. 1995 Jul;22(7):521-31. )VYYVTLV .3 :\]PULU ;0 9LHKL 7* ( comparison of the effects of group function and canine guidance interocclusal device on masseter muscle electromyographic activity in normal subjects. J Prosthet Dent. 1995 Aug;74(2):174-80. *OYPZ[LUZLU 3= 4VOHTLK :, )PSH[LYHS masseteric contractile activity in unilateral gum chewing: differential calculus. J Oral Rehabil. 1996 Sep;23(9):638-47.

26 Orthodontic practice

repositioning appliance was placed that balanced both the muscle and the forces, the headaches were relieved.

With the technology that is available today, an ordinary practicing dentist has the ability to more thoroughly evaluate the masticatory system than ever before. It is now possible to routinely adjust an occlusion, not only to equalize the occlusal forces, but also to create an environment where the muscles can function in harmony with each other.

+LYLR 4HOVU` )+: :`K 4:J6Y[O 3VU +6Y[O 9*: ,KPU 4+6Y[O 9*:7 .SHZ 46Y[O 9*: ,UN 46Y[O 9*: ,KPU -*+: /2 -9*+ *HU 0)6 -0*+ -0**+, PZ H :WLJPHSPZ[ 6Y[OVKVU[PZ[ MYVT 9HUK^PJR PU (\Z[YHSPH /L JHU IL JVU[HJ[LK H[ PUMV'KLYLRTHOVU` com.

:HPM\KKPU 4 4P`HTV[V 2 <LKH /4 :OPRH[H 5 ;HUUL 2 (U LSLJ[YVT`VNYHWOPJ L]HS\H[PVU VM [OL bilateral symmetry and nature of masticatory muscle activity in jaw deformity patients during normal daily activities. J Oral Rehabil. 2003 Jun;30(6):578-86.

4J*HYYVSS 9: 5HLPQL 4 2PT @2 /HUZZVU ;3 :OVY[ [LYT LMMLJ[ VM H Z[HIPSPaH[PVU ZWSPU[ VU [OL HZ`TTL[Y` VM Z\ITH_PTHS THZ[PJH[VY` T\ZJSL HJ[P]P[` J Oral Rehabil 4HY" !

5HLPQL 4 /HUZZVU ;3 :OVY[ [LYT LMMLJ[ VM [OL Z[HIPSPaH[PVU HWWSPHUJL VU THZ[PJH[VY` T\ZJSL HJ[P]P[` in myogenous craniomandibular disorder patients. J Craniomandib Disord. 1991 Fall;5(4):245-50.

3VIILaVV - ]HU KLY .SHZ /> ]HU 2HTWLU -4 )VZTHU - ;OL LMMLJ[ VM HU VJJS\ZHS Z[HIPSPaH[PVU ZWSPU[ HUK [OL TVKL VM ]PZ\HS MLLKIHJR VU [OL activity balance between jaw-elevator muscles during isometric contraction. J Dent Res. 1993 4H`" ! ,YYH[\T PU! J Dent Res 1993 Aug;72(8):1264. =PZZLY ( 5HLPQL 4 /HUZZVU ;3 ;OL [LTWVYHS masseter co-contraction: an electromyographic and JSPUPJHS L]HS\H[PVU VM ZOVY[ [LYT Z[HIPSPaH[PVU ZWSPU[ [OLYHW` PU T`VNLUV\Z *4+ WH[PLU[Z J Oral Rehabil.

4H`" !

HS 8\YHU -( 3`VUZ 4- ;OL PTTLKPH[L LMMLJ[ VM OHYK HUK ZVM[ ZWSPU[Z VU [OL ,4. HJ[P]P[` VM [OL masseter and temporalis muscles. J Oral Rehabil. 1999 Jul;26(7):559-63.

-LYYHYPV =- :MVYaH * ;HY[HNSPH .4 +LSSH]PH * 0TTLKPH[L LMMLJ[ VM H Z[HIPSPaH[PVU ZWSPU[ VU masticatory muscle activity in temporomandibular disorder patients. J Oral Rehabil. 2002 Sep;29(9):8105.

9VHYR (3 .SHYVZ (. 6Â?4HOVU` (4 ,MMLJ[Z VM PU[LYVJJS\ZHS HWWSPHUJLZ VU ,4. HJ[P]P[` K\YPUN parafunctional tooth contact. J Oral Rehabil. 2003 Jun;30(6):573-7.

4HULZZ >3 7VKVSVMM 9 +PZ[YPI\[PVU VM VJJS\ZHS JVU[HJ[Z PU TH_PT\T PU[LYJ\ZWH[PVU J Prosthet Dent.

1989 Aug;62(2):238-42.

4HULZZ >3 3HIVYH[VY` JVTWHYPZVU VM [OYLL occlusal registration methods for identification of induced interceptive contacts. J Prosthet Dent. 1991 Apr;65(4):483-7.

9LaH 4VPUP 4 5LMM 7( 9LWYVK\JPIPSP[` VM VJJS\ZHS JVU[HJ[Z \[PSPaPUN H JVTW\[LYPaLK PUZ[Y\TLU[ Quintessence Int 4H`" !

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in intercuspal position using the T-Scan system. Int J Prosthodont. 1994 Jan-Feb;7(1):62-71. .VUaHSLa :LX\LYVZ 6 .HYYPKV .HYJPH =* .HYJPH *HY[HNLUH ( :[\K` VM VJJS\ZHS JVU[HJ[ ]HYPHIPSP[` ^P[OPU PUKP]PK\HSZ PU H WVZP[PVU VM TH_PT\T PU[LYJ\ZWH[PVU \ZPUN [OL ; :*(5 Z`Z[LT J Oral Rehabil. 1997 Apr;24(4):287-90. .HYJPH *HY[HNLUH ( .VUaHSLa :LX\LYVZ 6 .HYYPKV .HYJPH =* (UHS`ZPZ VM [^V TL[OVKZ MVY VJJS\ZHS contact registration with the T-Scan system. J Oral Rehabil. 1997 Jun;24(6):426-32. :\KH : 4H[Z\NPZOP 2 :LRP @ :HR\YHP 2 :\a\RP ; 4VYP[H : /HUHKH 2 /HYH 2 ( T\S[PWHYHTL[YPJ HUHS`ZPZ VM VJJS\ZHS HUK WLYPVKVU[HS QH^ YLĂ&#x2030;L_ JOHYHJ[LYPZ[PJZ in young adults with normal occlusion. J Oral Rehabil.

1997 Aug;24(8):610-3. .HYYPKV .HYJPH =* .HYJPH *HY[HNLUH ( .VUaHSLa Sequeros O. Evaluation of occlusal contacts in TH_PT\T PU[LYJ\ZWH[PVU \ZPUN [OL ; :JHU Z`Z[LT J Oral Rehabil +LJ" !

2PY]LZRHYP 7 (ZZLZZTLU[ VM VJJS\ZHS Z[HIPSP[` by measuring contact time and centric slide. J Oral Rehabil. 1999 Oct;26(10):763-6.

2LYZ[LPU 9) 0TWYV]PUN [OL KLSP]LY` VM H Ă&#x160;_LK bridge. Dent Today 4H`" ! :\KH : 4HJ/PKH 5 4VTVZL 4 @HTHRP 4 :LRP @ @VZOPL / /HUHKH 2 /HYH 2 ( T\S[PWHYHTL[YPJ HUHS`ZPZ VM VJJS\ZHS HUK WLYPVKVU[HS QH^ YLĂ&#x2030;L_ JOHYHJ[LYPZ[PJZ PU HK\S[ ZRLSL[HS THUKPI\SHY WYV[Y\ZPVU before and after orthognathic surgery. J Oral Rehabil.

1999 Aug;26(8):686-90. :HYHJVNS\ ( 6aWPUHY ) 0U ]P]V HUK PU ]P[YV evaluation of occlusal indicator sensitivity. J Prosthet Dent 5V]" ! *VTTLU[ PU! J Prosthet Dent. 2003 Sep;90(3):310; author reply 310-1.

2LYZ[LPU 9) >YPNO[ 59 ,SLJ[YVT`VNYHWOPJ and computer analyses of patients suffering from chronic myofascial pain-dysfunction syndrome: before and after treatment with immediate complete anterior guidance development. J Prosthet Dent. 1991 5V]" ! *VTTLU[ PU! J Prosthet Dent. 1993 Jul;70(1):99-100. /PKHRH 6 0^HZHRP 4 :HP[V 4 4VYPTV[V ; 0UĂ&#x2030;\LUJL VM JSLUJOPUN PU[LUZP[` VU IP[L MVYJL IHSHUJL occlusal contact area, and average bite pressure. J Dent Res. 1999 Jul;78(7):1336-44.

2LYZ[LPU 9) *VTIPUPUN [LJOUVSVNPLZ! ( JVTW\[LYPaLK VJJS\ZHS Z`Z[LT Z`UJOYVUPaLK ^P[O H JVTW\[LYPaLK LSLJ[YVT`VNYHWO` Z`Z[LT Cranio. 2004 Apr;22(2):96-109.

Volume 3 Number 4

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Continuing education

,DWURJHQLF HʥHFʞV RI RUWKRGRQWLF treatment Dr. Shivani Patel discusses how to identify and avoid the potential risks of orthodontics

A

lthough orthodontic treatment has recognized benefits, including improvements in dental health, function, appearance, and self-esteem, orthodontic appliances can cause harm. The decision whether to proceed with orthodontics requires comparison of the potential risks with the potential benefits (Ellis and Benson, 2002).

Some patients are more at risk than others; they need to be identified early and managed appropriately to avoid adverse sequelae. The GP’s contribution is crucial, even if he or she does not fit orthodontic appliances, in helping to ensure that braces are properly maintained by reinforcing oral hygiene and preventive measures. The GP may also help in an emergency if a wire or bracket is causing softtissue damage (Ellis and Benson, 2002).

Only when the patient is informed about the reason for treatment and the risks involved can he or she make a fully informed choice and consent to go ahead.

The first part of this paper highlights all the potential intraoral hazards and suggests how they may be avoided or minimized.

The types of deleterious damage to the individual patient as a result of orthodontic treatment are listed below and are in reference to the most comprehensive classification compiled by NJ McGuinness.

Educational aims and objectives

This article aims to identify the potential iatrogenic effects of orthodontic treatment.

Expected outcomes

Correctly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader can r 9LHSPaL [OL WV[LU[PHS PU[YHVYHS OHaHYKZ VM orthodontics. r 3LHYU OV^ [V H]VPK VY TPUPTPaL [OVZL YPZRZ

Extraoral effects TMJ

TMJ

Soft tissues

Headgear induced Burns Allergies

Systemic effects

Allergy/sensitivity Cytotoxicity Bacterial endocarditis Cross-infection Risks from radiation

Other effects

Psychological Failed treatment

Intraoral effects

Unwanted effects from treatment

Teeth

Crowns: Decalcification Enamel trauma Surface wear Roots: Resorption Pulp: Pulpitis

Periodontium

Gingivitis Periodontitis Burns

Soft tissues

Direct trauma: Ulceration Headgear trauma Allergy/sensitivity Cytotoxicity Damage from appliances (removable and fixed)

28 Orthodontic practice

1) Teeth Crown Decalcification (Figure 1) can be caused by the production of acid by products of plaque metabolism.

This requires four elements to occur: plaque, substrate, susceptible tooth surface and time. Gorelick, et al, (1982) showed that 50% of patients in fixed appliance treatment were found to have at least one white spot lesion after treatment. Zachrisson (1971) showed a positive correlation between oral hygiene and caries incidence in patients wearing fixed appliances. Decalcification is often related to the length of treatment. Upper canines and laterals, lower premolars, and canines are most affected (Geiger, et al., 1992).

Treatment and Prevention: White spot lesions can resolve spontaneously, and the majority will resolve in 3 months post treatment. Acid pumice abrasion using 18% hydrochloric acid has been advocated by Croll and Volume 3 Number 4

Continuing education

-PN\YL ! :OV^Z L_[LUZP]L KLTPULYHSPaH[PVU PU H WH[PLU[ ^OV ^HZ PU fixed appliance treatment

Figures 2A and 2B: Picture showing wear of the upper canine tip by lower canine IYHJRL[

Figure 3: Wear of the upper incisor teeth due to the presence of lower ceramic IYHJRL[Z

Cavanagh (1986) as a method of reducing the visibility of effects of demineralization.

Avoid putting fluoride varnish on dematerialized lesions following removal of appliances, as this may arrest the lesion but will also leave a mark. Prevention involves appropriate patient selection. Orthodontic treatment should not be provided for patients with poor oral hygiene.

The orthodontist and his/her own GP/hygienist should carefully monitor every patient during treatment. Once provided with an appliance, each patient should receive an education program from the orthodontist, which includes: UÊ "À> Ê Þ} i iÊ ÃÌÀÕVÌ Ã UÊ iÌ>ÀÞÊ>`Û Vi UÊ / « V> ÊyÕ À `iÊpÊ`> ÞÊ ÕÌ Ü>à ʭä°äx¯ÊÊ Ê fluoride) has shown to reduce white spot lesions and has better compliance than weekly mouthwash (Benson, et al., 2005) Risks can also be reduced by modifying appliance designs, such as: UÊ 1ÃiÊ vÊÜi wÌÌ }ÊL> `à UÊ - > iÀÊLÀ>V iÌà UÊ ,i Û> Ê vÊy>à ÊvÀ Ê>À Õ `ÊÌ iÊLÀ>V iÌà UÊ 1ÃiÊ vÊ} >ÃÃÊ iÀÊVi i ÌÊÌ ÊL `Ê­ i à ]ÊiÌÊ> °]ÊÊ 2005) UÊ ` }ÊÀ>Ì iÀÊÌ > ÊL> ` }ÊÌiiÌ UÊ 1ÃiÊ vÊ }>ÌÕÀiÃÊÀ>Ì iÀÊÌ > Êi >ÃÌ iÀÃÊ­« >µÕiÊÀiÌi Ì Ûi® UÊ Õ À `iÊ «Ài} >Ìi`Ê Ì Ê `Õ iÃÊ> `Ê« ÜiÀÊV > ÊÊ has shown a 50% reduction decalcification over 18 months (Benson, et al., 2005) Crown surface wear Metal brackets placed on lower 3s can sometimes lead to the wear of the tips of the uppers 3s during canine retraction (McGuinness, 1992) [Figures 2A and 2B]. Swartz (1988) suggested that ceramic brackets on the lower incisors in deep bite cases could abrade the incisal edges of the upper incisors (Figure 3). During the debonding of ceramic brackets, there is also an increased risk of enamel damage, as is the use of debonding burs during the removal of excess composite. It has also been seen that the careless use of band seaters can lead to the enamel fractures.

Volume 3 Number 4

Prevention UÊ >ÀivÕ ÊLÀ>V iÌÊ« Ã Ì }Êà ÊÌ >ÌÊLÀ>V iÌÃÊ` Ê ÌÊÊ clash with teeth from the opposing arch UÊ Û ` }ÊÌ iÊÕÃiÊ vÊViÀ> VÊLÀ>V iÌÃÊ ÊÌ iÊ ÜiÀÊÌiiÌ ÊÊ in deep bite cases UÊ >ÀivÕ Ê`iL ` }Ê vÊ> ÊLÀ>V iÌÃÊiëiV > ÞÊViÀ> VÊÊ brackets and brackets placed on restored teeth UÊ 1Ã>}iÊ vÊÌÕ }ÃÌi ÊV>ÀL `iÊLÕÀÃÊ Ê>Êà ÜÊ > `« iViÊÌ ÊÊ remove excess composite.

Root resorption is a common idiopathic problem that occurs during fixed appliance orthodontic treatment (Figure 4). It is a major concern as it is unpredictable and irreversible. Kennedy, et al, (1983) have suggested that root resorption particularly affects upper and lower incisors and the distal roots of lower 6s. The mean loss (apically usually) is between 1-2 mm.

Brezniak and Wasserstein (1993) have identified four main types of root resorption: physiological, inflammatory, replacement, and idiopathic.

They also give a good account in their papers about the risk factors. These can be divided into: a) Biological factors UÊ ` Û `Õ> ÊÃÕÃVi«Ì L ÌÞ\Ê ` Û `Õ> Ê` vviÀi ViÊ ÊÌ ÃÃÕiÊ response UÊ i iÌ VÃ\Ê Ê`iw ÌiÊV V ÕÃ Ê Ê ÌÃÊivviVÌà UÊ-ÞÃÌi VÊ v>VÌ ÀÃ\Ê VÀi>Ãi`Ê ` ÃiÃÊ vÊ V ÀÌ V ÃÌiÀ `Ã]Ê increased alcohol causing vitamin D hydroxylation, and certain endocrine diseases such as hypothyroidism; hypopituitariam can cause root resorption, though these factors are rarely seen in our orthodontic patients UÊ ÕÌÀ Ì \Ê Ì ÃÊ ÃÊ ÌÊ >Ê > ÀÊ v>VÌ À]Ê LÕÌÊ ÃÌÕ` iÃÊ Ê animals have shown that malnutrition can be a cause UÊ i `iÀ\Ê Ì iÊ vi > iÊ Ì Ê > iÊ À>Ì Ê v ÀÊ ÃÕÃVi«Ì L ÌÞÊ vÊ risk is 4:1 UÊ }i\Ê Ü Ì Ê >}iÊ Ì iÊ Û>ÃVÕ >À ÌÞÊ vÊ Ì iÊ > Ûi >ÀÊ L iÊ decreases, and the density increases, and this can be a causative factor. Hence, susceptibility can increase with age UÊ,>Vi\Ê } iÀÊ V `i ViÊ Ê >ÕV>à > ÃÊ > `Ê Ã«> VÃÊ than Asians UÊ*ÀiÛ Õà ÞÊ ÌÀ>Õ >Ì âi`Ê ÌiiÌ \Ê Ì iÀiÊ ÃÊ > Ê VÀi>Ãi`Ê Orthodontic practice 29

Continuing education

Figure 4: Upper standard occlusal X-ray showing root resorption

-PN\YL ! :\YNPJHS V]LY L_WHUZPVU ZOV^PUN NPUNP]HS recession around the central incisors

risk with root resorption in teeth that have previously experienced root resorption UÊ/À> ë > Ìi`ÊÌiiÌ \Ê>ÀiÊ ÌÊ ÀiÊÃÕÃVi«Ì L i]ÊiëiV > ÞÊ if the transplant is without complications UÊ ` ` Ì V> ÞÊ ÌÀi>Ìi`Ê ÌiiÌ \Ê Ì iÃiÊ ÌiiÌ Ê >ÀiÊ ÌÊ necessarily at an increased risk as long as the root treatment is sound UÊ Ûi >ÀÊ L iÊ `i à ÌÞ\Ê V ÌÀ ÛiÀà > Ê Ài« ÀÌÃÊ ÃÌ>ÌiÊ Ì >ÌÊ increased bone density can affect movement but not related to resorption UÊ/ Ì Ê Ã >«i\Ê Ã ÀÌ]Ê L Õ Ì]Ê Li Ì]Ê ` >ViÀ>Ìi`Ê > `Ê pipette-shaped roots are more susceptible (Levander and Malmgren, 1988). Diminutive and peg-shaped laterals are not more susceptible UÊ > VV Õà \Ê> ÞÊ > VV Õà ÊÌ >ÌÊ VÀi>ÃiÃÊÌ iÊ >`Ê on teeth above physiological threshold can cause root resorption UÊ >L ÌÃ\Ê` } ÌÊÃÕV }Ê> `Ê > ÊL Ì }Ê`ÕÀ }ÊÌÀi>Ì i ÌÊ can cause jiggling forces, which may lead to root resorption. b) Mechanical factors Fixed appliances, usage of rectangular wires, Class II traction, increased distance moved by teeth, intrusion of teeth, excessive palatal expansion, and super elastic wires have shown to increase the risk of developing root resorption.

Prevention UÊ /> iÊ >Ê Ì À Õ} Ê `i Ì> Ê ÃÌ ÀÞÊ > `Ê V>ÀÀÞÊ ÕÌÊ >Ê } `Ê dental examination to identify any risk factors UÊ ,>` } V> Þ]Ê Ê v ÀÊ > ÞÊ «ÀiÌÀi>Ì i ÌÊ Ã } ÃÊ ÃÕV Ê >ÃÊ root shapes, previous trauma, root-treated teeth UÊ -Ì «Ê> ÞÊ >L Ìà UÊ 1ÃiÊ } ÌÊv ÀVià UÊ âiÊÌÀi>Ì i ÌÊ i }Ì UÊ ,iV à `iÀÊÌÀi>Ì i ÌÊ> ÃÊÜ i ÊÀià À«Ì Ê ÃÊ>««>Ài ÌÊ Pulp Ninety percent of orthodontic patients will experience pulpitis in the first month, and rarely will this lead to loss of vitality (Zachrisson, 1976).

2) Periodontium Gingivitis Nearly all patients will experience gingivitis during their treatment.

This can be due to (Turkkahraman, et al, 2005): UÊ * ÀÊ À> Ê Þ} i i UÊ VÀi>Ãi`ÊL>VÌiÀ > ÊV Õ ÌÃÊ`ÕiÊÌ Ê«ÀiÃi ViÊ vÊ>«« > Vià UÊ > `ÃÊ>À Õ `ÊÌiiÌ ÊV>ÕÃiÊ>Ê VÀ L > Êà vÌÊ­ VÀi>Ãi`ÊÊ anaerobes) 30 Orthodontic practice

-PN\YL ! :L]LYL SVZZ VM HS]LVSHY IVUL HUK NPUNP]HS recession

Figure 7: Typical malocclusion MVSSV^PUN ZL]LYL WLYPVKVU[HS disease

Figure 8: Ulceration caused due to long distal end wire

UÊ UÊ UÊ UÊ UÊ

>ÃÌ iÀ VÊ `Õ iÃ

« à ÌiÊy>à * ÀÊV i> }Ê>À Õ `ÊL `i`ÊÀiÌ> iÀà ÝViÃà ÛiÊ«À V >Ì ÉiÝ«> à ʭ }ÕÀiÊx® ` Û `Õ> ÊÛ>À >Ì However, Zachrisson study (1972) and clinical experience shows that these effects are transient and resolve once the appliances are removed. Adolescents are also seen to be affected more than adults.There are generally no long-term periodontal problems related to orthodontic treatment.

Prevention UÊ / À Õ} Ê«ÀiÌÀi>Ì i ÌÊÃVÀii }Ê> `Ê} `Ê«>Ì i ÌÊÊ selection UÊ `Ê À> Ê Þ} i iÊ«À }À> ÃÊ> `Ê Ì Û>Ì UÊ * Ê«À L }Ê Ê«>Ì i ÌÃÊ«ÀiÛ Õà ÞÊ>vviVÌi`ÊLÞÊÊ Ê periodontal disease UÊ ,i}Õ >ÀÊ Þ} i iÊÛ Ã Ìà Periodontitis: Orthodontic treatment does not cause periodontitis and generally has no long-term effects on the periodontium, (Polson, et al, 1988). Zachrisson (1976) showed in his studies that 10% of orthodontic patients had significant attachment loss (1-2 mm) compared with controls, but 50% had no loss.

Other periodontal problems that can be seen during treatment but are rare are: UÊ } Û> ÊÀiViÃà ʭ }ÕÀiÊÈ® UÊ V> âi`Ê ÕÛi iÊ«iÀ ` Ì Ì Ã UÊ ,>« ` ÞÊ«À }ÀiÃà }Ê«iÀ ` Ì Ì Ã UÊ *iÀ ` Ì> Ê` Ãi>ÃiÊ>Ãà V >Ìi`ÊÜ Ì ÊÃÞÃÌi VÊ` Ãi>ÃiÊÊ like diabetes Boyd and Baumrind (1989) have suggested that patients affected by periodontal disease should not be treated until their condition is stabilized. Patients with compromised periodontal health frequently have: UÊ Ê VÀi>Ãi`Ê ÛiÀ iÌ UÊ -«>Vi`Ê`i Ì Ì UÊ ÝÌÀÕ`i`ÊÌiiÌ UÊ > > } i ÌÊ­ }ÕÀiÊÇ® Volume 3 Number 4

Continuing education Orthodontic treatment is not contraindicated in this group, provided the disease is controlled and the patient is sufficiently motivated and dexterous to maintain excellent oral hygiene during treatment.

These teeth are easy to move as their center of resistance has shifted along with reduced periodontal support. As a result, these teeth post treatment will need permanent retention, as chances of relapse are higher. During treatment, these patients need three monthly screenings, and need to be seen regularly by their periodontist and hygienist.

Burns Careless use of acid-etch and electro-thermal bonders can lead to minor burns of the gingivae.

3) Soft Tissues Mucosal trauma is very common (McGuinness, 1982) in orthodontic treatment and can be caused by: UĂ&#x160; 1Â?ViĂ&#x20AC;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;LĂ&#x17E;Ă&#x160;`Â&#x2C6;Ă&#x192;Ă&#x152;>Â?Ă&#x160;iÂ&#x2DC;`Ă&#x192;Ă&#x2030;Â?Â&#x153;Â&#x2DC;}Ă&#x160;Ă&#x192;ÂŤ>Â&#x2DC;Ă&#x160;Â&#x153;vĂ&#x160;Ă&#x153;Â&#x2C6;Ă&#x20AC;iĂ&#x192;Ă&#x160;­ Â&#x2C6;}Ă&#x2022;Ă&#x20AC;iĂ&#x160;nÂŽ UĂ&#x160; Â&#x2C6;Ă&#x192;ÂŤÂ?>ViÂ&#x201C;iÂ&#x2DC;Ă&#x152;Ă&#x160;Â&#x153;vĂ&#x160;Â&#x2026;i>`Ă&#x160;}i>Ă&#x20AC;Ă&#x160;Ă&#x153;Â&#x2026;Â&#x2C6;Ă&#x192;Â&#x17D;iĂ&#x20AC;Ă&#x192; UĂ&#x160; 1Â?ViĂ&#x20AC;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;vĂ&#x20AC;Â&#x153;Â&#x201C;Ă&#x160;LĂ&#x20AC;>VÂ&#x17D;iĂ&#x152;Ă&#x192; UĂ&#x160; Ă&#x2022;Ă&#x20AC;Â&#x2DC;Ă&#x192;Ă&#x160;vĂ&#x20AC;Â&#x153;Â&#x201C;Ă&#x160;>VÂ&#x2C6;`Â&#x2021;iĂ&#x152;VÂ&#x2026; UĂ&#x160; /Â&#x2026;iĂ&#x20AC;Â&#x201C;>Â?Ă&#x160;LĂ&#x2022;Ă&#x20AC;Â&#x2DC;Ă&#x192;Ă&#x160;vĂ&#x20AC;Â&#x153;Â&#x201C;Ă&#x160;Â&#x2026;Â&#x153;Ă&#x152;Ă&#x160;Â&#x2C6;Â&#x2DC;Ă&#x192;Ă&#x152;Ă&#x20AC;Ă&#x2022;Â&#x201C;iÂ&#x2DC;Ă&#x152;Ă&#x192; UĂ&#x160; Â?Ă&#x2022;Â&#x201C;Ă&#x192;Ă&#x17E;Ă&#x160;Â&#x2C6;Â&#x2DC;Ă&#x192;Ă&#x152;Ă&#x20AC;Ă&#x2022;Â&#x201C;iÂ&#x2DC;Ă&#x152;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC; Prevention UĂ&#x160; >Ă&#x20AC;ivĂ&#x2022;Â?Ă&#x160;Â&#x2C6;Â&#x2DC;Ă&#x192;Ă&#x152;Ă&#x20AC;Ă&#x2022;Â&#x201C;iÂ&#x2DC;Ă&#x152;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC; UĂ&#x160; Ă&#x2022;Ă&#x152;Ă&#x152;Â&#x2C6;Â&#x2DC;}Ă&#x160;`Â&#x2C6;Ă&#x192;Ă&#x152;>Â?Ă&#x160;iÂ&#x2DC;`Ă&#x192;Ă&#x160;Ă&#x192;Â&#x2026;Â&#x153;Ă&#x20AC;Ă&#x152; UĂ&#x160; 1Ă&#x192;Â&#x2C6;Â&#x2DC;}Ă&#x160;LĂ&#x2022;Â&#x201C;ÂŤiĂ&#x20AC;Ă&#x160;Ă&#x192;Â?iiĂ&#x203A;iĂ&#x160;Â&#x153;Â&#x2DC;Ă&#x160;Â?Â&#x153;Â&#x2DC;}Ă&#x160;Ă&#x192;ÂŤ>Â&#x2DC;Ă&#x192;Ă&#x160;Â&#x153;vĂ&#x160;Ă&#x153;Â&#x2C6;Ă&#x20AC;i UĂ&#x160; *Ă&#x20AC;Â&#x153;Ă&#x203A;Â&#x2C6;`Â&#x2C6;Â&#x2DC;}Ă&#x160;ÂŤ>Ă&#x152;Â&#x2C6;iÂ&#x2DC;Ă&#x152;Ă&#x192;Ă&#x160;Ă&#x153;Â&#x2C6;Ă&#x152;Â&#x2026;Ă&#x160;Ă&#x153;>Ă?

UĂ&#x160; ->viĂ&#x152;Ă&#x17E;Ă&#x160;Ă&#x192;Ă&#x152;Ă&#x20AC;>ÂŤĂ&#x192;Ă&#x160;Â&#x153;Â&#x2DC;Ă&#x160;Â&#x2026;i>`}i>Ă&#x20AC; Cytotoxicity Studies carried out by Holmes, et al, (1993), Tell, et al, (1988) have shown that bonding agents, elastics, arch wires, bands, and brackets do not have any toxic effects.

References .VYLSPJR 3 .LPNLY (4 .^PUUL[[ (1 0UJPKLUJL VM ^OP[L ZWV[ formation after bonding and banding. Am J Orthod 1982; 81: 93â&#x20AC;&#x201C;98. .LPNLY (4 .VYLSPJR 3 .^PUUL[[ (1 )LUZVU )1 9LK\JPUN ^OP[L spot lesions in orthodontic populations with fluoride rinsing. Am J Orthod Dentofac Orthop 1992; 101: 403â&#x20AC;&#x201C;407.

7VSZVU (4 :\I[LSU` 1+ 4LP[ULY :> L[ HS 3VUN [LYT WLYPVKVU[HS status after orthodontic treatment. Am J Orthod Dentofac Orthop 1988; 93: 51â&#x20AC;&#x201C;58.

AHJOYPZZVU )< *H\ZL HUK WYL]LU[PVU VM PUQ\YPLZ [V [LL[O HUK supporting structures during orthodontic treatment. Am J Orthod 1976; 69: 285â&#x20AC;&#x201C;300. )YLaUPHR 5 >HZZLYZ[LPU ( 9VV[ YLZVYW[PVU HM[LY VY[OVKVU[PJ [YLH[TLU[! WHY[ 3P[LYH[\YL YL]PL^ Am J Orthod Dentofac Orthop 1993; 103: 62â&#x20AC;&#x201C;66.

3L]HUKLY , 4HSTNYLU 6 ,]HS\H[PVU VM [OL YPZR VM YVV[ YLZVYW[PVU during orthodontic treatment: a study of upper incisors. Eur J Orthod 1988; 10: 30â&#x20AC;&#x201C;38. ;LSS 9; :`KPZRPZ 91 0ZHHJZ 9+ +H]PKZVU >4 3VUN [LYT J`[V[V_PJP[` VM VY[OVKVU[PJ KPYLJ[ IVUKPUN HKOLZP]LZ Am J Orthod Dentofac Orthop 1988; 93: 419â&#x20AC;&#x201C;422.

Allergies/Sensitivity Ten percent of the population is allergic to nickel. This is 10 times higher in females due to constant contact to jewelry. Five to 12 times the nickel concentration would be required in the mouth to have an effect compared with the skin. This could be due to the protective nature of salivary glycoproteins, and the difference in permeability between skin and mucosa.

Patients allergic to latex can develop a type I (risk of anaphylaxis) or type IV sensitivity in response to gloves, elastomers, and intraoral elastics.

Preventative means include: UĂ&#x160; />Â&#x17D;iĂ&#x160;>Ă&#x160;}Â&#x153;Â&#x153;`Ă&#x160;Â&#x201C;i`Â&#x2C6;V>Â?Ă&#x160;Â&#x2026;Â&#x2C6;Ă&#x192;Ă&#x152;Â&#x153;Ă&#x20AC;Ă&#x17E; UĂ&#x160; *>Ă&#x152;VÂ&#x2026;Ă&#x160;Ă&#x152;iĂ&#x192;Ă&#x152;Â&#x2C6;Â&#x2DC;}Ă&#x160;Â&#x2C6;vĂ&#x160;Â&#x2DC;iViĂ&#x192;Ă&#x192;>Ă&#x20AC;Ă&#x17E; UĂ&#x160; Ă&#x203A;Â&#x153;Â&#x2C6;`Ă&#x160;iÂ?>Ă&#x192;Ă&#x152;Â&#x153;Â&#x201C;iĂ&#x20AC;Ă&#x192;Ă&#x160;qĂ&#x160;Ă&#x2022;Ă&#x192;iĂ&#x160;Ă&#x192;iÂ?vĂ&#x160;Â?Â&#x2C6;}>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;LĂ&#x20AC;>VÂ&#x17D;iĂ&#x152;Ă&#x192;Ă&#x2030;Â?Â&#x2C6;}>Ă&#x152;Ă&#x2022;Ă&#x20AC;iĂ&#x192; UĂ&#x160; 1Ă&#x192;iĂ&#x160;Â?>Ă&#x152;iĂ?Ă&#x160;vĂ&#x20AC;iiĂ&#x160;}Â?Â&#x153;Ă&#x203A;iĂ&#x192; UĂ&#x160; iĂ&#x20AC;>Â&#x201C;Â&#x2C6;VĂ&#x160;LĂ&#x20AC;>VÂ&#x17D;iĂ&#x152;Ă&#x192;Ă&#x2030;}Â&#x153;Â?`Ă&#x160;LĂ&#x20AC;>VÂ&#x17D;iĂ&#x152;Ă&#x192;Ă&#x160;V>Â&#x2DC;Ă&#x160;LiĂ&#x160;Ă&#x2022;Ă&#x192;i`Ă&#x160;Â&#x2C6;Â&#x2DC;Ă&#x160;ÂŤ>Ă&#x152;Â&#x2C6;iÂ&#x2DC;Ă&#x152;Ă&#x192;Ă&#x160;Ă&#x160; with a nickel allergy Clinical relevance: It is important for all the readers to appreciate that a high proportion of patients are considering or undergoing orthodontic treatment. It is important that they understand the potential risks of wearing an orthodontic appliance.

:OP]HUP 7H[LS )+: 4-+: 9*7: 4:* 3VUK 046Y[O 9*7: -+: 6Y[O 9*: PZ HU VY[OVKVU[PJ JVUZ\S[HU[ HUK H WHY[ULY H[ [OL H^HYK ^PUUPUN L L]LU 3VUKVU England. She qualified from Guyâ&#x20AC;&#x2122;s in 2000, gained her 4:J HUK 46Y[O PU HUK PU X\HSPĂ&#x160;LK ^P[O HU -+: 6Y[O MYVT [OL 9V`HS *VSSLNL VM :\YNLVUZ ^^^ LSSL]LUVY[OVKVU[PJZ JVT

;\YRRHOYHTHU / L[ HS (YJO ^PYL SPNH[PVU [LJOUPX\LZ TPJYVIPHS JVSVUPaH[PVU HUK WLYPVKVU[HS Z[H[\Z PU VY[OVKVU[PJHSS` [YLH[LK patients, Angle Orthod, 2005; 75:227-232.

Zachrisson BU and Zachrisson S. Caries incidence and orthodontic treatment with fixed appliances, Scand J of Dent Res, 1971;79:183192.

4J.\PUULZZ 5 7YL]LU[PVU PU VY[OVKVU[PJZ H YL]PL^ Dent Update 1982; 19:168-175. )V`K 93 HUK )H\TYPUK : 7LYPVKVU[HS JVUZPKLYH[PVUZ PU [OL \ZL VM bond and bands on molars in adolescents and adults. Angle Orthod 1992;62: 117-126 :^HY[a 43 *LYHTPJ IYHJRL[Z J Clin Orthod 1988; 22:82-88.

2LUULK` +) L[ HS ;OL LMMLJ[Z VM L_[YHJ[PVUZ VU [OL HS]LVSHY support. Am J Orthod 1983; 84: 183-190. /VSTLZ 1 L[ HS *`[V[V_PJP[` VM VY[OVKVU[PJ LSHZ[PJZ Am J Orthod Dentofacial Orthop 1993; 104:188-191. ,SSPZ 7, )LUZVU 7, 7V[LU[PHS OHaHYKZ VM VY[OVKVU[PJ [YLH[TLU[ ^OH[ `V\Y WH[PLU[Z ZOV\SK RUV^ Dent Update 2002; 492-496. )LUZVU 7, L[ HS -S\VYPKLZ VY[OVKVU[PJZ HUK KLTPULYHSPaH[PVU! H Z`Z[LTH[PJ YL]PL^ J Orthod 2005; 32:102-114.

AHJOYPZZVU : AHJOYPZZVU )< .PUNP]HS JVUKP[PVU HZZVJPH[LK ^P[O orthodontic treatment. Am Orthod 1972; 42: 26-34.

Volume 3 Number 4

Orthodontic practice 31

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:

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AGD registration no: License no: Address:

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

City, State and Zip Code:

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.

Telephone/Fax:

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

Refining occlusion with muscle balance to enhance long-term orthodontic stability Dr. Derek Mahony 1. However, today it is possible to precisely measure ___________, all simultaneously. a. the relative force of each occlusal contact b. the timing of the occlusal contacts c. specific muscle contraction levels d. all of the above 2. Over 50 years ago, one orthodontist began to record muscle activity through _____in an effort to better understand the functions of the muscles of mastication. a. synergy testing b. surface electromyography c. the tripod effect d. maximum intercuspation 3. In Figure 2, we see muscles that are _______. a. relaxed at rest (the normal condition) b. hyperactive at rest (indicating a maxillomandibular malrelation) c. exhibiting a neurological abnormality (large motor-unit firing) d. any of the above 4. Determining muscle balance in function is a(n) ____task for EMG. a. easy b. difficult c. impossible d. immeasurable 5. While surface EMG is a fast, easy, and reliable way to record the relative contraction levels of the muscles at rest or in function, it has _____to occlusal force locations and the timing of tooth contacts. a. a high sensitivity b. no sensitivity c. a low sensitivity d. no relationship

Iatrogenic effects of orthodontic treatment Dr. Shivani Patel

6. The simplest solution to the problem of evaluating the timing and force of occlusal contacts is ____. a. the T-Scan II b. the EMG c. a tracing d. calculating the force vector 7. According to the latest research on mandibular function (Gallo, et al), we now know that the sagittal path of closure is ______ a simple hinge movement. a. much easier than b. within the adaptive capacity of c. far greater than d. more complicated than 8. In fact, the ______moves from the vicinity of the angle of the mandible (early in opening) to about midramus (late in opening) in close proximity to where the inferior alveolar nerve enters the mandibular foramen. a. “helical axis of rotation” b. T-Scan wafer c. masticatory musculature d. lateral excursion 9. When we see that the highest force of contact is on the left, can we assume that the greatest muscle activity will be the same? ______ a. Most definitely. b. About half the time. c. Not at all. d. With adequate, stable contacts.

10. _____of the muscles of mastication that elevate(s) the mandible is (are) positioned such that there is a straight vertical relationship between the origin and the insertion. a. One b. Two c. Three d. Not one

1. Some patients are more at risk than others; they need to be ______to avoid adverse sequelae. a. referred to another type of specialist b. identified early c. managed appropriately d. both b and c 2. Gorelick, et al, showed that _____ of patients in fixed appliance treatment were found to have at least one white spot lesion after treatment. a. 25% b. 30% c. 50% d. 65% 3. Avoid putting _______on dematerialized lesions following removal of appliances, as this may arrest the lesion but will also leave a mark. a. composite b. fluoride varnish c. acid etch d. bonding agents 4. Kennedy, et al, (1983) have suggested that root resorption particularly affects _____. a. upper incisors b. lower incisors c. the distal roots of lower 6s d. all of the above 5. Fixed appliances, usage of rectangular wires, Class II traction, increased distance moved by teeth, intrusion of teeth, excessive palatal expansion, and super elastic wires have shown to ____the risk of developing root resorption. a. increase b. decrease c. have no effect on

d.

slightly reduce

6. ______ of orthodontic patients will experience pulpitis in the first month, and rarely will this lead to loss of vitality (Zachrisson, 1976). a. Twenty percent b. Forty c. About half d. Ninety percent 7. Boyd and Baumrind (1989) have suggested that patients affected by periodontal disease should not be treated until ______. a. they return to their GP for consultation b. they are evaluated by a medical doctor c. their condition is stabilized d. they sign a release form 8. _______can lead to minor burns of the gingivae. a. Smoking b. Careless use of acid etch c. Electro-thermal bonders d. Both b and c 9. Ten percent of the population is allergic to _____. a. nickel b. bonding agents c. ceramic brackets d. glass ionomer cement 10. Patients allergic to latex can develop a type I (risk of anaphylaxis) or type IV sensitivity in response to ________. a. gloves b. elastomers c. intraoral elastics d. any of the above

To provide feedback on this article and CE, please contact Orthodontic Practice US 15720 N. Greenway Hayden Loop #9, Scottsdale, AZ, 85260 | fax: (480) 629-‐4002 | email: education@medmarkaz.com 32 Orthodontic practice

Volume 3 Number 4

Grow Your Practice In Any Economy F R E E Practice Management Training “I liked Gary’s seminars so well, we are having him back to lecture at a hygienist meeting in Birmingham, Alabama. My staff was so motivated by the seminar on the WOW factor that we are heading to Orlando for a more in-depth training with Disney.”

David M. Sarver DMD, MS

www.practicemanagesolutions.com Free to current & future clients of DynaFlex® 2 CE Credits/webinar Relevant & Current Topics DynaFlex® is offering free online practice management training to offices that qualify by doing business with DynaFlex®. This is an easy to use, unique online platform that you and your team can utilize in the comfort of your office or home. Fresh and relevant topics are constantly added to the site to keep you and your team on the cutting edge of practice management.

1-800-489-4020

www.dynaflex.com For more information, email: Garyj@dynaflex.com

Education exploration

GCARE webinars: inspiration, exploration, and education Dentsply GAC is launching a new educational initiative described as, “Part Inspiration. Part Exploration.

All Education.” A new series of webinars, through GAC Clinical Alliance for Research and Education (GCARE), focuses on four aspects of the practice — clinical, esthetics, practice growth and management, and resident transition — to enhance Dentsply GAC’s quest to fulfill the educational needs of the contemporary orthodontic practice. Interviews by Orthodontic Practice US Managing Editor Mali Schantz-Feld explore how the new webinar program pertains to all stages of the orthodontic community, from residents to practicing orthodontists.

Todd Metts — Dentsply GAC Director of Professional Services “Through GCARE, we want to develop an educational site that supports our experienced clinicians and those in residency. In order to be successful in their professional lives, residents need to develop certain skills that may not be a key focus in their academic programs. We surveyed residents across the U.S. to find out what subjects they find most relevant. Then, we contacted expert clinicians in those areas to create our webinar series. We plan to introduce 10 modules in the next 6 to 10 months.

“Many talented people have been integral in the growth of this project. On the business side, the expertise of Dr. Lou Shuman and Amy Morgan, leaders of the Pride Institute, is key to us as we focus on topics pertaining to practice growth and management. Lou, with his orthodontic and technology background, has been a true resource for the development of our website.

“On the clinical side, we are excited to work with Dr. Antonino Secchi. His dedication to education is contagious, and as a university professor, he can bring the clinical material to life. His webinars will concentrate on helping practices to advance their clinical skills. With him, we have researched the top 10 clinical challenges in the orthodontic office and how to work through those clinical challenges.

His CCO™ (Complete Clinical Orthodontics) System finds solutions to obstacles for clinical success.

“Another group involved with the clinical aspect of GCARE is the AEO (Advanced Education in Orthodontics).

This group of clinicians and director Dr. Ted Freeland offer strong educational programs, and we will partner with them for some clinical modules.

“For practice transitions, Dr. Jerry Clark and Chris Bentson of Bentson Clark & Copple LLC, an orthodontic valuation and transition company, help doctors work through the complicated process of transitioning into retirement or selling practices. We will also have webinars to guide clinicians in the development of different esthetic cases, including lingual orthodontics, tray aligners, and esthetic brackets solutions.

“Dentsply GAC is more than a bracket and band company. We want to make our site a resource for clinicians, 34 Orthodontic practice

not an infomercial, but an opportunity to share solid, clinical information, and valuable practice growth information that can be implemented into practices immediately. The microsite is designed for simplicity and efficiency, with buttons that lead to clinical, esthetic, practice growth solutions, and resident-transition areas. The site is expected to launch in November, with the first two modules taught

by Dr. Antonino Secchi and Amy Morgan. In the future, we want the GCARE experience to be comprised of three parts—our microsite webinars to introduce the concepts; then, a full-day GCARE program where we get to spend the day with the doctors, and following that, we will again utilize the web to hold a follow-up live-session study club with the instructors to answer questions.

“For our webinar microsite, we talked and surveyed residents and orthodontists. We said, ‘Tell us what you need, where you want it, and we will build it.’ The GCARE webinars are the culmination of that goal.”

Dr. Antonino Secchi — At the University of Pennsylvania, Dr. Secchi has developed and implemented courses on orthodontic treatment mechanics, straight wire appliance systems and functional occlusion in orthodontics.

“I will be doing clinical webinars on treatment mechanics, specifically, on treatment mechanics utilizing active self-ligating appliances such as the In-Ovation® family of brackets developed by Dentsply GAC. These webinars will be a great introduction to the CCO™ (Complete Clinical Orthodontics) System. In this 1-hour webinar, I will explain some of the unique characteristics of active self-ligating brackets and how to take full advantage of them to improve treatment quality as well as efficiency in the practice. I will cover the stages of treatment mechanics – Stage 1-leveling and alignment, Stage 2-the working stage, and Stage 3-the finishing stage, and highlight the goals and objectives for each stage and what sequence of wires can be used to accomplish those objectives. I will also cover how to solve conditions such as Class II, Class III, open bite, deep bite, as well as management of anchorage in extraction cases.

“Mechanics has always been a hot topic in orthodontics.

Volume 3 Number 4

Education exploration

Over time, clinicians develop new products, new technologies and thus new, and many times better ways to deliver orthodontic care. By surveying a large pool of orthodontists, from residents to experienced clinicians, we found out that treatment mechanics was a highly requested topic. That is why we chose this as one of the first topics to be included in our webinars.

“Another aspect of the CCO™ System is the recently introduced CCO Rx. Today, because of both the research done and clinical experience gathered over the last decade on self-ligation, we understand much better how these appliances work; for instance, how different types of arch wires interact with the active clip, and how this relates to tooth movement and expression of torque, tip, and offset.

Therefore, we developed a new prescription to take full advantage of this interaction. I am very happy to see the great acceptance that the CCO Rx has already achieved!

Using the efficient and reliable In-Ovation® bracket systems with the CCO Rx will help clinician to achieve optimal final tooth position in the vast majority of their patients.”

Amy Morgan — CEO Pride Institute “Dr. Lou Shuman and I will deliver four webinars courtesy of Pride Institute. Based upon the 35-year foundation of Pride Institute as a training organization, we use our coaching and training to help doctors at every phase of their careers to implement strategies that achieve maximum success. After dental school and residency, there is a huge gap between life as a student and life as a first-phase professional. During school, the focus is on the clinical, and this leaves the students ill equipped to take the first step into the business of the practice, and have that first step serve as a foundation for the rest of their careers.

“There are so many obstacles and barriers on the journey from resident to professional — they have ‘analysis paralysis,’ look for ‘silver bullet solutions,’ and depend upon experts that are unregulated, because they don’t know enough to filter the information. This first foray into practice can be a very scary ice water dip. Dr. James Pride, founder of Pride Institute, was a dean at the University of the Pacific, so residents have always been near and dear to our hearts. Our goal has always been to give that student, for the general dental degree as well as specialties, as much Volume 3 Number 4

information as possible to ensure success. We are excited to partner with GCARE to supply our knowledge and years of content to create something really special for the residents and for orthodontists throughout each phase of their career!

“For our modules, I will be covering staff management, treatment presentation, and patient management. Together with Lou, we will cover key performance indicators of the orthodontic world, and Lou will teach key marketing strategies. We will cover the cornerstones for creating the very best foundations for a strong business model—whether the resident is entering into an associateship, grandfathered into an existing practice, doing a practice startup, or direct practice purchase, or an orthodontist who is already established. These concepts give clinicians the security and confidence to be successful.

“I joined Pride Institute as a consultant and trainer in 1992 after working in financial planning and cash flow crisis intervention for medical and dental fields. Every time that I worked with a dentist in true crisis, it shocked me that the crisis was precipitated by one bad month or a bad transition, and the doctors’ ‘panic moves’ led to very serious problems. My personal goal has been to be proactive before the crisis so doctors can have control of their business.

When Dr. Pride passed away and I became owner, my first goal was to complete the ownership group with a clinician with similar vision and values that could grow the Institute with new models and new methods. With orthodontist Lou Shuman, we compiled the content to truly exceed research expectations for creating a new orthodontic division. In partnering with Dentsply GAC and GCARE, we aim to educate, motivate, inspire, and support our orthodontic customers, so they can achieve their business goals.

“Interestingly, Dr. Antonino Secchi is a personal client and a VIP at GAC, and as he steps into his new office, we are working on his statistical, staff, patient, and marketing strategies, and are applying it as a best practices model. His credibility and longevity come from his years in clinical research and academism, and the fact that he is applying these strategies for his private practice says a lot about the concepts.

“Our ultimate goal is to give residents enough information to be able to choose experts wisely, recognize good advice from bad advice, and make decisions that will work best for them, for a lifetime of positive consequences.

With these webinars, we want to make sure that all of our dentists are as ‘armed and dangerous’ as they possibly can be.”

Orthodontic practice 35

Abstracts

7KH ODĘ&#x17E;HVW LQ RUWKRGRQWLF UHVHDUFK IURP DURXQG WKH ZRUOG Dr. Shalin R. Shah presents the current literature, keeping you in touch with the latest studies and evolving technologies Effects of local osteoprotegerin gene transfection on orthodontic root resorption during retention: an in vivo micro-CT analysis Zhao N, Liu Y, Kanzaki H, Liang W, Ni J, Lin J. Orthodontic Craniofacial Research (2012) 15(1):10-20 Abstract Aims: External root resorption (ERR) is a serious complication of orthodontic treatment. Aim of this study was to evaluate the effects of local osteoprotegerin (OPG) gene transfection on ERR during retention.

Materials and Methods: Eighteen 6-week-old male Wistar rats were divided into three groups. All the rats were subjected to 2 weeks of orthodontic tooth movement followed by a 2-week retention period. During retention, the three groups of rats received local OPG gene transfection (OPG transfection group, n = 6), mock vector transfection (mock group, n = 6), or no injections (control group, n = 6). ERR of all three groups was evaluated with in vivo micro-CT analysis at three different time points: baseline, the last day of orthodontic tooth movement, and the last day of retention.

Results: In the OPG transfection group, there was no significant difference between ERR at the baseline and ERR on the last day of retention. By the last day of retention, the repair ratio of ERR in the OPG transfection group was statistically higher in relation to the repair ratio of the other groups (p < 0.001).

Conclusions: The results indicated that local OPG gene transfection significantly enhanced the repair of ERR during retention. Local OPG gene transfection might therefore be a useful tool for ERR repair during retention.

Influence of thermoplastic retainers on Streptococcus mutans and Lactobacillus adhesion Turkoz C, Bavbek NC, Varlik SK, Akca G. American Journal of Orthodontics and Dentofacial Orthopedics (2012) 141(5):598-603 Abstract Aims: This study was designed to test the hypothesis that thermoplastic retainers influence oral microbial flora during the retention period because they prevent the flushing effect of saliva on dental and mucous tissues.

Materials and Methods: Twenty-four orthodontic patients finished the study. After debonding, the patients were given thermoplastic retainers (Essix ACE 0.040-in plastic, Dentsply International, York, PA) for both jaws and instructed to wear them all day. Plaque samples from tooth surfaces and saliva samples were collected from each patient just after debonding (T0), and on day 15 (T1), day 30 (T2), and day 60 (T3) of retention. The jaws were divided into six regions, and the data for each region were evaluated separately. Total viable Lactobacillus and Streptococcus mutans colonies were counted, and the numbers of the viable microorganisms were calculated.

Results: The numbers of Lactobacillus colonies at T3 were 36 2UWKRGRQWLF practice

higher than at T0, T1, and T2, and the difference between T0 and T3 was statistically significant (P <0.05). The numbers of S mutans colonies at T3 were higher than at T0, T1, and T2, and the differences between T0 and T1, and T1 and T2 were statistically significant (P<0.05).

Conclusions: Retention with thermoplastic retainers might create oral conditions conducive to S mutans and Lactobacillus colonization on dental surfaces.

Influence of initial strain on the force decay of currently available elastic chains over time Buchmann N, Senn C, Ball J, Brauchli L. The Angle Orthodontist (2012) 82(3):529-35 Abstract Aims: To investigate the dependence of force decay on the initial strain applied to currently available elastic chains.

Materials and Methods: Eight different elastic chains from eight major companies were tested for force decay over a period of 3 weeks at 50% and 100% strain. They were stored in water and thermocycled between 5uC and 55uC. An Instron 3344 was used for the force measurements.

Results: Absolute force values at 50% strain varied between 2.3 N and 4.1 N initially, and between 0.9 N and 1.6 N after 21 days. Thus, the force decay of the elastic chains varied from 37% to 75%.

At 100% strain, the force values varied between 2.9 N and 4.7 N initially, and between 1.3 N and 2.1 N after 21 days of continuous strain. The force decay varied between 39% and 67%. Most force decays between 24 hours and 21 days were not significant. This information should be taken into consideration when the appropriate elastic chain is selected for clinical use.

Conclusions: A wide array of elastic chains with various force levels is available. However, differences between products of greater than 100% were measured for force decay over time.

Apical root resorption of incisors after orthodontic treatment of impacted maxillary canines: a radiographic study Brusveen EMG, Brudvik P, Boe OE, Mavragani M. American Journal of Orthodontics and Dentofacial Orthopedics (2012) 141(4):427-35 Abstract Aims: The purpose of the study was to evaluate impacted maxillary canines, a risk factor for orthodontic apical root resorption.

Materials and Methods: The sample comprised of 66 patients treated with fixed appliances. Thirty-two patients with a unilateral impacted maxillary canine, which was distanced from the roots of the incisors at a preliminary phase of treatment before bonding, formed the impaction group, and 34 patients without impactions served as the controls. Root shortening was calculated by using pretreatment and posttreatment intraoral Volume 3 Number 4

Abstracts radiographs. Inclination of the eruption path of the impacted canine relative to the midline, axis of the lateral incisor, and nasal line, root development, and the medial and vertical positions of the impacted tooth were recorded on orthopantomograms and lateral cephalometric films. The follicle/tooth ratio was evaluated by using periapical radiographs.

Results: No significant difference in apical resorption of the maxillary incisors was detected between the impaction and control groups, or between the incisors of the impacted and contralateral sides in the same subject. Likewise, no difference in the severity of root resorption was found between the incisors of impacted side alone and the incisors of the control group.

Mesial and vertical inclinations of the impacted canines were negatively related to a lateral incisorâ&#x20AC;&#x2122;s root resorption. No correlations were found between resorption and medial or vertical position of the crown of the canine. The follicle/tooth ratio was significantly related to the mesial inclination of the impacted canine, but not to root resorption.

Conclusions: An impacted maxillary canine, after being distanced from the incisor roots, does not seem to be a risk factor for apical root resorption during orthodontic treatment.

Deciduous molar hypomineralization and molar incisor hypomineralization Elfrink MEC, Ten Cate JM, Jaddoe VWV, Hofman A, Moll HA, Veerkamp JSJ. Journal of Dental Research (2012) 91(6):551-5 Abstract Aims: This study was embedded in the Generation R Study, a population-based prospective cohort study from fetal life

Volume 3 Number 4

until young adulthood. This study focused on the relationship between Deciduous Molar Hypomineralization (DMH) and Molar Incisor Hypomineralization (MIH). First permanent molars develop during a period similar to that of second primary molars, with possible comparable risk factors for hypomineralization. Children with DMH have a greater risk of developing MIH. Clinical photographs of clean, moist teeth were taken with an intraoral camera in 6,161 children (49.8% girls; mean age 74.3 months, SD Âą 5.8). First permanent molars and second primary molars were scored with respect to DMH or MIH. The prevalence of DMH and MIH was 9.0% and 8.7% at child level, and 4.0% and 5.4% at tooth level. The odds ratio for MIH based on DMH was 4.4 (95% CI, 3.1-6.4). The relationship between the occurrence of DMH and MIH suggests a shared cause and indicates that, clinically, DMH can be used as a predictor for MIH.

Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine.

Currently, Dr. Shah is Clinical Associate of Orthodontics at the University of Pennsylvania and is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey and Philadelphia, Pennsylvania.

2UWKRGRQWLF practice 37

3D imaging

Dialogue STRAIGHT TALK

Imaging &%&7 LQ WKH PL[HG GHQWLWLRQ D FU\VʞDO EDOO Dr. Juan-Carlos Quintero explores the optimal management of common developmental problems in the mixed dentition “Two men say they’re Jesus, one of them must be wrong,” sings rock singer Mark Knopfler of Dire Straits (Dire Straits, Industrial Disease, Warner Bros., 1982). Such is usually the case with permanent supernumerary maxillary lateral incisors (Figure 1). Often, we must take nothing more than an educated guess as to which lateral incisor to extract and which to keep. Through the use of simplified available dynamic modeling known as Anatomodel™ (Anatomage Corp.) and Tx STUDIO™ (Imaging Sciences International), Cone beam CT data derived from the i-CAT® “Quick Scan can now easily produce digital, impressionless models for easy viewing, interaction, and treatment planning. This allows for the anatomical structures such as teeth, roots, and bone to be segmented, color-highlighted, virtually extracted, and better visualized to help determine which lateral incisor to keep and which to extract, among other treatment-planning enhancements (Figures 1 and 2). In the sample presented, the two permanent maxillary left lateral incisors were segmented and virtually extracted, positioned side by side, and the morphology of the clinical crowns were compared. From here, it was possible to determine that the lateral incisor marked “purple” was more amorphic, and therefore more likely to be the supernumerary tooth, and subsequently sent for extraction (Figure 2).

The process begins with the acquisition of Quick Scan from an i-CAT using parameters as follows: 4.8 sec, 0.4 mm voxel, 16x8 cm, which is a low radiation dose equal to 37 microseverts of exposure (Ludlow, et al) , the equivalent of only 1.5 typical panoramic radiographs (Figures 3 and 4).

True to ALARA (As Low As Reasonable Achievable) principles, particularly in young children in the mixed dentition, it is important to image as conservatively as possible, yet maximize the imaging benefit. This Quick Scan from i-CAT is ALARA-friendly and allows for routine evaluation of the mixed dentition with accurate, interactive data. Other useful CBCT applications using very low radiation levels for the mixed dentition include improved management of ectopic or impacted teeth (Figures 5, 6, and 7).

The advent of temporary anchorage devices (TADs) in the last 10 years has revolutionized clinical orthodontics as well. The power of virtual treatment planning through low-dose CBCT based digital models is also making a great impact in orthodontics. But when TAD technology meets 38 Orthodontic practice

Figure 1

Figure 2

Figure 3 Volume 3 Number 4

3D imaging

Figure 4

Figure 5

Figure 6

Figure 9 (Photo courtesy of Dr. Joseph McCain)

Figure 12

40 Orthodontic practice

Figure 7

Figure 10

Figure 8

Figure 11

virtual treatment planning, it is suddenly much easier to visualize, design mechanics, educate, communicate, and resolve even the most challenging of tooth movements (Figures 8 and 9).

Early management of congenitally missing lateral incisors is also enhanced through the use of the Quick Scan and an AnatoModel in the mixed dentition (Figure 10). To close space or open space has always been the question.

How about putting the orthodontists in a position where they can do either? It is now easier to plan for an ideal scenario of guiding the permanent canines into the space of the missing lateral incisors, while keep the primary canines in the permanent canine position. This approach maintains both the space, and more importantly keeps the bone vital and voluminous during the remaining years of growth, so that implant dentistry is a viable option for the patient (Figure 11). Once the patient reaches facial skeletal maturity for future implants, the primary canines are then removed and the permanent canines distalized into the canine position, while leaving a healthy trough of bone in its path for implants (Figure 12).

Volume 3 Number 4

3D imaging Several unique applications of CBCT technology in the mixed dentition have been presented. While the risks of ionizing radiation must always be kept to a minimum, it is also true that not a single case linking bodily harm to these low levels of ionizing radiation has ever been reported. It is also true that i-CAT Quick Scan can deliver dosimetry levels equivalent to a panoramic x-ray. One must conversely consider the harm to patients of not imaging patients properly, resulting in a misdiagnosis, underdiagnosis, or anything less than optimal management of common developmental problems in the mixed dentition, as presented in this report.

for more details visit:

Dr. Juan-Carlos Quintero received his Dental Degree from the University of Pittsburgh in Pennsylvania and degree in Orthodontics from the University of California at San Francisco (UCSF). He also holds a Masterâ&#x20AC;&#x2122;s of Science Degree in Oral Biology. He has served as National President of the American Association for Dental Research-SRG, is a faculty member at the L.D. Pankey Institute and an attending professor at Miami Childrenâ&#x20AC;&#x2122;s Hospital, Department of Pediatric Dentistry, as well as immediate past-president of the South Florida Academy of Orthodontists (SFAO). He currently practices in South Miami, Florida.

http://www.orthopracticeus.com/web/3d-imaging.html

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42 Orthodontic practice

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Volume 3 Number 4

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Service profile

Low price, online payroll services now available OrthoBanc has leveraged its buying power to offer low cost payroll services to orthodontic offices

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rocessing payroll and payroll taxes is a tedious and timeconsuming task that requires a thorough understanding of federal, state, and local payroll tax laws. However, most small business owners have a limited understanding of these laws, and they often rely on inefficient methods – inhouse, manual, or accounting software – to process their payroll and payroll taxes.

Orthodontic practice owners who manage their payroll in-house are tasked with responsibilities such as totaling hours, performing gross-to-net calculations for each employee, calculating and depositing payroll taxes, and preparing and filing tax returns accurately and on time.

Given the complexities of each step and the fast-changing regulations that affect tax law, outsourcing can provide you with an opportunity to save time and money and ensure compliance.

Run payroll on your schedule with OrthoBanc Payroll Services OrthoBanc Payroll Services provide a simple, affordable online alternative to expensive, traditional payroll services.

You just enter, review, and approve payroll online anywhere, anytime – they take care of everything else.

Clock in, clock out, and process payroll with OrthoBanc Payroll Services’ Time Clock Integration You can also simply import payroll information from your time and attendance system into your OrthoBanc Payroll Services account. This saves time and vastly reduces the potential for data entry errors. Time clock integration works in conjunction with many existing time clock software programs or systems to incorporate employees’ time and attendance information. It allows simple, per-pay-period exports that take seconds to complete, and the integration supports both hourly and salaried employees’ payroll hours.

Eliminate the risk of costly fines with free compliance and human resources tools This simple online tool can eliminate your risk of incurring hefty labor law non-compliance fines while cutting your time spent searching and creating HR forms and procedures down to a few minutes. HRAdvisor, a free suite of online HR and compliance resources already integrated with your OrthoBanc Payroll Services account, offers customized compliance posters, a complete library of pre-populated business forms, valuable best-practice guides, and helpful alerts and reminders.

OrthoBanc Payroll Services priced lower than traditional payroll management Because OrthoBanc Payroll is managed online, they can 44 Orthodontic practice

offer the same payroll management features as traditional providers for up to 50% of the cost. But online payroll management doesn’t mean watered-down service. The Payroll Services team has award-winning customer service including phone, email, and online help. Whether you are processing payroll yourself, or using a third party payroll service, OrthoBanc Payroll Services can help you.

This information was provided by OrthoBanc, LLC.

OrthoBanc LLC (DBA OrthoBanc, DentalBanc, and PaymentBanc) is a payment management company that has been serving orthodontists and other medical practices since 2001. OrthoBanc offers a suite of financial products, including credit recommendations, payment plan management, collections, practice management analytics, and payroll services. OrthoBanc currently serves more than 4,000 providers nationwide and manages over half a billion dollars in patient payments annually. They have been on the Inc. 5000 List of Fastest Growing American Companies for the last 4 years. This growth can be attributed to excellent customer service and solutions that are cost effective yet extremely valuable to practices offering an office payment plan.

Volume 3 Number 4

Want to get paid on time each month?

With OrthoBanc, every payment is a priority.

It always seemed that our office was last on the priority list for people to get paid. We could never predict with any accuracy what percent we would collect of our monthly payments. OrthoBanc has tremendously helped us collect almost all of our monthly payments on a regular basis. Â&#x2C6;(OLLY +OCHMAN $R -ICHAEL #OLLINS 7ACO 48

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s )DENTIFY 2ISK WITH #REDIT !NALYSIS AND 0AYMENT 0LAN 2ECOMMENDATIONS s 'ET 0AID /N 4IME WITH !#( $RAFT AND #REDIT #ARD 0AYMENT /PTIONS s $ECREASE 3TAFF 7ORK ,OAD WITH #OMPLETE -ANAGEMENT OF 9OUR !CCOUNTS s h-EASURE )T )MPROVE )T v WITH /RTHO-ETRICS 0RACTICE !NALYTICS s 2EDUCE 0AYROLL (EADACHES WITH ,OW #OST 0AYROLL 3ERVICES

Let OrthoBanc Payment Management do the work for you. Call 888-758-0585 today to learn more.

888-758-0585 | www.orthobanc.com

Product profile

Insignia™ Advanced Smile Design™

F

rom Ormco Corporation, Insignia™ Advanced Smile Design™ is an all-inclusive digital orthodontic solution that enables orthodontists to apply a higher level of finite design to cases, resulting in efficient, precise smile outcomes often in less time. The result of nearly two decades of research, Insignia combines 3-D technology, advanced computer algorithms, and interactive design software with customized treatment to build an ideal occlusion for patients.

While other braces are off-the-shelf and rely on the human eye to address variations in facial symmetry and tooth anatomy, Insignia braces and aligners are uniquely developed from a 3-D treatment plan designed in conjunction with the orthodontist to develop the best possible long-term occlusion that’s unique to each patient.

As the only orthodontic software and appliance system that delivers a complete customized solution from initial smile design to fabrication of patient-specific appliances, Insignia helps reduce mid-treatment adjustments and overall treatment time.

Insignia uses a high-resolution scan of a PVS impression to create a precise 3-D virtual model of the patient’s dental anatomy. Utilizing more than 40,000 data points per tooth, unique algorithms in the software define, coordinate, and design the patient’s arches. This initial occlusion is presented to the doctor who implements a more exact level of design, taking into consideration facial features and treatment preferences to create the perfect smile. With Insignia’s 3-D treatment digital rendering, doctors can modify the smile and occlusion, providing the patients with a preview of what their new smile will look like before starting treatment.

Appliances are then customized to deliver results that are unique to each patient.

Insignia provides the most expansive menu of orthodontic treatment options available – ranging from aligners to metal and esthetic fixed appliances. Unique to Insignia, clinicians have the option to choose traditional twins, self-ligating brackets, or aligners that are customized to the individual patient. Compatible appliances include Insignia Clearguide™ Express aligners, Damon® Q™, Damon® Clear™, Titanium Orthos™ and Inspire ICE™.

46 Orthodontic practice

In addition to versatile appliance compatibility, Ormco ensures Insignia treatment is user-friendly and delivers premium results by combining the software with the following support elements: UÊ Ã } >Ê - iÊ ià } Ê >L\ The Smile Design Lab analyzes each case, taking into account patient records and doctor preferences to assist the clinician in designing an optimal occlusion and smile UÊ Ã } >Ê ««À ÛiÀ\ The interactive Insignia Approver software allows orthodontists to view, edit, and incorporate their own treatment mechanics and case specific considerations to perfect the smile before customized brackets, wires, or aligners are manufactured. The Approver is the feature that gives patients the ability to view a digital 3-D model of their final smile before treatment begins, offering orthodontists a powerful consultation tool UÊ * >Vi i ÌÊ Õ `iÃ\ Precision Placement Guides— or jigs—accompany each case and aid in ideal bracket placement for the individualized patient treatment plan, resulting in reduced mid-treatment bracket repositioning while also encouraging chairside delegation of delivery UÊ } Ì> Ê- ÕÌ ÃÊ-«iV > ÃÌÃ\ Ormco’s team of Digital Solutions Specialists is a well-educated product support team that helps ensure all users are properly trained on software functions and treatment options UÊ Ã } >Ê } Ì> Ê/À> }\ Training is scheduled at the orthodontist’s convenience and can be accomplished in a few short intervals. Training is designed to minimize the learning curve and incorporate key staff members to ensure total office proficiency Insignia users also will benefit from greater practice differentiation and growth as a result of Ormco’s Insignia consumer education campaign, which involves a number of search engine marketing and public relations programs to drive prospective patients to www.insigniasmile.com where they are able to locate an Insignia doctor. A full range of turnkey in-office consultation materials, ranging from lobby videos to TC presentations, also are available exclusively to Insignia users.

This information was provided by Ormco Corporation.

Ormco is dedicated to manufacturing innovative products that improve the clinician’s opportunity to achieve excellent results in the least amount of time, in the fewest number of appointments, and with the greatest patient comfort. From personalized service to worldwide continuing education programs and marketing support, Ormco is committed to helping orthodontists achieve their clinical and practice management objectives. For more information, visit www.ormco.com.

Volume 3 Number 4

Technology

VPDUW ZD\V ʞR XSJUDGH \RXU UDGLRJUDSK\ LQ ʞRGD\ɱV HFRQRP\ Bryan Delano, co-founder of Renew Digital, discusses creative techniques for investing in innovative technologies

T

oday’s high-tech world demands advanced stateof-the-art equipment – both inside and outside the general dental and specialty practice. Numerous studies have shown that dental professionals who reinvest in their practices with modern technology tend to be leaders in their respective fields with increased production and higher profits. The challenges of our current economy, however, can often limit a practitioner’s practical and financial ability to adopt these innovative products and services. The use of creative purchasing techniques and tools such as Section 179 tax deductions and financing, trading in your current X-ray, or purchasing used or refurbished systems can help minimize the impact of upgrading and keeping up with current imaging technology.

IRS Section 179 Deduction Historically, one of the easiest ways to realize immediate savings on capital dental equipment purchases is through the IRS Section 179 deduction. This incentive allows business owners to deduct the full price of purchased, financed or leased qualifying depreciable equipment and software for the current tax year. The equipment purchased or leased must be within the specified Section 179 dollar limits and must be placed into service in the same tax year that the deduction is taken. In recent years, the size of the deduction provided an exceptional opportunity for dental practitioners to upgrade, modernize, and invest in their practices.

Prior to the economic downturn following the 9/11 tragedy, Section 179 allowed for a deduction of up to $25,000 of qualifying depreciable property used in trade or business activities. To help boost the economy through increased spending in manufacturing and technology, the Jobs and Growth Tax Relief Act of 2003 increased the Section 179 deduction limit from its annual ceiling of $25,000 to $100,000. The annual deduction limit was further increased in 2007 to $125,000 and then again in 2008 to allow for an annual deduction of up to $250,000.

It was revised significantly in 2010 to allow a maximum annual deduction of up to $500,000 for tax year 2011 Figure 1

48 Orthodontic practice

and then dramatically reduced the deduction back to an inflation-indexed $125,000 ($139,000) in 2012. Starting in 2013, the annual deduction limit under Section 179 is scheduled to return to its pre-2003 $25,000 level (see Figure 1).

As a result of these significant upcoming changes to Section 179 deductions at the end of this year, dental practitioners should contact their tax advisors to discuss the benefits of acquiring depreciable business assets, such as dental X-ray and cone beam systems in the remaining months of 2012.

Bryan Delano is a co-founder of Renew Digital, the leading provider of refurbished dental X-ray systems. With more than a dozen years in dental technology experience, he has held key management positions at Carestream Dental (KODAK Dental Systems), 360imaging, and topsOrtho. His extensive background includes practice management software, dental X-ray technology, implant planning and patient education. Mr. Delano lives in Atlanta, Georgia with his wife and two children.

Volume 3 Number 4

Technology licensed software, missing parts, and non-transferable warranties. Plus, delicate X-ray components can be easily mishandled in removal, shipment or installation, resulting in expensive repairs. All of these issues, combined with lost production while managing the process, can be more costly and time consuming than initially anticipated.

Trade-in The introduction of dental cone beam and the release of newer generations of these systems have created a previously unprecedented trade-in value for 2D panoramic digital X-ray and first generation cone beam units. Due to this demand, several reputable companies have surfaced that purchase, refurbish, and sell used dental X-ray equipment, allowing practitioners to recoup a portion of their initial investment by selling or trading their panoramic or cone beam systems. Often, these funds can be provided to the practitioner directly upon removal or sent to the equipment dealer or vendor to apply to the down payment of the new unit. Used equipment dealers can also work directly with the new equipment vendor to coordinate removal of their existing system with the implementation of the new unit, minimizing office “down time” or loss of production.

The fair market value of used dental X-ray and cone beam equipment, like that of used vehicles, depends on several factors such as the unit’s make and model, age, condition, and exposure count. Included hardware and networking components such as cephalometric capabilities, ethernet connectivity, and multiple sensors can affect the system’s value. Additional features such as extraoral bitewings, touch panel controls, and other upgrades can also impact the purchase price.

Some practitioners opt to sell their existing equipment on their own in an attempt to achieve the greatest profit.

However, these transactions often result in improperly Volume 3 Number 4

Refurbished equipment Many practitioners have chosen to purchase used or refurbished equipment that is current generation or only one generation behind. This strategy can offer a significant cost savings on more advanced 2D digital panoramic systems, 2D/cone beam 3D-hybrid units, or cone beam 3D scanners.

Companies that offer used and refurbished dental X-ray systems can often provide the “new” product experience with up to 50% savings off the cost of new equipment. This equipment is typically inspected at time of pick up, refurbished as needed at the company’s warehouse, thoroughly tested again, and resold in an “almost new” condition. They then coordinate product delivery and installation – including the latest imaging software, conduct on-site training, and provide after-purchase service and support. Some companies even include comprehensive product and manufacturer’s warranties.

Because refurbished X-ray companies are “vendor neutral” and have access to a wide variety of models, they can help practitioners select systems that best fit their practices, regardless of manufacturer. They can also help find previous generation models to “match” X-ray systems in primary offices for secondary locations, minimizing staff learning curve and software integration issues. Because they are equipment resellers, these companies are also often willing to take existing 2D digital equipment as trade-ins for more advanced 2D or cone beam systems, further reducing the purchase price.

For increased affordability, used or refurbished X-ray equipment is eligible for certain low-interest financing programs and Section 179 tax deductions.

There are many ways in which modern dental and dental specialty practices can benefit from innovative imaging technologies – and numerous ways to incorporate them, even in today’s tough economic landscape. Implement your smart X-ray upgrade plan today!

About Renew Digital Renew Digital is the leading provider of quality refurbished panoramic X-ray and cone beam 3D systems to dentists and dental specialists throughout the U.S. and Canada.

Since all systems include delivery*, installation, training, and a comprehensive warranty, Renew Digital offers dental professionals the features and reliability they need to deliver superior patient care more affordably. Visit www.renewdigital. com or call 888-246-5611 for more information. *Continental U.S. only.

Orthodontic practice 49

Practice management Gary Johnson explains the elements of the

I

experience

have the opportunity to lecture to thousands of dentists and orthodontic staff around the country. In my lectures, one of the areas I emphasize is providing the “WOW” experience. While many practices do a wonderful job providing a great clinical experience, my research shows that we take many aspects of the first impression or interactions with the patient for granted.

Let me give you an example. One question I always ask of the staff is to estimate the dollars spent each year to market the practice. I explain that the marketing budget is everything they think is done to attract new patients. I get a wide array of answers ranging from $0 to as much as $100,000 per year. When I explain to them that they are not even close to the real number, they all look at me with disbelief until I explain.

I ask the staff members to assume that their doctor had just come from back from a marketing symposium.

At that symposium, the first speaker was an expert on the Internet and suggested that if you plan to be in the field of dentistry over the next 10 to 15 years and do not have a strong web presence, you are in big trouble.

The reason for this is because research shows us that two out of every three people under the age of 50 will search the Internet first when trying to find a local business.

In addition to being on the web, the expert continues that you must not only have a presence, but you must be within the first two pages of their search, or they won’t find you.

This means that search engine optimization (SEO) and Really Simply Syndication (RSS) are absolute necessities in the development of your site.

The marketing expert goes on to describe the critical nature of choosing your “meta tag” wisely. A meta tag is the paragraph underneath your practice’s name in an Internet search. Most businesses unfortunately allow the search engine to randomly pull information from your site to place in your meta tag. The expert strongly recommends that you prepare these words wisely as this is what the searcher is reading to determine which site to click on.

In addition to SEO, RSS, and the meta tag, the marketing guru tells the audience that research shows that once someone clicks on your site, you have a whopping 4 seconds to make an impression before the searcher will hit the “back” button. This means that aspects like coloring and ability to easily navigate your site are critical. Other important considerations include pictures of staff, clearly demonstrating what makes your practice unique, and answering frequently asked questions.

Armed with this new information, you go back to the practice, and make changes to your website as suggested by the marketing consultant. You hire your region’s most expert website developer. You bring someone in from the novel writing department at the local university to write the 50 Orthodontic practice

meta tag and to reconstruct all wording throughout the site.

You hire an interior decorator to make recommendations on the “right” colors for each web page. You send the staff to the mall to get their pictures taken by Glamour Shots®. The site now truly looks incredible.

Now that your site is ready and available for viewing by the world, let’s go back and answer the question about your annual marketing budget. “Mom” is in search of a new dentist. She goes to the Internet and finds your site on page one of her search. The meta tag underneath your practice name catches her attention. She reads it and cannot wait to click on your site. She clicks and truly cannot believe the beautiful coloring of your site. The words on the site are like poetry. All of her questions are answered with flair and precision. She notices pictures of your staff and imagines how wonderful they will be to deal with. Everything about your site tells her that she has found the panacea of dentistry.

She hurriedly dials the phone with great anticipation of the beginning of a long and wonderful relationship. Then, everything comes to a screeching halt when the person on your end of the line answers and sounds like “Bonnie Bad Day” or “Nancy Negative.” What happened to all the money you spent to attract this potential new patient to your site?

It went right down the drain.

As humans, we are emotional decision makers, and every encounter with us is measured and analyzed. Mom will make decisions on whom she will pick to be her family’s dentist or specialist based on how your team makes her feel, not on the quality of your dentistry.

Staff will have the greatest impact on the growth of your practice. Period. No matter how good you are clinically, no matter how much you advertise, the greatest growth factor is the perception your staff creates in the mind of the potential patient. That is why you should never, never, never, take the first encounter for granted. Unfortunately, most practices do take that first impression for granted, and that is why their “appointment kept” ratios are not where they would like or their patients’ starts are below expectation.

So when considering your marketing costs, always remember that the first encounters we have with the patient are critical – everything from your website design, your search engine optimization, the look of your practice, but most importantly, the way your staff makes your potential or existing patient feel.

Gary Johnson is a national lecturer on practice management and author of The Momentum Maxim: Using the principles of W.O.W. to revolutionize your practice. He is a scheduled speaker for staff at the 2014 AAO in New Orleans. He offers free practice management for clients of DynaFlex. His website is www.practicemanagesolutions. com.

Volume 3 Number 4

Practice management

Toby Buckalew shows that there “arrrrrr” ways to avoid pirating software licenses

P

eople dress as pirates for Halloween. Sports mascots abound with the pirate theme. There are references to pirates everywhere. There is one type of pirate that may be lurking in your office – and it may be you! Software piracy is a serious situation that you may be unknowingly participating in – a lack of knowledge that could easily lead to large fines and a closing of your doors.

In its simplest terms, a software license is permission to use a piece of software within the terms of the license agreement. Install or use the software outside these rules, and you find yourself in the realm of the software pirate (in illegal use of the software). Is this a serious situation? Yes! Fines for software piracy can easily reach well into the sixfigure range, leaving many practices in a hole they may not be able to climb out of.

What makes illegally licensed software dangerous is that many businesses do not realize they have illegally licensed products on their computers – only learning when they are audited, making it too late to correct. How does this happen? People lose track of how many copies they own, misinterpret licensing terms, or have staff or consultants install software they were not aware of. Regardless of the circumstances, the business owner is always held as the responsible party. So it does not matter if it was a consultant, an ex-employee, a mistake, or even a current employee that did so without your knowledge.

“I’m too small to be audited by anybody!” We refer to these as famous last words! The industry’s major software vendors banded together to create the Business Software Alliance (BSA). The BSA’s mission is to educate, enforce, and promote legal software use. It is funded by the settlements 52 Orthodontic practice

and fines from illegal software use from businesses large and small. These result from software audits they perform on a business – any size business. The question often asked is, how do they choose a company to audit? The answer usually comes down to an anonymous call, posting on their website, or email to the BSA alerting them to potential illegal software use.

Knowing you are a responsible business owner and want to avoid any potential fines for illegal software use (piracy), it is important to understand some software basics in order to protect yourself and your practice. The first part of understanding is how software is licensed. Next, how to prove you legally own the license. Finally, how to ensure you remain compliant once you verify all is well.

License purchasing falls into four categories: retail boxed, downloaded, volume licensing agreements, and leased software.

UÊ ,iÌ> ÊL Ýi`\ÊÊ/ ÃÊ ÃÊÌ iÊ ÃÌÊÌÀ>` Ì > Êv À Ê vÊ Vi à }Ê – you go to the store (or online) and buy it. Most retail boxed software is licensed to be installed on one computer.

UÊ Ü >`i`\ÊÊ Ü >` }ÊÃ vÌÜ>ÀiÊ ÃÊLiV }Ê ÀiÊ common these days. This is just a modern version of retail boxed (without the box).

UÊ 6 Õ iÊ Vi à }Ê>}Àii i ÌÃ\ÊÊ6 Õ iÊ>}Àii i ÌÃÊÜ Ì Ê>Ê software vendor allow you to obtain quantities of software licenses for a discount. Today, these agreements also provide you an online record of your license purchases.

UÊ i>Ãi`ÊÃ vÌÜ>Ài\ÊÊ i>Ãi`ÊÃ vÌÜ>ÀiÊ> ÜÃÊÌ iÊV «> ÞÊÌ Ê use the software, as long as they maintain their contract, and make their support/lease payments to the software vendor.

Volume 3 Number 4

Practice management What makes illegally licensed software dangerous is that many businesses do not realize they have illegally licensed SURGXFĘ&#x17E;V RQ WKHLU FRPSXĘ&#x17E;HUV â&#x20AC;&#x201C; only OHDUQLQJ ZKHQ WKH\ DUH DXGLĘ&#x17E;HG PDNLQJ LW Ę&#x17E;RR ODĘ&#x17E;H Ę&#x17E;R FRUUHFW Once obtained, you need to understand how you are allowed to install and use your software â&#x20AC;&#x201C; this is the license type.

UĂ&#x160; *iĂ&#x20AC;Ă&#x160; Ă&#x2022;Ă&#x192;iĂ&#x20AC;Ă&#x160; Â?Â&#x2C6;ViÂ&#x2DC;Ă&#x192;Â&#x2C6;Â&#x2DC;}Ă&#x160; ­Ă&#x192;Â&#x153;Â&#x201C;iĂ&#x152;Â&#x2C6;Â&#x201C;iĂ&#x192;Ă&#x160; V>Â?Â?i`Ă&#x160; >Ă&#x160; Â&#x2DC;>Â&#x201C;i`Ă&#x160; Â?Â&#x2C6;ViÂ&#x2DC;Ă&#x192;iÂŽ\Ă&#x160;Ă&#x160; One license allows one user to use the software purchased.

Read the terms carefully; this may only be on one specific computer or one specific individual.

UĂ&#x160; Â&#x153;Â&#x201C;ÂŤĂ&#x2022;Ă&#x152;iĂ&#x20AC;Ă&#x2030;`iĂ&#x203A;Â&#x2C6;ViĂ&#x160;­Ă&#x152;Â&#x2026;Â&#x2C6;Ă&#x192;Ă&#x160;Ă&#x152;Â&#x2026;iĂ&#x160;Â&#x201C;Â&#x153;Ă&#x192;Ă&#x152;Ă&#x160;VÂ&#x153;Â&#x201C;Â&#x201C;Â&#x153;Â&#x2DC;ÂŽ\Ă&#x160;Ă&#x160;"Â&#x2DC;iĂ&#x160;Â?Â&#x2C6;ViÂ&#x2DC;Ă&#x192;iĂ&#x160; allows the software to be installed and used on one computer, for any number of different people that use that one computer.

UĂ&#x160; Â&#x153;Â&#x2DC;VĂ&#x2022;Ă&#x20AC;Ă&#x20AC;iÂ&#x2DC;Ă&#x152;\Ă&#x160; Ă&#x160; Ă&#x160; VÂ&#x153;Â&#x2DC;VĂ&#x2022;Ă&#x20AC;Ă&#x20AC;iÂ&#x2DC;Ă&#x152;Ă&#x160; Â?Â&#x2C6;ViÂ&#x2DC;Ă&#x192;iĂ&#x160; >Â?Â?Â&#x153;Ă&#x153;Ă&#x192;Ă&#x160; >Ă&#x160; Ă&#x192;ÂŤiVÂ&#x2C6;wVĂ&#x160; number of people to access a specific piece of software at the same time. For example, if you have five concurrent licenses, only five people could use the software at one time.

For a sixth person to use the software, another would have to stop using it.

Regardless of which method was used to acquire the software and license, or how it is licensed for use, you must still have proof of ownership of the license. Believe it or Â&#x2DC;Â&#x153;Ă&#x152;]Ă&#x160;Ă&#x152;Â&#x2026;iĂ&#x160;

Ă&#x160;Â&#x153;Ă&#x20AC;Ă&#x160; 6 Ă&#x160;`Â&#x153;iĂ&#x192;Ă&#x160;Â&#x2DC;Â&#x153;Ă&#x152;Ă&#x160;ÂŤĂ&#x20AC;Â&#x153;Ă&#x203A;iĂ&#x160;Ă&#x17E;Â&#x153;Ă&#x2022;Ă&#x160;Â&#x153;Ă&#x153;Â&#x2DC;Ă&#x160;Ă&#x152;Â&#x2026;iĂ&#x160;Â?Â&#x2C6;ViÂ&#x2DC;Ă&#x192;itĂ&#x160;Ă&#x160; There are a number of misconceptions as to what constitutes proof of ownership â&#x20AC;&#x201C; in the end, only a documented license agreement, contract, or invoice/receipt shows proof of ownership.

Many items believed to be proof of ownership or proof of legality are actually just anti-piracy measures. By themselves, they do not show illegal licensing, nor do they show proof of ownership â&#x20AC;&#x201C; they are simply tools. These include installation keys you type in to install the software and hologram disks, which simply help show the disk is legitimate â&#x20AC;&#x201C; not that you own a license to use it.

With that mountain of knowledge under your belt, we can put it to use! How do you ensure you are covered and legal? The simple answer is, audit yourself! This entails examining all the applications installed on all computers used by the practice in all locations and comparing them to your purchase invoices. You should have a matching license count, installed versus invoice/receipt.

So, you feel pretty good, went to your computer, and found something you did not expect â&#x20AC;&#x201C; lots of different programs that barely (if they do) match what you expected to see! This is the tricky part. When you purchase a new computer, it probably came with a number of preinstalled (legally licensed) applications you do not have Volume 3 Number 4

individual receipts for. For these, you simply need to locate the specifications of the machine showing the software it came with, and keep a copy of it with the invoice for the computer. The other thing you may see is a list of a dozen or more individual applications that are part of a suite â&#x20AC;&#x201C; the most common being MicrosoftÂŽ Office. When you install Microsoft Office, it actually installs a number of individual applications, not just one named â&#x20AC;&#x153;Office.â&#x20AC;? This makes your audit a little more difficult. The key here is to document what you purchased, and organize your invoices/receipts.

You finally complete your audit and found some employees downloaded a few things they should not have, or that you may be short a license or two. What are your next steps? Remove what you do not need, use, or have licenses for. For those items you do need, purchase the additional licensing.

After all this work â&#x20AC;&#x201C; the learning, the audit, the research, Ă&#x153;Â&#x2026;>Ă&#x152;Ă&#x160; Â&#x2C6;Ă&#x192;Ă&#x160; Â&#x2DC;iĂ?Ă&#x152;ÂśĂ&#x160; Ă&#x160; Â&#x153;VĂ&#x2022;Â&#x201C;iÂ&#x2DC;Ă&#x152;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;tĂ&#x160; Ă&#x160; 9iĂ&#x192;]Ă&#x160; >Ă&#x160; Ă&#x192;Â&#x2C6;Â&#x201C;ÂŤÂ?iĂ&#x160; vÂ&#x153;Â?`iĂ&#x20AC;Ă&#x160; Â&#x153;Ă&#x20AC;Ă&#x160; binder with the invoices, receipts, and licensing contracts you signed, together with your audit results, should be kept up-to-date. While a good start, you should consult with an experienced individual or company to help with your selfaudit. Ă&#x160;

Â&#x153;Â&#x2DC;}Ă&#x20AC;>Ă&#x152;Ă&#x2022;Â?>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x192;tĂ&#x160;Ă&#x160;9Â&#x153;Ă&#x2022;Ă&#x160;Â&#x2026;>Ă&#x203A;iĂ&#x160;Ă&#x153;i>Ă&#x203A;i`Ă&#x160;>Â&#x2DC;`Ă&#x160;LÂ&#x153;LLi`Ă&#x160;Ă&#x152;Â&#x2026;Ă&#x20AC;Â&#x153;Ă&#x2022;}Â&#x2026;Ă&#x160; the pirate infested waters of software licensing! Time to don your three-cornered hat and eye patch, buy a trained parrot, and proceed to feel confident about your software situation.

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.

Orthodontic practice 53

Practice management

HIRING the Right People For practices that want to hire great employees, Dr. Rick Steedle suggests why you may not have been successful in the past and offers sound advice on how to hire better staff in the future

U

ltimately, the success of your practice is not limited by the economy, competition, or any other external factor.

It thrives (or simply just survives) on your ability to hire, train, and retain an excellent staff. With an exceptional staff, you are able to consistently deliver outstanding service, which gives your practice a powerful competitive advantage.

But, how do we find good people? What’s the best way to select the right person? And, how do we decide if we should keep a new employee?

This article will take a detailed look at the hiring process, reviewing the key steps, suggesting ways to improve and, thereby, increasing your chances of choosing the right person.

The three essential hiring skills All of us have experience hiring staff, and no one can presume to know the unique situation or specific challenges you might face in finding good employees. Nonetheless, under all circumstances, hiring the right person for your practice comes down to three basic skills: UÊ ÀÃÌÊÞ ÕÊ ÕÃÌÊw `ÊÌ iÊÀ } ÌÊ«iÀÃ Ê UÊ / i ÊÞ ÕÊ ÕÃÌÊV ÃiÊÌ iÊÀ } ÌÊ«iÀÃ Ê UÊ `Êw > Þ]ÊÞ ÕÊ ÕÃÌÊi « ÞÊ> `ÊÀiÌ> Ê ÞÊÌ ÃiÊÜ Ê are right for your practice So, what are the best strategies to add someone who will become an asset to your practice?

Finding the right person Actually, we don’t really “find” the right person; instead, the best practices attract the right person. Good employees will not even consider your office unless it’s a great place to work. So, the best way to find the right person is to make your practice highly attractive to the right person. You must get your house in order first if you expect the best employees to apply.

So, even before you’re actively hiring someone, the best way to attract the right person is to work to make your 54 Orthodontic practice

practice the “employer of choice” for potential staff in your community. The best people will not even consider your practice unless your present staff raves about your office and encourages others to apply.

Finding Strategy #1: Become the “employer of choice” To attract great employees, focus on making your practice the “employer of choice” in four key areas: UÊ «iÌ Ì ÛiÊ V «i Ã>Ì — A good salary and benefits package is merely the “price of admission” to be considered by the best person. Since the best people in other offices are usually being paid well already, it will take more than a good financial package to attract them to your practice.

UÊ Ê `Þ > VÊ «À>VÌ ViÊ Ü Ì Ê «ÕÀ« ÃiÊ > `Ê ` ÀiVÌ 1 — Is your practice staying current and constantly adapting to new technologies and ways of serving your patients?

Is your leadership inspiring and your purpose clear? The

J. Richard (Rick) Steedle, DMD, MSEd, MS, received his dental degree with honors from the University of Pennsylvania, concurrently completing a Masters Degree in Education. He received his Masters Degree in Orthodontics at The University of North Carolina at Chapel Hill where he was awarded the Morehead Fellowship in Post Graduate Dentistry and a NIH research training fellowship. After orthodontic residency, he served on the faculty of the Wake Forest University School of Medicine for 4 years before entering private practice. During the next 20 years, he and Dr. Bruce McLain built a three-office orthodontic practice with a staff of more than 25 employees in Winston-Salem, North Carolina. In 2005, Dr. Steedle joined the part-time faculty at the Department of Orthodontics in Chapel Hill. Since then, he has developed a 3-year curriculum in Practice Management for the residents, complementing the work of Dr. Robert Scholz there. UNC now has one of the most comprehensive Practice Management residency courses in the country. Contact Dr. Steedle at DrSteedle@gmail.com.

Volume 3 Number 4

Practice management

best people don’t want to remain stagnant; they want opportunities to learn and grow. At the end of the day, they want job satisfaction and the feeling that they have made a meaningful contribution.

UÊ Ê «Ì Õ Ê Ü À }Ê i Û À i Ì — What are the key frustrations that staff feel when working in any dental practice? Have you solved these problems in your office? The best employees are looking for a great working environment that includes a manageable work schedule, a compassionate, yet fair, leave policy, great office systems, sufficient training, and the necessary support to do their jobs well.

UÊ ÝVi i ÌÊ Ü À }Ê Ài >Ì Ã «Ã. How are the interpersonal relationships in your office? Do all staff members work as one team, or do they often annoy each other with petty squabbles? The best people want coworkers who care for each other, a doctor who appreciates them, and a voice in improving the operations of the practice.

When you do begin to look for a new employee, how do you find and attract the best person? Where are the best potential applicants working now, and what type of advertisement would attract them?

Finding Strategy #2: Write an appealing ad A standard ad will not get the attention of the best people.

Invest your time and money in an ad that appeals to an excellent applicant by wording it to attract the type of person you want. Be sure to include which personal traits are desirable, what makes your practice unique, and how they may have opportunities to grow. It may take a little more time and possibly cost a little more money, but what is the value of finding the right person?

compliment, and you may have found an excellent future employee.

Choosing the right person The best way to choose the right person is to have a highly selective hiring process that involves the entire team. In order to choose the best employees, first you need to be clear on what type of individuals are best suited to work in your practice and, second, have an effective way to identify them.

à }Ê-ÌÀ>Ìi}ÞÊ £\Ê-i iVÌÊÌ iÊÀ } ÌÊÌÞ«iÊ vÊ«iÀà It’s natural to think that you need applicants with experience who can step right in and won’t need much training.

However, practices that over-value and hire only the skilled employee may discover that these are the same people who later create interpersonal problems with the staff and patients. We can usually train someone to perform the skills needed to do well, but we can’t train people to have strong interpersonal skills.

A better way is to choose self-motivated people who share your core values, can learn their jobs quickly, and who, by their very nature, are caring and compassionate.

The goal is to choose the right person, then, hire and retain “good heads” and “good hearts,” not necessarily just “good hands.” When hiring, it’s great if you can get all three, but it’s essential that you get the first two.

à }Ê-ÌÀ>Ìi}ÞÊ Ó\Ê V Õ`iÊÞ ÕÀÊÃÌ>vvÊÜ i Ê À } If you are the only one who interviews applicants and independently makes the hiring decision, you have created an environment in which your present staff is not fully invested in helping the new employee succeed. In the best practices, the staff is deeply involved in the interview ` }Ê-ÌÀ>Ìi}ÞÊ Î\Ê `ÕVÌÊ>ÊÜ `i À> } }ÊÃi>ÀV process, and guides the final decision about who to bring

>ÃÌÊ>ÊÜ `iÊ iÌÊ ÊÌ iÊ «iÊ vÊw ` }ÊÌ iÊLiÃÌÊ«iÀà °Ê ÀÊ on the team. business staff, design a classified ad to attract applicants Once applicants have met with your approval, let outside the dental profession. Applicants with the the final selection be made by a consensus of your staff. right attitude and outlook are often employed in other If everyone has a voice, then everyone can commit to customer service jobs. Although Craigslist is a popular and welcoming the new employee and training him/her to be a inexpensive way to advertise for a position, consider that the productive member of your team. best applicants may be more inclined to read the classifieds in the local paper and scan online services like Monster.com à }Ê-ÌÀ>Ìi}ÞÊ Î\Ê >ÛiÊ>ÊÌ À Õ} Ê À }Ê«À ViÃà or CareerBuilder.com when choosing new employment.

To be highly selective, you need a systematic approach for Ask your staff to refer others like themselves. If you’ve choosing the best applicant rather than counting on just made your office the “employer of choice,” they will not a favorable impression from an application and interview. hesitate to encourage other great potential employees to This should include: join your team.

UÊ Ê iÝÌi à ÛiÊ Ãi>ÀV Ê «À ViÃà — prepare an attractive Ê > Þ]Ê V ÃÌ> Ì ÞÊ LiÊ Ê Ì iÊ ÕÌÊ v ÀÊ }Ài>ÌÊ advertisement, and conduct a wide-ranging search. employees even when you’re not hiring. This way you UÊ Ê ivviVÌ ÛiÊ ÃVÀii }Ê «À ViÃà — identify applicants can create a pool of potential applicants for when you whose resumes display the qualities desired, and have a need it. When you encounter people who give you great trained staff member prescreen them on the phone, inviting service, hand them a business card, and ask them to call if for an office visit only those applicants whose telephone they are considering a job change. “We’re always looking interview meets your standards. for excellent people like you.” They’ll be flattered by the UÊ Ê Ì À Õ} Ê ÌiÀÛ iÜÊ «À ViÃÃÊ — have the applicant Volume 3 Number 4

Orthodontic practice 55

Practice management

meet with the staff who will work closely with the new employee and schedule a short interview with you to get a preliminary impression. If the initial impression is favorable, invite the applicant for a one-half to full day in the practice to better assess the fit. Even though first impressions are important, several hours with the applicant is a better way to gauge his/her true nature.

UÊ ÊÀ } À ÕÃÊ`iV Ã Ê«À ViÃÃ — hire someone only when there is consensus among the staff that this is a person who is self-motivated, shares your core values, and has a good head and heart. If there are reservations among the staff, don’t hire, keep looking. Taking additional time finding the right person is preferable to endlessly spending time managing the wrong person.

Retaining the right person The best way to employ the right person is to have a highly discriminating probationary period, so that an applicant is retained only when you are 100% certain that he/she is right for your practice.

Even if you attract and select the right person, you still must be absolutely certain that this new employee can become a productive and harmonious member of your team. Both the team and the new hire need a probationary period of at least 90 days to evaluate the fit. During this time, the new employee is considered a temporary hire, and either party can walk away without giving advance notice.

value as high performers and excellent teammates in the first 3 months.

Retaining Strategy #3: Be 100% certain If you have done your job well in the selection phase, the probationary period usually goes well. In some cases, however, the new employee may learn that the position is not what he/she expected. In other cases, you may discover that he/she is not all that you thought. If you or your team has any doubts, it’s best that you dismiss the new person during the probationary period.

As difficult as this might be, you should retain a new hire only when everyone is 100% certain that the employee is right for your team. It’s not a question of whether everyone likes the new person. Usually everyone will. The decision is based purely on the “fit” for your office. Not being decisive at this point only sets the stage for problems later on.

The key hiring principles

Developing an outstanding staff starts with hiring good people and then forming them into an All-star Team.

Unfortunately, as Jim Collins points out in his classic book, Good to Great, “If you have the wrong people on the bus, it doesn’t matter whether you discover the right direction; you still won’t have a great company,”3 or a great practice. Ê ÀÊ«À>VÌ ViÃÊÌ >ÌÊÜ> ÌÊÌ Ê}iÌÊÌ iÊLiÃÌÊi « ÞiiÃʺ Ê the bus,” the “key hiring principles” then are: UÊ ÌÌÀ>VÌÊÌ iÊÀ } ÌÊ«iÀÃ Ê ,iÌ> }Ê-ÌÀ>Ìi}ÞÊ £\Ê*À Û `iÊ>`iµÕ>ÌiÊÌÀ> } By becoming the “employer of choice” for the best people Even the best new employees need a thorough training and conducting a wide-ranging search to locate them. program. The program should include several key elements. UÊ -i iVÌÊÌ iÊÀ } ÌÊ«iÀÃ Ê It should: Through a rigorous selection process in which team UÊ iÊ V `ÕVÌi`Ê ÌÊ LÞÊ Þ ÕÀÊ ÃÌÊ Ã i`Ê «iÀà ]Ê LÕÌÊ LÞÊ members participate in the decision to choose the right type your best trainer (someone who can give clear guidance and of person, not just the one with the right skills. emotional support to the new employee).

UÊ ,iÌ> ÊÌ iÊÀ } ÌÊ«iÀÃ Ê UÊ -ÞÃÌi >Ì V> ÞÊ «À }ÀiÃÃÊ vÀ Ê Ã « iÊ Ì>Ã ÃÊ Ì Ê Ì iÊ ÀiÊ By using a well-designed training program with frequent complex. feedback and retaining the new employee only when you UÊ iÊ}Õ `i`ÊLÞÊ>ÊÌÀ> }Ê > Õ> ]ÊÜ V ÊV Ã ÃÌÃÊ vÊÜÀ ÌÌi Ê and your staff are 100% certain that he/she is right for the protocols documenting your processes and procedures. team.

UÊ *À }ÀiÃÃ Ûi ÞÊ ÛiÊ Ì iÊ ÌÀ> iiÊ vÀ Ê `i«i `i ViÊ Ì Ê independence (using direct observation of the trainer, followed by the trainee performing the task with the trainer observing, progressing to executing the position with a ready backup, and finally leading to independent performance).

References ,iÌ> }Ê-ÌÀ>Ìi}ÞÊ Ó\Ê ÛiÊvÀiµÕi ÌÊvii`L>V During the probationary period, frequent and specific feedback from the trainer is essential. Is the new person learning quickly, displaying professional behavior, demonstrating a caring and compassionate attitude, and taking the initiative to become a team member?

At least monthly, the trainer should take some time with the new employee to honestly assess progress and offer suggestions for improvement. Any reservations about the new hire should be communicated immediately to the doctor and team. Everyone should be given a fair chance, but the best future employees will clearly demonstrate their 56 Orthodontic practice

1. Steedle JR (2011) Becoming the successful, not stressful practice: Part 1 – Choosing the right direction. Orthodontic Practice US 2 (2): 45-47.

2. Steedle JR (2010) Leading an all-star staff, J Clin Orthod, 44(8): 487-494.

3. Collins, J (2001) Good to Great: Why Some Companies Make the Leap... and Others Don’t. HarperCollins Publishers, New York.

Volume 3 Number 4

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists Endodontists

Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

The advantages of 2D & 3D in one comprehensive unit

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

For standard 2D images, it offers the most comprehensive selection of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing,

sinus, TMJ options and many more.

Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patientâ&#x20AC;&#x2122;s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977