Orthodontic Practice US November/December 2018 Vol 9 No 6 by MedMark, LLC

ce t cti men a r P age e n u Ma Iss

clinical articles • management advice • practice profiles • technology reviews November/December 2018 – Vol 9 No 6 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Employee-driven performance metrics: If you can’t measure it, you can’t manage it Ali Oromchian, JD, LLM

A tri-dimensional diagnosis and treatment planning guide Dr. Larry White

How digital dreams become a reality Dr. Andrew Nalin

Engaging wires, engaging employees: how employee engagement in the orthodontic office is tied to productivity and profit Manon D. Newell, JD

Corporate profile Planmeca Group

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The Inseparable Truth Among Orthodontics, Occlusion, TMD, and Sleep

DR. STUART FROST

Emotional Intelligence and its Impact on the Workplace DR. SONIA PALLECK

The Butterfly Effect: How Small Changes Can Make an Amazing Impact in Your Practice DR. JAMIE REYNOLDS

DR. DANIEL KLAUER

Explode Your Practice and Educate Your Patients with Instagram DR. DOVI PRERO

Igniting a Movement. Aligner Innovation Redefined DR. VAS SRINIVASAN

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INTRODUCTION

Keep learning!

Nov/Dec 2018 - Volume 9 Number 6

EDITORIAL ADVISORS

uring my formative years, I was always amazed at how my father kept learning at his profession. He was a business executive and was one of the first executives to implement a computer into his business. It was a huge piece of equipment, and I remember a picture of him standing next to the computer in the Wall Street Journal. His message to me when I attended dental school was to keep learning — there are always new frontiers in every profession. I attended dental school at the University of Michigan and will always be thankful that I went to that particular dental Dr. Robert Kaspers school. Each semester I would have a course in occlusion, and it paid huge dividends when I pursued a career in orthodontics. I also developed an interest in the temporomandibular joint as well as the musculature that controlled the movements of the mandible. At the time, our diagnosis of temporomandibular dysfunction consisted of a thorough medical history and clinical exam along with a muscle palpation examination. Splint therapy was initiated, but treatment was driven by symptoms. Today, the orthodontic profession can evaluate skeletal asymmetry by utilizing 3D technology. Taking a CBCT scan in maximum intercuspation gives the clinician a functional radiograph. Analyzing the condylar position informs the clinician of skeletal asymmetries we could never see with our 2D radiographs. We can now accurately analyze all three dimensions (anterior-posterior, transverse, and vertical) for each patient. In the past, my dentist friends told me that they would refer patients to the orthodontist for braces when they were in their teens. The patients would start bruxing in their twenties and have TMD symptoms in their thirties. Thanks to 3D technology, we can put a stop to that pattern. Orthodontists will soon be swamped with business when the dentists realize that we can treat their patients to a seated condylar position before they perform their restorative work. 3D technology also has helped orthodontists become leaders in screening for constricted airways. I cannot think of a more important benefit we can perform for our patients. 3D technology not only helps the clinician detect a constricted airway — but also gives us the necessary information, so we can treat the problem. Change is extremely difficult when your practice has been a successful business model. However, 3D technology is worth “learning” what it can do for you and your patients. The amount of important information you can acquire from a CBCT scan is amazing. Your professional journey is far from over. Keep learning! Dr. Robert Kaspers

Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

Robert Kaspers, DDS, received his dental degree with honors from the University of Michigan. He then completed specialty training in orthodontics at the Northwestern University Dental School and earned a Master of Science degree in Radiology. While in Ann Arbor, Dr. Kaspers worked with Dr. Major Ash on research projects pertaining to temporomandibular dysfunction. Dr. Kaspers has lectured to hundreds of dentists and orthodontists on diagnosis and treatment for both orthodontic and TMD cases. Dr. Kaspers is the founder of the Five Condylar Positions©, which has helped make diagnosing and treatment planning easier for the practitioner. Dr. Kaspers is the founder of ProActive Orthodontics, and it is his desire to help the profession understand the advantages of the CBCT scan machine so that diagnosis of orthodontic cases can be made more easily and more accurately. Currently, Dr. Kaspers maintains a private orthodontic and TMD practice in Northbrook, Illinois.

© FMC 2018. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

ISSN number 2372-8396

2 Orthodontic practice

Volume 9 Number 6

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Model analysis and set-up

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TABLE OF CONTENTS

Corporate profile Planmeca Group

A global leader in health care technology

Practice management What do gossip and gum disease have in common? Cynthia Goerig discusses achieving an office environment based on teamwork .......................................................16

Abstracts Abstracts Dr. Shalin Shah presents the latest literature, keeping you in touch with the latest studies and evolving technologies.................................... 20

Treatment tips Let the celebrities help

Orthodontic insight

Dr. Donald J. Rinchuse discusses showing famous smiles to illustrate orthodontic variations...................... 24

Esthetics in orthodontic treatment: helping patients understand what they really want Dr. Anoop Sondhi discusses patients choices between clear aligners and ceramic brackets ON THE COVER Inset photo on monitor courtesy of Dr. Andrew Nalin. Article begins on page 44.

4 Orthodontic practice

Volume 9 Number 6

Virtually Invisible. Practically Invincible. Hard to Beat Esthetics from a Hard to Break Bracket

Introducing Ovation® S by GAC New polysapphire Ovation S brackets give you the esthetics patients want with the compliance and control you need. Second in hardness only to diamond, the polysapphire structure of Ovation S resists the cracking and crumbling that can occur with traditional ceramic brackets. But it’s what you don’t see that will truly impress. Offering an esthetic experience that rivals clear aligners, Ovation S gives you the precision, performance and control that removable solutions can’t match. Give your patients the new Ovation S, the brackets that appear to disappear.

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TABLE OF CONTENTS Continuing education A tri-dimensional diagnosis and treatment planning guide Dr. Larry White examines some foundations of orthodontic therapy .......................................................26

Motivational marketing Patients don’t know how good they have it today — because no one is telling them Tom Owens offers tips about how to effectively spread the word about your practice’s technologies.................... 34

Orthodontic perspective

Continuing education Employee-driven performance metrics: If you can’t measure it, you can’t manage it

Ali Oromchian, JD, LLM, discusses how to effectively achieve targeted business objectives

Symetri™ Clear’s esthetic and clinical benefits Dr. Mark N. Coreil discusses a new ceramic bracket system................... 38

Step-by-step Having the AcceleDent® conversation with patients Dr. Michael Woods discusses motivating patients about the benefits of low pulsatile forces...................... 40

Technology How digital dreams become a reality Dr. Andrew Nalin discusses his journey to a digital office..............................44

Employee engagement Engaging wires, engaging employees: how employee engagement in the orthodontic office is tied to productivity and profit — part 1 Manon D. Newell, JD, discusses the first step in the orthodontist’s journey toward excellent business practices .......................................................48 6 Orthodontic practice

Product profile Damon™ Q2 2x the rotation control......................52

Going viral/legal matters

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118

The importance of an independent cybersecurity audit in the orthodontic practice

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com

Gary Salman and Justin Joy discuss ways to keep patients’ records safe .......................................................54

NATIONAL ACCOUNT MANAGER | Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com

Product insight Importance of design in the strength and function of 3M ceramic brackets Armineh Khachatoorian discusses the advantages of 3M ceramic brackets .......................................................58

Event recap Inaugural 3Shape Community Symposium.................................64

VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com

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Volume 9 Number 6

CORPORATE PROFILE

Planmeca Group

Planmeca showroom in Helsinki, Finland

A global leader in health care technology

hiny white design and devices with colors from metallic silver to lime green, 3D-printed skulls of humans and pets in illuminated glass display cabinets, touchscreens surrounding the devices that look like they’re parts of a spaceship. This futuristic yet inviting pastel-colored scene is not part of a science fiction novel but is reality in a showroom in Helsinki, Finland. This showroom belongs to the Planmeca Group, a company that develops and manufactures cutting-edge Finnish health care technology. Planmeca Group’s product range covers high-technology dental care equipment, world-class 2D- and 3D-imaging devices, comprehensive CAD/CAM and software solutions, mammography systems as well as dental instruments, supplies, and services. President and founder of Planmeca, Heikki Kyöstilä, has seen his company and the industry evolve hand-in-hand. Fortyseven years ago, in 1971, Kyöstilä saw a market opportunity for manufacturing dental equipment after doing business for German companies in the same field and decided to start a company of his own. Today, the parent company of the group, Planmeca Oy, is the third-largest dental equipment manufacturer in the world and also the largest privately owned company in the field. “It was all about hard work and an urge to put Finland on the map. And today, Planmeca is a global leader in health care technology,” said Kyöstilä. 8 Orthodontic practice

Planmeca’s aim is to create functional, durable, and beautifully designed products that stand the test of time. Planmeca’s dental care units, X-rays, and software solutions are all designed and manufactured in Finland. Using the latest technology and the best materials, products are tailored to meet the needs of dental professionals in different markets. Planmeca Group’s advanced mammography and orthopedic imaging products are manufactured by the group’s subsidiary Planmed Oy. Plandent Division of the group is the biggest dental supply and service chain in Northern Europe. The division consists of comprehensive dental supply houses, which offer innovative digital solutions and supply high-tech equipment manufactured by Planmeca. The division also offers a comprehensive selection of high-quality materials and instruments from the world’s leading manufacturers. Over 98% of products manufactured by Planmeca are exported around the world. Planmeca Group operates in over 120 countries, employing nearly 2,700 people worldwide. Kyöstilä explains that a strong commitment to building customer relationships around the world and a passion for innovation guide everything the company does. Customers provide the company with the focus to consistently develop revolutionary technology and gain a deep

Heikki Kyöstilä, president and founder of Planmeca

understanding of the needs of dental and health care professionals. He believes these values have led them to where they are today — at the forefront of the dental industry.

Strong commitment to R&D The secret behind the success and never-ending innovation decade after decade is, according to Kyöstilä, a strong and unwavering commitment to R&D. “As a privately owned company, we are in control of our own destiny and able to make the long-term R&D commitments that are the driving force behind our innovations. We also collaborate closely with health care professionals and leading universities. I firmly believe that this dedication to continuous development will enable us to make the work of dental professionals easier and more efficient for many years to come.” Up to 10% of the company’s annual revenues are invested in R&D. Planmeca’s in-house R&D department employs 140 people: a mixed group of experts, including software, mechanics, and electronics engineers together with usability and industrial designers. Unrivaled scientific knowledge and in-depth understanding of clinical Volume 9 Number 6

A digital pioneer Already in the late 1990s, Planmeca realized that a shared software platform would be the logical next step, bringing diagnostics and treatment planning into a single workflow. Planmeca’s solution for this was, and still is, the ever-evolving Planmeca Romexis®, an all-in-one software connecting all of the equipment in a dental clinic.

Volume 9 Number 6

Planmeca USA, Inc. Planmeca USA, the North American Subsidiary of Planmeca, was launched in

1987 and the first to introduce the softwaredriven dental care unit concept in America. For the past 31 years, Planmeca USA has lead the North American dental industry with advanced dental imaging systems starting with film based, then digital 2D, and now 3D-imaging equipment with patented SCARA (Selectively Compliant Articulated Robotic Arm) technology. Today, it is one of the most admired dental-imaging companies in North America. Planmeca offers one of the most robust product lines in the world, which includes dental care units, dental lights, dental stools, dental cabinets, intraoral X-rays, intraoral sensors, 2D extra oral imaging, 3D imaging products, chairside milling units, and intraoral scanners. “The U.S. is one of the most competitive regions in the dental industry. As a company, Planmeca USA is poised to solidify its position as a leader across several categories within the dental market. A strong product line, energized product launches, and an innovative pipeline will provide the company with upward momentum and exciting times for the U.S. division,” states President for Planmeca USA, Edwin J. McDonough. Planmeca’s newest technology, Planmeca Viso™, has the capability of capturing the industry’s largest single scan volume covering the entire maxillofacial area. McDonough describes the technology — “the innovation that paves the way for the launch of Planmeca 4D™ Jaw Motion, a new exclusive

Orthodontic practice 9

CORPORATE PROFILE

workflows are vital parts of the product development.

In 2011, Planmeca launched the concept of digital perfection. The company took digital imaging to the next level by enabling the combination of three different 3D datasets (photo, X-ray data, and digital impression) into one complete 3D model. Planmeca was also among the forerunners to market the integration of CAD/CAM to dental treatment units. Due to the open-source STL file format of Planmeca’s CAD/CAM solutions, it is easy for dentists to connect with the rapidly growing computer-aided dental manufacturing community. The Planmeca FIT™ solution offers dentists a completely integrated and digital workflow with three simple steps — ultra-fast intraoral scanning, sophisticated design, and high-precision chairside milling. All of this is seamlessly integrated into Planmeca Romexis software. CAD/CAM dentistry is an integral part of Planmeca today — a wide range of open architecture CAD/CAM solutions lets the dental professionals choose their preferred way to treat patients, improve workflow, and opens opportunities in growing the business scope. Planmeca’s newest intraoral scanner, Planmeca Emerald™, was designed on an open architecture platform and lets dentists offer more services by collaborating with laboratories or integrating additional equipment within their office.

CORPORATE PROFILE

Mill manufacturing line

X-ray production

specialty program, is the only CBCT integrated solution for tracking, recording, visualizing, and analyzing jaw movement in 3D in real-time.” McDonough describes a company initiative that focuses on offering dentists specialty workflows, more treatment options, and ultimately better patient care through efficiency. “With our current products and additions to the product portfolio, Planmeca can offer solutions to meet the needs of patients needing restorations, orthodontics, and even implants. Anticipating the needs of our clinicians is our number one priority. One area of dentistry that we will be exploring in the future is 3D printing. Planmeca Creo™ C5 is a new product tailored to meet the needs of our orthodontic partners and is primed to be a blockbuster for our CAD/CAM Division,” McDonough says. All of Planmeca’s imaging, dental care units, and CAD/CAM products are built on open-architecture platforms. Designed with clinicians in mind, Planmeca’s upgradable, modular platform allows doctors to keep up with new technology by easily integrating the newest advances in hardware and software.

Elements of future growth Planmeca has stayed on the cuttingedge of dental products now for almost

1971

1979

1986

Planmeca OY The 1st dental unit founded in brought to market Helsinki, Finland

The 1st patient chair brought to market

1975

1983

2006

Launched a microprocessorcontrolled panoramic X-ray device

Planmeca introduces 1st microprocessor controlled dental chair

10 Orthodontic practice

half a century. The plan is to stay on the cutting-edge in the future too. But what does the future of dentistry and health care technology look like? Kyöstilä sees a digital future ahead. “We are living in an exciting era. Dentistry is at a crossroads; the digital revolution has already begun. In the future, dentistry will be completely digital, and 3D technology is going to transform the entire field. Software-driven innovations are now the heart of progress, and cloud services are reality. This presents unforeseen opportunities, but also new challenges.” “The industry is moving from products to services. In a completely digital dental workflow, it will be of paramount importance that all devices and software work together completely seamlessly. The future will not only be digital, but also increasingly mobile. This reality is at the core of all Planmeca product development,” Kyöstilä explained. When Kyöstilä describes his visions of the industry’s future, phrases like software, industrial internet, 3D printing, CAD/CAM, 3D, and even 4D keep coming up. “It is our goal to design and manufacture high-end digital products that work together as smoothly as possible. To achieve this, we have been forerunners in building a rich ecosystem of devices, software, and

This information was provided by Planmeca Group.

2008

Launched all-in-one Planmeca Romexis software, Planmeca Clinic Management introduced Romexis

Cone Beam Volumetric Dental Unit with symmetrical Tomography system for 3D motorized movements dental imaging introduced enabling fully adaptable unit

2005

services. Our unrivaled product portfolio covers everything needed in a high-tech dental clinic: all 2D- and 3D-imaging modalities together with digital treatment centers, CAD/CAM systems, and software.” “Software used to be something people received with the device they purchased, but now software is often the most important product. Software is the brains behind the products. We keep developing our software solutions and improving them constantly. This is all part of our goal to create the most powerful dental ecosystem in the market.” “At Planmeca, we always operate with the future in mind. The possibilities with CAD/ CAM, 3D, and even 4D are endless. I strongly believe that Planmeca will guide dentistry into the future like no one else can.” Planmeca USA has distribution in the United States and Canada servicing over 160 dealer locations throughout North America. Currently, Planmeca USA maintains 42 sales representatives in the field, one of the best management teams in the industry, and 40 technical support professionals with a total of over 135 employees supporting our North American distributors and doctors. OP

2007

Planmeca Digital Academy launched – education/ training

2016

2017

Planmeca Planmeca PlanMill 40 Emerald S launched launched

Full range of open Planmeca Romexis Planmeca Viso CAD/CAM solutions 4.0 – 1st software to and 4D Jaw to labs and dentists combine imaging Motion launched and CAD/CAM 2013 2018 workflow.

Volume 9 Number 6

Experience the Planmeca Difference You don’t have to move mountains to make a big difference. You know that small moves can have a big impact. At Planmeca, we’ve built our solutions on the smallest details.

Planmeca ProMax® 3D

Our digital workflow for orthodontics offers complete integration at every step:

•

Planmeca 3D units offer large field-of-views*, cephalometric imaging and low dose radiation for patient safety

•

Jaw motion technology for real-time visualization of mandibular jaw movements in 3D

•

Fast and accurate full arch scanning including automatic bite alignment

•

Orthodontic software for digital dental models including clear aligners, indirect bonding, Bolton analysis, and measurements Planmeca Romexis® 3D Ortho Studio

The small things form the big picture – delivering treatment and care your patients deserve. Learn more about Planmeca products today.

630-529-2300

www.planmecausa.com

Planmeca Emerald™

ORTHODONTIC INSIGHT

Esthetics in orthodontic treatment: helping patients understand what they really want Dr. Anoop Sondhi discusses patients choices between clear aligners and ceramic brackets

n recognizing where we are with esthetic orthodontic treatment, I typically discuss three approaches with patients. First, esthetic appliances can refer to ceramic brackets, which are much less visible than traditional metal brackets. Second, esthetics can refer to treating cases with clear aligners and eliminating the need for brackets. The third choice is a combination of the first two options. If a patient walks in my door asking for a specific appliance, we focus on the patient’s main concern about his/her smile and treatment goals. We show patients a model with metal braces and a model with clear braces — 90% of the time they pick the ceramic braces or aligners. Occasionally, children will select metal because their friends have them, and they want the same thing. Almost every adult, without exception, opts for ceramic braces or aligners. With clear aligners, we must appreciate that there has been a tremendous amount of advertising directed at consumers. This brings people into the office asking for aligner treatment because they saw a commercial advertisement, or they’ve seen a friend who has them. As our knowledge and capability in managing aligners progresses, we are finding that there are quite a few clinical problems that can be managed just as well with aligners as they could with braces. However, there are certain cases that do not treat as well with aligners as they do with fixed brackets — we have more control with fixed braces. In this instance, what we find with some patients is that they are disappointed because they had their heart set on aligners — until we

Figure 1: Patient under active treatment with 3M™ Clarity™ aligners

educate them! We show them their smile photographs and are able to point out that the lower teeth are often not visible when they smile. We can use aligners on the upper teeth and brackets on the lower teeth where more work is frequently needed anyway. This maximizes the treatment options while also maximizing the esthetic possibilities!

Origins of esthetics How did the concept of esthetic orthodontics come about anyway? There was a shift in public perception aided by several factors, including the improvement of ceramic brackets over the years. In reality, we’ve had clear brackets for many, many years, but older brackets were made of plastic, were not as durable, and would stain a lot. Once manufacturers switched to high-quality ceramic materials, all that changed. The brackets did not stain, and

Anoop Sondhi, DDS, MS, received his Doctor of Dental Surgery degree from the Indiana University School of Dentistry and his postgraduate certificate and Master’s Degree in Orthodontics and Dentofacial Orthopedics from the University of Illinois. He taught as a professor in the Department of Orthodontics at Indiana University and continues as a visiting professor at several postdoctoral orthodontic programs around the country. He teaches advanced courses on treatment techniques at national and international orthodontic conferences. He has authored chapters in several orthodontic textbooks and journals. Dr. Sondhi and his wife, Rani, have four children — Jason, Sara, Jennifer, Melissa — and five grandchildren. Disclosure: Dr. Anoop Sondhi is a consultant and/or speaker for 3M Orthodontics.

12 Orthodontic practice

they remained esthetic throughout treatment. Concurrent with these material improvements, you had the entertainment industry using orthodontics in a certain negative light. For the longest time, you would make someone look nerdy by putting braces on them. Some people remember the television show “Ugly Betty.” Unfortunately, the main character had big, obnoxious metal braces. Social media has also changed the landscape. In the past, kids had braces and maybe a few friends and relatives knew; however, with Facebook and Instagram, now EVERYONE knows. Treatment would be evident, and everyone would know about it. This expanded awareness was pushing patients toward demanding more options from their orthodontists. So the combination of the sociocultural shifts and the advanced ceramic technology worked toward the transition to esthetic braces. Another factor that comes into play with patients includes lifestyle preferences. I’ve had patients come in who want aligners and not braces. We then talk about what is required of them to be successful with aligner treatment — 20-22 hours of aligner wear, the attachments on the teeth that are needed to effect certain tooth movements (which never seems to be shown in the clear aligner Volume 9 Number 6

New

is now

SureSmile Ortho

Clinically Proven. Clinician Controlled. The SureSmile® Aligner system is powered by a robust, clinically driven digital treatment planning platform. It ensures the clinician is in control of treatment, and is designed to enable optimal patient customization. Each aligner is custom designed to the clinician’s treatment plan and anatomically designed to the patient’s facial photo for ideal smile design. Engaging 3D visuals show doctor and patient the desired outcome at the beginning of treatment to drive patient acceptance. Even better, practices have a choice with SureSmile Aligner: Complete for greater flexibility and peace of mind for full arch treatment. Select is ideal for treatment plans under a year, as well as for hybrid therapy. SureSmile Aligner. Your Patient. Your Plan.

To order your SureSmile Aligner case: Register for an elemetrix® account at elemetrix.com For more information: Call 888.672.6387 (Toll-free US & Canada) or email CustomerCare@suresmile.com

Dentsply Sirona Orthodontic Inc. 7290 26th Court East Sarasota, FL 34243

ORTHODONTIC INSIGHT

Figure 2: Patient in treatment with a hybrid approach, with aligners on the maxillary arch and brackets on the mandibular arch

commercials), changing the aligners, and cleaning them. Once this is explained, the patient can then make an informed decision. I had one patient say, “I’m a forgetful person, doc! I lose my glasses six times a day; my cellphone weekly. I’m going to lose these darn things! Give me another option.” So we showed her the 3M™ Clarity™ Advanced Ceramic Brackets. She said, “You put them on the teeth, and I don’t have to do anything? Great. Let’s do it. You can hardly see them.” It’s wonderful to have options to meet the needs of all kinds of patients! In another example, I have a patient who is a pilot, meaning that he travels a lot and lives a relatively nomadic life. He didn’t want to carry many pouches of aligners around with him and worry about where he might leave them. So, we went with ceramic brackets. At the end of the day, both of these patients got what they wanted, which was an esthetic treatment option.

Finding the win-win … win In reviewing the esthetic options available for patients, there are a number of factors to consider. First, the patients’ own desires are considered. Sometimes, even though it’s more work and time, they still want aligners. I have had patients in sales as well as television news anchors. Even though the case might be more work with clear aligners, patients have overriding factors that make them want the aligners anyway, and we can do that. I recently had a child come in with her mother. 14 Orthodontic practice

Figure 3: Patient in Clarity Advanced Ceramic Brackets. The patient had originally come in requesting treatment with aligners

My practice has approached the demand for esthetics by being prepared with a spectrum of options that we can customize to fit the patient’s wants.

The child was very active in theater, so for the purposes of auditioning, she didn’t want metal brackets. We did Clarity Advanced Ceramic Brackets, and she got a lot of joy out of telling me about auditions. She said, “You can’t see them on the stage!” Second, we look at the clinical situation in terms of the bite discrepancy and dental alignment. We educate the patients about their options. Third, you must take into consideration the patient’s compliance. There is a big difference between a 13-year-old boy who may be there just because his parents want him to get his teeth straightened, and adult patients who are very motivated because they made the decision for themselves and are also paying for the treatment. You have to take all those things into account — the patient expectations, the clinical situation, and the patient compliance scenario. Lastly, there is another “win” that orthodontists need to identify in their approach to working with manufacturers. Ultimately, I want control over what I order, and how I

order it. Frankly, the fewer vendors involved in the treatment, the better. In this way, I can appreciate that the left hand can talk to the right hand — or the upper aligner can speak to the lower brackets. In the past, if I wanted to do a hybrid case, the main aligner company would charge me for the entire case. With recent changes in the industry, more companies are providing aligners, so there is more competition, which is good for orthodontists and patients. Of course, if I really want fewer vendors in the process, I want a manufacturer that offers both brackets and aligners, as well as the service and support that comes with that relationship. Orthodontists should look for a single vendor that provides aligners and esthetic brackets. My practice has approached the demand for esthetics by being prepared with a spectrum of options that we can customize to fit the patient’s wants. Being flexible and in control of our esthetic treatment options is good for my practice, good for my patients, and good for me! OP Volume 9 Number 6

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PRACTICE MANAGEMENT

What do gossip and gum disease have in common? Cynthia Goerig discusses achieving an office environment based on teamwork

entists want to look forward to going to the office. And although they wish they could just perform dentistry and not have to deal with all of the business aspects of running a practice, they realize that a typical day may include glitches that need their attention before the first patient arrives. When team member drama is involved, there may be tension and hushed whispers,

and the doctor may be visited by multiple team members who update him with the latest gossip, suggesting who is to blame and who did something wrong. Many times the practice owner knows he/she needs to address the situation but doesnâ&#x20AC;&#x2122;t, hoping it will go away. Throughout the day, similar distractions pop up, as well as scheduling and patient issues, and by the end of the

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16 Orthodontic practice

day, the dentist could feel drained and exhausted, privately wishing he/she could just do dentistry and feel the satisfaction of completing cases. What do gum disease and gossip have in common? It is an infection that can spread without being noticed, and when left to fester, puts the patient or practice at risk and is expensive to treat. Gossip is a very expensive production killer. The negative energy is off-putting to the rest of the staff and the patients, and creates unnecessary frustration and stress for the doctor. Gossip damages relationships, manipulates emotions, creates competition, causes drama in the workplace, and affects the bottom line. In one Volume 9 Number 6

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PRACTICE MANAGEMENT

Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving.

case, an endodontic office was burdened with gossip and a team openly at war with each other. When this was addressed, production increased 36%, slightly better than the doctor’s prediction.

Gossip fosters an environment of blaming A little-known fact: people who gossip are terrified of conflict. When there is a culture of blaming, people do not take responsibility to solve problems. They would rather make someone

else wrong for fear they will get in trouble. People will look to find fault in why something doesn’t work and manipulate your time in convincing you who is to blame.

Now imagine … Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving. A culture of celebration is pronounced around the success of the day and a team that

Step One Answer the following questions: 1. What is your vision for how people treat each other in the office? 2. What is your vision for how the team will treat patients? 3. Pick three to five words to describe the daily environment or culture of the office. (examples — focused, supportive, fun, friendly, professional, caring, etc.) Step Two Call a team meeting, and schedule it for 30 minutes. Step Three At the meeting ... 1. Share your answers from questions 1-3. Explain why this is important to you, coming from an authentic and vulnerable place, and ask for their help in achieving it. People respond when they feel they are needed to help create the new vision. 2. Create a “no gossip” rule. Explain why there is no gossip, and how it will reinforce the culture you want. 3. In closing the meeting, ask if everyone can get behind this and agree by raising his/her hand. When people physically act, like raising their hand, in front of everyone, they feel like they have a choice and are more likely to follow through.

18 Orthodontic practice

rallied to close the office and prepare for the next day. Imagine not having to remind your team members what they are supposed to do that they already knew, and that it was taken care of. They know the objectives and goals, and are invested in the vision — not only sharing it, but also owning it. Envision that the team felt safe at work, knowing that if something goes wrong, the whole team will help.That they don’t criticize or judge each other; instead, they look for the strengths in each other and improve upon their weaknesses. Finally, imagine when leaving the office, the team thanks the doctor and each other, leaving everyone energized, proud of the team and the work they do. In short time, the practice becomes known as one of the best to work for. The good news is that you are a few steps away from this possibility. (See the steps in the red box.) The most effective way for a change in a practice to occur is for the leader to model it. I recommend printing out your three to five words that describe the environment you want to cultivate (from question 3) and review them daily. Inspire your team to make the change, model it, and become the office that everyone wants to work for. OP

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ABSTRACTS

Abstracts Dr. Shalin Shah presents the latest literature, keeping you in touch with the latest studies and evolving technologies Accuracy of clear aligners: A retrospective study of patients who needed refinement Charalampakis O, Iliadi A, Ueno H, Oliver DR, Kim KB. American Journal of Orthodontics and Dentofacial Orthopedics (2018) 154(1):47-54. Abstract Aims: The purpose of this study was to determine the accuracy of specific tooth movements with Invisalign (Align Technology, Santa Clara, California). Materials and Methods: The study sample included 20 Class I adult patients treated with Invisalign®; they completed their first series of aligners and had to have a “refinement” series. Initial and predicted models were obtained from the initial ClinCheck® (Align Technology). The starting point of the refinement ClinCheck was used to create the achieved models. Predicted and achieved models were superimposed over the initial ones on posterior teeth using the three-dimensional Image Analysis opensource software Slicer CMF. Three hundred ninety-eight teeth were measured for vertical, horizontal, and rotational movements, and transverse widths were measured. The amount of predicted tooth movement was compared with the achieved amount for each movement. Results: The teeth with a negative response to the electric pulp tester still responded to the thermal test. We found odontoblast disruption; vacuoliza horizontal movements of all incisors seemed to be accurate, with small (0.20 mm-0.25 mm) or insignificant differences between predicted and achieved amounts. Vertical movements and particularly intrusions of maxillary central

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 Kennet Square, Pennsylvania.

20 Orthodontic practice

incisors were found to be less accurate, with a median difference of 1.5 mm (P <0.001). All achieved rotations were significantly smaller than those predicted, with the maxillary canines exhibiting the greatest difference of 3.05° (P <0.001). Conclusions: The most inaccurate movements identified in this study were intrusion of the incisors and rotation of the canines.

Fully digital workflow for presurgical orthodontic plate in cleft lip and palate patients Krey KF, Ratzmann A, Metelmann PH, Hartmann M, Ruge S, Kordaß B. Int J Comput Dent (2018) 21(3):251-9. Abstract Aims: In most cases, according to our treatment concept, a presurgical orthodontic treatment (POT) is performed on patients with cleft lip and palate (CLP). The aim of this case report is to demonstrate a completely digital workflow for the production of a palate plate. Materials and Methods: For the assessment of the maxillary arch, a digital impression of the jaw was made on two patients with an intraoral scanner (Cerec Omnicam Ortho). After reconstruction of a virtual model from the scan data, appropriate areas of the jaw could be blocked out and a plate

constructed. This was printed with a DLP three-dimensional (3D) printer (SHERA® EcoPrint D30) with Class IIa biocompatible material. After minor surface finishing, the plates could be incorporated in the patients’ mouths. Results: The scans could be performed in a short time without affecting the very young patients. All clinically relevant areas for the production and digital measurement of the models could be recorded. The plates showed an extremely good fit, and there were no differences in wear compared with a conventionally manufactured plate. Conclusions: For the first time, a risk-free digital impression of the edentulous jaw in CLP babies with a subsequently completely digitally constructed and 3D-printed palatal plate could be shown.

Dose analysis of photobiomodulation therapy on osteoblast, osteoclast, and osteocyte Na S, TruongVo T, Jiang F, Joll JE, Guo Y, Utreja A, Chen J. J Biomed Opt (2018) 23(7):1-8. Abstract Aims: The objective of this study was to evaluate the effects of varying light doses on the viability and cellular activity of osteoblasts, osteocytes, and osteoclasts. A light Volume 9 Number 6

ABSTRACTS application device was developed to apply 940 nm wavelength light from light-emitting diodes on three cultured cells: MC3T3-E1, MLO-A5, and RANKL-treated RAW264.7 cells. The doses (energy density) on cells were 0, 1, 5, and 7.5 J / cm2. The corresponding light power densities at the cell site were 0, 1.67, 8.33, and 12.5 mW/cm2, respectively, and the duration was 10 minutes. The results showed that the three cell types respond differently to light, and their responses were dose-dependent. Low-dose treatment (1 J/ cm2) enhanced osteoblast proliferation, osteoclast differentiation, and osteoclastic bone resorption activity. Osteocyte proliferation was not affected by both low- and highdose (5 J/cm2) treatments. While 1 J/cm2 did not affect viability of all three cell types, 5 J / cm2 significantly decreased viability of osteocytes and osteoclasts. Osteoblast viability was negatively impacted by the higher dose (7.5 J/cm2). The findings suggest that optimal doses exist for osteoblast and osteoclast, which can stimulate cell activities, and there is a safe dose range for each type of cell tested.

Effects of monocortical and bicortical mini-implant anchorage on bone-borne palatal expansion using finite element analysis Lee RJ, Moon W, Hong C. American Journal of Orthodontics and Dentofacial Orthopedics (2017) 151(5):887-97. Abstract Aims: Bone-borne palatal expansion relies on mini-implant stability for successful orthopedic expansion. The large magnitude of applied force experienced by miniimplants during bone-borne expansion may

22 Orthodontic practice

Bone-borne palatal expansion relies on mini-implant stability for successful orthopedic expansion. lead to high failure rates. Use of bicortical mini-implant anchorage rather than monocortical anchorage may improve miniimplant stability. The aims of this study were to analyze and compare the effects of bicortical and monocortical anchorages on stress distribution and displacement during bone-borne palatal expansion using finite element analysis. Materials and Methods: Two skull models were constructed to represent expansion before and after midpalatal suture opening. Three clinical situations with varying mini-implant insertion depths were studied in each skull model: monocortical, 1 mm bicortical, and 2.5 mm bicortical. Finite element analysis simulations were performed for each clinical situation in both skull models. von Mises stress distribution and transverse displacement were evaluated for all models. Results: Peri-implant stress was greater in the monocortical anchorage model compared with both bicortical anchorage models. In addition, transverse displacement was greater and more parallel in the coronal plane for both bicortical models compared with the monocortical model. Minimal differences were observed between the 1 mm and the 2.5 mm bicortical models for both periimplant stress and transverse displacement. Conclusions: Bicortical mini-implant anchorage results in improved mini-implant stability, decreased mini-implant deformation and fracture, more parallel expansion

in the coronal plane, and increased expansion during bone-borne palatal expansion. However, the depth of bicortical mini-implant anchorage was not significant.

Cephalometric appraisal of the effects of orthodontic treatment on total airway dimensions in adolescents Maurya MRK, Kumar CP, Sharma LCM, Nehra LCK, Singh H, Chaudhari PK. J Oral Bio Craniofac Res (Epub 2018) 9(1):51-6. Abstract Aims: This retrospective study was performed to rule out any jeopardizing effect of extraction therapy of four first premolars on airway at any level of its anatomic course. Materials and Methods: Lateral cephalograms of 50 adolescent patients divided into two groups of 25 each, based on orthodontic treatment by first premolar extraction as group I and without extraction as group II, were selected for the study. Thirteen angular and 11 linear measurements were compared pre-and post-treatment via statistical analyses using SPSS (Version 17.5, SPSS, Chicago) software. Paired t-tests were used to assess the variability. P-value < 0.05 was considered to be statistically significant. Results: Comparison of angular parameters showed that the average percentage (%) change in SNA, SNB, ANB, IMPA, FMA, saddle, articulare, gonial, total angle, and hyoid did not differ significantly across two study groups (P > 0.05), but values of UI/LI, UI/NA, and LI/NB, differed significantly among both groups. Similarly, linear parameters showed that the average % change in nasopharyngeal airway space (NAS) and width of soft palate differed significantly across two study groups (P-value<0.05), whereas the average % change in posterior airway space (PAS), hypopharyngeal airway space (HAS), hyoid distance and length of tongue did not differ significantly (P-value>0.05). However, no significant differences were observed during intragroup and intergroup comparisons of the combined angular and linear measurements of both groups. Conclusions: Present study showed no significant change on airway after therapeutic orthodontic tooth movement with or without extraction treatment. OP Volume 9 Number 6

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TREATMENT TIPS

Let the celebrities help Dr. Donald J. Rinchuse discusses showing famous smiles to illustrate orthodontic variations

he great Hall of Fame football coach Vince Lombardi said, “Perfection is not attainable, but if we chase perfection, we can catch excellence.” This author has been in practice for over 40 years and is still waiting for that perfectly finished case. In addition, there are instances in orthodontics when, for a number of reasons, we truly fail in the sense that the results of treatment are far from optimal. The only justification we have for such failure(s) is that we have warned and advised the patient and family that this could happen prior to the start of orthodontic treatment during the informed consent consultation — i.e., “All, or a certain aspect of treatment will not be ideal.” When various aspects of treatment do not work out, and this has to be explained,

it can be helpful to show a picture of a celebrity (celebrities) with the very same dental/ facial deviation. I have often shown patients and families who have midlines deviations a close-up picture of Tom Cruise’s smile (and midline deviation). In this regard, one mom would always say with a smile when I was about to look at her son‘s mouth (Figures 1A and 1B), “Your Tom Cruise patient is here.” I have a collection of photographs of celebrities with all sorts of dentofacial deviations that I show to the patient/ families to lessen the reality that orthodontic treatment did not, or will not, be ideal. So “let the celebrities help.” Table 1 is a listing of celebrities with various dentofacial “imbalance” categories. It must be pointed out that the celebrities listed are very attractive

Figure 1B: Same patient illustrating the dental midline deviation (observe where the philtrum of the lip is)

and gorgeous people, and the reason I am showing them to patients/families is not in any way to disparage them. All human beings are beautiful and made in God‘s image, and lasting beauty is that which is “inside.” We are only pointing out that even the most celebrated in our society have physical flaws just like us “commoners.” It is recommended that the orthodontist and/or staff make a similar categorization of celebrities, or use ours, to keep on hand when the need arises to show patients/families as previously discussed. There may be the need to have several listings, reflecting the celebrities most familiar to the different generations. In addition, orthodontists and staff can have photographs of celebrities such as Gwen Stefani, Carrie Underwood, Tom Cruise, Prince Harry, Serena and Venus Williams, Justin Bieber, Angelina Jolie, Emma Watson, Emma Stone, Beyonce, Miley Cyrus, Gwyneth Paltrow, Ryan Seacrest, and many more who have had orthodontic treatment. And also recognize those celebrities who supposedly have had clear aligner treatment such as Zac Efron, Katherine Heigl, Eva Longoria, and so forth. So “let the celebrities” help when you face difficult situations in which orthodontic treatment does not work out as anticipated. OP

Table 1: Celebrities with various dentofacial deviations

Figure 1A: Patient with dentofacial midline deviations Donald J. Rinchuse, DMD, MS, MDS, PhD, received his dental degree (DMD) and Master of Science degree (MS) in Pharmacology and Physiology in 1974, a certificate and Master of Dental Science degree (MDS) in orthodontics in 1978, and a PhD in Higher Education in 1985 — all from the University of Pittsburgh. He has been involved in orthodontics for more than 42 years. He is a Diplomate of the American Board of Orthodontics and a manuscript review consultant for several journals including the American Journal of Orthodontics and Dentofacial Orthopedics. He has 130 publications to his credit, which includes two books. He has given many lectures and presentations. Dr. Rinchuse is presently in corporate orthodontic practice in Greensburg, Pennsylvania.

24 Orthodontic practice

Deviations

Celebrities

Prognathic mandible (protruded chin)

Jay Leno, Scott Pelley, Kirk Douglas, Bill Cowher

Prognathic mandible and/or retruded maxilla

Roger Federer, Justin Timberlake

Class III profile with proclined maxillary incisors

Idina Menzel

“Black triangle”

Alicia Keys

Full lips and teeth

Shaun White, Dionne Warwick

Midline deviation

Tom Cruise

Gingival display

Nancy Kerrigan

Narrow buccal corridors

George Clooney, Meg Ryan, Richard Gere, Michael Phelps

Retrognathic mandible/profile

Ben Stiller, Carol Burnett (Before orthognathic surgery)

“Dished-in facial profile”

Drew Barrymore, Jameson Taillon (Pittsburgh Pirates)

Class II occlusion and profile

Jackie Kennedy, Keira Knightly, Kirsten Dunst

Protruded maxillary teeth

Emma Stone, Elke Sommer

Diastema

Michael Strahan, Samuel L. Jackson, David Letterman, Andy Murray, Lauren Hutton, Omar Sharif

Volume 9 Number 6

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CONTINUING EDUCATION

A tri-dimensional diagnosis and treatment planning guide Dr. Larry White examines some foundations of orthodontic therapy Introduction Artists paint a canvas from what they know, what they feel, and what they see. To a remarkable degree, many orthodontists approach diagnosis in the same way. While it may be permissible for artists to create paintings from what they know or feel, orthodontists would do well to evaluate objectively only what they see. If there is any secret to accurate diagnosis and treatment planning, it is not to let previously acquired knowledge or feelings about a patient interfere with what is observed. Unfortunately, by training and by patient expectation, dentists are primarily therapists, and they often launch into action before rendering a complete diagnosis. For many patients, the etiologies and remedies of problems are obvious, and the ensuing acceleration of treatment causes few problems. However, when the diagnosis is obscure or difficult, patients will suffer from our haste, and ineffective regimens will often baffle clinicians. This rush to therapy reminds one of Napoleon’s instructions to his generals when he advocated “On s’engage et puis on voit!” which liberally translates into “Jump into the fray, and see what happens.” The most grievous mistakes I make are those from misdiagnosis. Orthodontists can easily overcome errors of mechanics but have much more trouble correcting a wrong diagnosis and faulty treatment plan. A sound diagnosis remains the foundation of all successful therapy and provides the primary responsibility of conscientious clinicians.

Patient data collection Chief complaint The first step in forming an accurate diagnosis in any of the healing arts begins with a collection of information from patients regarding their concerns. The chief complaint of the patient should be recorded in the patient’s own words in order to prevent confusing the clinician’s perception of the problem with the description offered by the patient. The importance of this point cannot

Educational aims and objectives

This clinical article aims to examine how correct diagnosis and treatment planning continue to be the foundation of orthodontic therapy.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify various aspects of patient data collection. • Identify various systems analyses such as cephalometric, skeletal, and soft tissue analysis. • Examine various aspects of the Visualized Treatment Objective (VTO). • Realize the value of an occlusogram.

be overemphasized, since any therapy that fails to address the patients’ main concern will be considered a failure — no matter how satisfying it may be to the clinician. So the orthodontist’s first task is to listen to the patient and make certain the chief complaint is understood. General health questionnaire Certainly, a general health questionnaire will help the orthodontist discover systemic defects or medications that might affect orthodontic therapy. For instance, daily medication with nonsteroidal anti-inflammatory agents (such as MOTRIN® or aspirin) inhibits ordinary bone metabolism.1,2 Chronic use of such drugs makes routine rotational corrections or space closures almost impossible to achieve. There are several systemic medications or conditions that affect orthodontic treatment, and doctors need to discover them before treatment begins. Clinical examination Once these preliminary features of the examination are completed, the doctor can begin in earnest the clinical examination that will list the problems found in the mouth, face, and head. Orthodontists have a tendency to rely too much on the records they take to the exclusion of the physical examination — a major error. No set of records can ever gather the quantity or quality of information available while the patient is in the examination chair. Muscle strains, oral hygiene,

Larry White, DDS, MSD, FACD, is in private practice of orthodontics in Dallas, Texas.

26 Orthodontic practice

the dynamic relationships between the jaws, static occlusal relationships, and gingival conditions are assessed much better at the chair than with any collection of secondary data such as X-rays, models, photographs, and articulator settings. Clinicians should use orthodontic records to confirm the diagnosis, not to make it. The problem list Clinicians must develop a clinical examination that uses a problem list in an unvarying manner. Hershey and Bayleran3 developed and published one of the most useful guides for using a problem list. I have used one over the years that prevents me from overlooking potential problems. Figure 1 displays this document. Such a problem list works similarly to that which airline pilots use before taking off and landing their aircrafts. This type of diligence prevents many catastrophes.4 As clinicians work their way through the questions, the answer is either yes or no. If answered no, then there is no problem. If answered yes, then that feature becomes part of the problem list, and the clinician must address it. At the end of the clinical examination, a preliminary problem list has been formed and needs only to add the information that comes from the radiographic and cephalometric examinations along with the information from the occlusograms.

Systems analyses Cephalometric analysis All of the early cephalometric analyses and treatment planning regimens relied on osseous tissues for correctly aligning the teeth. Tweed,5,6 Steiner,7,8 Ricketts,9 and Volume 9 Number 6

Skeletal analysis The growth potential of patients is one of the most important pieces of information orthodontists can have. Bjork and Skeller developed the interpretation for the handwrist X-ray, and it remains the most accurate assessment clinicians can use for determining skeletal age. Unfortunately, it requires an additional X-ray, extra time, and more expense, and many patients and parents object to additional radiation.15 Lamparski16-18 and others have developed techniques that avoid the hand-wrist X-ray and use the cephalometric image of the cervical vertebrae. Although these vertebral analyses do not have the precision of the hand-wrist X-ray, they have accuracy for determining if patients will grow for 6, 12, or more months during their treatments. While orthodontists may want to know within 3 months the skeletal age of a patient, they do not need that quality of information to make an accurate diagnosis and treatment plan. Orthodontists need to know if the patient will grow, and if they can take advantage of that growth.

Oral Examination and Problem Listing Angle Classification Chief Complaint (Patient's Words) Chief Complaint (Clinical) Clinical and X-ray Evaluations Ectopic Caries Decalcification Missing Ankylosed Retained Tooth Resorption Atypical Form Stains Supernumerary Impacted Pathology Decelerated Roots Osseous Loss Clinical Teeth Relations Maxillary Crowding Maxillary Excess Space Mandibular Crowding Mandibular Excess Space Midline Deviation Overbite Severe Open Bite Overjet Underjet Posterior Crossbite Anterior Crossbite MDFL Mand. Incisor Discrepancy

Orofacial Habits Tongue Thrust Snoring Nail Biting Digit Sucking Lip Biting Face and Soft Tissue Cant of Occlusal Plane Mentolabial Field Interlabial Gap Nose Lips Thick Nasiolabial Angle Resting Lip Incisor Length Lips and Facial Profile Max Lip Length Smile Line Lip and/or Palatal Cleft Abnormal Maxillary Frenum Abnormal Mandibular Frenum Obstructed Nasal Airway Enlarged Tonsils and/or Adenoids Tongue Posture Gingival Recession Gingivitis Periodontal Bone Loss Oral Hygiene Speech Impediment

Cast Analysis Max. Transverse Asymmetry Mnd. Transverse Asymmetry Max. AP Asymmetry Mnd. AP Asymmetry Curve of Spee Max. Arch Length Discrepancy Mnd. Arch Length Discrepancy Max. Tooth Size Discrepancy Mnd. Tooth Size Discrepancy Maxillary Spacing Mandibular Spacing Cephalometric Evaluation Maxillary Incisors Mandibular Incisors Maxilla Length Mandible Length AP Discrepancy Anterior Face Height Vertebral Evaluation TMD Evaluation Joint Noise Muscle Pain Frequent Headaches TMJ Tenderness Restricted Right Lateral Motion Restricted Translatory Motion Restricted Protrusive Motion Bruxism CoCr Discrepancy

Figure 1: A Clinical Examination and Problem List document

Soft tissue analysis A soft tissue analysis involves an assessment of the gingiva, adenoids, and tonsils as well as the tongue, lips, forehead, nose, and chin. The role played by enlarged tonsils and adenoids in open-bite and tonguethrust patients is well documented and will not be discussed in detail here.19 Nevertheless, whenever orthodontists suspect these tissues may limit their orthodontic success, they need to encourage a medical consultation with an otolaryngologist to see if the removal of that soft tissue can aid in the resolution of the malocclusion.

The tri-dimensional diagnosis and treatment plan The three-dimensional diagnosis and treatment plan is nothing more than an attempt to evaluate and use the data Volume 9 Number 6

Figure 2: Effect on the profile by relying on osseous tissue for setting treatment goals vis-Ă -vis the Tweed Triangle Orthodontic practice 27

CONTINUING EDUCATION

Williams10 preferred to place the mandibular incisors in a predetermined position to achieve treatment goals. Holdaway11,12 was the first orthodontist to suggest the maxillary central incisors as the key to achieving proper lip posture and, thus, sought to position them correctly in the face. Subsequent studies and publications by Alvarez13 and Creekmore14 have corroborated Holdawayâ&#x20AC;&#x2122;s emphasis on the maxillary incisors as the principal feature of orthodontic diagnosis. By combining these three treatment planning schemes, orthodontists can avoid some of the ruinous soft tissue effects the reliance on osseous tissues sometimes causes (Figure 2).

CONTINUING EDUCATION collected from the examination and the various analyses in the horizontal, vertical, and transverse dimensions. The Visualized Treatment Objective (VTO) is used to correctly position the teeth and jaws in the vertical and horizontal dimensions, while the occlusogram evaluates and rearranges the teeth in the transverse dimension. The Visualized Treatment Objective (VTO) and the horizontal and vertical dimensions The Visualized Treatment Objective derives positions for the incisors and molars

in the vertical and horizontal dimensions. By using the VTO, clinicians can determine how much anchorage they will need, where to apply it, and how far the incisors and molars must move horizontally and vertically to achieve ideal positions. As originally developed, the VTO sought to blend the growth of a patient with the movements necessary to effect ideal tooth and jaw positions. Several publications describe step-by-step procedures for doing Visualized Treatment Objectives, and the reader can refer to these for instructions.9,11,12,20

Figure 3: Class II Division 1 patient with arch-length discrepancies

Figure 4: Static VTO displaying incisor and molar tooth movements needed for correction 28 Orthodontic practice

Knowledge of Chaos Theory21 acknowledges periodicity, intermittency, randomness, unpredictability, and sensitive dependence on initial conditions, and orthodontists have begun to understand why dynamic VTOs based on average yearly growth increments become less accurate and valuable as treatment time lengthens. Chaotic systems such as growth are notoriously difficult to forecast and become ever more fickle as the forecast period extends. That is, a 15-month VTO has a much better chance of accurately forecasting facial growth than a 30-month projection — much like a 12-hour weather forecast remains more reliable than a 5-day forecast. Since most of my treatments extend beyond 12 or 15 months, I seldom use dynamic VTOs and rely on static ones that simply position the teeth in ideal positions vis-à-vis the initial cephalometric tracing. This helps me set goals for the movement of teeth and jaws, and I start treatment by trying to achieve these movements quickly. Readers can access a step-by-step procedure for doing these static VTOs from my website: larrywwhiteddsmsd.com (lectures – Chapter One Revised – user name: orthotx; password: orthodox). The occlusogram and the transverse dimension Fewer than 1% of orthodontists now use occlusograms as aids in their diagnoses, but that does not lessen their value at all. On the contrary, no diagnostic technique offers orthodontic clinicians more useful information about malocclusions than do occlusograms. They provide particular help in evaluating and planning in the transverse dimension. The occlusogram, popularized by Burstone, is a technique that arranges teeth in ideal arch forms in two dimensions on a piece of tracing paper and thus allows a transverse evaluation of the occlusion. Several articles describe the use of occlusograms.22-27 Readers can also access a useful technique in Chapter One Revised on my website. Patient therapy using a static VTO The following late-stage adolescent patient presented for treatment displaying Class II molars and canines, a midline discrepancy, a large overjet, moderate overbite with maxillary and mandibular arch length discrepancies (Figure 3). The VTO (Figure 4) showed that the maxillary incisors needed some retraction with no vertical changes; the mandibular incisors would require only intrusion with no change in their horizontal positions. This would require removal of maxillary first premolars and interproximal reduction in the mandibular dentition of 4 mm (Figure 5). Volume 9 Number 6

Min

-3

-4

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Arch Length Discrepancy

Max Arch Development Relocation Incisor

-7

Mesial Molar Movement

-5

Distal Molar Movement Curve of Spee Interproximal Reduction Extractions

+4 15

Relocation of Max. 3s Total Net

Figure 5: Modified Steiner Box with calculations needed for corrections

Extraction of teeth in the mandibular arch would inevitably result in more retraction of the incisors than the VTO indicated, and the patient would risk flattening of the profile. The result (Figure 6) shows good correction of the Class II canines, resolution of the arch length discrepancies, and an improvement in the profile. The VTO and the resultant therapy display good coordination (Figure 7).

Figure 6: Result of treatment with a good smile arc, Class I canines, and an improved profile

Conclusion Correct diagnosis and treatment planning continue as the foundation of orthodontic therapy, and any attempt to de-emphasize these features will result in disappointment. The use of soft tissue diagnostic regimens will limit severe damage to the profile and often result in fewer extractions. The VTO offers orthodontists an efficacious and efficient instrument for designing orthodontic therapies, and, as Holdaway28 once advised, allows them to “start with the end in mind.” OP

REFERENCES 1. Giunta D, Keller J, Nielsen FF, Melsen B. Influence of indomethacin on bone turnover related to orthodontic tooth movement in miniature pigs. Am J Orthod Dentofacial Orthop. 1995;108(4):361-366. 2. Vane JB. Prostaglandins, Pain, and Aspirin, Pain and Prostaglandin. Research Triangle Park, NC: Burroughs Wellcome Co.; 1977. 3. Hershey SE, Bayleran ED. Problem-oriented orthodontic record. J Clin Orthod. 1986;20(2):106-110. 4. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books, Henry Holt and Company, LLC; 2009. 5. Tweed CH. The Frankfort-mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment, planning and prognosis. Angle Orthod. 1954;24(3):121-169. 6. Tweed CH. The diagnostic facial triangle in the control of treatment objectives. Am J Orthod. 1969;55(6):651-657. 7. Steiner CC. Cephalometrics in clinical practice. Angle Orthod. 1959;29:8-29. 8. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod. 1960;46:721-735. 9. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive Therapy, Book I. Denver, CO: Rocky Mountain Orthodontics; 1979. 10. Williams R. The diagnostic 1969;55(5):458-476.

line.

Orthod.

11. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod. 1983;84(1):1-28.

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Figure 7: VTO (striated lines) and final tracing (red lines) coincide nicely excepting intrusion of the mandibular incisors 12. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod. 1984;85(4):279-293.

19. Linder-Aronson S. Nasorespiratory considerations in orthodontics. In: Graber LW, ed. Orthodontics: State of the art, essence of the science. St. Louis: C.V. Mosby Co.; 1986.

13. Alvarez A. The A line: a new guide for diagnosis and treatment planning. J Clin Orthod. 2001;35(9):556-569.

20. Jacobson A, Sadowsky PL. A visualized treatment objective. J Clin Orthod. 1980;14(8):554-573.

14. Creekmore TD. Where teeth should be positioned in the face and jaws and how to get them there. J Clin Orthod. 1997;31(9):586-608.

21. Gleick J. Chaos: The Making a New Science. New York, NY: Viking Penguin Group; 1987.

15. Helm S, Siersbaek-Nielsen S, Skieller V, Björk A. Skeletal maturation of the hand in relation to maximum pubertal growth in body height. Tandlaegebladet. 1971;75(12):1123-1234. 16. García-Fernandez P, Torre H, Flores L, Rea J. The cervical vertebrae as maturational indicators. J Clin Orthod. 1998;32(4):221-225. 17. Fishman LS. Radiographic evaluation of skeletal maturation. A clinically oriented study based on hand-wrist films. Angle Orthod. 1982;52(2):88-112. 18. Lamparski DG. Skeletal age assessment utilizing cervical vertebrae [thesis]. Pittsburgh: University of Pittsburgh; 1972. In: O’Reilly MT, Yanniello GJ: Mandibular growth changes and maturation of cervical vertebrae—a longitudinal cephalometric study. Angle Orthod. 1988;58(2):179-84.

22. Faber RD. Occlusograms in orthodontic treatment planning. J Clin Orthod. 1992;26(7):396-401. 23. Marcotte MR. The use of the occlusogram in planning orthodontic treatment. Am J Orthod. 1976;69(6):655-667. 24. Melsen B, Fiorelli G. Biomechanics in Orthodontics. Arezzo, Italy: Libra Ortodonzia; 1995. 25. White LW. Individualized ideal arches. J Clin Orthod. 1978;12(1):779-787. 26. White LW. The clinical use of occlusograms. J Clin Orthod. 1982;16(2):92-103. 27. White LW. Modern Orthodontic Diagnosis, Treatment Planning and Therapy. Glendora, CA: Ormco Corp; 1996. 28. Holdaway RH. A Professional Profile. Rocky Mountain Society of Orthodontists Newsletter. 1988;33:12-16.

Orthodontic practice 29

CONTINUING EDUCATION

Employee-driven performance metrics: If you can’t measure it, you can’t manage it Ali Oromchian, JD, LLM, discusses how to effectively achieve targeted business objectives

etrics are numbers and statistics that provide valuable information about how effectively a business is achieving targeted business objectives. You are probably most familiar with growth-based metrics such as the number of referrals received, case acceptance rate, and your practice’s gross revenue — all of which are objective data points. Objective data points are imperative to ensure you are gauging performance factually and without bias. These sets of quantifiable measures are created to objectively compare performance as it relates to operational goals. One of the most mismanaged metrics for a business is HR metrics. HR metrics evaluate a broad range of HR topics from onboarding to termination. In this article, we will be focusing on HR metrics as they relate to performance management and the employees within the organization.1 Performance management can be broken down into three main points: gathering data, implications of data, and managing this data.

Four pillars of employee-driven performance metrics 1. Documents and compliance Workflows and task management systems measure the level of completion of required documents. These metrics ensure compliance is met in a timely manner. All of these required documents safeguard your practice from a broad range of threats such

Ali Oromchian, JD, LLM, received his BA from the University of California at Davis, LLM in taxation from George Washington University Law School, and JD law degree from the University of California, Davis School of Law. He is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. Disclosure: Mr. Oromchian is co-founder and Chief Executive Officer of HR for Health in the San Francisco Bay area.

30 Orthodontic practice

Educational aims and objectives

The aim of this article is to explore employee-driven performance metrics, including gathering data, implications of data, and managing data.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize the importance of objective metrics.

•

Identify the four pillars of employee-driven performance metrics.

•

Realize the implications of employee-driven performance metrics.

•

Identify deficiencies and opportunities for improvements based on trends in performance metrics.

•

Identify alternative approaches to individual development.

HR metrics are only truly useful when you are analyzing the data you gather to pinpoint deficiencies and spearhead improvement. as claims of harassment or discrimination, and notices of protected leaves of absences.

performance. Finding these trends is one of the core functions of HR metrics.

2. Absenteeism, tardiness, and excessive overtime This aspect of performance is important because it provides objective data of absenteeism, tardiness, overtime, and missed time clock punches. It is important to ensure you are handling these aspects (such as excessive absenteeism and time clock edits) impartially. Additionally, this information can also pinpoint deficiencies within the practice’s efficiency as a whole.

4. Performance reviews Performance reviews are designed to evaluate the performance of each employee throughout a predetermined time frame. They are most commonly conducted toward the end of an employee’s introductory period and then on an annual basis thereafter. Performance reviews should take into consideration the HR metrics acquired throughout the predetermined time frame such as frequency of tardiness or violations of your policies. This annual realignment of expectations and performance ensures that areas of improvement are brought to light, while reinforcing positive performance.

3. Violations Documenting violations of your policies or procedures and the subsequent disciplinary actions will ensure individual metrics consistently reflect an employee’s performance. They establish tangible documentation factored into overall performance evaluations. It is important that violations are detailed to ensure you spot trends in poor

Implications of employee-driven performance metrics 1. Documents and compliance Typically, incomplete and unsecure documents indicate much larger issues. First, Volume 9 Number 6

CONTINUING EDUCATION

this could mean that compliance is not a top priority in your office, and there are likely other areas of high risk. Second, this means you could be currently operating in violation of many labor requirements. You could be operating without an at-will agreement or without verifying if your team members are authorized to work in the United States. In escalated situations, these incomplete or missing documents may encourage a plaintiffâ&#x20AC;&#x2122;s attorney to pursue a legal claim. This is because these issues imply additional missteps by the employer. 2. Absenteeism, tardiness, and excessive overtime You need to have policies that outline processes regarding absenteeism, tardiness, and unapproved overtime and enforce violations for excessive absenteeism and poor attendance. If not, it indicates that proper expectations have not been set in advance for your team. This means enforceability is probably ambiguous and lacks structure. This could reflect a lack of structure regarding processes: Your team members should be familiar with the processes around requesting a day off, a late arrival, or unscheduled overtime. This means prior (documented) approval must occur before a change to the schedule can be made. If the absence, tardy, or overtime is unapproved or worked without following the designated structure, then they can be subject to a written violation. 3. Violations Although not always the case, violations can be a reflection of bigger issues within the practice. In this step, you are looking for trends in violations. The better you can spot deficiencies, the better you can implement processes to improve. Unclear expectations and policies: If you notice recurring confusion or difficulty from your team adhering to specific expectations, it might be time to reevaluate your policies. Consistent violations from multiple team members can mean an ambiguous or flawed policy. Itâ&#x20AC;&#x2122;s important to remember that policies should be updated and amended according to business and legislative needs. Itâ&#x20AC;&#x2122;s important to gauge the feedback you are receiving during violation conversations and performance reviews. Poor training: If you notice recurring issues with your staff executing tasks or handling tough situations, it might be time to consider providing additional training supported by a written development plan. Volume 9 Number 6

Keep in mind, all violations should be issued with the intention of improvement. Only after recurring issues or non-improvement, should termination be considered. 4. Performance Reviews Performance reviews are a powerful resource to pinpoint areas of individual performance and insight on the productivity of the practice as a whole.2 For example, if you notice recurring issues with many team members, such as overtime, you can infer that the issue could be overscheduling patients. However, if you notice issues with only a few staff members, it could reflect shortcomings of individual task management that requires further support and training.

Managing the employee-driven performance metrics 1. Documents and compliance These metrics indicate a need for new stringent processes to ensure timely completion of documents. For example, this could mean deadlines and audits to create urgency. Another alternative could be allotting time (in the practice) to complete all documents. 2. Absenteeism, tardiness, and excessive overtime Absenteeism and tardiness: Create policies that outline processes for requesting time off. The clearer the processes, the easier to issue objective violations and evaluate how prevalent absenteeism and tardiness affects your practice. This will ensure that high rates of tardiness and

absenteeism are reflections of individual performance. Trends in excessive overtime: Create overtime processes that require your staff to define reasons for overtime. This will ensure you can pinpoint specific deficiencies. This could include poor operational scheduling, poor task management, necessity of additional training for team members, and/or poor timekeeping by your team. 3. Violations Evaluating HR metrics as they relate to violations issued is an effective resource in assessing whether your policies, training, and processes need further improvement. They will also pinpoint individual team members who are performing below average. This could also mean evaluating whether someone is a good fit for the practice, or whether further individual development is necessary. Below are two forms of effective individual development. Development plans: Development plans are a good way to begin an improvement process for individual performance issues. They not only effectively document incidents of unfavorable issues, but also outline what needs to be improved, how it is to be improved, and the date this should be improved.3 Based on your HR metrics data, you can assess whether this would be the best process to improve individual performance. Typically, at this point, termination would be the next option for unfavorable results. Coaching/one-on-ones: Coaching is a helpful resource to improve performance on Orthodontic practice 31

CONTINUING EDUCATION a one-on-one basis. Based on the finding in your HR metrics, you may want to implement monthly one-on-ones to assess consistent improvement and feedback to your newly implemented processes. 4. Performance Reviews Using data gathered from past performance reviews and assessing the changes in current or future reviews will ensure you are accurately measuring growth, stagnation, or diminished work performance. Most importantly, you must use this data to create processes to improve and overcome shortcomings pinpointed in these annual reviews. Additionally, these reviews create an open door to discuss issues â&#x20AC;&#x201D; you will be surprised how much insight you will gain from a simple conversation with your team members. Taking this insight and implementing improvements will ensure you are putting your best foot forward at advancing your practice. Below

are reinforcement-based approaches to individual development. Shoutouts and kudos4: Although kudos are great at highlighting an employeeâ&#x20AC;&#x2122;s achievements/hard work, they also present tangible examples of how to ideally handle similar situations. For example, if you issued kudos for an employee handling a difficult patient situation, you will want to highlight the situation, the problem/obstacle, and what this employee did to effectively handle this situation. This not only will reinforce great service, but also will educate other employees on how to handle similar situations.

Takeaway HR metrics must always be objective in nature to ensure measurement is uniform among all of your staff. Additionally, you must recognize that HR Metrics alone offer limited value.5 In other words, HR metrics are only truly useful when you are analyzing the data you gather to pinpoint deficiencies

and spearhead improvement. Using past data to compare and assess the effects of current or future processes will ensure you are accurately gauging the effects of your improvement efforts. Most importantly, your focus should always be improvement! OP

REFERENCES 1. Gifford A. HR Metrics. Study.com. https://study.com/ academy/lesson/what-are-hr-metrics-definition-types.html. Accessed October 1st, 2018. 2. Caramela S. 4 Tips for Writing an Effective Performance Review. Business News Daily. https://www.businessnewsdaily.com/5760-write-good-performance-review.html. Published: July 3, 2018. Accessed October 8th, 2018. 3. Rochester Institute of Technology. Building a development plan. https://www.rit.edu/academicaffairs/facultydevelopment/ sites/rit.edu.academicaffairs.facultydevelopment/files/dept_ head_resource_files/building_a_development_plan_0.pdf. Accessed October 2nd, 2018. 4. Hoffman J. Simple Ways to Recognize an Employee. Bevi. https://www.bevi.co/blog/9-simple-ways-recognizeemployee/. Published October 10, 2017. Accessed October 1st, 2018. 5. Feffer M. 9 Tips for Using HR Metrics Strategically. Society for Human Resource Management (SHRM). https://www. shrm.org/hr-today/news/hr-magazine/1017/pages/9tips-for-using-hr-metrics-strategically.aspx. Published September 21, 2017. Accessed October 2nd, 2018.

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32 Orthodontic practice

Volume 9 Number 6

REF: OP V9.6 OROMCHIAN REF: OP V9.6 WHITE

FULL NAME

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 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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Employee-driven performance metrics: If you can’t measure it, you can’t manage it

A tri-dimensional diagnosis and treatment planning guide

OROMCHIAN

WHITE

_______ measure(s) the level of completion of required documents. a. Workflows b. Task management systems c. A dedicated staff document manager d. both a and b

______ violations of your policies or procedures and the subsequent disciplinary actions will ensure individual metrics consistently reflect an employee’s performance. a. Discussing with other office staff b. Maintaining complete secrecy regarding c. Documenting d. Verbally addressing

It is important that violations are ______ to ensure you spot trends in poor performance. a. detailed b. general enough to cover all the staff c. mentioned often d. none of the above

4. They (Performance reviews) are most commonly conducted _______. a. only if there is a violation of company policy b. toward the end of an employee’s introductory period c. on an annual basis after the introductory period d. both b and c 5.

excessive absenteeism and poor attendance. a. absenteeism b. tardiness c. unapproved overtime d. all of the above

In escalated situations, ___________ may encourage a plaintiff’s attorney to pursue a legal claim. a. verbal encounters b. incomplete or missing documents c. an at-will agreement d. requesting necessary documentation You need to have policies that outline processes regarding ________ and enforce violations for

Volume 9 Number 6

Keep in mind, all violations should be issued with the intention of _______. a. termination b. improvement c. placating other staff d. scaring the employee into compliance Development plans are a good way to begin an improvement process for individual performance issues. They not only effectively document incidents of unfavorable issues, but also outline ________. a. what needs to be improved b. how this is to be improved c. the date this should be improved d. all of the above Using data gathered from past performance reviews and assessing the changes in current or future reviews will ensure you are accurately measuring _________. a. growth b. stagnation c. diminished work performance d. all of the above

10. Most importantly, you must use this data (performance reviews) to ______. a. immediately eliminate all staff problems b. embarrass employees into compliance with office policies c. create processes to improve and overcome shortcomings pinpointed in these annual reviews d. create an office hierarchy

The chief complaint of the patient should be recorded ________ in order to prevent confusing the clinician’s perception of the problem with the description offered by the patient. a. in the patient’s own words b. in the dentist’s clinical jargon c. from the assistant’s interpretation d. by the person accompanying the patient

Subsequent studies and publications by Alvarez and Creekmore have corroborated ______ emphasis on the maxillary incisors as the principal feature of orthodontic diagnosis. a. Holdaway’s b. Tweed’s c. Ricketts’ d. Williams’

Certainly, a general health questionnaire will help the orthodontist discover ________ that might affect orthodontic therapy. a. foods b. systemic defects c. medications d. both b and c

While orthodontists may want to know within _______ the skeletal age of a patient, they do not need that quality of information to make an accurate diagnosis and treatment plan. a. 1 month b. 3 months c. 6 months d. 1 year

Muscle strains, _______, and gingival conditions are assessed much better at the chair than with any collection of secondary data such as X-rays, models, photographs, and articulator settings. a. oral hygiene b. the dynamic relationships between the jaws c. static occlusal relationships d. all of the above

A soft tissue analysis involves an assessment of the gingiva, adenoids, and tonsils as well as the tongue, ______, and chin. a. lips b. forehead c. nose d. all of the above

Nevertheless, whenever orthodontists suspect these tissues (enlarged tonsils and adenoids) may limit their orthodontic success, they need to encourage a _________ to see if the removal of that soft tissue can aid in the resolution of the malocclusion. a. consultation with an oral surgeon b. more detailed radiographic imaging protocol c. medical consultation with an otolaryngologist d. referral with a pediatrician

10.

_______ derives positions for the incisors and molars in the vertical and horizontal dimensions. a. An occlusogram b. The Visualized Treatment Objective c. Chaos Theory d. Bayleran’s theory

At the end of the clinical examination, a preliminary problem list has been formed and needs only to add the information that comes from the _____. a. radiographic examination b. cephalometric examination c. information from the occlusograms d. all of the above

______ was the first orthodontist to suggest the maxillary central incisors as the key to achieving proper lip posture and, thus, sought to position them correctly in the face. a. Williams b. Tweed c. Holdaway d. Stein

Orthodontic practice 33

CE CREDITS

ORTHODONTIC PRACTICE CE

MOTIVATIONAL MARKETING

Patients don’t know how good they have it today — because no one is telling them Tom Owens offers tips about how to effectively spread the word about your practice’s technologies

entistry is going through a major transformation being driven by technology, which makes the dental profession more efficient, fun, and profitable. Practices that embrace this technological revolution see the positive results on a daily basis. Their use has reinvigorated the dynamic between dentist and team and, certainly, between dental office and patients. Technology reduces patient time in the chair, condenses multiple visits for treatment, and frees up your schedule for additional new appointments, while helping dentists deliver higher levels of comfort and convenience to patients.

Tom Owens, a specialist in dental practice marketing, is currently a Marketing Manager at Dentistry.com, part of Dentsply Sirona’s Futuredontics division.

34 Orthodontic practice

Why then, does the dental community not give the same time and attention to marketing these innovations as they do adopting them? Thanks to innovative technologies like CAD/CAM single-visit dentistry, clear aligners, dental lasers, noninvasive oral cancer-screening, in-chair teeth whitening, and more, dentists are able to provide patients with a level of care and comfort that was unimaginable just a few years ago. Unfortunately, the typical dental patient has no idea that these remarkable tools exist, what they do, or where to find them. According to the Futuredontics’ survey, “What Dental Patients Want,” nearly half (45%) of individuals between the ages of 45-54 said their decision to patronize a practice is based on its use of advanced technology. What’s more, many patients between

the ages of 25-44 said that they would switch from their current dentist if they did not offer advanced technology treatment options. Because most dentists don’t feature technology in their practice marketing, few practices are reaping the full benefit of their sizable investments in new technology. Dentists using the latest dental technologies enjoy a distinct marketing advantage that — when properly leveraged — has great patient appeal. The good news from a marketing standpoint is that any dental practice sophisticated enough to have invested in cuttingedge technology will likely already have all the marketing tools needed to successfully promote it to patients. The real challenge of marketing the benefits of dental technology is making sure you’re using all the tools at your disposal to their maximum effectiveness.

Volume 9 Number 6

MOTIVATIONAL MARKETING The golden rule of successful technology marketing: Think like a patient Over-explaining the equipment is a frequent mistake. The simple fact is that patients don’t care about technology for technology’s sake. All they really want to know are the benefits (i.e., what’s in it for them), so be sure to keep clinical jargon to a minimum. You need to translate the advantages your technology offers into language the average patient can appreciate. Generally speaking, the benefits with the broadest patient appeal are those that enhance their lifestyle with a minimum disruption to their day-to-day life. Patients want to hear about technologies that save time and reduce costs, or improve cosmetic appearance and promote peace of mind — but it’s up to you to get them to see it that way. Technology fails as a marketing tool if patients don’t know about it. And it fails if you tell them just what it does, not how it makes their life better.

Spreading the word Here are the top seven ways to help you grow your patient-base and get the best return from your investment in dental technology. No. 1: Website It’s important to prominently feature your technological capabilities on your website for both new and existing patients. Use callouts or headlines to promote the specific benefits your technology offers, (e.g., “sameday restorations” or “safely whiten teeth up to eight shades,” and “state-of-the-art oral cancer screening in 5 minutes”). You should also consider adding separate pages dedicated to popular treatments like CEREC®, Invisalign®, and implants. These pages should include a brief — not overly technical — explanation of what the treatment does and a detailed breakdown of the many ways this amazing technology benefits patients (e.g., comfort, cost, appearance, timesaving). Ideally, your website will have a video that explains why so many patients today are choosing specific, technology-based treatments over more traditional methods or a video testimonial from a satisfied patient. No. 2: New patient phone calls It’s important to distinguish your practice as the high-tech, comfort-conscious office when speaking with new patients on the telephone. That’s why it’s crucial that your whole staff is well versed in the benefits of specific 36 Orthodontic practice

The real challenge of marketing the benefits of dental technology is making sure you’re using all the tools at your disposal to their maximum effectiveness. technologies like CAD/CAM systems, dental lasers, and digital X-ray imaging equipment, among others. Mentioning your technological capabilities offers the perfect opportunity to assure callers that you provide state-of-theart care in a manner they’ll appreciate: efficiently, economically, and comfortably.

when you’re trying to bring on a new patient. Talk about the benefits of technology during treatment; remind patients that you invested in this technology to make their experience better — and make sure they understand how specific high-tech treatment options are better than other methods.

No. 3: Practice brochures Be sure to display promotional brochures for the new technologies you offer in your waiting room and operatories. Your product sales representative may be able to supply you with preprinted marketing materials, or you can create your own brochure. If you opt to develop your own custom brochure, make sure it’s professionally written and designed. Depending upon the quantity you need, beautiful 4-color, 8 ½" x 11" two-fold brochures can be printed for just pennies apiece at your local digital printer.

No. 6: Social media Social media sites like Twitter, Facebook, YouTube, and especially Instagram are ideal for promoting your technology. You can post articles, coupon promotions, video testimonials, and before-and-after photos to generate interest in the benefits of each product. Be sure to always get a signed release before posting any photos or videos of patients.

No. 4: Office tours Office tours offer a unique opportunity to wow patients with your practice’s technical capabilities. They’re also the ideal time to explain the advantages of specific technologies and treatments. Come up with a simple script you and your staff can use to explain your technology to interested patients on their first visit. No. 5: Existing patients Your practice’s existing patients are your best candidates for new treatments. That’s because it is much easier explaining the benefits to a patient whose trust you’ve earned than folding it into the conversation

No. 7: Patient communications Patient communications (e.g., newsletters, social media, emails, special offers, postcards) are among the most cost-effective ways to let patients know that your practice offers a variety of advanced treatment options.

Smart marketing is a must It must be reiterated that your practice’s use of advanced technology cannot live in a vacuum. You invested in the technology — now make sure to feature it prominently in your marketing, so both you and your patients enjoy its benefits. It’s important to use every tool at your disposal across all channels — traditional, digital, and social — to educate and motivate patients to seek out your quality of care. Do this, and you are sure to enjoy profitable production for years to come. OP Volume 9 Number 6

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ORTHODONTIC PERSPECTIVE

Symetri™ Clear’s esthetic and clinical benefits Dr. Mark N. Coreil discusses a new ceramic bracket system

or just about as long as I’ve been a practicing orthodontist — 30 years — we’ve witnessed the orthodontic industry undergo a relatively significant evolution, especially when it comes to ceramic bracket systems. Historically, when ceramic brackets first entered the market in the mid-1980s, there was a handful of known issues with regard to removal and placement; these limitations were not immediately or easily remedied. Over the years, however, as clinical needs changed, and patient demands evolved, ceramic materials also advanced. This sort of advancement, paired with dedicated research and development as well as proprietary manufacturing technologies, has allowed clinicians like myself to meet the esthetic needs of patients — with outstanding results. In my practice in Lafayette, Louisiana, my staff and I regularly work with ceramic systems, and typically, we latch onto solutions that check a few very important boxes, including stellar esthetics, superior strength, a low profile, and ease of debonding. We’re always on the hunt for revolutionary systems that employ the latest technologies and orthodontic innovations. Over the past year or so, I’ve had the opportunity to experience and test out one of the industry’s newest ceramic bracket systems, Symetri™ Clear from Ormco Corporation. I’ve been able to witness firsthand the incredibly low profile, ample torque, and tie-wing strength that Symetri Clear can provide. As my friends and colleagues very well know, there are often challenges that come with leveraging a ceramic system — bracket breakage, wire notching, and difficulties while debonding. So, when deploying a treatment solution rooted in ceramics, manufacturing technologies and the ceramic materials used must

meet the quality demands of clinicians as well as patients. Further, in order to ensure enhanced patient comfort and optimal wire placement and sliding, we desire a bracket with round surfaces and edges, like Symetri Clear. In just about every treatment case I come in contact with today, esthetic appeal is a priority consideration for the prospective patient. Because clear aligners aren’t a fit for each and every case, or perhaps due to clinical preference, clear brackets are the known and desirable alternative. When it comes to ceramic options, there can be a preconceived notion from doctors and patients alike that the bracket won’t function as a truly “clear” option; previous systems could appear muddy and wouldn’t esthetically complement the patient’s natural tooth shades. Since adopting Symetri Clear, I’ve noticed how positively patients have responded to the heightened esthetics. The manufacturer states that the bracket design has more rounded surfaces, which diffuse

Mark N. Coreil, DDS is a board-certified orthodontist. Over the past 10 years, he has worked with children who have craniofacial problems. Dr. Coreil is Associate Professor of Clinical Orthodontics at the Louisiana State University School of Dentistry and is actively involved as an orthodontist on the Children’s Hospital Cleft and Craniofacial Team. Dr. Coreil graduated from Louisiana State University School of Dentistry in 1986 and completed his orthodontic specialty training at LSU in 1988. He completed the Roth/Williams Advanced Clinical Program in 1993. Dr. Coreil lectures both nationally and internationally on a number of topics pertaining to orthodontics. Disclosure: Dr. Coreil is a paid consultant for Ormco Corporation.

38 Orthodontic practice

light better than a flat surface. Our team can attest that these brackets virtually disappear and naturally blend with tooth enamel. On my side of the chair, no matter the circumstances, bracket strength and ease of debonding is paramount to a positive patient experience. For patients, it’s all about the esthetics and the comfort of the bracket, and we are able to offer Symetri Clear in both arches because of the exceptionally low profile. We will still use bite ramps when needed, but I’ve been pleased to find that the smaller bracket hasn’t compromised strength. The under tie-wing area allows for double tying, making the bracket perform similarly to larger metal brackets on the market. When it comes to debonding, its proprietary laser-etched pad technology allows for a controlled surface that results in reliable bonding and safe, nondestructive single-piece removal — a win-win for doctors and patients. Patients and parents dislike emergency appointments as much as the doctors and staff. So far, we haven’t had one yet, which frankly has surprised me. We have moved into steel wires and tied with steel ligatures and have not yet seen an undesirable breakage. I’ve participated in some testing for this bracket as well as debonded some recent retreats, and the ease in which the bracket removes from the tooth with minimal pressure is truly impressive. OP Volume 9 Number 6

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STEP-BY-STEP

Having the AcceleDent® conversation with patients Dr. Michael Woods discusses motivating patients about the benefits of low pulsatile forces

y first experience with AcceleDent® was not as a clinician, but actually as a patient. While working as an associate for my mentor, Dr. Amy James (Haddonfield, New Jersey), I decided to treat myself with clear aligners. After the first year of treatment, it was evident a refinement was needed to achieve the results I desired. Unfortunately, I had completely lost my motivation to continue treatment. Prompted by Dr. James, I decided to give the technology a try. I was immediately blown away by the reduction in discomfort that I had previously experienced during my aligner treatment, despite the fact that I was changing trays faster. As a clinician, I draw from my personal experience when talking to patients about the benefits of AcceleDent as I find it is helpful in exploring their treatment options. Here’s my approach:

1. First, ask patients if they have a concern about discomfort, and then ask about treatment time. We generally offer AcceleDent to our adult patients who have an expressed concern about discomfort and treatment time, especially when we are attempting difficult movements (torque, space closure, crossbite correction, open bite, and deep bite correction). I specifically ask them if they have any concerns about experiencing pain during treatment or if they are looking to complete treatment prior to a specific time deadline or milestone. Many of our adults have had prior orthodontic treatment that has relapsed. These patients vividly remember their previous orthodontic experience and are less than eager to relive a similar experience. If time and discomfort are important

factors to them, I tell them that AcceleDent has been clinically shown to speed up orthodontic tooth movement by as much as 50% and reduce discomfort by up to 71% in some cases, not all.

2. Explain to patients how teeth move, and show them their X-rays. When talking to my patients about AcceleDent, I think it’s valuable to educate them about tooth movement. I review their

Michael Woods, DMD, MS, is a board-certified orthodontist and is the owner of Simply Southern Smiles in Statesville, North Carolina. A graduate of Morehouse College, Dr. Woods earned his dental degree from the University of Connecticut School of Dental Medicine. Following dental school, he completed a 3-year orthodontics residency at the University of California Los Angeles (UCLA). Dr. Woods worked as a research fellow at the National Institutes of Health in Bethesda, Maryland, prior to beginning his orthodontic career. Disclosure: Dr. Woods does not receive any financial compensation from OrthoAccel. He is an orthodontist who offers AcceleDent to his patients.

40 Orthodontic practice

panoramic X-ray with a specific emphasis on the ratio of crown and root length. I explain that we’re actually remodeling bone around those roots in order to shift the teeth into their desired positions. When patients observe the difference in root length relative to crown height, they seem to appreciate the importance of bone remodeling in the tooth movement process. Similar to a tree or an iceberg, teeth are supported by a much larger structure below the surface. Therefore, it’s what we don’t see below the surface that provides the stability and the support for what we do see above the surface. I use these analogies to explain why the rate of tooth movement is dependent upon the rate of bone remodeling around the roots of teeth. The technology behind AcceleDent aims to enhance the remodeling process at the cellular level by Volume 9 Number 6

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STEP-BY-STEP employing low pulsatile forces. This technology is not new; moreover, it was borrowed from our medical colleagues in orthopedics who discovered the benefit of low pulsatile forces in enhancing the rate of bone remodeling during the repair of fractured bones.

3. Discuss the difficulty of the case. Clinically, my experience has demonstrated that AcceleDent makes difficult tooth movements more predictable and efficient, especially during clear aligner therapy. I have observed a clinical benefit to having patients use AcceleDent when treating open bites, closing an extraction space (lower incisor extraction), jumping a crossbite (anterior and posterior), and rotating teeth. I find it helpful to discuss my clinical limitations, especially with adults, so they are not surprised when more difficult tooth movements take more time to accomplish or complete. AcceleDent provides a meaningful alternative to accomplish some of these difficult movements, while reducing the pain and discomfort commonly associated with these movements. Since some difficult movements can be unpredictable in clear aligners, I offer AcceleDent as a tool to efficiently treat patients and accomplish movements that typically slow down their treatment.

4. Ask if patients prefer braces or aligners. We offer AcceleDent to our braces and aligner patients. For patients who choose aligners, I let them know that instead of changing their aligners every 2 weeks or every week, with AcceleDent they can change their aligners every 5 days. I see these patients about every 10 to 12 weeks, and at each appointment, I’m impressed by how closely the teeth track and mirror the ClinCheck®. Another benefit that the clear aligner patients appreciate with AcceleDent is the reduction in refinements, which gives them a sense of confidence in the estimated treatment time we estimate. For braces patients who use AcceleDent, they’re coming in for appointments every 8 weeks, and I’m noticing that the leveling and alignment are accomplished more efficiently. I’m using fewer archwires in my patients using AcceleDent as I find that I am getting much more movement out of each archwire. The common finding among my patients using the AcceleDent technology is the reduction in discomfort during the more 42 Orthodontic practice

Clinically, my experience has demonstrated that AcceleDent makes difficult tooth movements more predictable and efficient, especially during clear aligner therapy.

difficult stages of treatment in both braces and clear aligners.

acknowledging their commitment to pay the remaining balance.

5. Explain costs.

Conclusion

We do not use AcceleDent as a significant profit generator in our office, which makes it easier for patients to justify making the investment. Instead, we use it as a way to streamline clinical efficiencies and create satisfied patients. We essentially pass the cost of the device directly through to the patient. Even though we’re speeding up treatment, we still allow patients to stick to their payment plans. In the event patients complete treatment ahead of schedule, we have adopted a practice of extending their payments beyond their active treatment time, and we have the patients sign a new contract

AcceleDent is one of the many technologies and appliances that help orthodontists operate more effectively and efficiently. Like most doctors, I was very skeptical, but what I learned during my firsthand experience with AcceleDent is that you can’t rely solely on what’s presented in the academic journals or product marketing. Instead, formulate your own opinion by trying AcceleDent yourself or having a staff member use it. You really need to see how it works in your hands by using it in its intended context and clinical setting to make an informed decision about its clinical efficacy. OP Volume 9 Number 6

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TECHNOLOGY

How digital dreams become a reality Dr. Andrew Nalin discusses his journey to a digital office

’ve always dreamed of having an all-digital office since first purchasing my practice 11 years ago. I took the first step toward going fully digital with an intraoral scanner, the CS 3500 (Carestream Dental), and when the opportunity came to upgrade, I switched to the CS 3600 intraoral scanner. We started using it for digital impressions — in fact, we got rid of alginate impressions almost completely — but that was just the beginning. Next, came a Formlabs 3D printer, the perfect piece of technology to combine with the open architecture of the CS 3600 for printing clear aligners. Finally, I took my imaging 3D with a system that combines 2D-panoramic imaging, cephalometric imaging, CBCT, and model scanning — the CS 8100SC 3D. CS OrthoTrac Cloud for practice management completes my digital integrated workflow.

Digital dimensions There were several reasons I had my heart set on digital, and I’ve seen numerous benefits in every aspect of my practice. From patients to referrals, going digital isn’t just trendy; it has had far-reaching positive effects on the people I interact with daily. Patients Most important, patients reap the benefits of digital technology. Dealing with children means many arrive at the practice for a first appointment nervous and shy. Unfortunately, I overhear too many parents psych out their Andrew Nalin, DDS, earned a bachelor’s degree in microbiology (1990) and a Doctorate of Dental Surgery (1998) from the University of Washington. After dental school, he completed an Advanced Education in General Dentistry residency at the Wright Patterson Air Force Base Medical Center (1999) and served our country in the United States Air Force for 9 years. In 2005, he completed his Orthodontic Residency in the Tri-Service Orthodontic Residency Program in San Antonio, Texas. Dr. Nalin is a published author and is currently involved with research at the University of Washington. He is a member of the American Association of Orthodontists, American Dental Association, Washington State Dental Association, Pacific Coast Society of Orthodontists, Washington State Society of Orthodontists, and the Mount Baker District Dental Society. Disclosure: Dr. Nalin is a Key Opinion Leader for Carestream Dental.

44 Orthodontic practice

Going digital means impressions are easily stored on a computer, not in boxes on shelves

kids with outdated information: “Ugh, they’re going to put this yucky goo in your mouth that will make you gag.” That’s when my team and I step in with the great news that we’re a digital practice. Both parents’ and children’s eyes light up as they watch the

digital impression take shape on the screen. We even give patients their 3D printed model when we’re done; they love having something to walk away with. Overall, the experience is less stressful and more accurate for our patients. Volume 9 Number 6

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TECHNOLOGY

Tips for realizing your digital dreams I have three 3D printers throughout the practice, and the CS 8100SC 3D is compact enough to fit in tight spaces

Staff Staff members also appreciate digital technology as it has a shorter learning curve and is faster and easier to use. For example, the imaging system is intuitive enough that new team members pick it up right away, and digital impressions are less messy and faster than traditional impressions. In fact, now — after becoming accustomed to the intraoral scanner — staff hate it when they see traditional impressions on the schedule. (We still take a few for expanders since labs struggle with digital impressions for that kind of device.) I even find myself taking more impressions with a scanner than I ever would have taken traditional impressions. Office production and workflow One of my main reasons for investing in the scanner and 3D printer was to fabricate my own clear aligners. It’s more costeffective (about $3 a model) and faster since there’s no need to wait on shipping from a lab, and things will only get better as technology continues to evolve. The cost of resin has already come down since installing the printer, and the scanner has received firmware updates that improve speed and accuracy. Digital technology also lets us provide our patients with better service. If a retainer is lost or broken, the patients can bring their 3D-printed model in, and we can fabricate a new aligner in about 5 minutes. In the past, a stone model would break when the retainer was made, so a new impression would have to be taken if the patients lost their retainer. Digital impressions are a better way of doing business and a value-add for the patient, not to mention cheaper for them and the practice. Referrals Since investing in digital technology, I’ve noticed an increase in referrals. They send 46 Orthodontic practice

their patients to me for several reasons. The four-in-one CS 8100SC 3D imaging system can capture images that meet almost all specialists’ clinical needs while keeping patients in a friendly practice environment (rather than sending them to an imaging center). Additionally, it features low-dose protocols that suit the pedodontic and young adult markets well. Referrals are also impressed with my setup for fabricating clear aligners; I’m the only practice in the area that’s doing so, and word has gotten out.

The digital future I may have my all-digital practice, but that doesn’t mean I’ve stopped dreaming. With a new year ahead of us, there are several new ways orthodontists can make their digital workflow even better. New ways to approach treatment With the ease of digital technology and the low cost of in-house aligners, my mindset has changed as I plan treatment for patients. I’m starting to prefer aligners to brackets, and I’m doing things with aligners I never would have done 2 years ago. To ensure that the patients fully understand the treatment and are comfortable with a somewhat “experimental” approach, I make a deal with them: Let’s try it with aligners, and if it doesn’t work, we’ll do braces. I’ve found there are a few who eventually do need braces, but even then, if they can do 90% of treatment with aligners first, they’re thrilled. More technology in-house I recently had a study club come to my office to observe my workflow. As the word spreads, we’ll see more practices bringing workflows in-house, not just to cut out the lab, but to even cut out clear aligner companies. Direct-to-consumer aligner marketing is increasing patient demand, but orthodontists must adapt to capitalize on this increased

• What is your long-term digital goal? Pinpoint what you hope to accomplish with digital technology, so you know exactly what you need to achieve it. • When new technology is released, see if your manufacturer is offering trade-in deals to upgrade. • Keep your eye on the mail. I found my long-sought-after 3D printer thanks to a flyer for a company that sells the printer and recognized early on that it could be used for dentistry. • Visit vendors’ booths at the annual association meetings — a lot have relationships with other companies that can help put together a complete digital solution. • Join Facebook groups that discuss these emerging technologies. As you sift through these discussions, you can learn a lot.

interest. More cost-effective equipment and faster, more intuitive software will help facilitate this transition. Exciting advancements in 3D printing The future advancement I’m most excited for is using software to virtually place brackets and then directly print the template itself rather than the model. Additionally, I’m eagerly awaiting the day we can direct print aligners, without having to print the models then thermoform and trim the aligners. The desire for a digital practice wasn’t because it was cool or trendy, but because an integrated digital workflow is more accurate, saves time, and helps me provide the best care for my patients. As technology continues to advance, I look forward to incorporating new technology and treatment paths into my practice. OP Volume 9 Number 6

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EMPLOYEE ENGAGEMENT

Engaging wires, engaging employees: how employee engagement in the orthodontic office is tied to productivity and profit – part 1 Manon D. Newell, JD, discusses the first step in the orthodontist’s journey toward excellent business practices

s an orthodontist, you know that you must engage the archwire to achieve tooth movement. Clinically, measurements play an important role in the diagnosis and treatment of your patients. You measure facial proportions, tooth size and discrepancy, malocclusions, and the list goes on. But have you considered that engagement and measurement also play an important role outside of the clinic? In residency programs, the business of orthodontics is too often left out of the curriculum, and while clinical excellence is a top priority, orthodontists must understand the business aspect of their profession in order to succeed in an increasingly complicated market. If wire engagement is the first step in the patient’s treatment journey, employee engagement is the first step in the orthodontist’s journey toward excellent business practices! Employee engagement is a term coined by the Gallup® organization. In its simplest form, employee engagement is the emotional connection that an employee has to an organization and its goals — in this case, your practice.1 Engaged employees aren’t simply showing up for a paycheck; they are committed and invested in the outcomes of the business and see themselves as an integral part of the overall success of the practice. An engaged employee will work to further the reputation and interests of your practice. Engaged workers stand apart from their not-engaged and actively disengaged counterparts because of the discretionary

Manon D. Newell, JD, has a unique background that weaves together experience in law, business, and orthodontics. After focusing in appellate and employment law, Manon transitioned into a business role in Medical Orthodontic Devices. In 2016, Manon became a partner at Systemized Orthodontics and married her passion for orthodontics and business. At Systemized, she manages the day-to-day business of the company. She works closely with clients on their financial benchmarking and goal setting. Manon also coaches clients and especially enjoys working with practice administrators to develop their strengths. She most enjoys seeing the progress that practices make in the time that she partners with them.

48 Orthodontic practice

effort they consistently bring to their roles. These employees willingly go the extra mile, work with passion, and feel a profound connection to their company. They are the people who will drive innovation and move your business forward.2 The level of employee engagement affects both the ability of your practice to grow as well as the profitability of the practice. Because businesses with high levels of engagement routinely outperform their competition, it stands to reason that orthodontic practices with high levels of engagement will have a competitive edge in today’s market. Considering that only one-third of employees in the United States are actively engaged at work, chances are you need to make employee engagement a strategic priority and part of your overall business plan. The orthodontic market is undergoing profound changes. You would be hardpressed to meet an orthodontist who does not have concerns about the viability of their business model in the changing economy. Consolidation, corporate dentistry, a rush of new and expensive technology, and new delivery channels are just a few of the recent changes that have orthodontists concerned about the health and staying power of their practices in the coming years. Instead of lowering fees, or becoming an employee

orthodontist, we encourage our clients to rise to the top of the profession. An orthodontist who is motivated and business-minded can embrace a model that will do more than just survive in the current conditions. There is a large segment of the patient population that will always pay for excellent clinical care backed by top-notch customer service. These are the same patients who boost word-of-mouth referrals and bolster practice reputation. Because increased employee engagement is a proven method of delivering quality care, outstanding customer service, and increased productivity, it is imperative that orthodontists understand both the concept of employee engagement and how to measure it. Employee engagement is tied to nine specific business outcomes that have a profound impact on your bottom line. Gallup’s longitudinal research on employee engagement began in 1997 and is ongoing with the most recent meta-analysis being released in 2016. There is now 25 years’ worth of research that unequivocally ties employee engagement to key business outcomes and overall success. Gallup researchers have studied more than 82,000 work units, including nearly 1.9 million employees. This research spans diverse industries from corporate to health care and Volume 9 Number 6

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EMPLOYEE ENGAGEMENT diverse geographies. The latest iteration of the meta-analysis in 2016 further confirms the well-established connection between employee engagement and the following key performance outcomes: customer ratings, profitability, productivity, turnover, safety incidents, shrinkage (theft), absenteeism, patient safety incidents, and quality.2 Additionally, businesses with high levels of employee engagement report higher levels of productivity and customer satisfaction.3 Furthermore, these findings are important because they mean that generalizable tools — namely, the Q12 Assessment (formerly the Gallup Workplace Assessment or GWA) — can be used across different organizations and business models with a high level of confidence that they elicit important performance-related information. The data from the 2016 analysis further substantiates the theory that doing what is best for employees does not have to contradict what is best for the business.1 Much has been studied about the impact of employee engagement on a company’s financial performance, and there is a general consensus that increased engagement is a driver of productivity and profitability. Gallup’s research, for example, suggests a 20% or better boost to productivity and profitability for companies with high levels of engagement.4 In practice, our orthodontic clients routinely see 20%-40% increases in annual productivity depending on the maturity of the practice. It is clear that employee engagement has a number of implications for the health of an orthodontic practice. In Gallup’s State of the American Workplace, it was clearly shown that companies with high levels of employee engagement withstood the recession successfully, outperformed their competitors, and grew at a much faster rate with the economic recovery.5 It stands to reason that if we can weather economic downturns, improve employee retention, and increase patient loyalty, productivity, and safety, an orthodontic practice should be able to keep the bottom line more than healthy even, and maybe especially, in a complex and changing market. If longitudinal research clearly shows the correlation between improved business outcomes and employee engagement, how do we increase engagement in the orthodontic practice? To achieve increased engagement, we first have to measure. We have to know where things stand to know where we want to go. Working with orthodontic practices across the country, we implement Gallup’s Q12 Assessment at the beginning of our work. Initial Q12 results give us a clear picture of how engaged the overall team is, and what its current impact is on the 50 Orthodontic practice

Courtesy of Gallup® https://www.gallup.com

practice. We routinely find that orthodontists are measuring performance by the wrong standards. Without focusing on the correct performance measures, they can neither implement effective change nor improve key business outcomes. Once we have the correct metrics to assess, we can begin to strategically implement systems for positive change and measure over time. Employee engagement does not happen overnight. If your team is your best asset and opportunity for growth, orthodontists should be investing in their team as a strategic priority. In our work with clients, we focus on tapping into every employee’s strengths profile. This helps employees realize how they operate both individually and within a group. It also helps us to see whether employees are in the best position on the team to maximize individual performance. Many times, a simple change in an employee’s role that taps into his/her innate talents will drastically increase engagement at work. We are all more satisfied and fulfilled when we are happily engaged doing what we do best! When employees are recognized for who they are and not just what they do, they begin to bring their best to work every day. Further, employees and team leaders alike must take responsibility and be held accountable for high levels of employee engagement. The doctors who we work with make engagement a top priority in their practices. The most successful practices that we work with fully integrate the concept of engagement into every aspect of their practice. We consistently see positive results when our clients tap into their own strengths as

well as the strengths of their employees and drive engagement as a top priority. Consistent measuring helps us to gauge progress, and the results are concrete. In the practices that we partner with, we see that as engagement levels increase, customer service improves, doctors have less staff turnover, patient satisfaction and word-of-mouth referrals skyrocket, productivity increases year over year, and work becomes fun again! For orthodontists, the business of measuring is a no-brainer. When you begin to measure the right things and respond accordingly, you will see key business outcomes improve. Science proves this, and our clients live it every day! Part 2 of the series will discuss ways to implement employee engagement in the orthodontic environment. OP

REFERENCES 1. Harter JK, Schmidt FL, Agrawal S, Plowman SK, Blue A. The Relationship between Engagement at Work and Organizational Outcomes: 2016 Q12 Meta-analysis 9th Ed. Gallup, Inc. April 2016. http://www.workcompprofessionals.com/ advisory/2016L5/august/MetaAnalysis_Q12_ResearchPaper_0416_v5_sz.pdf. Accessed October 1, 2018. 2. Reilly R. Five Ways to Improve Employee Engagement Now. Gallup Business Journal. https://www.gallup.com/workplace/231581/five-ways-improve-employee-engagement. aspx. Accessed October 1, 2018. 3. Graber S. The Two Sides of Employee Engagement. The Harvard Business Review. https://hbr.org/2015/12/the-twosides-of-employee-engagement. Published December 4, 2015. Accessed October 1, 2018. 4. Fuller R. A Primer on Measuring Employee Engagement. The Harvard Business Review. https://hbr.org/2014/11/aprimer-on-measuring-employee-engagement. Published November 17, 2014 Accessed October 1, 2018. 5. Sorenson S. How Employee Engagement Drives Growth. Gallup Inc. https://www.gallup.com/workplace/236927/ employee-engagement-drives-growth.aspx. Published June 20, 2013. Accessed October 1, 2018.

Volume 9 Number 6

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PRODUCT PROFILE

Damon™ Q2 2x the rotation control

or several decades, the orthodontic industry has undergone rapid and significant change, especially when it comes to the evolution and growth of passive selfligating (PSL) bracket systems. Over the years, with each bracket advancement, manufacturers have kept one goal consistent: improve treatment efficiency while providing patients with optimal comfort. Despite the breakthroughs with self-ligating systems in terms of efficiency and productivity, there are natural and inherent challenges and technical nuances that need to be addressed. With passive self-ligating brackets, some orthodontists may struggle with a lack of rotational control or the absence of tie-wing space, making it difficult to insert power chains underneath the wire. With that in mind, optimal rotation control is something that today’s clinicians demand and desire. Now, following years of dedicated research and development through customer collaboration, Ormco Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, is pleased to unveil the newest addition of the Damon System — Damon™ Q2 (DQ2). The new bracket system features 2x the rotation control,1 providing clinicians with the versatility to help efficiently treat all cases with simplified mechanics. DQ2’s superior control allows for heightened treatment reliability,2 efficiency, predictability, and flexibility. DQ2 arms clinicians with the treatment solution

52 Orthodontic practice

DQ2’s superior control allows for heightened treatment reliability, efficiency, predictability, and flexibility. needed to help them efficiently and effectively care for patients to the best possible smile result. Key product features of DQ2 include: • 2x improvement in rotation control — DQ2 provides four solid walls with a refined precision slot and 2x the rotation control for optimal precision, predictability, and efficient finishing. Arming doctors with 2x rotation control helps provide them with the toolset needed to treat all cases with the utmost confidence and bracket reliability.2 • Enhanced tie-wing design — DQ2 provides ample under tie-wing area3 to better accommodate all power chain, elastics, steel ligatures, and other auxiliaries for treatment versatility. Designed for heightened patient comfort and esthetics, the bracket system features a small profile and size with smooth, rounded corners. • Vertical scribe line, new drop-in hook, and modified prescription — DQ2 features a rhomboidshaped pad and new vertical scribe

line to guide desired bracket placement. The new DQ2 drop-in hook4 was designed to provide improved bending strength and durability with Ormco’s elastics and auxiliaries. Additionally, DQ2 provides a modified prescription5 for upper, central, and lateral standard torque brackets, designed to deliver predictable finishing and efficient treatment. As the PSL market leader, the Damon System offers a combination of PSL brackets, light force archwire sequencing, and minimally invasive treatment protocols used to successfully finish over 6.5 million cases. To learn more about DQ2, please visit www.ormco.com/products/damon-q2/ or connect with your Ormco sales representative directly for more information. OP

1. +2x U3-3 compared to original DQ bracket 2. Compared to other Damon Systems 3. Damon Q2 compared to Damon Q 4. New drop-in hook coming in Q4 2018 5. Standard Damon 3MX prescription Internal data on file.

This information was provided by Ormco.

Volume 9 Number 6

GOING VIRAL/LEGAL MATTERS

The importance of an independent cybersecurity audit in the orthodontic practice Gary Salman and Justin Joy discuss ways to keep patients’ records safe

n independent cybersecurity audit to analyze your current security posture is one of the most important things you can do to protect the confidentiality of your patient records. As an owner or associate of the practice, you must have a thorough understanding of the state law related to cybersecurity and HIPAA. Strictly “hoping” that the correct measures are in place may leave you in a compromised situation in the event of a security or privacy incident impacting your patients and practice. As a clinician, you must take a proactive approach and have a very clear picture of exactly where you stand from a cybersecurity and HIPAA perspective. For instance, are you conducting documented cybersecurity awareness training? Have you conducted a risk assessment and risk analysis, and is it up to date? Have you implemented advanced security measures such as quarterly vulnerability scanning and network penetration testing to demonstrate the effectiveness of the current security measures? Have these tests been documented, and are they part of your HIPAA documentation? If the answer is no, then it is critical that you Gary Salman is Chief Executive Officer, Black Talon Security, Katonah, New York (www.blacktalonsecurity.com). He has more than 26 years of dental technology and IT experience. Justin Joy is an attorney with the Tennessee-based law firm of Lewis, Thomason, King, Krieg, and Waldrop, PC. He specializes in assisting healthcare practices in the areas of incident investigation and breach response management, HIPAA Privacy Rule, Security Rule, and Breach Notification Rule compliance.

54 Orthodontic practice

engage with an independent company that can assist in these matters. In the IT space, progressive IT companies typically recommend to their clients that they engage with a company that specializes in cybersecurity to audit the work that they have performed. IT companies that tell their clients, “Doctor don’t worry about that, we have it taken care of,” are the ones who typically do not understand the complexities of cybersecurity, and how easy it is to exploit a network if the proper steps have not been put in place to identify and mitigate vulnerabilities. Engaging with a company that specializes in cybersecurity is critical for two reasons. First, the complex nature of computers and networks often leaves room for misconfiguration errors or improper practices resulting in the ability for hackers to exploit these mistakes and gain access to your data. It only takes one vulnerability on your network for your data to be exploited. The next thing you know, your patients’ data is being bought and sold on the dark web. Second, the sophistication of cyberthreats has evolved to the point where, if you are not immersed in this field on a daily basis and do not have the tools and technologies to combat them, you are way behind. A reputable cybersecurity company invests heavily in the tools and human resources needed to protect and defeat the complex assaults against our healthcare system. Covered entities (orthodontic practices) are required to completely and accurately assess the potential risks and vulnerabilities

to the security of electronic protected health information (ePHI) held by the practice. IT firms and managed service providers are good at keeping your practice’s network, desktops, and applications running on a dayto-day basis. In most instances, however, these firms lack the expertise to assess and identify vulnerabilities, resulting in risk to your practice’s data. It is simply not their area of focus. Additionally, from an audit perspective, if your IT firm engineered and set up your network environment, it is necessary for an independent party to examine the work and provide feedback to you, the client, as to the security posture and vulnerabilities within the environment. The U.S. Department of Health and Human Services Office for Civil Rights, which enforces HIPAA, requires that the assessment of your practice’s risks and vulnerabilities be documented. If you are relying on a company that does not have expertise in information security to identify and assess technical vulnerabilities, you are not only potentially exposing your practice to considerable security risk, but also likely not meeting the HIPAA Security Rule requirement for identifying and assessing all vulnerabilities to your ePHI. You must also be aware of your requirement to analyze your risks and vulnerabilities on an ongoing basis. Here again, an audit by an independent firm is not only valuable but in many cases necessary, to reduce risk to your practice’s data and meet regulatory requirements. The Security Rule requires Volume 9 Number 6

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GOING VIRAL/LEGAL MATTERS posture is to reduce the chances of a data breach resulting in patients becoming the victim of identity theft — especially minors. In the event of a data breach, most states and the federal government will expect you to offer identity theft monitoring to your patients. The cost associated with this is extremely expensive and often twice the price for minors. As orthodontists, a majority of your patients are minors — think what that means from a public relations perspective. No parent is going to be happy knowing that his/her 13-year-old child has been a victim of identity theft due to a data breach that occurred at your practice. According to a Carnegie Mellon study on identity theft, a child is 51 times more likely to be a victim of identity theft than adults.1 Don’t put yourself, your practice, and especially your patients in a compromised position by eroding patient trust for something that is highly preventable. OP

REFERENCE 1. Power R. Child Identity Theft. Carnegie Mellon CyLab. https://www.cylab.cmu.edu/_files/pdfs/reports/2011/childidentity-theft.pdf. Accessed September 28, 2018.

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are familiar with and comply with both the HIPAA Privacy Rule and Security Rule. Some of the items that they need to have in place are the following: 1. A complete HIPAA compliance manual, including a risk assessment and risk analysis 2. Annual HIPAA training 3. Annual cybersecurity awareness training 4. Documented security measures that protect their data such as vulnerability scanning and penetration testing Ask them for proof of this documentation; don’t just take their word for it. Imagine what would happen if their networks were breached, and the hacker gained access to your practice’s IP address, user name, and passwords for your servers and workstations. It could potentially be a disaster for all parties involved. Compliance and cybersecurity must be implemented by all parties that have access to your network and data. It is a team effort, not just a requirement for the covered entity (healthcare provider). Another vital reason to have an independent security audit to evaluate your security

SEE

that assessment documentation must be updated any time there is an environmental or operational change potentially affecting the security of your group’s ePHI. Given the never-ending proliferation of cyber threats, these environmental changes are ongoing, and the assessment of the risk to your group’s PHI as a result of any vulnerabilities in the face of these threats must be ongoing as well. Another key area for you to be cognizant of is your interaction with your business associates. Under HIPAA, business associates such as your IT company, practice management software company, imaging company, consultants who have access to your computers, and third party software integrators must comply with the same HIPAA rules that you do as an orthodontist. In the event of an audit or security incident, the Office for Civil Rights often requests you to provide copies of signed business associates agreements with all of your vendors. Make sure that you check to see that you have executed agreements with these parties. When making purchasing decisions or engaging with IT companies, ask them if they

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Volume 9 Number 6

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Sell All or Part of Your Practice; Let a Partner Finance New Growth LPS Clients Will Complete Over $100,000,000 in Transactions in 2018

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CASH TO YOU Today’s environment offers you many choices in transaction structures. Certainly, you can sell 100% of your practice for cash. However, many doctors are opting for other structures in which they sell part of their practice for cash and retain an ownership interest in their practice. Doctors can get millions in cash to secure their financial future and a partner to finance expansion and assist in growth. The values of large dental, orthodontic and pediatric dental practices have never been higher; for the right practices. We do not expect the current extraordinary valuations to last; the timing is NOW. Large Practice Sales (LPS) helps dentists, orthodontists and pedodontists sell their practices for far more than typical “transition advisors.” We focus exclusively on the sale of practices with $1,000,000+ in annual earnings, (EBITDA) not collections. We do not provide consulting, valuations, associate searches or any other ancillary service. We exclusively sell large practices, primarily to Private Equity backed buyers.

PRODUCT INSIGHT

Importance of design in the strength and function of 3M ceramic brackets Armineh Khachatoorian discusses the advantages of 3M ceramic brackets

he top trend in the orthodontic industry today is esthetic treatment. The growing significance of dental esthetics, awareness of such procedures among the general population, and increasing disposable income in developing countries have allowed numerous patients to undergo treatments that they may not have chosen earlier. This has led to the development of a wide range of products, techniques, and procedures designed to meet specific patient needs. A key player in the expanding esthetic orthodontic market is ceramic brackets. Ceramic brackets have been around for more than three decades, having evolved from a number of design iterations to achieve their current prolific status and worldwide reputation. By combining the visual needs of the patient with the technical performance required by the orthodontist, ceramic brackets deliver on desired esthetics, efficiency, and predictability. Driving new market innovations as the premier ceramic bracket manufacturer, 3M Oral Care was the first to launch a fully ceramic bracket in 1987. Now, 3M offers a comprehensive portfolio of esthetic treatment options under 3M™ Clarity™ Esthetic Orthodontic Solutions. 3M™ Clarity™ Advanced Ceramic Brackets, 3M™ Clarity™ Ultra Self-Ligating Brackets, and 3M™ Clarity™ Aligners provide the flexibility and control that orthodontists need to deliver the best results for patients who highly value esthetics. Exploration of 3M’s history with ceramic brackets, particularly with regard to design Armineh Khachatoorian received her B.S. in Chemistry from the University of Southern California. She worked as an R&D and Product Development Engineer before joining 3M Unitek in 1997 as a Senior Technical Service Engineer in R&D. In 2002, she became a Marketing Product Manager responsible for Adhesives, Ligated Appliances, Tubes and Bands, and APC™ Adhesive Systems. She has participated in the introduction and marketing of the Ortholux™ Luminous Curing Light, the APC™ Flash-Free Adhesive System, and other adhesive products. Her current role is Scientific Affairs Manager.

58 Orthodontic practice

and development, reveals key attributes that have empowered their success.

History Modern ceramic brackets offer excellent optical properties and the promise of additional esthetic appeal, without significant functional compromises. Ceramic brackets are durable, allow adequate force control over long treatment periods, and have

minimal risk for discoloration. The introduction of the first ceramic brackets, 3M™ Transcend™ Ceramic Brackets, completely altered the market landscape with their brilliant esthetics, strength, and stain-resistant qualities. The ceramic brackets drew unprecedented treatment acceptance among both adult and teen patients, when compared to that of metal brackets. Moreover, they contributed significantly to the expansion and Volume 9 Number 6

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PRODUCT INSIGHT development of contemporary orthodontic treatment modalities.1 Transcend ceramic brackets, individually designed for each tooth, worked in concert with the archwire to gradually reposition teeth into proper alignment. Created to meet the need for an esthetically appealing orthodontic appliance that were as clinically effective as metal braces, the brackets were composed of a very hard, shatter-resistant alumina with high strength and maximum translucency.2 They were designed to prevent staining, discoloration, deforming, or bending. Transcend ceramic brackets remained a popular treatment solution for more than a decade, laying the foundation for future esthetic treatment innovations. And as 3M continued to experiment with design developments to improve treatment efficiencies, it was only a matter of time before they introduced a new and improved ceramic bracket. In 1996, 3M Oral Care unveiled its 3M™ Clarity™ MetalReinforced Ceramic Brackets with enhanced bonding and debonding efficiencies. As their name suggests, the brackets featured a unique, patented metal-lined archwire slot that delivered sliding mechanics not yet found in ceramic brackets. The innovative slot gave Clarity brackets the reinforcement required to achieve higher torque strength while also helping to resist bracket fractures during treatment. Clarity ceramic brackets also introduced a proprietary “stress concentrator,” or scoring in the bracket base, that allowed the bracket to collapse under gentle pressure — for consistent, reliable debonding. Fast-forward to today, and the Clarity portfolio remains one of the top-selling ceramic brackets on the market. To maintain this rank, 3M eliminated metal visibility for improved esthetics, lowered the profile for increased patient comfort, and improved the bonding base design for optimal tooth fit. In 2011, Clarity Advanced Ceramic Brackets were launched with these new features, preserving the strength of the metal-reinforced brackets while enhancing overall esthetics and functionality yet again. Virtually unnoticeable, the brackets were created to be used with clear or colored elastic ligatures — giving patients the option to go bold or be natural. 60 Orthodontic practice

Clarity Advanced Ceramic Brackets

and clinical performance have greatly improved, ensuring that ceramic brackets are not only well accepted by patients, but also actively sought after by both patients and orthodontists. Specific developments in material, shape, ceramic grain size, and design elements have enabled functional advantages over time. Clarity Ultra Self-Ligating Brackets

New to the Clarity portfolio just this year, Clarity Ultra Self-Ligating Brackets took design development one step further, removing the need for ligation and reducing visibility of the archwire. Clarity Ultra SelfLigating Brackets feature a wide-door mechanism that helps conceal the archwire and provide rotation control without the addition of accessories. Designed for patient comfort with unparalleled esthetics and efficiency, the Clarity portfolio remains one of the top ceramic bracket choices among practitioners today — offering a variety of treatment options, based on desire and need.

The ceramic advantage Apart from offering esthetics, ceramic brackets still provide excellent biocompatibility, corrosion resistance, stability in the oral environment, and non-toxic nature — making them an integral part of an orthodontist’s product offering. Since their introduction, product design, technology,

Material and manufacturing processing First, ceramic is a stronger material than metal, with a higher tensile strength than stainless steel brackets.1 All of the currently available ceramic brackets are composed of aluminum oxide and can be made available in two forms, according to the manufacturing process: polycrystalline or monocrystalline. Polycrystalline brackets are made of many small aluminum oxide crystals fused at high temperatures; monocrystalline brackets are made of a single crystal produced from molten aluminum oxide. The main advantage of the polycrystalline manufacturing process is its ability to mold brackets; this is a relatively inexpensive operation that yields large quantities. Ceramic press mold and grinding is a common process used to make ceramic components. The disadvantage of this process is that grinding or machining is required for precise details, which can introduce structural defects and lead to cracking. Injection molding is an alternative method of making polycrystalline brackets that does not require the brackets to be machined, thus Volume 9 Number 6

PRODUCT INSIGHT eliminating structural imperfections created by the cutting process. This molding process and heat treatment, used to create Clarity Ultra Self-Ligating Brackets, produces fused aluminum oxide with grain boundaries that refract light and result in a degree of opacity that distinguishes polycrystalline from monocrystalline brackets. With optimum translucency, polycrystalline brackets are designed to blend better with different tooth colors. Single-crystal, or monocrystalline, ceramic brackets are manufactured by an entirely different process, in which manufacturers purchase large single crystals and mill them into the shapes and dimensions of various brackets with ultrasonic cutting techniques, diamond cutting, or a combination of the two. After milling, most synthetic sapphire brackets are heat-treated to remove surface imperfections and relieve stresses induced by the milling operations. The primary advantage of this process is the elimination of possible stress-inducing impurities or imperfections. The disadvantage is the difficulty and added expense of milling the third-hardest known material. Transparent in appearance, monocrystalline brackets have noticeable optical clarity but are also more difficult to produce.2 Ceramic grain size and texture In addition to being polycrystalline or monocrystalline, ceramic part grains can either be fine-grained or coarse-grained. Parts made of smaller, or finer, ceramic particles are typically stronger and present more advantages than coarse-grained ceramic brackets. They tend to stain less and have a decreased chance of breaking or shattering. The injection molding process of finegrained, polycrystalline brackets — like that of the Clarity brackets — further creates a

Clarity Ultra bracket base 62 Orthodontic practice

smoother surface with continuous, rounded edges that enhance patient comfort and minimize irritation from soft tissue contact. In contrast, larger coarse-grained ceramic brackets can become structurally weaker, less smooth, and susceptible to staining. Design shape Because patients can feel every bump of a bracket on the inside of their mouth, bracket shape and smoothness significantly influence product acceptance and, therefore, market success. Brackets that are low profile by design, with their shorter height, reduce occlusal interference and increase intraoral comfort, as well as patient confidence, throughout treatment. An ample under tie-wing area supports easy ligation without affecting bracket size. Bonding and debonding reliability and efficiencies Ultimately, doctors and patients want the same thing: effective treatment options with positive results. To achieve this, orthodontists need control and predictability from start to finish, from initial bonding to final debonding. One of the important, and challenging, requirements of ceramic brackets that 3M aims to achieve is the ability to provide adequate bond strength during the orthodontic treatment, along with an easy debonding procedure that is reliable and predictable. Because ceramic brackets bonded to enamel have such high-bond strength, manufacturers have adjusted the design of the brackets over time — first, by introducing mechanical locking of the bases, rather than chemical retention, and more recently, by introducing indentations in the construction of the base of the brackets. Mechanical retention is created by the microcrystalline alumina grains on the bracket base that enable reliable bond retention. A hallmark of Clarity ceramic brackets, its “stress concentrator” is designed for precise, predictable outcomes, with a minimum of discomfort to the patient. Reports also confirmed that the debonding characteristics of the Clarity Advanced Ceramic Brackets are similar to metal brackets in laboratory testing. The bonding of orthodontic appliances has progressed from a messy, two-part, chemical cure, slow-setting adhesives used with large brackets, to small esthetic appliances bonded with strong, durable, quicksetting, and light-curable adhesives. The most efficient bonding system in contemporary

orthodontics is the 3M™ APC™ Flash-Free Adhesive Coated Appliance System, which creates an adhesive bonding substrate directly on the base of the bracket to ensure faster and more efficient bonding than nonprecoated brackets. The system eliminates the flash removal step from bonding and enables easy cleanup at debonding, benefiting both the doctor and patient. Flexibility and versatility Because practitioners want choice and control, bracket systems that are compatible with a range of products and systems and that facilitate various treatment options are in demand. Ceramic brackets designed with ample tie-wing undercut spaces allow for flexible treatment and ligation options. Hooks on the bracket can add a similar advantage by facilitating tooth movement for Class II or Class III treatment options. Examples of versatility in self-ligated brackets can be seen with features that allow the doctor to activate the bracket on-demand or accommodate double-ligation, if and when needed. Horizontal and vertical reference markers on the bracket also support effective bracket placement while providing water soluble removal with water spray or brushing.

Bringing it all together To enable success, orthodontists need treatment options designed for efficiency and reliability throughout treatment — and ceramic brackets present a valid solution. A tried-and-true esthetic option since the 1980s and 1990s, ceramic brackets have also seen significant design improvements — particularly in the manufacturing process, bonding surface and debonding process — that have boosted their strength, functionality, and acceptance in recent years. As emerging technology advances new efficiencies in bracket design, ceramic brackets continue to offer the flexible and effective treatment control you need, and the precise and predictable outcomes that help to create beautiful, healthy smiles. OP

REFERENCES 1. Gautam P, Valiathan A. “Ceramic brackets: In search of an ideal!” Trends Biomater. Artif. Organs. 2007;20(2):000-000. http://medind.nic.in/taa/t07/i1/taat07i1p122.pdf. Accessed September 25, 2018. 2. “Invisible Braces.” NASA. https://ntrs.nasa.gov/archive/ nasa/casi.ntrs.nasa.gov/20020087639.pdf. Accessed September 25, 2018.

This information was provided by 3M Oral Care.

Volume 9 Number 6

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EVENT RECAP

Inaugural 3Shape Community Symposium

Shape kicked off its Inaugural Community Symposium on Thursday, October 4, 2018, at the Arizona Biltmore, a Waldorf Astoria Resort, in Phoenix, Arizona. The beautiful weather and Squaw Peak Terrace were an ideal complement to the outdoor evening welcome reception. Attendees were treated to a formal welcome Friday morning by 3Shape co-founders co-CEO Tais Clausen and Vice President of Product Strategy Rune Fisker. This standing-room-only presentation was brimming with excitement as new releases and updates were revealed, the first of which was the new 3Shape TRIOS® AI scan. This advanced artificial intelligence (AI) makes intraoral scanning easier than ever. AI scan improves the speed of digital impressiontaking by automatically removing soft tissue while you scan. Delivering a cleaner-looking scan, it saves a step for the experienced dental professional and removes clutter for novice users. The releases kept coming with higher capacity batteries for the 3Shape TRIOS Wireless intraoral scanner and 3Shape Patient Excitement Apps. Among the apps: the 3Shape TRIOS Smile Design app, which allows the clinician to design new teeth/smiles on a photo-realistic image of the patient for improved patient acceptance; the 3Shape Treatment Simulator app, which can compare an intraoral scan of the patient to the simulated results of orthodontic treatment to drive case acceptance; and the 3Shape TRIOS Patient Monitoring app, which enables clinicians to compare patient intraoral scans between visits to monitor changes and share with the patient. The newly revealed features and upgrades were on par with the Symposium’s theme, “Changing Dentistry Together.” After a clinically driven keynote address by Dr. Lyndon Cooper, participants were encouraged to take a deep dive into digital dentistry with general session lectures, master classes, and hands-on classes. Ranging from tips and tricks to aligner workflow to maximizing efficiency using 3Shape systems in your laboratory, the hands-on sessions held many gems. Senior Clinical Product Manager Morten Ryde really delivered in the Tips and Tricks for Optimal TRIOS Scanning class. Users of all levels found value in his insights about scan depth (12 mm from first contact), implant body scanning (circle around it), edentulous patient scanning (start with the alveolar ridge), etc. The 2-day Symposium schedule of courses held interest for everyone. 64 Orthodontic practice

3Shape co-founder and co-CEO Tais Clausen speaks about the company’s history during the welcome presentation

The hands-on courses provided attendees with opportunities to perfect their skills

During course breaks, attendees could visit one of several 3Shape Genius Bars where a 3Shape expert in your specialty would provide one-to-one product advice and technical help. Also, a cozy exhibit hall held several booths with additional handson opportunities with event sponsors and 3Shape brand partners. The stellar 2-day event exceeded expectations. 3Shape’s digital dentistry experts displayed their innovative culture and shined in every aspect. Save the date for next year’s 3Shape Community Symposium, September 12-14, 2019.

About 3Shape

The 3Shape Genius Bar stations gave clinicians a chance to speak one-to-one with an expert in their field

3Shape is changing dentistry together with dental professionals across the world by developing innovations that provide superior dental care for patients. Its portfolio of 3D scanners and CAD/CAM software solutions includes the multiple award-winning 3Shape TRIOS intraoral scanner, the upcoming 3Shape X1 CBCT scanner, as well as marketleading scanning and design software solutions for both dental practices and labs. Two graduate students founded 3Shape in Denmark’s capital, Copenhagen, in the year 2000. Today, 3Shape has over 1,400 employees serving customers in over 100 countries from an ever-growing number of 3Shape offices around the world. 3Shape’s products and innovations continue to challenge traditional methods, enabling dental professionals to treat more patients more effectively. Visit www.3shape.com to learn more. OP Volume 9 Number 6

3Shape TRIOS Orthodontics

Advance case acceptance and grow your business TRIOS MOVE allows you to bring digital scans and treatments to life for patients, from the comfort of their chair. Show them photo-realistic final outcomes of proposed treatment plans close-up to gain case approval quicker and boost your orthodontic business like never before.

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