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s • technology reviews





Sharing smiles for a lifetime Dr. Robert Sheffield

Treating adults with advanced digital technology Dr. Jaime Rojas

BioDigital Orthodontics: Planning care with SureSmile technology: part I Dr. Rohit C.L. Sachdeva

Complete Clinical Orthodontics: treatment mechanics: part 1 Dr. Antonino G. Secchi


Practice profile Dr. James B. Reynolds

For more information see seepage page5 XX

January/February 2013 – Vol 4 No 1

EDITORIAL ADVISORS 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 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 Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD


Email: Tel: (480) 403-1505


Email: Tel: (727) 515-5118

ASSISTANT EDITOR Kay Harwell Fernández



Dear Readers: Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012, but in fact, so much has happened in the dental profession and in our publications, that the time has just flown by. The positive momentum of the past year continues to propel us forward. We are happy to note that this year brings a fresh, contemporary look for the magazines. New design elements, an easy-to-read print style, and expanded page size are just a few of the exciting changes that you will find in this, and future issues. The best news is that this year, we will publish six issues of Orthodontic Practice US, two more than in past years! Orthodontic Practice US is growing and evolving to help you grow and evolve. We strive to keep up with current trends in orthodontics and to keep our readers up-to-date on the latest techniques, technology, and trends in the specialty. Our dentist-authors give their time and expertise to share the methods that result in better dental care for patients. We are always seeking out new ideas and innovation in our clinical, technology, and continuing education articles, and case studies. Our corporate profiles tell the stories of companies that facilitate innovation, and practice profiles share the insights and concepts that inspire practice excellence. And, practice management columns spotlight ways to improve the business aspects of the dental office that can make lives easier for the staff and the boss! Besides our magazine, Orthodontic Practice US also features a vital and continually changing website ( and e-newsletter with the latest industry news, articles, and information. Our social media mavens keep the action going on Facebook, Twitter, and LinkedIn. So whether you like to turn the pages or click the mouse, information can be in your lap or on your laptop! Publishing a thought-provoking, diverse magazine with such high standards is a challenging task, but our authors, peer reviewers, editorial advisory board, advertisers, and columnists make it a smooth and enjoyable process. Our editors, sales and production staff, and I appreciate all of our authors and readers, and value feedback as we continue to strive for excellence. Please feel free to call or email – we’d love to hear from you. January is a time for resolutions. We strive to keep up the momentum so that we all can grow together in 2013. All the best,

E-MEDIA MANAGER/GRAPHIC DESIGN Greg McGuire Email: PRODUCTION ASST./SUBSCRIPTION COORDINATOR Lauren Peyton Email: MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Web: SUBSCRIPTION RATES Individual subscription 1 year (6 issues) 3 years (18 issues)

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Lisa Moler Publisher

© FMC 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 4 Number 1

Orthodontic practice 1


January/February 2013 - Volume 4 Number 1


New Year’s resolution — adopt a new technology! I simply cannot imagine a better time to be a part of the orthodontic world that we are living in today! How lucky are we? I am a believer that the so-called “Golden-Age” of orthodontics has yet to happen. I feel that it is easy to say this because with each passing year in practice we, as orthodontists and our teams, are witnessing changes to our profession that seem to make our practice lives better, more efficient, and more rewarding from a treatment outcome perspective. It doesn’t matter if your passion is active or passive self-ligation, ligature wires, and zero-zero brackets, or adjunctive and/or functional appliances, there is new technology available for all of us to adopt. This technology may be incorporated in the décor of your office, or it may be in the imaging systems you have chosen. Choosing what you consider to be critical to keeping your practice life updated and modern is what will make your office unique. Fifteen years into private practice seems like the blink of an eye. Yes, I am not of the “band-pinching” generation of orthodontic specialists (they are the true pioneers), but still feel that the advances in technology are vast, and even at times, overwhelming. We are surrounded by technology that makes the experience for the patients, the most important part of our day, that much better. This is how we can set our self, our team, and our practice apart in this competitive age. Patients will choose you and your team based on what they experience when they cross the threshold into your office. We should always keep this in mind! Patients have choices when they are seeking orthodontic treatment, so the details of your practice must make you stand out from the competition. How is the phone answered? Is the website representative of the practice? Does the office smell fresh? Is the waiting area clean and modern? Did the doctor make treatment seem appealing? The list can go on and on. That being said, we need to keep our offices up-to-date and adopt technology that is appropriate for our patient population. We are so fortunate to have resources like Orthodontic Practice US as a resource for both our clinical and practice management needs. The clinical articles, management advice, practice profiles, and technology reviews are priceless. If you are considering a remodel, purchasing a piece of equipment, or even simply want to see what our colleagues are doing around the country, you couldn’t reach for a better piece of literature. Let’s continue the momentum that our profession is taking on in 2013 and make it our best year ever. CHEERS!

David H. Seligman, DMD Specializing in Damon® technology and Invisalign® 898 Park Avenue New York, NY 10075 212-988-8235

2 Orthodontic practice

Volume 4 Number 1

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TABLE OF CONTENTS Orthodontic concepts

Practice profile Dr. James B. Reynolds: Revved up about orthodontics in the Motor City Dr. Reynolds digs into his orthodontic toolbox for insights on achieving excellent clinical and experiential results as well as ensuring that patients feel like family


BioDigital Orthodontics: Planning care with SureSmile technology: part I Dr. Rohit C.L. Sachdeva begins the first part in a series on a patientcentered approach to orthodontic treatment..................................... 18

Corporate profile Planmeca: Digital perfection The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice

12 Case study Treating adults with advanced digital technology Dr. Jaime Rojas presents a challenging adult case, treating dental malocclusion, dolicocephalic, anterior, and end-to-end bite with Insignia™


The “White” paper Analysis of a Class II therapeutic failure Dr. Larry W. White examines a common outcome of the removal of maxillary and mandibular premolars in Class II malocclusions.............. 24

Continuing education Complete Clinical Orthodontics: treatment mechanics: part 1 Dr. Antonino G. Secchi introduces the concepts of treatment mechanics within the CCO System™ to correct malocclusions.............. 28 What’s new with finishing and mechanics? Dr. Stuart Frost discusses advanced bracket and wire technology and sound treatment mechanics........ 36

4 Orthodontic practice

Volume 4 Number 1

YOUR PRACTICE GCARE UOBG ADVANCEMENT IN-OVATION R SUCCESS GAC POWERED It Runs Through Everything We Do You know how our In-Ovation products help you enhance treatment outcome. Now discover how our companion offerings can help you enhance your practice income. From the business-building acumen of and the educational leadership of GCARE to the tangible savings provided by the UOBG, we make the products and the programs that help make you more successful.

800.645.5530 www. n e wd e n tsp l y g a c . c o m


Sharing smiles for a lifetime


Banding together

Event preview

Sharing smiles for a lifetime In daily professional life, much time and effort is spent developing clinical expertise and efficient business practices. While these skills improve patient care and create a positive office environment, we have discovered that humanitarian efforts not only correct the dental condition, but also touch the hearts of the patient, the doctor, and the community....................................40

Ormco Corporation readies for its

Product profile At the heart of digital orthodontics Avi Cohen, Director of Global Dental - Stratasys Ltd., discusses the Objet Eden260V printing system.............42

12th Annual Damon Forum Dr. Dwight Damon will headline the 2013 educational conference, which includes lectures on progressive technologies, marketing workshops, and differentiation strategies for orthodontic professionals..............45

Education exploration

Observations on growing an orthodontic practice: part 1 Chris Bentson offers tips for growing a practice in a competitive economy.. .....................................................50 Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims............53

GCARE webinars: inspiration, exploration, and education: part 2 Dentsply GAC is launching a new educational initiative described as, “part inspiration, part exploration, and part education�.......................46

Industry news Objet hosts WKE 2012 Annual Orthodontic Conference............49

6 Orthodontic practice

Practice management

Service profile Gaidge OrthoMetrics takes on a new name and a new look .............................55

Materials & equipment.......................56 Volume 4 Number 1


Dr. James B. Reynolds

Revved up about orthodontics in the Motor City

What can you tell us about your background? I grew up in Lake Orion, Michigan, which, at the time, was a small town, home to the largest automotive factory under one roof in the world. My father worked for the phone company and traveled quite a bit. My mom was a teacher who retired from teaching at the Michigan School for the Blind to raise me and my sister. Both of my parents are very strong people who did everything they could for our family. As a kid, my dad would take me to Detroit Pistons games, and I desperately wanted be in the NBA.

Why did you decide to focus on orthodontics? Once I figured out my jumpshot and crossover dribble weren’t up to snuff, I wanted to be an athletic trainer. I started college at the University of Michigan, intending to work as a trainer for a professional sports team. After 2 years working as a student-trainer, I decided it wasn’t for me. A conversation with a close family friend (who was a general dentist) convinced me 8 Orthodontic practice

to take a good look at orthodontics. The rest is history.

How long have you been practicing, and what systems do you use? I am in my 11th year of practice. We use Insignia™, the Damon® System (including Damon Clear), and Invisalign® in our practice. In the last few months, we have begun dabbling with Orchestrate custom aligners as well. I am really interested in digital orthodontic products.

What training undertaken?



My residency at the University of DetroitMercy was very eclectic. We learned everything from zero prescription braces to self-ligation. Our philosophies ranged from substantial functional appliance usage to hardcore Roth-Williams techniques. I think these broad-ranging experiences really opened my eyes to carefully evaluate different techniques and take a little from each. Since residency, I have taken a wide

variety of courses including the Damon Forum, Invisalign Summit, and courses on neuromuscular dentistry at LVI. I participate in several study groups, including Ormco’s Insiders group and the Progressive Orthodontist group. It takes a lot of tools in the orthodontic toolbox to achieve an excellent clinical and experiential result, and each patient requires a slightly different approach. The more you know about different techniques, the better able you are to solve challenging situations in the clinic.

Who has inspired you? Now, my biggest inspiration is my awesome wife and kiddos. Everything I do is ultimately for them. Professionally, Dwight Damon has had the biggest impact on my clinical philosophy. Also, I was fortunate enough to work with a very sharp guy and great orthodontist, Larry Spillane, right out of residency. He has taught me a lot, and I am much further along clinically from working with him. And the list goes on: Bob Smith, Tom Pitts, David Sarver, Volume 4 Number 1

Dr. Reynolds’ lecture at the 2012 Insignia Core meeting in Anaheim, CA. He has 10 lectures scheduled for 2013 already

The Novi office front desk

John Graham, Jim McNamara, Jeff Kozlowski, and many others. We have an amazing profession with a lot of incredible and inspirational people.

What is the most satisfying aspect of your practice? Hard to pick. We have such an awesome profession! If I had to narrow it down to just one thing, the post-debond conference is really great. Every day we take braces off people, reveal their new smile, and — if we have done our jobs — have super happy patients who are beaming from ear to ear. Hard to beat that with any other profession.

Professionally, what are you most proud of? We try really, really, hard to bring leadingedge treatment back home to Metro Detroit. Larry (Spillane) and I are both born and raised in Detroit. When you grow up here, you are used to other areas of the country having different opinions about what things are like in Detroit. Most of us get a pretty big chip on our shoulder when Volume 4 Number 1

it comes to sticking up for our hometown. It is super important to me to bring the best orthodontic treatment in the world to the patients and families in my practice, and we are relentless in this pursuit of excellence.

Jeff Kozlowski (the world expert on Insignia) and Dr. Reynolds

What do you think is unique about your practice? First and foremost, we try to treat each person who walks in the door as if he/ she were a member of our family. Any advice we give for treatment is exactly how we would advise a family member. Also, our practice is one of the most experienced practices in the world using Insignia customized braces. Individually customized orthodontics has become a huge component of our practice.

Dr. Reynolds and his team at Halloween

What has been your biggest challenge? I am a big believer in the saying, “If you aren’t getting better, you are getting worse,” so am constantly challenging myself in as many areas of my life as I can. Except dancing; I will never be a good

Dwight Damon with Dr. Reynolds and his wife, Dawn, at the 2012 Damon International Symposium in Cannes, France Orthodontic practice 9


Detroit Tigers baseball team fans and partners, Drs. Reynolds and Spillane


Dr. Reynolds and son, Walker, ready for a Michigan game

The Reynolds family – Dr. James, wife Dawn, Walker, and Reese

dancer. Recently, I have been asked to lecture a lot. It is very intimidating to get up and speak in front of brilliant doctors who have taught you everything you know. It has been very challenging for me to keep my nerves in check before speaking.

What would you have become if you had not become a dentist? If I were a little taller, or if I was born in California, I would love to have become a beach volleyball player. I played professionally around the Midwest for a while, but could never quite make the cut for the national circuit. But, I love getting to the beach as much as I can. Believe it or not, Michigan has some of the most beautiful beaches in the country. Just a little harder to play around here in December than it is in Manhattan Beach.

What is the future of orthodontics and dentistry? Without a doubt, the future lies in digital treatment planning and individually customized orthodontics. Treatments like Insignia, which allow a customized set of braces and wires to be built for each patient before treatment, will rapidly become the standard of care. I am also really interested in accelerated orthodontics and am enjoying the new techniques and devices that increase the speed — while maintaining the quality — of orthodontic treatment.

10 Orthodontic practice

What are your top tips for maintaining a successful practice? Look at every single patient, and treat him/ her like you would your own family. And, take your patients’ time into consideration like your own. Accomplish as much as possible each visit to minimize the amount of time your patients spend in your office. They all have very busy lives and will appreciate your respect of their time.

What advice would you give to budding orthodontists? Most of us get out of residency with a pretty clear vision of what we want our practice to be about. However, most residencies are biased based on the individual views of the leaders in their program. Get out and go to as many CE meetings as you can afford in your first few years. There is a ton of information out there that wasn’t given in your residency, and your eyes may be opened to some incredible new things. Mine were.

What are your hobbies, and what do you do in your spare time? Love spending time with my family. My wife and I really love to travel. It’s tougher now with two kiddos, but we travel when we get a chance. Orthodontic meetings are, thankfully, usually in fun places. I am getting a little long in the tooth to compete at a high level on the beach volleyball court, so I am giving triathlons a shot now. Last summer, I did my first and am looking forward to trying a bunch more this summer. OP

At the end of his first triathlon TOP 10 THINGS I AM THANKFUL FOR: 1. My family. I have such an amazing family. 2. My health. Without your health, what do you have? 3. Insignia. Totally changed my practice, both my results and my efficiency. I can finally give results like you see presented at big meetings on the vast majority of my patients. Thanks to Jeff Kozlowski and Bob Smith for getting me involved. 4. My Apple® products. If it starts with “i,” I probably have it. I was one of those dorks waiting in line for the first iPhone®. I don’t carry a picture of Steve Jobs around in my wallet, but I have thought about it. 5. The Big House — Michigan Football Stadium. If you haven’t taken in a game there, add it to your bucket list. Whether you see Michigan play Toledo or that other team from Ohio, there isn’t a better place on the planet to watch a football game. Go Blue! 6. Digital Scanners. Love my iTero™. Anxiously awaiting the new Ormco scanner. Patients hate impressions. 7. The private island at the Renaissance® Hotel in Aruba. Book a trip, and enjoy an amazing time with your spouse. 8. My Kindle app. Kind of goes along with the everything Apple, but I go to sleep every night reading on my iPad®. I enjoy reading, as it helps my mind slow down from hectic days. 9. George R. R. Martin. If you haven’t gotten into the Game of Thrones books or the HBO series, I highly recommend those. Yes, I am a science fiction nerd, but my wife really likes it, too. And not because she is humoring me (I think). 10. My office team. I always tell them I would put our team up against anyone’s, and I really mean it. Our team is awesome!

Volume 4 Number 1

why suresmile? jeff johnson


suresmile has made it possible to not only plan specific tooth movements, but to do so in concert with the patient and the overall treatment plan. Patients can now be more fully engaged in their treatment and understand what we are attempting to accomplish. suresmile is so much more than wires.


eric howard 3D imaging allows us to create patient-specific plans with tooth positions determined by supporting bone. The ultimate reward, however, is when you demonstrate with images and metrics that you’ve reached your treatment goal.


randy moles suresmile is not just a better wire nor does it simply offer incremental treatment improvement. suresmile positively affects all aspects of our clinical and practice management: diagnostics, treatment planning, clinical case management, delegation, scheduling, and marketing.


manish lamichane Designing exceptional smiles‌ that’s what suresmile consistently empowers.

If you would like to learn more, call for a practice consultation:

suresmile digital technology empowers you to plan, anticipate tooth movement and root position, and achieve consistently superior outcomes. Patient after patient.


to be sure.


Innovative, upgradeable imaging technology Company history Planmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide. Planmeca’s imaging units offer superior image quality, reduced radiation during routine procedures, easy upgradeability, and advanced, user-friendly imaging software. Planmeca has been a leader in digital imaging and advanced computer-integrated dental care concepts for years, and remains in the forefront of technology. Since the company’s establishment, Planmeca’s developers have worked closely with dentists and leading universities to anticipate future trends, using this data to design an advanced line of high-tech products. From the introduction of the first microprocessor-controlled chair, to the development of the ProMax™ line of imaging units with SCARA (Selectively Compliant Articulated Robotic Arm) technology, Planmeca has always led the way with new technology. The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.

Unique 3D combination for open CAD/CAM

Patented SCARA technology What truly sets Planmeca apart from the competition is the company’s patented, exclusive SCARA technology. This robotic arm, which comes standard on all ProMax units, enables free geometry based on image formation and can produce any movement pattern required. The precise, free-flowing arm movements allow for a wide variety of imaging programs not possible with any other X-ray unit on the 12 Orthodontic practice

The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice. Volume 4 Number 1

True extraoral bitewing program Planmeca’s ProMax imaging units offer an exclusive extraoral bitewing program, possible only with SCARA technology. This innovative program consistently opens interproximal contacts, eliminates patient positioning errors, and is more diagnostic than other intraoral modalities. ProMax extraoral bitewings are ideal for a number of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain. All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing.

the ALARA radiation principle (As Low As Reasonably Achievable). Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety. Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest. By selecting these options, patient dosage can be reduced by up to 93%, which is highly advantageous when follow-up images are needed. Autofocus automatically positions the focal layer using a low-dose scout image of the patient’s central incisors, and uses landmarks within the patient’s anatomy to calculate placement. The result is a fast, diagnostic pan every time, which drastically reduces retakes caused by false

level of customer care, dealer support, and product education. The company offers inhouse training sessions for dealers, as well as in-office trainings for dentists performed by a national team of highly trained sales representatives. Other training programs, such as live webinars and video tutorials, ensure that dealers and dentists alike are able to confidently use all equipment features and programs.

Digital Perfection™ – the new standard Building on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011. Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a

Planmeca sets new standards with the world’s first dental unit integrated intraoral scanner for open connectivity to various CAD/CAM systems. Upgradeable innovation One of Planmeca’s greatest contributions to dental imaging is its innovative, upgradeable product platform — all based on exclusive, patented SCARA technology. This robotic arm enables limitless possibilities to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments. For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ ceph capabilities, which can be further upgraded to accommodate 3D imaging needs. Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need. This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market.

Reduced radiation procedures



All Planmeca products are designed around Volume 4 Number 1

positioning. Pediatric programs automatically select the narrow focal layer of young patients, adjust the collimator, and reduce the area of exposure from the top and the sides. This reduces the dosage area, while providing full diagnostic information.

Exclusive dealer network In order to meet the growing demand for high-quality dental imaging units in the United States, Planmeca has partnered with an exclusive network of dealers to create a unique sales and distribution system for all Planmeca products. The company has chosen a very selective distribution network, which consists of Henry Schein Dental, Patterson Dental, six ADC members, and two independents. Through this network, Planmeca is able to accommodate its growing customer base with a support team of professionals throughout the country. Planmeca strives to provide its dealer partners and the dental community with products that are backed by an unmatched

treatment environment where all equipment shares an open interface. The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike. As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated hightech device and software options with exquisite design. For more information, please visit OP This information Planmeca.




Orthodontic practice 13


market; this allows the dental professional to take images based on diagnostic needs, not machine limitations.


Treating adults with advanced digital technology Dr. Jaime Rojas presents a challenging adult case, treating dental malocclusion, dolicocephalic, anterior, and end-to-end bite with Insignia™ Introduction A recent study released from the American Association of Orthodontists indicated that one-third of American adults are unhappy with their smile. From reduced selfconfidence to “untagging” themselves in Facebook pictures, which according to the study, 48% of Americans ages 18-24 have done due to distaste with their smile — adults are increasingly eager to treat smile imperfections that have long impacted daily life. As orthodontists, this presents us with a unique opportunity to attract a larger portion of the adult marketplace. However, in order to do so, it has been my practice experience that you need to have the right value-added treatment benefits — reduced treatment time, increased comfort, and a visually appealing appliance option. The following case illustrates how I’ve used Insignia™, Ormco’s digital 3D treatment system, paired with Damon® System brackets to treat a 37-yearold adult who presented a number of orthodontic challenges.

Case presentation Diagnosis A 37-year-old, healthy female patient presented dental malocclusion, dolicocephalic, anterior end-to-end bite, anterior crossbite in the 22 area, worn

Jaime Rojas, MS, DDS, a Damon System and Insignia orthodontist, brings more than 15 years of experience to his three practice locations in London, Ontario, Canada. Dr. Rojas attained his DDS from Universidad Javeriana in Bogota, Colombia, and then attended the University of Minnesota for further orthodontic training. He also earned his Master of Science from the University of Minnesota, graduating in 1997. After graduation, Dr. Rojas taught orthodontics at the University of Manitoba, and worked at the University of Western Ontario as a full-time orthodontist. Dr. Rojas grew up in Bogota, Colombia, and currently lives in London, Ontario, where he practices together with his wife, Dr. Paula Baby. They have three children ages 9, 7, and 5. Readers with questions can contact Dr. Rojas at To learn more about his practice, visit

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1 2 3 4 5 6 7

3.2 10.1 -5.6 -6.3 -0.9 -8.0 -12.3

5.2 8.6 -1.8 -7.0 -1.4 -15.0 -15.1

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-0.5 -0.9 -11.2 -7.8 -8.1 -25.4 -16.0

1.1 2.5 -9.9 -8.9 -8.9 -18.0 -17.8

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Figure 1: Displays a combination of low, high, and standard torques recommended by the Insignia system

down upper incisors, small upper laterals, upper and lower crowding. Along with worn down upper incisors, the patient vocalized a desire to increase her facial profile, while also achieving optimal tooth movement. Treatment In assessing the case, it was determined that the best course of action was to use full fixed upper and lower, Insignia SL brackets following the Damon System principle. Over the last 6-1/2 years, I have applied the Damon System principles that are based on light forces, used for longer periods of time. This can be accomplished by using high tech copper NiTi wires. This was a case that didn’t require extractions, but it did require an increase of the interpremolar maxillary area and the use of early elastics. After conducting a thorough initial examination, where we analyzed not only the functional aspects but the esthetic aspects of treatment, we concluded that the upper incisors were significantly worn down and would present difficulty in our proposed treatment plan. To improve the patient’s smile, my treatment plan sought to marry the point of view of a cosmetic dentist with that of an orthodontist. To that end, I designed a smile arc protocol for Insignia based on the golden proportion— the concept that a smile arc design should begin with the central incisors’ proportions.

The main question we had to assess before the treatment is that of “quantification.” How much should we move teeth? Where do we move them? How much torque? Insignia helped answer these questions. In the past, trying to get answers to these types of treatment questions was a more subjective approach for two reasons: first, we couldn’t see the end result (we could visualize it in our minds, but we couldn’t physically show it to the patient), and second, we couldn’t quantify with 100% accuracy how much movement was required to accomplish our visualized result. Based on these two reasons, I have developed a smile protocol that I applied on this case, and it is as follows: 1. The smile line — First and foremost, it was critical to analyze the patient’s smile line in relation to her smile pattern. In this case, the patient’s smile pattern was a commissure smile, and her smile line was completely “flat” or straight. Additionally, her smile line did not follow her lower lip. Based on this analysis, it was clear that to improve her smile line, her incisors needed to be extruded, but the question then was by how much? The next question was, since the incisors were already worn down, how much lengthening would they need? Insignia helped us to determine, with a great deal of accuracy, that 2 mm of Volume 4 Number 1

extrusion would be required, and that 2 mm would be required for lengthening, if the patient chose to do that after orthodontic treatment. Due to the fact that the patient had a tendency to open bite, the decision was made to extrude the upper incisors instead of the lower. Therefore, the upper incisor brackets were placed to extrude the upper incisors by 2 mm. Using the Insignia overlay tool, we could view the projected before and after changes, and it was clear that the extrusion would occur in the upper incisor area. This benefit is a core example of how Insignia is helping us to deliver not just good, but excellent results. However, we still need to be orthodontists. Knowing that I needed to extrude the upper incisors by 2 mm, I placed the upper incisor brackets more gingivally by adjusting the occlusal plane in the anterior area more gingivally. This can be viewed more clearly on the T1 model. 2. Relative dental proportions — The golden proportion theory was used in this step. By measuring the height and width of the upper central incisors, we can determine the rest of the smile. During this step, the patient’s teeth proportions were analyzed, and we deduced from measuring the central incisors’ height verses width that the centrals were short due to normal wear. This step is extremely important because now we are looking at the microesthetics. In other words, once we have analyzed the smile pattern and smile line, we are ready for the microesthetics that will help us enhance the smile line based on the smile pattern. 3. Dominance of maxillary central incisors — Next, we examined the Volume 4 Number 1

height of the centrals. A pleasing smile is one that has dominant central incisors, and in this case, due to the wear of the teeth, we knew the incisors were not as dominant as they could be. This emphasized the fact that extrusion and tooth lengthening were required. 4. Silhouettes — In this step, we reviewed the two sets of silhouettes — the anterior and posterior. The posterior silhouette is described as the particular line angle of the cuspids. The premolars and molars should follow this line. Therefore, it was important to evaluate, not the particular line angle, but rather how the lines silhouette together. From there, we started reviewing the TIP and torque — a trained eye should be able to determine the amount of torque required. In this particular case, we decided to upright (lingual root torque) the premolars and adjust the canine/ lateral junction. This step is very crucial because a majority of the success will depend on how all the teeth silhouette. There are many patients where the canine lateral junction is off, and from the canines to the molars, they are tipped in, and the incisors are tipped out, and it doesn’t matter if the case is Class I, esthetically, it doesn’t look right. A pleasing esthetic case is the one where the teeth follow the same silhouette. 5. Progression of maxillary incisal embrasures — Embrasures in dentistry were something that could only be accomplished by cosmetic dentists when they were building up teeth or doing porcelain in the lab. For orthodontists, historically, it was literally impossible to determine how the embrasures would be at the end of the

Orthodontic practice 15


Figure 2: Highlights the small amount of IPR performed in the lower area of this patient case

treatment especially if the teeth were rotated. But today, with 3D treatment tools, we are able to predict exactly how the embrasures will be at the end of the treatment. In this case, even though her upper incisors were worn down, we could, with 100% accuracy, determine the size of the embrasures. Note, in theory the embrasures should be between the centrals small, the central and lateral should be twice the size, and between the lateral and canine, they should be twice the size as well. 6. Progression of contacts — Finally, I analyzed the progression of contacts to ensure they followed the smile pattern. This was another point that was previously impossible for orthodontists to determine before the treatment start. If we look at the initial center picture, we can see that the patient’s smile was flat, indicating that the contact points were all at the same level. With the Insignia Approver software, we can predict exactly where the contact points will be at the end of treatment and can place the brackets to specifically move the teeth to ensure the contact points follow the patient smile pattern. As outlined above, leveraging the smile arc protocol I designed for Insignia, and using our orthodontic knowledge, we were able to solve the issue of quantification, and plan the case with the end in mind. Next, we’ll focus on the treatment archwire sequence. As indicated above, I followed the Damon System wire sequence that provides light forces — a system I have used over the years on non-extraction cases and truly believe has brought our profession to higher standards in terms of the understanding of variable torque. There has been no other time in our profession in which we have paid so much attention to variable torque. My understanding of variable torque has greatly helped to determine, with accuracy, what torque, and how much torque to apply in a case. In terms of torque, the torque values shown on the torque table (Figure 1) represent a combination of low, high, and standard torque. These were the values supplied by Insignia. Now, if I were to do this case bonded directly with stock brackets, the torque values would be similar to the ones Insignia provided, but they would not be as accurate. It’s my belief that with Insignia’s level of accuracy, results will continue to be better. Let’s put it this way, can we torque a wire 2.2 degrees of labial root torque

CASE STUDY with 100% accuracy? The other important factor about torque is that the Insignia system provides us with torque that will account for the mechanics used. For example, in this case a small amount of IPR was performed in the lower area as seen in Figure 2, and also Class III elastics were used. For this reason, it was necessary to counteract the force applied by the elastics and the possible retroclination of the lower incisors that would occur. Insignia is the only system that allows us to determine the torque based on what we want to accomplish (functionally and esthetically), and based on counteracting the specific case mechanics. I used Damon stock .014 and .018 CN wires, and the other three wires were Insignia wires. The full expression of the torque was accomplished with the TMA wires, and in this case, I didn’t need the help of stainless steel wires since I wasn’t closing any spaces. Short Class III 2 oz. elastics were used right from the beginning of the treatment. The following is a recap of the treatment archwire sequence: 1- U-L .014CN Stock Damon wires 2- U-L .018 CN Stock Damon wires 3- U-L 14X25 CN Insignia wires 4- U-L 18X25 CN Insignia Wires 5- U 19X25 TMA Insignia and L 17X25 TMA Insignia wires

Results It is very important to understand that the height/width ratio of the upper incisors was off, and therefore, the patient could benefit from restorative treatment veneers. We extruded the upper incisors about 2 mm, and crown lengthening with veneers could happen after, if the patient was interested. Gingivoplasty was not an option in this case as the biologic width would have

been encroached. Treatment was completed in less than 17 months. Note, it is anticipated that the treatment time could have been slightly reduced with more familiarity with the treatment tools. While our staff was well equipped and capable, it is inevitable that you learn treatment tips and tricks with experience that help you to maximize the efficiency that Insignia is able to offer. It is also important to understand that as the demographics in orthodontics change, so are the problems that we are dealing with. There are more adults seeking orthodontic treatment, which means that we are dealing with more worn down teeth. This makes the height/width ratio in the anterior area a problem, and most patients would benefit from lengthening of the teeth via gingivoplasy or veneers. Whether patients do that or not remains to be seen, since most patients are quite happy after orthodontic treatment. Given that we extruded the patient’s upper incisors, the result was a “softer” smile line and a smile line that follows her lower lip. Based on the golden proportion (her incisors are short), the patient could benefit from having cosmetic dentistry. Additionally, by increasing her interpremolar maxillary distance, her smile is now fuller. Overall, I believe that we accomplished an improved esthetic result and were able to also maintain the nice Class I posterior occlusion that she presented.

Retention Today, the patient displays no orthodontic shifts that raise concern. In terms of the retention protocol, I decided that based on the initial malocclusion, it would be prudent to give her a fixed upper 1-1 retainer and a lower 3-3 fixed. I also combined these two

retainers with nighttime Essix retainer wear for a year.

Conclusion While I personally never advertise that treatment is guaranteed to be shorter with Insignia, or any orthodontic tool, it is. Historically, our practice has seen that when using digital treatment tools, we can introduce a heightened level of customization that results in faster transformation and more precise finishes. One of the core features of Insignia is the ability to adjust our treatment plan for the best possible outcome. As discussed, the increased ability to determine torque values with accuracy and visualize the smile line ensures we deliver premium results. Additionally, Insignia enhances our lines of communication with patients through a 3D visual smile morph that showcases the end result. We’re always looking for ways to increase doctor-patient communication, and ensure patients are comfortable and well informed — Insignia helps us succeed in this area. As discussed, the latest technology services and appliances can help each and every clinician better appeal to the growing adult market while simultaneously delivering showstopping results. Even with high-tech digital treatments, we need to be orthodontists. We cannot leave treatment, adjustments, and finishing mechanics to the software, which is why I developed a smile arch protocol specific for Insignia. It is my opinion that orthodontic technology will never replace our brains and intuitive skills as trained professionals, but it is wise to recognize that today’s advancements can support us in accomplishing outstanding treatments. OP

12-DGAC-142, Visionary Cover Banner OP FA.pdf



2:43 PM

clinical articles • management advice • practice profiles • technology reviews

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January/February 2013 – Vol 4 No 1





Sharing smiles for a lifetime Dr. Robert Sheffield

Treating adults with advanced digital technology

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Dr. Jaime Rojas

BioDigital Orthodontics: Planning care with SureSmile technology: part I

Practice profile Dr. James B. Reynolds

Dr. Rohit C.L. Sachdeva

Complete Clinical Orthodontics: treatment mechanics: part 1 Dr. Antonino G. Secchi


16 Orthodontic practice

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BioDigital Orthodontics: Planning care with SureSmile technology: part I Dr. Rohit C.L. Sachdeva begins the first part in a series on a patient-centered approach to orthodontic treatment Introduction BioDigital Orthodontics is an approach to patient care developed by Dr. Sachdeva1-8, which is nucleated around the practice of patient-centered care9,10 and a culture of patient safety.11-14 Practically speaking, this translates to doing the right thing for the right patient at the right time all the time in a practice whose operations are organized around both relational and functional components. The relational elements focus on delivering patient care with empathy. The functional elements are designed around the framework of high reliability organizations. Such operations are designed around “system-based thinking” run by high performance teams who subscribe to a “blame-free” and a reporting culture.15-17 Care delivery is value and process driven, evidence-based, and focused on minimizing variation. A passion for continuous improvement18 and lifelong learning19 are also hallmarks of such regenerative environments. Suresmile® technology5,6 has been designed around an integrated platform to enable the orthodontist to practice high reliability orthodontics7,8 with the aim of maximizing patient safety by minimizing variation in all aspects of the care cycle. These include diagnosis, planning care, communication, therapeutics, and patient management. Also, this technology has been designed to blend into normal clinical processes. Its clinical application can be broadly classified into three distinct components:6 a) Clinical decision support and communication b) Customized therapeutics c) Outcome evaluation

Dr. Sachdeva, co-founder and chief clinical officer of OraMetrix, can be reached by email at: rohit.sachdeva@

18 Orthodontic practice

Figure 1A: Initial photographs 1B. Initial ceph 1C. Initial ceph tracing 1D. Initial panoramic radiograph

The purpose of this article is to discuss the application of the Clinical Decision Support System (CDSS) in clinical practice. This tool enables the orthodontist to provide more effective diagnosis through 3D visualization. In addition, it allows the doctor to be more effective in decision making by using simulations on a virtual 3D surrogate of the patient to plan different treatment scenarios and choose the appropriate treatment design and care pathways. When used appropriately, planning care with 3D simulations can guide the doctor and his team to achieve predictable and controlled outcomes and overcome the limitations of heuristic thinking.6,8,20,21 Additionally, the use of simulations as a patient learning aid enhances the communication experience between the doctor and patient.20 However, simulation-guided care needs to be planned with a thorough understanding of the biological limitations of orthodontic therapy and within the framework of a realistic mental model in order to achieve desirable outcomes.22 Finally, designing care proactively with 3D simulations is an acquired skill and can only be mastered through deliberate practice.7 In this article, an example of a single patient is used to provide an overview of the design principles and simulation techniques developed by Dr. Sachdeva for planning proactive 3D care on a virtual patient with SureSmile Clinical Decision Support technology. The interaction of the practice with SureSmile digital laboratory in

the production of the virtual patient is also briefly discussed. The clinical application of customized therapeutics and outcome evaluation tools developed by SureSmile within the context of a culture of patient safety will be addressed in subsequent articles.

Diagnosis and establishing 3D care plan with SureSmile Decision Support System There are four major steps involved in

Figure 2: CBCT or OraScan are the modalities of capturing 3D images of dental and dentofacial structures. Currently, the following CBCT machines are certified by OraMetrix: Imaging Sciences International (i-CAT® Classic, Next Generation), Kodak (9300, 9500). The recommended resolution for CBCT scan is 0.2mm voxel Volume 4 Number 1

D) Developing patient learning and treatment monitoring aids These steps are described in detail below with reference to the treatment of patient K.S.

Table I: Initial ceph analysis

A. Diagnosis Patient K.S. was a 14-year-old male patient who presented with the chief complaint, “I don’t like the appearance of my teeth” (Figure 1A). A summary of his clinical findings (Table II) radiographs and cephalometric analysis is presented in Figure 1 and Table I. B. Creating a virtual patient record The virtual patient is a composite of both 2D and 3D images (Figures 1 and 4). The practice takes its normal records, which include both intraoral and extraoral photographs, and also cephalometric and panorex radiographs (Figure 1). 3D CBCT in-vivo images or 3D in-vitro scans of the plaster model are also taken at the practice side. In-vitro 3D scans may be obtained by taking CBCT images of plaster models or by using the OraScanner™ (OraMetrix™, or i-Tero™(Cadent™, Also, both scanners may be used to take direct in-vivo images of the dentition. The choice of either in-vivo or in-vitro scans to capture 3D representation of the dental or dentofacial elements is driven by the doctor’s assessment of the patients’ needs (Figure 2). These records are collated in the local SureSmile relational database system and then transmitted to the Suresmile digital laboratory via a VPN for processing (Figure 3). The 3D in vivo CBCT images are processed to create a virtual model that is surface volume rendered and segmented to create various moveable individual objects that represent anatomical

Table II: 3D Orthodontic diagnostic summary

Figure 3: Transmission of image data: Images are collated in the local SureSmile relational database system and transmitted to the SureSmile digital laboratory via a VPN for processing Volume 4 Number 1

Orthodontic practice 19


establishing a proactive care plan for a patient with SureSmile. A) Diagnosis B) Creating a virtual patient record C) Strategic design of a 3D care plan by simulating treatment scenarios


Figure 4: Initial diagnostic model (decision support) for patient K.S. was created by scanning his plaster model

Figure 5: Image processing at SureSmile digital lab. Both CBCT or plaster model scans are processed to create separate objects. Examples are shown 5A. Tooth with bone. 5B. Only bone. 5C. Bone with tooth and gingiva. The gingiva is obtained by scanning the plaster model and fused to the CBCT image. 5D. Tooth models with root. 5E. Tooth models without root. 5F. Tooth model with gingiva. 5G. Only gingiva. H and I show the teeth have been separated as objects to allow the operator to move them individually.

Figure 7: Information flow between digital lab and practice

structures such as the patient’s crowns, roots, gingiva, and bone — i.e. the maxilla and the mandible (Figure 5). In addition, the virtual model is registered to the extraoral frontal image and the cephalometric X-ray to facilitate comprehensive planning within the boundaries of both the osseous and soft tissue environment (Figure 6). In-vivo CBCT volumetric scans are processed to yield 3D decision support models with crowns, roots, and bone but without the gingival tissue. The scans obtained by the OraScanner or i-Tero, as one may anticipate, are processed with no roots or bone, but with the crowns and gingival tissue are linked to the cephalometric X-ray and the frontal extraoral image of the patient. Gingival tissue obtained from such scans can be fused with the in-vivo CBCT image if the need arises. The virtual patient is processed within 5 business days and shipped back to the orthodontist via a VPN and resides in the local server in the doctor’s practice for viewing and planning (Figure 7). For patient K.S., his plaster diagnostic models were scanned with the OraScanner to create his virtual patient model (Figure 4). 20 Orthodontic practice

C. Strategic design of a 3D care plan by simulating treatment scenarios The strategic design of a patient’s treatment plan with simulations is driven by defining six boundary conditions namely the Midline (M), Archform (A), Occlusal plane (O), Class of occlusion and Reference teeth (R). In addition, any Special (S) attributes particular to the needs of the patient are considered (Sachdeva).5-8 Collectively, these can be described by the acronym MACROS (Sachdeva) [Figure 8].

Midline It was decided to treat to the upper dental midline since it appeared close to the facial, and it was also coincident with the lower midline (Figure 9).

Occlusal plane The level and cant of the natural occlusal plane was evaluated. It is apparent that the patient has a deep curve of Spee. In planning the occlusal plane, it is best to consider it in three segments, namely anterior, functional, and posterior occlusal plane (Sachdeva) [Figure 10]. From the sagittal perspective, it was decided to maintain the cant and level of the functional

Figure 6: Combination of 2D and 3D composite images that can be used for better care planning. 6A. Initial photo. 6B. Model superimposed intraorally. 6C and 6D. Tooth models with or without roots can be superimposed to facial image. 6F. Tooth models with or without roots can be superimposed to lateral cephalogram

Figure 8: The six boundary conditions defined by “MACROS” are 8A. Midline (M). 8B. Archform (A). 8C. Class (C). 8D. Reference teeth (R). 8E. Occlusal plane (O). 8F. Special instructions (S). In this patient, planning the location and amount of space is required to build up the upper laterals

Figures 9A and 9B. Midline: The upper dental midline was chosen as a treatment midline for the patient

occlusal plane. However, it is apparent when looking at the upper aesthetic occlusal plane (AOP) that the patient can afford to display a little more incisor, and therefore, its level anteriorly was planned to be dropped by 1 mm. The transverse functional occlusal plane was maintained while it was planned to correct the cant in the AOP (Figure 11). It was also decided to level the posterior occlusal plane rather than maintain a posterior curve. However, leveling a posterior occlusal plane needs to be considered with caution since it places demands on the posterior arch length. Furthermore, if a patient has an unfavorable growth potential, clockwise open rotation of the mandible may result as the upper molar is extruded, and the lower does not intrude as planned. Finally, leveling the posterior occlusal plane Volume 4 Number 1

Figures 11A-11C: 11A. Frontal photo displaying level of AOP. Note lack of incisor display. 11B. Note the cant in the AOP. 11C. The treatment AOP level is dropped about 1.0 mm and flattened to correct the cant of the AOP

Figures 13A and 13B: Molar buccolingual inclination in transverse plane. Note the teeth appear to have normal buccolingual inclination. 13C and 13D. Note the left and right canines are not tipped, favorably to allow any changes in intercanine width. 13E. Note the slight lip strain in the lower lip. 13F. It was planned to retract lower incisors to reduce the risk of increasing lip strain

Figures 14 A-D: Archform selection: The treatment archform is the natural archform with the intermolar and intercanine width maintained and the lower incisors retracted 1.4 mm

Figures 12A-12E: 12A. Comparison of NOP to treatment occlusal plane (TOP). 12B. Note the level of the FOP is maintained while it is dropped anteriorly. 12C. The maxillary (TOP). Note that the upper second molar will be extruded to the level of the FOP and the upper anteriors as well. 12D. TOP in the mandible; note the second molar will need to be intruded to the level of the FOP and the lower incisors as well. 12E. Note the cant of the TOP is the same as FOP

Figures 15A-C Dynamic Arch Length Discrepancy (Sachdeva). 15A and 15B. Simulation of the alignment of the dentition within the boundary conditions defined. Based upon these constraints, the arch length discrepancy (LR:-5.4, LL:-3.5) is automatically measured per quadrant. 15C. Bolton ratio and tooth size are automatically measured. These measures help in making extraction decisions

requires substantial torque control of the second molars to maintain posterior arch width. The treatment occlusal plane that was decided upon is shown in (Figure 12).

Archform The patient appeared to have a narrow arch width, but there was little indication to suggest that there was a significant skeletal contribution. Also the buccolingual inclinations of the molars when viewed in the transverse direction showed no signs of dentoalveolar compensations (i.e. buccal tipping of the maxillary molars and lingual tipping of the lower molars), a finding that one might expect to see in a patient with a skeletal transverse problem (Figures 13A and 13B). The collapsed arches appeared to be more a consequence of the nature of crowding. Therefore, minimal changes in intermolar width were planned. Another consideration in the decision to maintain Volume 4 Number 1

the intermolar width in the mandibular arch was driven by the concern for stability. It was also planned to maintain the intercanine width. There was no indication that they were tipped lingually (Figures 13C and 13D), and furthermore, any changes in their arch width may add to the risk of instability.23, 24 The anterior limit of the archform is defined by the AP position of the incisors. It was planned to retract the lower incisor since any proclination could negatively affect the lip profile and exaggerate lip strain that could affect longterm stability23,24 (Figures 13E and 13F). Therefore, it was decided to plan to the natural form (Figure 14).

Determining, managing arch length inadequacy, and establishing a reference arch For the purposes of planning care and simulations, it is best to establish one

reference arch and then treat the opposing arch (dependent) to the independent (Sachdeva). The reference arch commonly chosen is the lower arch since it tends to be more limited to orthodontic change especially when considering arch width changes. The above described boundary conditions were established as constraints for running a simulation to assess lower arch crowding. The arch length discrepancy per quadrant is shown in Figure 15. It is important to note that this dynamic approach for assessing arch length discrepancy (Sachdeva) provides for a more realistic measure of crowding than the traditional approaches that are static and which cannot possibly account for all the variables discussed. Based upon this simulation, it was apparent that extraction therapy was warranted in the patient. The choice of the extraction pattern was driven by the location of crowding, size Orthodontic practice 21


Figures 10A-10D: Natural occlusal plane (NOP). Segmentation of the NOP into three categories is useful for planning purposes. These include anterior occlusal plane (AOP) (canine to canine), functional occlusal plane (FOP) (mesiobuccal cusp of the first molar to first premolar), posterior occlusal plane (POP) (distal to distobuccal cusp of first molar)


Figures 16A-16B: 16A. Simulation of extractions of LL5 and LR4. 16B. Simulations of alignment of teeth post extraction. Note the amount of residual space left post alignment

Figures 17A-17C: Management of residual space post alignment. A-C. Note 1.4 mm of retraction planned of the lower anteriors and protraction of 2.4 mm (right molar) and 3.1 mm (left molar). B. Final setup of lower arch

Figure 18: Independent arch. Note the lower arch is set as the reference arch. As the next step, the upper arch (dependent) is planned to the lower

Figures 19A-19E: 19A. The final simulated diagnostic setup. 19B. Comparison of initial decision support diagnostic model to the final. These can also be evaluated against the lateral cephalogram. 19C. Anchorage values for upper and lower space closure. 19D and 19E. The nature and amount of orthodontic tooth movement required for achieving correction. These measures may also be used to define the degree of difficulty of treatment (Sachdeva analysis)

of the teeth (Figure 15D), anchorage requirements, difficulty of mechanics, treatment time, and stability. Based upon these considerations, a decision was made to extract both the lower right first bicuspid and the lower left second premolar (Figure 16). The second phase of simulation was designed to close the extraction sites. The boundary conditions defined earlier, which included the midline, archform (based upon 1.4 mm retraction of the lower incisors), and the occlusal plane as planned before, were established, and a simulation was run to close the residual space. The amount of lower molar protraction per quadrant needed to close the extraction site is shown in Figure 17. This is a measure of the anchorage requirements. In addition, the nature and magnitude of displacements of all teeth based upon the constraints defined is shown in Figures 19C and 19D. These measures are very valuable in planning the appropriate mechanotherapy and assessing the degree of difficulty of a treatment approach.8 Normal arch length discrepancy measures are limited in their scope of assessing difficulty of treatment since they do not consider the nature and magnitude of tooth movement. In the Sachdeva8 method, these measurement attributes are accounted for. At the completion of this phase of simulation, a reference or independent arch (the mandibular) is established, and the opposing arch (the maxillary) is next treated to it (Figure 18). 22 Orthodontic practice

Class of occlusion In the upper arch, the first maxillary premolars were extracted and the fifth boundary condition defined, which is the class of malocclusion for patient K.S.; this is an Angle Class I molar relationship. The simulation was run, and the final planned outcome represented by the virtual diagnostic setup is shown in Figure 19.

Reference teeth An objective of orthodontic treatment is to establish root parallelism. Therefore, it is important to identify teeth whose axial inclination are considered favorable and then establish relative positions of the other teeth to the selected reference teeth. Figure 20 shows the reference teeth selected for the purposes of simulation.

Special attributes Additional features that can be considered in simulation with a virtual diagnostic model include distribution of spacing, if tooth size discrepancies exist or location, and amount of interproximal reduction. In this patient, these were not planned. The final virtual diagnostic setup is shown in Figure 19A, and the nature and magnitude of planned orthodontic tooth movement is shown in Figures 19C-19E. The initial diagnostic decision support model is compared to the final virtual diagnostic setup (Figure 19B). By changing the boundary conditions, multiple simulations depicting different

treatment scenarios can be performed and the optimal plan selected. This can be done very rapidly, and on average does not take more than a few minutes per simulation to run a specific scenario. Because once the boundary conditions are selected, the simulations are run automatically to produce a virtual setup. However detailing of the occlusion may require some manual intervention, but this is often not needed because the doctor relies on these simulations primarily to validate his/her decisions.

Patient learning/communication aids, monitoring treatment Presenting a visual and personalized simulation of the treatment plan provides a valuable learning experience for the patient. These can be performed interactively in the patient’s presence. Also this may be accomplished remotely with the patient at home while the doctor is in his office by using remote desktop applications such as GoToMeetingŽ (www. Another benefit of the virtual setup is that it provides the practice team a clear visual definition of the doctor’s treatment goals. Time-based orthodontic treatment milestones (Sachdeva) may also be planned. These are shown in Figure 21. Although these milestones are based upon a linear algorithm and may not be completely accurate; nevertheless, they do provide a great resource for the doctor to both monitor the effectiveness Volume 4 Number 1

of his/her treatment strategies and the ability to predict time based treatment response. Furthermore, these visuals are very effective in communicating treatment progress to the patients chairside, which is very patient motivating to them and which reinforces their commitment to orthodontic care.


Figure 21: Staging of tooth movement. The treatment progress is matched against the appropriate stage to evaluate progress in orthodontic care. These staged objectives are found very useful for patient communication and motivation

References 1. Sachdeva RCL, Kubota T, Hayashi K, et al. Transforming Orthodontics-4: BioDigital Orthodontics (1): Planning care with SureSmile Technology Journal of Orthodontic Practice 2012;7:83-97. 2. White L, Sachdeva R. Transforming orthodontics-Part 1 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012:10-14. 3. White L, Sachdeva R. Transforming orthodonticsPart 2 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(2):610.

Virtual treatment planning with the SureSmile decision support system provides a very valuable resource to the doctor in planning reliable care for a patient by helping him validate his decisions and defining clear care objectives proactively. The simulations can be done rapidly, and its effective use is a skill that a doctor needs to develop. The predictive quality of a simulation is based upon the doctor defining a realistic prescription, i.e., the input parameters for

Acknowledgement I wish to thank Dr. Takao Kubota, DDS, PhD, and Dr. Sharan Aranha, BDS, MPA, for their invaluable assistance provided in the preparation of this manuscript. Visit Dr. Sachdeva’s blog on http:// All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact for access information.

8. Sachdeva RCL. Integrating digital and robot technologes: diagnosis, treatment planning, and therapeutics. Orthodontics Current Principles and Techniques. Graber LW, Vanarsdall RL, Vig KWL (editors). 5 ed: Elsevier/Mosby; 2011.

17. Reason J. Human error: models and management. British Med J. 2000;320.

9. Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Aff. 2007;26(3):726-30.

18. Cole RE. From continuous improvement to continuous innovation. Total quality management 2002;13(8):1051-56.

10. Shaller D. Patient-centered care: what does it take. The Commonwealth Fund, commissioned by the Picker Institute. 2007; Oct, Vol. 74. 11. Ralsto JD, Larson E. Crossing to safety: transforming healthcare organizations for patient safety. J Postgrad Med. 2005; Jan-Mar;51(1):61-7.

4. White L, Sachdeva R. Transforming orthodonticsPart 3 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(3):6-9.

12. Yassi A, Hancock T. Patient Safety – Worker Safety: Building a Culture of Safety to Improve Healthcare Worker and Patient Well-Being. Healthcare Quarterly 2005;8:32-38.

5. White L, Sachdeva, RCL. A total orthodontic care solution enabled by breakthrough technology. J Clin Ortho. 2000; 223.

13. Shaha SH, et al. Establishing a culture of patient safety through a low-tech approach to reducing medication errors. Advances in Patient Safety.

6. Sachdeva RCL, Feinberg MP. Reframing clinical patient management with SureSmile technology. Pacific Coast Society of Orthodontists. 2009;2(1):1-24.

14. Harney M. Building a culture of patient safety. Report of the Commission on Patient Safety and Quality Assurance. 2008.

7. Scholz RP. Interview with an innovator: SureSmile chief clinical officer Rohit CL Sachdeva. Am J Orthod Dentofacial Orthop. 2010;138(2):231.

15. Runciman, WB. Error, blame, and the law in health care—an antipodean perspective. Ann Intern Med. 2003.

Volume 4 Number 1

the boundary conditions. Besides being of benefit to the doctor and his team, visual simulations provide an excellent medium for patient-doctor communication. Part II of this series will consider the design of custom therapeutics for patient K.S. with Suresmile. OP

16. Leape LL. Learning from mistakes: toward errorfree medicine. Health Policy Research. 2004(11).

19. Elkin PL. Continuing medical education and pPatient safety: an agenda for lifelong learning. J Am Med Inform Assoc. 2002;9(90061):128S-32. 20. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(suppl_1):i2-i10. 21. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–204. 22. Sachdeva R. Limits of orthodontic tooth movement. A review of literature. OraMetrix. 2012. 23. Boley J, Sachdeva RCL, Franklin S. Stability in orthodontics. Mission possible. Orthodontics for the next millennium. Ed. Sachdeva RCL. 1997. Ormco, Glendora, CA. 24. Boley J, Mark J, Sachdeva R, Buschang P. Longterm stability of class I premolar extraction treatment. Am J Orthod Dentofacial Orthop. 2003;124(3):277-87.

Orthodontic practice 23


Figures 20A-20C: For patient K.S., reference teeth are selected by using the panorex 20A. The upper left second bicuspid and the first lower bicuspid were selected because they demonstrated favorable root axial inclinations 20C. Final setup. Note that the axial inclinations of all buccal teeth are simulated parallel to the reference teeth. Also, note the favorable alignment of the marginal ridge in the final setup


Analysis of a Class II therapeutic failure Dr. Larry W. White examines a common outcome of the removal of maxillary and mandibular premolars in Class II malocclusions Abstract Dr. Charles Tweed had enormous influence in orthodontics by developing a rationale for the extraction of premolars and the Tweed Triangle, which he used as a diagnostic and treatment-planning instrument. He used the premolar extraction spaces to center the mandibular incisors in the alveolus at an angle of 90° ± 3° to the mandibular plane, and then positioned the maxillary incisors to occlude properly with them. Dr. Tweed’s skill and expertise allowed him to build a large cadre of imitators, and the removal of maxillary and mandibular first premolars became an accepted protocol in the treatment of Class II malocclusions and remains largely unquestioned by orthodontists to the present time. Nevertheless, within the past decade, doubt has arisen about the efficacy of such a protocol, and the current article will offer an illustration of a common outcome of the removal of maxillary and mandibular premolars in Class II malocclusions.

Figure 1: Typical Class II malocclusion

Figure 2: Occlusal result when the mandibular canine occupies one-third of the extraction space, and the maxillary canine has fully retracted

Figure 3: Occlusal result when the mandibular first premolar and canine occupy one-third of the extraction space, and the maxillary canine has fully retracted

Figure 4: Occlusal result when extracting only the maxillary first premolars. The overjet and overbite can now be corrected

established himself as the one of the most formidable and successful along with Raymond Begg3,4. Angle’s non-extraction system had so disappointed Tweed that he retreated many of his patients by extracting maxillary and mandibular premolars, and subsequently developed his own diagnostic and treatment planning procedure, i.e., the Tweed Triangle5-8. Janson,9-14 et al., began to challenge the efficacy and efficiency of Tweed’s extraction technique for Class II malocclusions by showing that the removal of four premolars resulted in longer treatments with less satisfying results than when clinicians chose to remove only two maxillary premolars. Bryk15 had earlier illustrated why the removal of four premolars in Class II malocclusions created a particularly difficult environment for the successful resolution of these orthodontic problems (Figures 1-4). When clinicians choose to remove mandibular premolars in the correction of a Class II malocclusion, they need to

realize that only one-third of the extraction space need occupation by the retraction of the mandibular canines to make the achievement of Class I canines unusually difficult (Figure 2). At this point, only forceful Class II interarch mechanics, e.g., Class II elastics, will arrange the canines in a Class I relationship. But such mechanics will also displace the mandibular arch more forward, which negates any effort to upright the incisors to 90°± 3° relative to the mandibular plane. Growing patients can, of course, benefit from the use of cervical retractors, but this has the disadvantage of retracting not only the entire maxilla but also the upper lip16,17. When limited-growing or noncooperative Class II patients reach this impasse, few remedies remain for the clinician to employ, and many will resort to so-called noncompliant devices such as Saif Springs18, Forsus19, MPAs20,21, Eureka Springs22,23, etc. Unfortunately, at this point, patients have been in treatment for 1 year or more, and many are suffering from orthodontic fatigue, which makes

Introduction The enormous influence and innovation of E. H. Angle continues to this day in orthodontics. Even his treatment protocol of non-extraction therapy has seen a recent resurgence that challenges the removal of premolars for the correction of malocclusions. Tweed was not the first to challenge Angle’s narrow prescription for universal nonextraction1,2, but he

Larry W. White, DDS, MSD, graduated from Baylor Dental College, and then served for 2 years in the United States Air Force Dental Corps. He returned to Baylor Dental College and received a graduate degree in orthodontics, and then practiced in Hobbs, New Mexico for 31 years. He was the first director of the University of Texas Health Science Center in San Antonio’s orthodontic residency program. Dr. White has published more than 100 professional articles, authored several books about orthodontics, and edited numerous professional publications. He is a Diplomate of the American Board of Orthodontists and a Fellow in the American College of Dentists. Dr. White has authored over 100 clinical articles, lectured in 35 countries, and was editor of the Journal of Clinical Orthodontics for 17 years.

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Volume 4 Number 1


Figure 5: Adult Class II malocclusion

Figure 6: Occlusal result of maxillary first and mandibular second pre-molar extractions

Figure 7: Mature adolescent patient with a Class II malocclusion

Figure 8: VTO illustrating needed movement of the incisors

their cooperation with even noncompliant appliances questionable. Some clinicians have sought to avoid this dilemma by removing maxillary first premolars and mandibular second premolars; but, again, if the mandibular first premolar and canine occupy just one-third of the extraction space, the same end-on canine will result (Figure 3). For this strategy to work, almost all of the extraction space will need occupation by the molar. Bryk and Janson have suggested the extraction of only maxillary first premolars as a remedy for this type of malocclusion, which will result in Class I canines and Class II molars (Figure 4). This strategy offers a predictable Class II correction of overjet, overbite, and canine position.

Therapeutic reports Critics may counter that the above illustrations are just that and don’t reflect clinical realities, but clinicians need only view a few of their Class II patients they have treated with maxillary and mandibular premolar extractions to see Volume 4 Number 1

the truth of these remarks. The following patient is only one of the many I could, unfortunately, provide, but it is typical of the predictable failure that results with the removal of maxillary first and mandibular second premolars in Class II adult, poorlygrowing patients or noncompliant patients (Figure 5). This patient displays a Class II malocclusion complicated by maxillary and mandibular arch length discrepancies (6 mm respectively), which causes clinicians to believe that the extraction of maxillary and mandibular premolars remains the only option. Figure 6 shows the result of that decision. The patient now has four fewer teeth, end-on canines, and a slight overjet with under-torqued maxillary incisors. Outside of better alignment and a midline correction, it would be hard to qualify this patient as having even a marginal treatment result. Certainly, it is not one acceptable to the American Board of Orthodontics. By the time the patient needed to use forceful Class II elastics, she was worn out and was only mildly compliant.

This tempts the clinician to claim that the poor outcome was the result of marginal patient cooperation, but is that a satisfactory answer? Might not the questionable consequence be due to the original treatment plan? In this case, I am certain it was. A better treatment would have resulted from the removal of the maxillary first premolars and interproximal enamel reduction (IER), aka Air Rotor Stripping25 of 6 mm in the mandibular arch. Some might object to that much polishing of enamel, but it is much more conservative than removing 15 mm of tooth structure through extractions, and multiple studies have shown minimum harmful effects24-27, 28-32 from interproximal enamel reduction; and it would have offered much better occlusion and a quicker, less traumatic conclusion. The following patient offers a clinical illustration of this type of strategy (Figures 7-11). The patient displayed a bilateral Class II malocclusion characterized by maxillary and mandibular arch length discrepancies, a large overjet, and moderate overbite, a Orthodontic practice 25


Extractions Figure 9: Modified Steiner box for calculating space needs of this patient

midline deviation, and a slightly protrusive soft tissue profile. The Visualized Treatment Objective (VTO) developed in Figure 8 was based on a consensus derived from the Alvarez32, Holdaway16,17 and Creekmore33 treatment planning strategies. All of these analyses had agreement regarding the protrusiveness of the maxillary incisors and the need of the mandibular incisors for intrusion but to remain in place otherwise. The Tweed, Steiner, and Ricketts treatment planning strategies would have repositioned the mandibular incisors lingually, which would have required the removal of mandibular premolars also. The modified Steiner box in Figure 9 illustrates the calculations that determined the need to remove maxillary first premolars only, while leaving the mandibular arch non-extraction and using interproximal enamel reduction of 4 mm to resolve the mandibular arch length discrepancy. Figure 11 displays the results of the strategy of removing only maxillary first premolars and using IER to provide space to resolve the mandibular arch length discrepancy. Figure 10 shows how the final cephalometric result coincided with the original VTO. The VTO with cross-hatched replicas of the teeth coincide quite nicely with the actual treatment result outlined in red. This treatment finished in less than 2 years without the need of Class II elastics or mechanics and only a slight amount of time with Class III elastics to bring the maxillary molars forward to close the remaining extraction spaces.

Discussion The removal of maxillary and mandibular premolars in Class II malocclusions has become such a routine procedure that it remains almost unchallenged. However, by simply arranging a schematic to illustrate how difficult positioning the maxillary canine in a Class I relationship after such 26 Orthodontic practice

Figure 10: VTO superimposed on the actual treatment result

Figure 11: Completed therapy for Class II patient

a decision, clinicians can understand the difficulty they routinely encounter with this strategy. In Class II malocclusions, the maxillary canines start with a decided deficit by their mesial position vis-à-vis the mandibular canines, and the slightest movement distally of the mandibular canines increases the difficulty in achieving Class I canine occlusion. When patients do not or cannot experience substantial mandibular growth to overcome this inherent deficit, or benefit from a retractor that moves the entire maxilla and/or maxillary dentition distally, the only remedy left is to apply powerful Class II mechanics, which will displace the mandibular dentition forward. Such tactics, of course, result in what has become known in orthodontic parlance as “round tripping,” and this introduces more treatment time along with the uncertainty of Class II mechanics side effects, which often negate their positive contributions. Also, the additional time required to correct the end-on canines resulting from the removal

of mandibular premolars causes patients to have a vulnerability to root resorption34,35 decalcification36, caries37, and periodontal problems38. Unfortunately, when clinicians need to apply Class II mechanics for these types of patients, it is after several months of therapy that has resulted in end-on canines. By then, patients can see good alignment and other corrections in their malocclusions, and they often display serious treatment tiredness, and a reluctance to cooperate in the application of forceful Class II mechanics. It is exactly this common scenario that has resulted in the development and popularity of the so-called noncompliant appliances, and clinicians eagerly seek and use them — even with their substantial extra cost. Orthodontic clinicians would do well to develop alternative approaches to the treatment of Class II malocclusions that require space to correct their protrusiveness and/or arch length discrepancies they often display. Rather than removing Volume 4 Number 1

References 1. Case C. Disto-mesial intermaxillary force Chicago Dental Society. Chicago, IL; 1893. 2. Case C. Dental orthopedia and correction of cleft palate. New York, NY: Quick Lithographers; 1921. 3. Begg PR, Kesling PC. Begg orthodontic theory and technique. Philadelphia, PA: W.B. Saunders Co.; 1977.

• use aggressive Class II interarch mechanics, e.g., Herbst, MPA, Eureka, Forsus, Jasper Jumper, MARA etc; • carefully monitor the mandibular extraction space, and do not exceed one-third of it with canine retraction; • consider removing maxillary first molars in addition to the first premolars; • use Temporary Anchorage Devices, aka TADs, to retract the maxillary arch.

Conclusion When orthodontic clinicians design a Class II malocclusion strategy that involves the removal of maxillary and mandibular premolars, they will inevitably face a particular problem in achieving Class I occlusion if the mandibular canines occupy more than one-third of the extraction space. To avoid such a conundrum, they

in 2-and 4-premolar -extraction protocols. Am J OrthodDentofacial Orthop. 2006;129(5):666-671.

premolar region: the new approach. Aust Orthod J. 1990;11(4):236-240.

14. Pinzan-Vercelino C, Pinzan A, Janson G, de Almeida R, Henriques J, de Freitas MR. Comparison of the occlusal outcomes and treatment timeof Class II malocclusion with the Pendulum appliance and with two maxillary premolar extractions. Dental Press J Orthod. 2010;15:89-100.

27. Twesme DA, Firestone AR, Heaven TJ, Feagin FF, Jacobson A. Air-rotor stripping and enamel demineralization in vitro. Am J Orthod Dentofacial Orthop. 1994;105(2):142-152.

4. Begg PR, Kesling PC. The differential force method of orthodontic treatment. Am J Orthod. 1977;71:1-39.

15. Bryk C, White LW. The geometry of Class II correction with extractions. J Clin Orthod. 2001;35(9):570-579.

5. Tweed CH. The Frankfort-mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment planning, and prognosis. Angle Orthod. 1954;24(3):121-169.

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

6. Tweed CH. Evolutionary trends in orthodontics, past, present and future. Am J Orthod Dentofacial Orthop. 1953;39(2):88.

17. Holdaway RA. A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod. 1984;85(4):279-293.

7. Tweed CH. Clinical Orthodontics. St. Louis, MO: C.V. Mosby Co.; 1966.

18. Boley JC, White L. Class II mechanics for noncompliant patients. World J Orthod. 2003;4:206214.

8. Tweed CH. The diagnostic facial triangle in the control of treatment objectives. Am J Orthod. 1969;55(6):105-121. 9. Janson G, Carmardella LT, Araki JD, de Fritas MR, Pinzan A. Treatment stability in patients with Class II malocclusion treated with 2 maxillary premolar extractions or without extractions. Am J Orthod Dentofacial Orthop. 2010;138(1):16-22. 10. Janson G, Estelito S, Barros S, Simao T, de Freitas MR. Variaveis relevantes notratamento da ma oclusao de Classe II. Rev Dent Press Ortodon Ortop Facial. 2009;14(4):149-158. 11. Janson G, Janson M, Nakamura A, de Freitas MR, Henriques JF, Pinzan A. Influence of cephalometric characteristics on the occlusal success rate of Class II malocclusions treated with 2- and 4-premolar extraction protocols. Am J Orthod Dentofacial Orthop. 2008;133(6):861-868. 12 Janson G, Brambilla AC, Henriques JF, de Freitas MR, Neves LS. Class II treatment success rate in 2-and 4-premolar extraction protocols. Am J Orthod Dentofacial Orthop. 2004;125(4):472-479. 13. Janson G, Maria FR, Barros SE, Freitas MR and Henriques, JFC. Orthodontic treatment time

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would be well advised to remove only the maxillary premolars and conclude the therapy with the maxillary canines in a Class I relationship and the molars in a Class II relationship. At the least, they should approach such therapies with full knowledge of the problems they will face, should they elect to remove maxillary and mandibular premolars. One final caveat regarding the diagnosis and treatment planning of Class II patients: avoid treatment planning regimens that emphasize restrictive positions for the mandibular incisors to the exclusion and neglect of the maxillary incisors, which have the ultimate responsibility for lip support. OP

19. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction patients treated with the Forsus Fatigue Resistant Device versus intermaxillary elastics. Angle Orthod. 2008;78(2):332-338. 20. Coelho Filho CM, Coelho FO, White LW. Closing mandibular first molar spaces in adults. World J Orthod. 2006;7(1):45-58.

28. Betteridge MA. The effects of interdental stripping on the labial segments evaluated one year out of retention. Br J Orthod. 1981;8(4):193-197. 29. Jarjoura K, Gagnon G, Nieberg L. Caries risk after interproximal enamel reduction. Am J Orthod Dentofacial Orthop. 2006;130(1):26-30. 30. Mikulewicz M, Szymkowski J, MatthewsBrzozowska T. SEM and profilometric evaluation of enamel surface after air rotor stripping--an in vitro study. Acta Bioeng Biomech. 2007;9(1):11-17. 31. Germec D, Taner TU. Effects of extraction and nonextraction therapy with air-rotor stripping on facial esthetics in postadolescent borderline patients. Am J Orthod Dentofacial Orthop. 2008;133(4):539-549. 32. Alvarez AT. The A line: a new guide for diagnosis and treatment planning. J Clin Orthod. 2001;35(9):556569. 33. 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. Coelho Filho CM. Mandibular protraction appliance IV. J Clin Orthod. 2001;35(1):18-24.

34. Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part II. Treatment factors. Am J Orthod Dentofacial Orthop. 2001;119:511-515.

22. Stromeyer EL, Caruso JM, DeVincenzo JP. A cephalometric study of the Class II correction effects of the Eureka Spring. Angle Orthod. 2002;72(3):203-210.

35. Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part I. Diagnostic factors. Am J Orthod Dentofacial Orthop. 2001;119(5):505-510.

23. Sheridan JJ. Air-rotor stripping. J Clin Orthod. 1985;19:43-59.

36. Mitchell L. Decalcification during orthodontic treatment with fixed appliances—an overview. Br J Orthod. 1992;19(3):199-205.

24. El-Mangoury NH, Moussa MM, Mostafa YA, Girgis AS. In vivo remineralization after air-rotor stripping. J Clin Orthod. 1991;25(2):75-78. 25. Crain G, Sheridan JJ. Susceptibility to caries and periodontal disease after posteriorair-rotor stripping. J Clin Orthod. 1990;24(2):84-85. 26. Jarvis RG. Interproximal reduction in the molar/

37. Zachrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Scand J Dent Res. 1971;79(6):394–401. 38. Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapyon periodontal health a systematic review of controlled evidence. J Am Dent Assoc. 2008;139(4):413-422.

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mandibular premolars when an arch length discrepancy exist in Class II malocclusions, clinicians should consider some alternative strategies such as: • removal of only the maxillary premolars combined with IER of the mandibular teeth; • correction of the Class II malocclusion before removing maxillary and mandibular premolars; • removal of the maxillary second molars and retract the entire maxillary arch with IER of the mandibular teeth; • consider removing a mandibular incisor if occlusograms confirm it. When the mandibular arch length discrepancy is so large that extractions must be done, then clinicians can remove the maxillary first and mandibular second premolars and elect one of the following:


Complete Clinical Orthodontics: treatment mechanics: part 1 Dr. Antonino G. Secchi introduces the concepts of treatment mechanics within the CCO System™ to correct malocclusions The concept Treatment mechanics has always been of tremendous interest for all practicing orthodontists. Since the beginning of the specialty, orthodontists have looked for the best, fastest, more consistent, and easiest way to achieve the orthodontic correction for our patients. This continuous quest has allowed emerging technologies to integrate, although slowly sometimes, with everyday practice until they become a routine. As a consequence, new materials, improvement in design of appliances, and innovative ideas repeatedly transform the way orthodontics is practiced. It is important for the contemporary orthodontist to be knowledgeable of current changes, to gain the benefits of such innovation. Today, after the first decade of the 21st century has already passed, orthodontic fixed appliances have experienced an interesting blend between technologies that have been around for decades such as the straight wire appliance (SWA), self– ligating brackets (SLB), and low deflection heat-activated arch wires. This integration, in my opinion, represents an improvement that, when correctly applied, facilitates the practice of orthodontics. The main objective of this series of three articles (parts 1, 2, and 3) is to introduce the concepts of treatment mechanics within the CCO System™. Part 1 will review how the SWA integrates with SLB to produce an appliance that, when combining with specific arch wires on a specific sequence, can help the orthodontist to correct different types of

Educational aims and objectives This article aims to introduce the CCO System for correcting malocclusions. Expected outcomes Correctly answering the questions on page 39, worth 2 hours of CE, will demonstrate the reader can: • Become familiarized with the basics of the CCO System and its various stages and how it relates to the correction of malocclusions.

malocclusions. Relevant characteristics of active SLB, a newly introduced prescription (CCO Rx) along with a review of the three stages of treatment mechanics will be discussed. Part 2 will focus on bracket placement, arch coordination, leveling the occlusal plane, and vertical problems. Part 3 will focus on anchorage management in extraction cases.

The evolution of the straight wire appliance The SWA was developed and introduced by Lawrence Andrews in 19701 with the idea of having an orthodontic fixed appliance that would enable the orthodontist to achieve the “six keys” of normal occlusion2 in the vast majority of cases in an efficient and reliable fashion. Even though the SWA is 42 years old and has become the most common appliance concept over the past three decades, a review of some of the original concepts on which the SWA was designed, and the evolution it has gone through, are fundamental to better understanding of the beauty of this

Antonino G. Secchi, DMD, MS, is a clinical assistant professor and former clinical director of the Department of Orthodontics at the University of Pennsylvania. Dr. Secchi received his DMD, Certificate in Orthodontics, and a Master of Science Degree in Oral Biology from the University of Pennsylvania. He is a Diplomate of the American Board of Orthodontics and member of the Edward H. Angle Society of Orthodontists. At the University of Pennsylvania, he has developed and implemented courses on Orthodontic Treatment Mechanics, Straight Wire Appliance Systems, and Functional Occlusion in Orthodontics for postdoctoral orthodontic residents. Dr. Secchi wrote the chapter “Contemporary Mechanics Using the Straight Wire Appliance” for the latest edition of the Graber/Vanarsdall/Vig orthodontic textbook. He also received the 2005 David C. Hamilton Orthodontic Research Award from the Pennsylvania Association of Orthodontists (PAO) and the 2010 Outstanding Teacher Award from the Department of Orthodontics of the University of Pennsylvania. Dr. Secchi is the founder of the “Complete Clinical Orthodontics System” (CCO System™), which he teaches to orthodontists throughout the world. He also maintains an active orthodontic practice in Philadelphia and Devon, Pennsylvania.

28 Orthodontic practice

Figure 1: Shows the ideal relationship between the center of the slot, the center of the bracket base, and the reference point (middle of the clinical crown occlusogingivally along the facial long axis of the crown)

Figure 2: (A) Shows a clinical closed up of the In-Ovation R bracket with a 0.020” x 0.020” BioForce. The active clip already started pushing the wire into the slot, which will begin to express torque. (B) Shows a SEM photo of an InOvation R bracket, (taken at the University of Pennsylvania as part of a research by the author’s research group). Bracket features such as the design of the slot and the clip can be better appreciated

appliance and the treatment mechanics. A few features need to be present in an appliance to be considered a true SWA3. First, each bracket has to be tooth-specific and have built-in torque, tip, in/out, and, for the molars, the proper offset. Second, the torque has to be built in the base of the bracket, not in the face, and the tip in the face of the slot. These prerequisites are very important in order Volume 4 Number 1

Self-ligation becoming popular Although the history of SLB started Volume 4 Number 1

many decades ago11, it was not until the beginning of this century that it became a popular option. Because of the fast increase in popularity of these bracket systems, the market became a “battlefield,” and unfortunately, a lot of unsupported and often ridiculous claims in favor of some of these systems were done. This phenomenon, sort of “shut the door closed” to many clinicians who wanted to learn more about and or started using selfligating brackets. However, at the same time, a significant number of clinicians focused on quality treatment started to use these type of appliances taking notes of all the advantages as well as possible disadvantages of them. Also, a significant number of peer-review studies became available helping to better understand SLB12. I was fortunate to start using SLB early in my career. I had my first experience with different types of SLB systems as a resident at the University of Pennsylvania more than 10 years ago. Since that time, I steadily increased the percentage of SLB cases in my practice up to 100%. I have studied different SLB systems, done research on them, and had the opportunity to meet and share knowledge with a great number of orthodontists around the world who use SLB systems. So, today I can say with responsibility and confidence, that there is no reason to “close the doors” to the SLB system. They definitely came to stay, and therefore, the clinician should make the effort to understand how SLB works. Over the years, the debate between active and passive SLB has been intense. Since active SLB is this author’s preference (Figures 2A and 2B), all the content of this article is based on this author’s experience with active SLB, specifically the In-Ovation® R and C bracket system (Dentsply GAC). The three stages of treatment mechanics will be reviewed in detail later in this article, as well as the following advantages of active SLB at each stage of treatment mechanics. Active SLB provides complete control at each stage of treatment. Leveling and aligning: - The wire can be fully engaged from day one. Therefore, it provides faster alignment and correction of rotations. - Due to the reduced resistant to sliding of SLB, the wire can easily slide through

Figure 3: Shows the CCO System with all the torque, tip, and offset values for each tooth

the teeth. Then displaced teeth can move to alignment without causing unwanted tooth movement of adjacent teeth such as proclination of anterior teeth or loss of anchorage of posterior teeth. Working stage: - With the proper arch wire selection, the active clip provides a perfect balance between resistance to sliding and tooth control. In most cases a .019” x .025” ss wire as the working arch wire will be preferred. Teeth can easily slide through the wire mesially or distally to either open spaces or close spaces. The gentle, but constant, pressure of the clip on the wire keeps the moving tooth or teeth straight, minimizing unwanted tipping or rotation commonly seen when using conventional brackets with ligatures. The active clip pushes the .019” x .025” ss into the bracket’s slot, which allows for full torque expression10. There is no need to overcorrect the Rx for play or go up to a full size arch wire to express torque. Finishing stage: - Granted that all brackets have been placed in the optimal position, by the time the clinician gets to the finishing stage, each tooth should be optimally position with the right tip, torque, and offset. Finishing should not be a problem. If some fine-tuning has to be done, such as repositioning some bracket, and or placing some offsets in the wire, the active clip will help to express that correction. There is no reason why, with active SLB, an orthodontist should not be able to finish cases with quality and consistency.

The CCO Rx The CCO Rx is a new prescription (Figure 3) developed to take full advantage of the bracket/arch wire interaction when using Orthodontic practice 29


to achieve proper alignment of the center of the slot, the center of the base, and the reference point (middle of the clinical crown occlusogingivally along the facial long axis of the crown) for all teeth at the completion of treatment (Figure 1). This is the only way that the desired built-in features can be properly transferred from the bracket to the tooth. Third, the base of the bracket must be contoured mesiodistally and occlusogingivally. This has been referred to as “compound contour” base, and it allows the bracket to firmly adapt to the convexities of the labial surface of each tooth, helping the orthodontist to achieve an optimal bracket placement4. Andrews’ treatment mechanics in extraction cases, which was based on sliding teeth using round stainless steel wires, made him develop a series of additional brackets with different degrees of overcorrection to account for undesired tooth movement that occurs when closing spaces. For example, if a maxillary canine had to be moved distally, the canine most likely would tip and rotate distally. Therefore, he introduced more mesial tip and rotation to the canine bracket. Andrews then came out with a line of overcorrected brackets, which he called first extraction brackets5,6 and then translation brackets7. Andrews’ complete bracket system (standard and translation brackets) became less popular than expected, in part due to the large bracket inventory needed to satisfy his treatment mechanics. In the early 1980s, Ron Roth combined some of the Andrews’ standard prescription (Rx) values with some of the values found in the translation bracket Rx to come out with the “Roth setup”8. Filling the slot with a large stainless steel arch wire to express the Rx was one of the premises of the Roth system. The Roth Rx became one of the most popular SWA Rxs in the world. In the 90s, McLaughlin, Bennett, and Trevisi modified the SWA Rx based on the perception that most orthodontists would finish cases with a .019”x.025” ss wire, which on a .022” slot could have up to 12° of play9. Among others, they increased buccal crown torque of maxillary incisors, reduced lingual crown torque of mandibular molars, and increased lingual crown torque of mandibular incisors. These modifications gave form to the MBT10.


Figure 4: Shows a SEM photo of an In-Ovation R bracket with a 019” x .025” ss wire, (taken at the University of Pennsylvania as part of a research by the author’s research group). The springing active clip pushes the wire into the slot providing full torque expression on a .019” x .025” ss wire

Figure 5: Highlight CCO Rx, torque for the upper incisor

an active clip and to achieve optimal tooth position at the end of treatment. The goal was to offset some of the problems commonly seen with previous Rx that were meant to be used with traditional bracket system.

Rotational control The springing capability of the In-Ovation clip, as well as its quite long mesial-distal span, facilitate the correction of all rotations within the stage of leveling and aligning. Also, the active clip favors complete engagement of the wire into the slot. This means that if the wire is not fully engaged, the clip will not close. This avoids leaving small rotations uncorrected as the wire sequence progresses. Therefore, the CCO Rx removed some of the overcorrection of the offset found in previous Rxs.

Full torque expression The active clip of the In-Ovation brackets provides full torque expression on a .019” x .025” ss wire. The springing clip pushes the wire into the slot (Figure 4). Gick, et al.,13 shows that on the In-Ovation brackets a .019” x .025” ss wire can express the same amount of torque than a .021” x .025” ss wire. Therefore, some of the overcorrections of torque implemented in previous Rxs to overcome the play between the slot of the bracket and a .019” x .025” ss, do not apply when using the InOvation bracket, and therefore the CCO Rx removed those overcorrections.

Molar control It is the interaction between the bracket and the wire that will transfer the values of tip, torque, and offset to the teeth. 30 Orthodontic practice

Figure 6: Highlight CCO Rx, torque for the lower incisor

Figure 7: Highlight CCO Rx, tip for the upper canine

Tubes are passive attachments. Tubes are not able to transfer the values they have, specifically torque, even if large wires are used14,15. Trouble correcting the curve of Wilson of maxillary molars and excessive lingual crown torque of mandibular molars are some of the problems commonly seen by many orthodontists. Therefore, the CCO Rx has specific overcorrections for the maxillary and mandibular first and second molars to achieve proper molar control.

Incisor control To achieve optimal torque of the maxillary and mandibular incisors is very important for both esthetics and function. It affects lip support, and consequently facial esthetics, as well as anterior coupling of the incisors, and therefore, anterior guidance. For the maxillary incisors, to achieve optimal torque is sometimes difficult due to the large amount of bone the roots must go through, specifically in extraction cases as well as class II, division II cases. The inclination of the mandibular incisors is critical for both function and stability. Their position should be upright onto the alveolar bone. Class III camouflage, Class II mechanics, and deep curve of Spee are specifically challenging regarding the upright position of mandibular incisors over the basal bone. The CCO Rx combines proven values of torque for maxillary incisors that can be fully expressed thanks to the active clip, with a lightly overcorrection for the mandibular incisors to achieve optimal control in all kind of clinical situations. The CCO Rx is conveniently and progressively expressed throughout the stages of treatment mechanics by using specific arch wires at each stage. The ultimate goal is to

Figure 8: Highlight CCO Rx, torque for the lower canine

achieve optimal tooth position at the end of treatment, even before the appliance is removed.

CCO Rx highlights The CCO Rx works as one system from second molar to second molar. The following are some of the highlight changes that were introduced: • U1/U2: 12°/10° of torque have been selected. These values have been proven time after time to be optimal if full expression of torque is achieved. Thanks to the active clip, full expression can be achieved on a .019” x .025” ss wire. It is not necessary to increase and/or overcorrect these values (Figure 5). • L1/L2: -6°, 0°, 0° of torque, tip, and offset have been selected. A small lingual crown torque overcorrection has been shown to help keeping the incisors in an upright position in situations such as leveling and aligning, class II correction, leveling deep curve of Spee, etc. 0° tip and 0°offset makes all four lower incisors bracket to be interchangeable facilitating bracket inventory (Figure 6). • U3: 10° of tip has been selected as the best of both worlds. The increased mesial crown tip found in some Rx (13°) has shown undesired distal tip of the U3 root, frequently seen in X-rays. However, an upright U3 (8° or less) could compromised proper coupling with the L3 and could also decrease arch perimeter compromising proper class I molar and canine relationship (Figure 7). • L3: -8° of torque: In many cases where Volume 4 Number 1

Figure 10: Highlight CCO Rx, torque for the lower molar

Figures 11A-11B: A diagram showing reciprocal forces developed when leveling and aligning (A) As the wire can move easily through the SLB and tubes, teeth move back to the space behind the canines rather than forward (B)

the width of the maxillary and mandibular arches is normal, an excessive lingual crown torque (-11°), found in some Rxs, makes the coupling difficult with the U3. Therefore, the lower canine was upright to facilitate intercanine coupling (Figure 8). • U6/U7: -14°/-20° of torque. Increased lingual crown torque, specifically for the second molar, facilitates the correction of the curve of Wilson, and therefore arch coordination, minimizing the need to add extra torque through a bend in the wire or by using auxiliaries such as palatal bars (Figure 9). Tables 1 and 2: Suggested wire sequence for Stage 1 and 2

• L6/L7: -25°/-20° of torque. These values have been selected to prevent the commonly seen lingual rolling of lower molars (Figure 10).

Stages of treatment mechanics For didactic purposes, treatment mechanics has been usually divided in different stages, from three to seven depending on the author’s preference. Simplicity is of paramount importance when teaching, and therefore, all the mechanics to be accomplished in orthodontic treatments with the CCO System can be divided into three stages: stage 1, leveling and alignment; stage 2, working stage; and stage 3, finishing stage. At each of these stages, there are specific movements of teeth that will occur and specific goals that have to be achieved before continuing to the next stage of treatment. It is important to emphasize that both the treatment outcome and its efficiency will be greatly improved if the orthodontist follows these stages. Volume 4 Number 1

Stage 1: Leveling and aligning Leveling and aligning is a complex process in which all the crowns are moving at the same time and in different directions. As the teeth level and align, reciprocal forces between them develop, which can be of great help to guide the movements to our advantage (Figures 11A and 11B). Then, when possible, all teeth should be engaged from the beginning to obtain maximum efficiency of tooth movement. Usually at this stage, round small-diameter heatactivated wires such as a 0.014” Sentalloy® (Dentsply GAC) for severe crowding, or a 0.018” Sentalloy for moderate to minimum crowding, are preferred. It is always recommended to place crimpable stops to avoid undesirable movement of the wire, causing discomfort to the patient. These round wires can be in place for as long as 8 to 12 weeks before proceeding to the next wire, which usually is a 0.020” x 0.020” BioForce® (Dentsply GAC). The BioForce

wire is a low-deflection, heat-activated wire that works very well as a transitional wire from stage 1 to stage 2. The 0.020” x 0.020” BioForce corrects most of the rotations left by the previously used round wires and provides more stiffness to start leveling the curve of Spee and therefore flatten the occlusal plane. It is important to notice that even if treatment could be started with a rectangular or square heatactivated low-deflection wire, with the assumption of saving time and providing torque from the beginning of treatment, this is absolutely not recommended, because it may cause loss of posterior anchorage. Since the only teeth with positive labial crown torque are the maxillary central and lateral incisors, and the mesial crown tip of the maxillary and mandibular canines is rather large, if treatment is started to resolve the crowding with a rectangular or square wire, labial crown torque is provided to the maxillary incisors and mesial crown tip to Orthodontic practice 31


Figure 9: Highlight CCO Rx, torque for the upper molar


Figure 13: Shows arch coordination. Stainless steel arch wires must be coordinated for every patient. The upper wire should be 2 to 3 mm wider than the lower wire (B) Figures 12A-12B: Diagrams A and B show how round wires will allow molars and premolars to level, align, and upright, which will produce a “lasso” effect on the incisors. This will upright and sometimes even retract the protruded incisors

canines, which will increase the anchorage in the front part of the arch facilitating the loss of anchorage in the posterior part of the arch. This is critical in cases where the treatment plan calls for maximum retraction of the maxillary and/or mandibular incisors. Then, round wires will allow the molar and premolars to level, align, and upright, which will produce a “lasso” effect on the incisors that will upright and sometimes even retract (Figures 12A and 12B). The 0.020” x 0.020” BioForce will make the clip of the SLB active and thus start delivering torque; nonetheless, its strength is not sufficient to compromise the anchorage that has already been created with the round wires. Usually, after 8 to 10 weeks with the 0.020” x 0.020” BioForce, the stage 1 of leveling and aligning is finished, and it is the first time to evaluate bracket placement and debond/rebond as necessary. Then, the patient is ready to start stage 2, the working stage. Table 1 shows the most common wire sequence for this stage of treatment. Stage 2: Working stage At this stage, the maxillary and mandibular arches are coordinated, proper overbite and overjet are achieved, Class II or Class III are corrected, maxillary and mandibular midlines are aligned, extraction spaces are closed, and maxillary and mandibular occlusal planes are paralleled. Although most of these corrections happen simultaneously, some important points must be emphasized regarding arch coordination, management of the overbite/ overjet, and the use of intermaxillary elastics.

Arch coordination The maxillary and mandibular arch wires must be coordinated in order to obtain a stable occlusal intercuspation and proper 32 Orthodontic practice

overjet. In an ideal intercuspation of a Class I, one-tooth to two-teeth occlusal scheme, the palatal cusps of the maxillary molars should intercuspate with the fossae and marginal ridges of mandibular molars; the buccal cusp of the mandibular premolars should intercuspate with the marginal ridges of the maxillary premolars; and the mandibular canines and incisors should intercuspate with marginal ridges of the maxillary canines and incisors. If this occlusal scheme occurs, it will then provide an overjet of 2 to 3 mm all around the arch from second molar to second molar. Then, the maxillary arch wire must be 2 to 3 mm wider than the mandibular arch wire. The arch wire coordination is done with the stainless steel wire. Even if they come preformed, the clinician should not rely on this, and should check them before insertion (Figure 13). Another important aspect of arch coordination is the effect that it has on the vertical dimension and the sagittal dimension. This specific issue will be reviewed in detail in part 2.

Overbite and overjet correction An optimal overbite/overjet relationship does not have to be a certain predetermined number of millimeters. More important is the functional relationship they have. This means that the overbite/overjet should be compatible with a mutually protected occlusal scheme, and thus, allow for a proper anterior guidance in protrusion and lateral excursive movements. Although, as mentioned earlier, the number of millimeters is less important than the function, it is found that an optimal overbite is usually around 4 mm, and an optimal overjet is 2 to 3 mm. When diagnosing and treatment planning overbite/overjet problems, it is important to take the following key points into consideration: arch space management,

position of the mandible in centric relation, and relationship of the upper/lower incisors with the lips. Arch space management is important to understand because the SWA tends to flatten the curve of Spee, which requires space in the arch. If not enough space is available or created, the incisors will procline, increasing the arch perimeter. This incisor proclination will also decrease the overbite and may help, if it only occurs in the lower arch, to decrease the overjet. Flattening the maxillary and mandibular occlusal planes, proclining the incisors, can be of help in deep bite cases. When the incisors are not allowed to procline, space in the arch must be created. This is specifically important to avoid periodontal problems in cases with thin bone surrounding the incisor area. Up to 4 to 6 mm can be created with interproximal reduction of teeth, usually done on the incisors and, less often, the canines and premolars. If more than 6 mm of space is required, extraction of premolars could be indicated. Another important factor to consider when evaluating overbite/overjet problems is the position of the mandible. Often, differences between a maximum intercuspation (MIC) and centric relation (CR) can produce significant differences in the overbite/overjet relationship. And last, but by no means the least important, is the sagittal and vertical relationship of the maxillary and mandibular incisors with the lips. In an open bite case, should the orthodontist intrude the molars or extrude the incisors? In a deep bite case, should the clinician intrude the maxillary incisors, the lower, or both? These basic but very important questions can be answered through an understanding of the optimal relationship of the incisors with the lips. According to contemporary esthetic Volume 4 Number 1

A 12-year, 6-month-old Caucasian female consulted for orthodontic treatment due to a crossbite of the upper-right canine. Patient presented with a Class I malocclusion in late mixed dentition. Upper-right canine and upper-left lateral incisor were in crossbite. Midlines were off.

Composite 1: Extraoral initial photos

Composite 2: Intraoral initial photos

Composite 3: Mid course of the stage 1, leveling an aligning. Upper and lower .018” Sentalloy wires. The bite was temporarily open with composite buildup on the lower first molar to allow the canine to move buccaly into alignment

Composite 4: Upper .020” x .020” BioForce wire to finish leveling upper arch

Volume 4 Number 1

Orthodontic practice 33


Case example


Case example, continued

Composite 5: Upper and lower .019” x .025” SS coordinated arch wires. Notice parallelism of the upper and lower occlusal planes

Composite 6: Upper and lower .021” x .025” braided arch wires. At this time, triangular short vertical elastics are used to achieve optimal intercuspation

Composite 7: Intraoral final photos

Composite 8: Extraoral final photos

34 Orthodontic practice

Volume 4 Number 1

trends and taking into account the aging process, for adolescents and young adults, maxillary incisors should have, at rest, an exposure of about 4 mm beyond the most inferior point of the upper lip known as upper stomion. As explained earlier, an optimal functional overbite should be about 4 mm. Now, if we put together the last two concepts, the incisal edge of the lower incisors should be at the same level with the most inferior point of the upper lip. Therefore, any vertical change of the incisors will affect not only the function through changes of the anterior guidance, but also the esthetics through the amount of tooth exposure. These anterior functional/esthetic references can help the clinician to determine the best strategies to correct overbite/overjet problems and will be of special importance for planning cases involving orthognathic surgery.

Intermaxillary elastics Discretion is a good word to describe the use of intermaxillary elastics. I use them and like them, but it is important to understand how they are used to avoid problems. I usually do not use intermaxillary elastics in the following situations: • Round wires • Initial leveling and aligning, low-deflection wires • To a terminal tooth, last tooth in the arch • In the anterior part of the mouth to close open bites • In the posterior part of the mouth to

References 1. Andrews LF. Six keys to normal occlusion. Am J Orthod. 1972;62(3):296–309. 2. Andrews LF. The straight wire appliance origin, controversy, commentary. J Clin Orthod. 1976;10(2):99– 114. 3. Andrews LF. The straight wire appliance explained and compared. J Clin Orthod. 1976;10(3):174–195. 4. Andrews LF. JCO interviews on the straight-wire appliance. J Clin Orthod. 1990;24:493-508. 5. Andrews LF. The straight-wire appliance. Extraction series brackets. J Clin Orthod. 1976;10(6):425-441. 6. Andrews LF. The straight-wire appliance. Extraction series brackets. J Clin Orthod. 1976;10(7):507-529.

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correct crossbites • For an extended period of time. I usually use intermaxillary elastics in the following situations: • At the working and finishing stages • On square or rectangular stainless steel wires • On the buccal side of the mouth, short class II or III and/or triangular verticals The three types of intermaxillary elastics this author commonly uses are 3/16” 4 oz., 6 oz., and 8 oz. elastics. Short means, in a Class II, for instance, from the maxillary canine to the mandibular second premolar in a non-extraction case and to the first mandibular molar in an extraction case. Table 2 shows the most common wire sequence for non-extraction cases, at this stage of treatment. Wire sequence for extraction cases will be specifically covered in part 3). Stage 3: Finishing stage As I discussed previously, the active clip of the In-Ovation bracket system, pushes, and sits the wire onto the slot achieving optimal bracket expression with a 0.019” x 0.025” stainless wire. This is especially true in non-extraction cases with an average curve of Spee. However, in some cases the size and stiffness of a 0.021” x 0.025” stainless steel is indicated, such as in cases with a deep curve of Spee and extraction cases where minimum anchorage is required. Once the maxillary and mandibu-

7. Andrews LF. Fully programmed translation brackets. In: Andrews LF, ed. Straight wire: the concept and appliance. San Diego, CA:LA Wells; 1989. 8. Roth RH. Treatment mechanics for the straight wire appliance. In: Graber TM, Swain BF, eds. Orthodontics: current principles and techniques. St Louis, MO:Mosby; 1985. 9. McLaughlin RP, Bennett JC, Trevisi HD. Systemized orthodontic treatment mechanics. St Louis, MO:Mosby; 2001. 10. Moesi B, Dyer F, Benson PE. Roth versus MBT: does bracket prescription have an effect on the subjective outcome of pre-adjusted edgewise treatment? [published online ahead of print Nov 2, 2011] Eur J Orthod. 11. Woodside DG, Berger JL, Hanson GH. Self-ligation orthodontics with the SPEED appliance. In: Graber TM,

lar occlusal planes are parallel and all the bracket slots are aligned, bracket position should be carefully checked for minor correction of tooth position, and therefore the second time of debond/rebond should be done. The last wire to be used is a stainless steel multibraided 0.021” x 0.025” arch wire. Although this wire is large enough to fill the slot of the bracket and then maintain the tip, torque, and offset of each tooth, its resilience permits both minor bracket repositioning and settling of the occlusion into an optimal intercuspation. It is important to notice that at this point in treatment, all the appliance interferences should be removed using a finishing carbide bur on a high-speed handpiece. With a thin articular paper, all contacts must be checked. Only tooth-tooth contacts should be allowed. All brackets, tubes, or band contacts must be removed to allow proper settling. Vertical triangular 3/16” elastics, either 6 oz. or 8 oz., are used to achieve proper intercuspation. These vertical elastics should not be used with the braided wire for more than 6 weeks to avoid rolling premolars and molars lingually, which can be detected not from the buccal but rather from the lingual, where premolars and/or molars will not be contacting. Finally, before removing the appliance, a complete assessment of the occlusal “end of treatment” goals should be performed. Table 3 shows the most common wire sequence for this stage of treatment. OP

Vanarsdall RL and Vig KW, eds. Orthodontics: current principles and techniques. St Louis, MO:Mosby; 2005. 12. Chen SS, Greenlee GM, Kim JE, Smith CL, Huang GJ. Systematic review of self-ligating brackets. Am J Orthod Dentofacial Orthop. 2010;137(6):726. 13. Gick MR, Nóbrega C, Benetti JJ, Jakob SR, Zucchi TU and Arsati F. Comparative study of the movement of torque induced by systems self-ligation and conventional. Orthodontic Science and Practice. 2012;5(17):37-46. 14. Raphael E, Sandrik JL, Klapper L. Rotation of rectangular wire in rectangular molar tubes. Part I. Am J Orthod. 1981;80(2):136-144. 15. Lang RL, Sandrik JL, Klapper L. Rotation of rectangular wire in rectangular molar tubes. Part II. Pretorqued molar tubes. Am J Orthod. 1982;81(1):2231.

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Table 3. Suggested wire sequence for Stage 3


What’s new with finishing and mechanics? Dr. Stuart Frost discusses advanced bracket and wire technology and sound treatment mechanics This article reviews what’s new in the art of finishing — tricks and tips from an educational workshop Dr. Frost will be conducting at the 2013 Damon Forum, Feb. 13-16, in Orlando, Florida.


n excellent finish is often thought to be orthodontic treatment’s “holy grail.” It’s not just about having straight teeth — the right finish has an ideal occlusion, arch width, a smile arc, incisor display, full lips with vermillion curl, and properly torqued teeth. To achieve each of these characteristics, clinicians must have a treatment approach that keeps the end result top of mind — from the beginning — while also combining advanced technology with esthetic-driven techniques, such as paying close attention to the incisors’ end positions, like torque. Why produce a quality finish? Our patients’ primary concerns are facial and smile esthetics, and the stability of the orthodontic industry relies much on the results we as clinicians produce. Regardless of practice size, reevaluating finishing mechanics cannot only redefine treatment efficiency, it will help improve final results across a broad range of patients.

Three key factors for achieving an advanced finish Advanced finishing goes beyond the lining up of buccal segments. Keep the profile as full as possible, with a strong chin, and plan for a mutually protected occlusion in centric relation to the marginal ridge. I also recommend striving for optimal soft and

Educational aims and objectives The aim of this article is to discuss advanced bracket and wire technology and sound treatment mechanics Expected outcomes Correctly answering the questions on page 39, worth 2 hours of CE, will demonstrate the reader can: • Recognize the three key factors for advanced finishing. • Realize the importance of bracket positioning. • Discuss the significance of bracket torque. • Be aware of the value of simultaneous mechanics.

hard tissue response, and healthy TMJs. There are three crucial elements to achieving an advanced finish: bracket positioning, bracket torque selection, and simultaneous mechanics. Most crucial of all three is bracket positioning. The most common cause of a poor or mediocre finish is incorrect bracket placement at initial bonding. Without proper placement, it is more difficult to close a case with a beautifully shaped finish. In the words of my esteemed colleague, Dr. Mike Steffen, “You can’t straighten teeth with crooked braces.” The sentence speaks to the importance of correct bracket placement and has become a motto in my practice. And while it may be an artistic challenge, once the concepts of precision bracket placement are grasped, your cases will finish beautifully every time.

Bracket positioning: the building block of finishing success The importance of bracket positioning cannot be overemphasized — it can have a profound and definitive impact on patient

Stuart Frost, DDS, is a native of Arizona and comes from a family of dentists. In addition to being committed to excellent patient care and treatment, he is dedicated to educating his colleagues and patients, and to the advancement of orthodontic technology. He graduated with honors from the University of the Pacific School of Dentistry in 1992. He then practiced general dentistry in Phoenix and Mesa until 1997. In 1997, Dr. Frost completed a 1-year fellowship for Temporomandibular Joint Dysfunctions at the University of Rochester in New York. He continued his education there and completed a 2-year residency in Orthodontics and Dentofacial Orthopedics. Dr. Frost is dedicated to the advancement of the orthodontic profession. He is a Damon System Mentor to many orthodontists around the country. He is an associate professor at the University of the Pacific School of Orthodontics where he educates and trains residents about the Damon System. He also oversees the treatment of all Damon orthodontic cases along with Dr. Tom Pitts of Reno, Nevada and Dr. John Graham of Phoenix, Arizona. He was invited to participate on a board of orthodontists who created the curriculum for Damon selfligation that is used in dental and orthodontic programs nationwide. Dr. Frost is a member of the Ormco Insiders Group, Progressive Study Club, Damon Phoenix Study Club, AAO, PCSO, ADA, and AZDA.

36 Orthodontic practice

results. As you may have read in other industry articles, now, more than ever, there is an emphasis on bracket positioning. It has become self-evident that the more precise the placement of brackets, the easier it is to settle the occlusion. To achieve ideal position, I reiterate the importance of taking into account the smile arc and symmetry. My specific bracket position will vary in the anterior, and every case depends on the smile arc and enamel display. When I bond, I focus on the mandibular arch first and then the maxillary arch: second molar to canine on half of the arch, the same sequence on the other half, and then finish lateral to lateral. I bond the maxillary arch in the same sequence. I focus on esthetics and smile arc protection for the maxillary Volume 4 Number 1


anterior and overbite, and overjet for the mandibular anterior, bonding all other teeth for ideal occlusion. In terms of the buccal segments, ensure your patient’s marginal ridges are perfectly aligned, and rely on contact points for optimal references. In addition, impressive technology is emerging from leading orthodontic manufacturers, such as Insignia™ Advanced Smile Design, which is designed to support your treatment plans and can provide precise bracket placement.

Excellence is in the details: selecting proper bracket torque Torque selection is imperative for finishing correctly and must be analyzed during the treatment planning process. Proper bracket torque is not automatic, nor is it universal. In other words, every patient is different, and individual, customized treatment plans will ensure optimum esthetics. With that said, I have found customized appliances to be great, practice-enhancing tools. Variable torque brackets work well for finishing, as the brackets minimize the guesswork of adding torque to wires later in treatment. These types of brackets and appliances afford orthodontists increased efficiency and reduced treatment time by easing the finishing process and correcting torque of the finished case. Bracket selections can be customized, when using digital orthodontic systems, to produce a torque prescription that considers each patient’s individual tooth anatomy and the occlusogingival positioning of the Volume 4 Number 1

bracket to best achieve the patient’s final result. And while sophisticated appliances can make treatment easier, the technique can’t be lost. I’ve included three tips below that I recommend when selecting the correct torque: 1) Plan around the maxillary incisors, keeping in mind sagittal position for enhanced soft tissue esthetics, verticalfrontal smile, and rest position

mechanics. This new treatment approach has helped me reevaluate my treatment mechanics and refine my efficiency as an orthodontist. Traditional treatment used to be a step-by-step process; clinicians would begin by leveling and aligning, and then focus on arch width, and finally, the patient’s anterior and posterior teeth. The detailing and finishing would wait for

Possibly one of the greatest advancements in the past 10 years is the evolution and implementation of simultaneous mechanics.

2) Don’t over-torque centrals, laterals, or cuspids. Many orthodontists have a tendency to over-torque upper anteriors and under-torque upper canines 3) When choosing anterior bracket torques, if you are going to err, err towards selecting a low torque

Moving beyond traditional treatment: simultaneous mechanics increase efficiency Possibly one of the greatest advancements in the past 10 years is the evolution and implementation of simultaneous

the end of the case. This meant one step had to be complete before the next step was executed. It also resulted in all the heavy mechanics to begin 6 to 12 months into treatment, creating added patient discomfort and frustration. Today, with implementation of simultaneous mechanics, we use passive self-ligation appliances (such as the Damon® System), disarticulation, and initial elastics in conjunction with each other to level, and align and correct the transverse and A-P of the case simultaneously — we work on all three planes of occlusion, Orthodontic practice 37


from the very beginning of treatment. For example, for a Class ll patient with moderate overjet, with traditional treatment, we would usually wait 8 months to 1 year to correct the Class ll with heavy elastics. Now, with simultaneous mechanics, we use early light elastics to start correcting the Class ll from the moment brackets are placed. Simultaneous mechanics is an individualized and highly efficient method of managing cases; it also forces the orthodontist to focus on finishing the smile and making the occlusion better from the beginning of treatment.

preventing the occlusion from settling together. On occasion, we’ll use finishing elastics as an end-of-case detailing technique, where we’ll cut or clip the archwire in the posterior segment, and run finishing elastics to get a better occlusion. After the brackets are removed, I run through a sequence of polishing burrs to address any uneven edges and recontouring needed. I also keep a diamond bur, a handpiece, articulating paper, and Shofu sandpaper discs on hand to recontour cuspids and reshape any teeth that need to be refined further.

Work is not finished when the brackets come off: final touches and preparing for the finish

The difference a decade makes: technology and procedure innovation

While there are specific protocols I execute in the final stages of a case, remember that finishing methods, such as contouring and tooth shaping, should be done throughout the course of treatment, not just at the end. For example, if you save all of your contouring work for the debonding day, you may not be able to get the correct smile symmetry and tooth shapes that you would like. Sometimes the finer elements of finishing are overlooked, but it is very important when in final finishing stages to not be afraid to equilibrate the occlusion. Two weeks before debonding the case, I will use articulating paper to check for any occlusal discrepancies that may be

In the past, orthodontists compromised facial and dental esthetics for functional occlusion. Today, with access to hightechnology treatment appliances and support tools, we plan our cases to ensure facial and dental esthetics are optimal in the end result. We are now doing things we could not imagine years ago. We never thought that we would be opening spaces, creating arch width, and beautiful smiles without extractions. We have been fortunate to witness innovations in orthodontic technology, which continues to produce optimal results in less time than traditional braces. Contemporary orthodontic treatment

38 Orthodontic practice

has changed. Now with advanced bracket and wire technology, and sound treatment mechanics, we not only pursue beautiful functioning occlusions, but more beautiful smiles and finishes than ever before. I consider this to be the “holy grail” of orthodontics. If you’re interested in learning more about the above treatment methods, please consider attending this year’s 12th Annual Damon Forum hosted by Ormco Corporation where I’ll be presenting an in-depth clinical workshop on finishing techniques and mechanics. As the largest privately-sponsored orthodontic event in the world, the Damon Forum offers more than 30 lectures, educational discussions, and workshops presented by world-renowned clinicians on a variety of orthodontic topics, designed specifically for orthodontists, clinical staff, treatment coordinators, office managers, and front office staff. OP Visit to review the workshops and register. Volume 4 Number 1

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Complete Clinical Orthodontics: treatment mechanics: part 1 REF: OP V4.1 SECCHI 1. (To be considered a true SWA) First, each bracket has to be tooth-specific and _____. a. have built-in torque, b. tip, in/out c. for the molars, the proper offset d. all of the above

6. With the proper arch wire selection, the active clip provides a ______ between resistance to sliding and tooth control. a. barrier b. new wire sequence c. perfect balance d. new value of tip, torque, and offset

2. Third, the base of the bracket must be contoured _____. a. occlusofacially b. mesiodistally c. occlusogingivally d. both b and c

7. Granted that all brackets have been placed in the optimal position, by the time the clinician gets to the finishing stage, each tooth should be optimally positioned with the right ______. a. tip b. torque c. offset d. all of the above

3. Andrews treatment mechanics in extraction cases, which was based on sliding teeth using round stainless steel wires, made him develop a series of additional brackets with different degrees of overcorrection to account for _______that occurs when closing spaces. a. undesired tooth movement b. pressure on the wire clip c. incorrect offset d. reduced lingual crown torque

8. The springing capability of the In-Ovation clip, as well as its quite long mesial-distal span, _________ within the stage of leveling and aligning. a. facilitate the correction of all rotations b. transfer the values c. interfere with molar control d. affect anterior coupling

4. Filling the slot with a large stainless steel arch wire to express the Rx was one of the premises of ______. a. the Roth system b. the Andrews system c. Ovation R bracket system d. the CCO Rx

9. Another important factor to consider when evaluating overbite/overjet problems is _________. a. the arch wire coordination b. inefficient reciprocal forces c. the position of the mandible d. the curve of Wilson

5. (In the leveling and aligning stage of SLB) The wire can be fully engaged from day one. Therefore, it provides _______ alignment and correction of rotations. a. slower b. faster c. less predictable d. no need for

10. ______ is a good word to describe the use of intermaxillary elastics. a. Efficiency b. Discretion c. Versatile d. Universal

Volume 4 Number 1

What’s new with finishing and mechanics? REF: OP V4.1 FROST 1. There are three crucial elements to_______: bracket positioning, bracket torque selection, and simultaneous mechanics. a. achieving an advanced finish b. smile esthetics c. minimizing the guesswork of torque to wires later in treatment d. planning the sagittal position 2. It has become self-evident that ________, the easier it is to settle the occlusion. a. the more optimal the soft tissue response b. the healthier the TMJ c. the more precise the placement of brackets d. the worse the overbite 3. ______ is imperative for finishing correctly and must be analyzed during the treatment planning process. a. Leveling b. Torque selection c. Aligning d. Defining arch length 4. Bracket selections _______, when using digital orthodontic systems, to produce a torque prescription that considers each patient’s individual tooth anatomy and the occlusogingival positioning of the bracket to best achieve the patient’s final result. a. cannot be customized b. can be overrated c. can serve as a template d. can be customized 5. When choosing anterior bracket torques, if you are going to err, err towards selecting a ____ torque. a. high b. low c. medium d. universal

6. Possibly one of the greatest advancements in the past 10 years is the evolution and implementation of ______. a. simultaneous mechanics b. automatic bracket torque c. occlusogingival positioning d. heavy elastics 7. Today, with implementation of simultaneous mechanics, we use _________ in conjunction with each other to level, and align and correct the transverse and A-P of the case simultaneously — we work on all three planes of occlusion, from the very beginning of treatment. a. passive self-ligation appliances (such as the Damon® System) b. disarticulation c. initial elastics d. all of the above 8. Sometimes the finer elements of finishing are overlooked, but it is very important when in final finishing stages to not be afraid _______. a. to use light elastics b. to equilibrate the occlusion c. to focus on the vermillion curl d. fine tune bracket placement 9. _____ before debonding the case, I will use articulating paper to check for any occlusal discrepancies that may be preventing the occlusion from settling together. a. Two weeks b. Three weeks c. One month d. A few days 10. _______ I run through a sequence of polishing burs to address any uneven edges and recontouring needed. a. After the brackets are removed b. Before putting on the brackets c. Before using elastics d. After leveling and aligning

Orthodontic practice 39




Sharing smiles for a lifetime Note from Managing Editor, Mali Schantz-Feld: In daily professional life, much time and effort is spent developing clinical expertise and efficient business practices. While these skills improve patient care and create a positive office environment, we have discovered that humanitarian efforts not only correct the dental condition, but also touch the hearts of the patient, the doctor, and the community. This new column “Banding Together,” will feature stories about how orthodontists treat teeth and change lives at the same time.

Dr. Robert Sheffield’s story Case 1 When Renee’s mother dropped off her Smile For a Lifetime (S4L) scholarship application, she expressed sincere hope that her daughter might be selected. She described the relentless teasing of her daughter by classmates who called her “lizard face.” She said her daughter hated to go to school. On the day Renee was surprised with her scholarship, she broke into a huge smile and said, “They won’t be able to tease me anymore.” Her mother broke down in tears, thanking everyone for saving her daughter from her classmates’ taunts. Renee is full of life at each appointment, and we all enjoy seeing a patient so appreciative and deserving of one of our S4L scholarships. Renee is the embodiment of what the S4L foundation is all about.

Case 2 When Ashley and her mother came to the office for the screening visit prior to the final selection process, her mother explained that they’d been saving for orthodontic treatment for a year, but the unexpected death of Ashley’s father prevented them from pursuing treatment. They were so excited to hear about the S4L Foundation. Ashley rarely smiled, but the opportunity for orthodontic treatment has made a difference. Her mother says she smiles all the time and approaches life with renewed confidence. She brought in Ashley’s senior portrait, and said that when she asked Ashley about the option to “digitally remove the braces” Ashley said, “No, I want to leave them on; they are part of my story.”

Dr. Robert Sheffield is a native Californian and East Bay resident. He was born in Oakland and raised in Walnut Creek. His family was from Antioch and has strong ties to the area. Dr. Sheffield attended Northgate High School in Walnut Creek. He continued his education at UCLA graduating Phi Beta Kappa with a degree in Political Science. He then attended UCLA School of Dentistry graduating with honors. Dr. Sheffield continued at UCLA for his specialty training, completing a combined residency in both Orthodontics and Pediatric Dentistry. He served as Chief Resident of Orthodontics at UCLA Medical Center. During that time, he worked extensively with the craniofacial team, and developed and directed the first clinical trials in Distraction Osteogenesis at the UCLA Medical Center. Dr. Sheffield has given research presentations on facial esthetics and distraction osteogenesis at the American Dental Association and American Association of Orthodontists annual meetings. He is a member of the Delta Study Club, the Contra Costa Dental Society, American Dental Association, Pacific Coast Society of Orthodontists, the American Association of Orthodontists and is a Diplomate, American Board of Orthodontics. He is married to his high school sweetheart, Cristie. They have three children, Courtney, Ryan “Ryno,” and Kaitlyn.

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Volume 4 Number 1

Volume 4 Number 1

to 13 awardees. Our chapter is committed to awarding 12 scholarships every year. The day we surprised the recipients and their parents with their scholarships are easily some of the most memorable days of my professional career. Some kids are quiet, some scream with joy, and everyone cries! I’ve always known that orthodontics can make a difference, but listening to some of our scholarship recipients tell of the relentless teasing and bullying they’ve experienced due to the appearance of their teeth breaks my heart. Having a child tell you braces will save her life was never something I thought I would hear. Watching the change in our scholarship recipient’s personalities provides continual joy to me and my team and reaffirms our commitment to this program. I view the S4L Foundation as an opportunity to create a grassroots movement for positive change. Our recipients and their families are very thankful and regularly tell us so. I use each of those moments to remind the kids that I expect them to help others now and in the future; to remember to use their talents and resources to help others. I like to compare it to the commercial that shows people observing a good deed and then doing one themselves, and it is continually paid forward. I applaud all the orthodontists who have stepped up to be a part of this organization. I’d like to thank Dr. Don Montano for sharing his story with me, and Todd Blanton from Ormco, a S4L Board member, for giving me the final push while we were out playing golf one day. I am continually humbled by the gratitude of the scholarship winners and their families, and thankful that I made the effort to use my time and talents to help our community in this fashion, because my professional career will never be the same. OP

Scholarship winners

About Smile for a Lifetime Foundation The Smile for a Lifetime (S4L) Foundation’s mission is “to create self-confidence, inspire hope, and change the lives of young people in a dramatic way” through the gift of a smile. S4L changes lives one smile at a time! If you are an orthodontist interested in using your time and talents to make a difference in a young person’s life, please contact Michelle at or visit to learn more about how you can serve. Orthodontic practice 41


I consider myself extremely fortunate to practice the profession of orthodontics. I believe loving what we do provides us with the excitement to begin each day with enthusiasm. I enjoy going to the office each day because I know it will always present new and exciting challenges. I am fortunate to work with a talented and dedicated team who are passionate about helping others. Dentistry and orthodontics in particular, is a profession where we can make a significant difference in people’s lives. We do orthodontics every day, and to have patients so thrilled to be treated is such an uplifting experience that it fills my entire spirit. All of our patients are happy to get their braces off, but I think the S4L scholarship winners are more thrilled to get them on. Like many orthodontists, I frequently provided pro bono treatment for some patients at the request of colleagues, local teachers, or the dental society. However, there was no structure to our program, and our efforts were not focused. Like many people we have been impacted by the decline in the economy, our area suffered more than most from the housing bubble, and consequently, many current patients suffered financial hardship. Many prospective patients found that orthodontic treatment had to take a back seat to mortgage payments and food for the family. I got caught up in the “poor me” mindset regarding the economy and continued to reminisce about the good old days. However, I finally grew tired of all the negative news and stories of sadness and loss and decided I needed to figure out a way to do something positive for the community and our practice psyche. Dr. Don Montano shared his involvement with the S4L Foundation with me, and his presentation of the scholarship recipients in his office moved me to tears. I realized that making the effort to start a chapter and provide orthodontic treatment to deserving children in the community could create a positive buzz. What I didn’t realize was the amazing impact S4L would have on me personally. We launched our chapter in April 2011. I am so very grateful to have a board comprised of nine local community members, former patients, business leaders, and dental professionals who take an active role in our chapter. We awarded seven scholarships in 2011 and just had our fall 2012 board meeting, selecting six more recipients and bringing our 2012 total


At the heart of digital orthodontics Avi Cohen, Director of Global Dental - Stratasys Ltd., discusses the Objet Eden260V printing system


s the cost of orthodontic laboratory work is becoming a major factor in orthodontic appliances planning and production, some forward-thinking orthodontic labs are adopting digital orthodontics processes to set themselves apart. In recent years, orthodontic appliances based on software design have become common, and most orthodontic companies now have access to 3D printing, whether in the orthodontic practice or laboratory, or via production centers. This opens valuable benefits to orthodontic companies, including: access to new, almost defect-free, industrially prefabricated and controlled materials; higher quality and reproducibility; data storage commensurate with a standardized chain of production; improved precision planning, and efficiency.

When hands are not enough Dental and orthodontic lab technicians traditionally rely on steady hands and expert eyes to prepare orthodontic appliances. Although they often are considered artists, the manual process is time-consuming, imprecise, and requires materials that might not provide the best durability or esthetic appearance. The known digital workflow is based on few steps that usually are: scan (using 3D scanner, intraoral

Avi Cohen, director, Global Dental, Stratasys Ltd., based in Rehoboth, Israel, joined Objet Geometries Ltd In 1999 after nearly 7 years on the graduate business faculty at University of New Haven in Connecticut. Since coming to Objet Geometries Ltd, he has served as the Global Customer Support Manager, and brings with him 7 years of experience in management of international customer support organizations. Prior to that, he served at different bio-medical companies, in various customer and product support high management positions, both in Israel and in the APAC. Since 2005, Mr. Cohen has been involved in developing and setting up global applications solutions responsibilities at Objet Geometries Ltd, and in past years has focused on the growing medical and dental segments.In his current position, he is managing the worldwide dental and medical solutions at Stratasys Ltd. He has experience in the following industries: medical CT and MRI, dental scanning and software solutions, 3D printing, modeling, and design – in both marketing and business development aspects. Mr. Cohen has recent specialization in bringing digital solutions into dental and medical arena and is considered a technology leader in this market.

42 Orthodontic practice

scanner or impression scanner), CAD, where software is being used to design the end product based on the scanning data, and 3D printing system. Rapid manufacturing is about to offer dentists and patients an affordable and attractive option. The old days when dentists had to ladle quantities of goo into patients’ mouths to take impressions for the orthodontic appliances has gone. Instead, exciting new high technology has been developed that will do a 2-minute digital scan of a patient’s entire set of teeth. Once the information is captured by an intraoral scanner, the dentist passes around the teeth the scanner has delivered to a orthodontic lab where 3D printing machines are used to manufacture the stone model. Hence, the 3D printing technology bullet train continues to accelerate the pace of change in orthodontics. For those who have predicted the day when everything from scheduling to finished orthodontic appliances can be handled digitally, the day is here. Intraoral scanners and the software that manages them continue to improve on proven models. And now one can see the astounding diagnostic possibilities provided by cone beam CT scanners, as scan speed and image capture, and enhancement capabilities continue to improve at record speed. Most impressive this year has been

the explosion in devices dedicated to digital imaging, impressioning, and 3D printing fabrication of orthodontic appliances, both chairside and in the lab. With the roll out of new systems, materials, and capabilities over the coming year, many believe that more dentists will begin to see the technology as a viable alternative for their practices. To summarize the moving trend: some day in the near future, we may look back at 2012 as the year when the orthodontic laboratory industry passed the point of no return from a traditional manual workflow toward an all-digital design and manufacture process. In many respects, all-digital orthodontics is already here, and a growing number of laboratory owners have incorporated digital orthodontics in some form into their strategic business models. For many orthodontic professionals, this evolution has been a long-awaited and welcome transition to a more rapid and labor-saving automation that improves quality and precision while keeping businesses competitive. The Objet Eden260V™ 3D printing system from Stratasys provides the ideal solution for orthodontic labs, as it enables them to improve the quality of orthodontic appliances manufacturing. Objet systems provide such labs with the ability to rapidly manufacture digital stone models using the Eden260V™ 3D printing systems. Volume 4 Number 1

The Secret to Orthodontic Lab

Survival in the Next Decade? Go Digital.

For a lab to survive in today’s market you need to expand your reach. Win new customers. Open fresh markets. In short – you need to go digital! 3D printing helps you better plan and execute your digital workflow so your clients will immediately notice the difference in quality and turnaround. Objet 3D Printers from Stratasys are leading the digital revolution and can be found in many of the world’s leading labs, including Glidewell, ClearCorrect and ClearStep. So why let it wait? Call Stratasys to find out why now is the right time to move to digital production with Objet 3D Printers!

Find out how Objet 3D Printing from Stratasys can transform your orthodontic business today. F O R A 3 D W O R L D TM

PRODUCT PROFILE 3D-printed orthodontic models guarantee dentists a high level of precision in the placement of orthodontic appliances that is difficult to achieve using freehand traditional techniques. The Objet Eden260V offers unparalleled return on investment for professional rapid manufacturing solutions. Printing with the high accuracy of ultrathin 16µ layers, all Eden systems produce models with exceptionally fine details and smooth surfaces. With the Eden 3D printing systems family, you can select the system that best suits your 3D rapid manufacturing needs. The compact design and the clean process of Objet’s Eden systems make these machines ideal for any lab or office environment.

Top accuracy and productivity in dental 3D printing A new era of 3-dimensional printing The manufacturing world is increasingly turning to 3D printing in a search for meeting the requirement for higher pace time to market in today’s competitive marketplace. By answering all orthodontic appliances production challenges, orthodontic lab owners can save costs and move more quickly to digital production. Objet’s advanced technology, featuring ultra-thin build layers, sets a new standard in 3D printing. High-speed, easy, and clean production of smooth surfaced, fine detailed models are available with the Objet Eden™ systems from Stratasys. The dental 3D system award winner With its innovative, multidisciplinary approach to hardware, software, and polymer materials, the Eden260V was the first technology to successfully jet acrylic polymer material. Over the past few years, Objet has focused on continually improving its technology in order to offer best-inclass 3D printing features and capabilities. Objet’s patented jet-head technology was designed to jet the company’s proprietary dental material, VeroDent®, layer by layer onto a build tray, until completion of the required model. The process produces fully cured models that can be handled and used immediately. The PolyJet process The PolyJet jetting head slides back and forth along the X-axis, similar to a line printer, depositing a single super-thin layer of polymer onto the build tray. Immediately after building each layer, UV bulbs 44 Orthodontic practice

alongside the jetting bridge emit UV light, immediately curing and hardening each layer. This step eliminates the additional post curing required by other technologies. The internal jetting tray moves down with extreme precision, and the jet heads continue building, layer by layer, until the model is complete. Sophisticated software tools enable all heads to work in perfect harmony and superb accuracy to synchronously jet identical amounts of materials on the tray. This results in a perfectly even and smooth surface. Two different materials are used for building: one for the actual model – the VeroDent material, and another gel-like material for support. The geometry of the support structure is preprogrammed to cope with complicated geometries, such as cavities, overhangs, undercuts, delicate features, and thin-walled sections. Advanced features Objet’s exclusive focus on polymer jetting and the dental market drives the technology to ever-higher achievements in ultra-thin build layers, material properties, accuracy, speed, and ease-of-use. • 16-micron super-thin layers for smooth surfaces Microscopic drops are jetted in superthin layers of up to 16 microns (0.0006”). This results in ultra-smooth surfaces regardless of the geometric complexity of the model. • Accuracy A combination of fine chemical development, precise mechanics and electronics, and advanced software features enable builds that fit very tight tolerances for the dental market. • Durable models for the dental industry An integral part of the PolyJet technology is the VeroDent® material. This material offers excellent flexibility, impact strength, and stone model appearance. The material was tested and approved by leading dental companies and labs, such as Sirona, Glidewell, ClearCorrect, and hundreds more. • High-speed jetting for greater productivity PolyJet technology uses a raster process to produce polymer models, enabling the machine to build in slices rather

than point-by-point. Several models can therefore be created in the same amount of time it takes other technologies to produce a single model. The combination of a raster process with high-speed mechanical movement further reduces build times compared to alternative technologies. • Thin walls for unique geometries The high-precision jetting of PolyJet technology enables super-thin walls and die margin lines, depending on the geometry. • Clean, easy process Objet’s 3D printing systems can be used in an office or lab-type facility, as the model and support materials are environmentally stable and are loaded in sealed cartridges, with the VeroDent material fully cured (Solidifield) immediately after build. The PolyLog™ materials management system optimizes materials usage, and alerts the user when cartridges should be replaced. Objet Studio software is simple to use and intuitive, enabling virtually anyone to operate Objet systems efficiently. • Easy support removal on any geometry Objet’s support and model materials are completely separated with a high pressure WaterJet, resulting in clean, smooth surfaces. This process is quick and simple and allows finishing of most parts within minutes. Fast jetting, combined with easy support removal, creates finished models ready for use in record time. As the cost of laboratory work is becoming a major factor in dental restoration planning and therapy, and in pricing, some forward-thinking dental labs are adopting digital dentistry processes to set themselves apart. In recent years, dental restorations based on software design have become common, and most dental companies now have access to 3D printing, whether in the dental practice or laboratory, or via production centers. This opens valuable benefits to dental companies, including: access to new, almost defect-free, industrially prefabricated and controlled materials; higher quality and reproducibility; data storage commensurate with a standardized chain of production; improved precision planning, and efficiency. OP Volume 4 Number 1

Dr. Dwight Damon will headline the 2013 educational conference, which includes lectures on progressive technologies, marketing workshops, and differentiation strategies for orthodontic professionals

Ormco Corporation, manufacturer and provider of advanced orthodontic technology and services, is registering attendees for its 12th Annual Damon Forum, which will take place February 13-16, 2013, at the JW Marriott Orlando Grande Lakes Resort & Spa in Orlando, Florida. The clinical educational and practice-building conference, touted by the company as the largest privatelysponsored orthodontic event in the world, was designed specifically for orthodontists, clinical staff, treatment coordinators, office managers, and front-office staff. It will feature interactive clinical workshops that integrate leading-edge research and outline the latest orthodontic treatment advancements. The Damon Forum offers more than 30 in-depth lectures, educational Volume 4 Number 1

discussions, and workshops presented by world-renowned clinicians on a variety of orthodontic topics. Notable speakers include Dr. Dwight Damon, inventor of the Damon® System, who will be joined on the main stage by Drs. Stuart Frost, Hisham Badawi, and John Graham, previous president of the Arizona Orthodontic Association. Additional breakout sessions led by practice development experts in the orthodontic profession will focus on clinical treatment mechanics, new technology applications, and practice-building tactics through referral network strategies, as well as online marketing, and social media. Furthermore, attendees can network with more than 1,100 worldwide orthodontic professionals and are eligible to earn up to 20 American Dental Association (ADA)

continuing education credits. Vicente Reynal, president of Ormco, said, “It’s our privilege to host this one-ofa-kind conference, bringing together the most elite talent pool within our industry for unmatched education, technology integration, and practice-enhancing opportunities. The orthodontics profession is rapidly evolving, and both new and returning Damon Forum attendees can expect to walk away with a wealth of new techniques and digital solutions to help them grow their practices and improve patient treatments.” For more information about the 2013 Damon Forum conference, please visit OP This information was provided by Ormco.

Orthodontic practice 45


Ormco Corporation readies for its 12th Annual Damon Forum


GCARE webinars: inspiration, exploration, and education: part 2 Dentsply GAC is launching a new educational initiative described as, “part inspiration, part exploration and part education.” A new series of webinars, through GAC Clinical Alliance for Research and Education (GCARE), focuses on four aspects of the practice — clinical, esthetics, practice growth and management, and resident transition —to enhance Dentsply GAC’s quest to fulfill the educational needs of the contemporary orthodontic practice. Interviews by Orthodontic Practice US Managing Editor Mali SchantzFeld explore how the new webinar program pertains to all stages of the orthodontic community, from residents to practicing orthodontists. Chris Bentson — President, Bentson Clark & Copple, LLC “Bentson Clark & Copple has a long standing relationship with GAC. We have provided our company’s quarterly, subscriptionbased newsletter, the Bentson Clark reSource, to GAC’s executives and sales team for the last 6 years. The publication’s content and our ongoing involvement within the orthodontic resident base have resulted in several resident presentations organized by GAC. Bentson Clark & Copple has presented many resident lectures focused on transitioning out of residency into private practice and how to successfully run that practice. Additionally, we have provided copies of our annually produced Orthodontic Resident Survey and quarterly published Consultant Note publication to GAC’s management team to offer a third party view of the orthodontic marketplace. Bentson Clark & Copple has no financial interest in GAC; however, we greatly value our relationship and respect the company’s position as a leading provider of orthodontic supplies and technology products. “This webinar is titled ‘Locating a Practice – Associateship or Purchase Opportunity.’ This presentation is geared towards orthodontic residents and is focused on locating potential practice opportunities. A number of other topics will be discussed, including ways to polish your CV, industry resources for locating a practice opportunity, and an overview of the types of practice transitions. Tips are offered on how to analyze a practice’s profit and loss statements/financial data to 46 Orthodontic practice

help residents understand if a practice is a ‘good opportunity.’ There is also a brief discussion regarding the current business state of the orthodontic industry, existing benchmarks, and how these factors can affect residents’ future plans. “A big trend we have observed in the last 6 years is orthodontic residents graduating their programs with a desire to become an employee rather than a practice owner. In the past, orthodontists did not work as employees; however, if they did, it was only for a short period of time. Almost 20% of orthodontic residents today are now entering into employment arrangements. We have catered this webinar series not only towards orthodontists who want to buy a practice or build one when they graduate, but for those who want to be employees. For this reason, the webinar will also discuss employment agreements, non-compete covenants, standards of normal pay schedules, and desirable geographic locations. “According to our 2012 Annual Orthodontic Resident Survey, residents are beginning their careers with an average of $250,000 in educational debt. As we all know, the orthodontic profession offers a tremendous income opportunity, but when residents are faced with buying a practice for $1 million, it can be quite frightening. Ownership transfer is a large business decision that doctors usually make only twice in their professional career; once when purchasing and once when selling. The webinar will help residents understand the valuation process, understand if a practice is valued appropriately, and comprehend a cash flow pro forma. “The webinar will allow residents to visualize practice operations from a profit point of view and how to divide spending money between staff, orthodontic supplies,

business management, marketing and occupancy expenses. Many residents have very little knowledge about these types of business expenses; some simply believe they will finish their program, enter a practice, and it will become profitable. An orthodontic practice is more than bending wires and creating smiles; it is running a business. One of the webinar’s goals is to teach residents about the aspects of practice ownership. There is a brief discussion of where to locate the proper resources during the ownership transition process and consultants who can assist with post-transition, business operational needs. “At the end of the webinar, residents should recognize and understand that practice ownership is an easy-tounderstand process. We hope to bring awareness that individuals and companies are available to help during a transition, and there are specific areas that should be explored in depth before beginning the transition process. Residents are often more educated than sellers on this topic because of the vast array of resources available, such as these types of webinars.”

Doug Copple — Accredited Valuation Analyst (AVA); Partner at Bentson Clark & Copple, LLC “This webinar, ‘Understanding Orthodontic Valuation and Transitions,’ walks orthodontic residents through a practice transition timeline and its steps. As an element of the timeline, negotiations regarding partnership arrangements and buyout transactions, association Volume 4 Number 1

periods, and employment agreements are examined in great detail. The webinar also delves into practice valuations, how a reasonable price is obtained, and what key elements affect practice value. Some rules of thumb are provided when it comes to practice valuations expectations. Tax allocations of the purchase price and how they differently affect buyers and sellers are also examined. “An interesting aspect that is currently affecting the dynamic of buying and selling orthodontic practices is the large amount of education debt residents have accrued during their program. Many selling doctors did not have a large amount of educational debt when they graduated years ago and are surprisingly unaware of the amount of debt today’s residents are carrying when starting their professional careers. When the seller views a practice cash flow, some do not understand why residents request more money or a longer loan repayment period. From our company’s experience, if one party understands the other’s perspective, the practice transaction will be smoother and allows reasonable expectations for all parties. “It is important to ensure that each resident understands cash flow projections so a reasonable and affordable practice price can be recognized. We have developed an example cash flow and a buy-in projection that appears in the presentation. Using this example, residents can learn to review and correctly understand the documents’ details. This is an example discussed within the webinar that illustrates the subject: When a buyer purchases a practice grossing a certain amount of money with a specific profitability for a set price, there are certain repayment terms that must be determined in order for a buyer to understand if he/she can afford the opportunity. Cash flows also allow residents to plan if the opportunity will generate enough money to cover one’s Volume 4 Number 1

school debt, house and car payments, and support their family. “In regards to partnership arrangements, we talk about profit allocations, tax effects, and debt repayments. We delve into employment agreements and association concerns such as the length of the association and the compensation one can expect. Whether a buyer is entering into a buyout opportunity, partnership deal, or employment arrangement, we illustrate how compensation levels vary. Within each of these types of transactions are details residents should negotiate such as price, lease terms, and pre-and-post closing employment arrangements. As a general rule of thumb, when residents enter into a partnership deal, they must deal with buy-sell arrangements, income or profit allocations, and what percentage that buyer will be buying and when. “Armed with all of this information, a resident/buyer can determine if a business deal makes sense to him/her and his financial needs and desires. With the recent economic challenges, there are less sellers resulting in more difficult buyout and less employment opportunities than seen in the past. This webinar allows residents to understand what to expect in today’s economic environment. We have observed time and time again, that the better educated buyer typically wins the deal. Sellers respect buyers who understand the business aspects of a practice and do not have unreasonable expectations in regards to the transaction. “We appreciate GAC for allowing us to participate in these educational webinars. We enjoy each opportunity that provides an outlet of sharing knowledge with the upcoming generation of orthodontic providers. The more information a resident is armed with, the better one’s chances for success in today’s orthodontic marketplace.”

“My webinars within the GCARE series are designed to pique the interest of orthodontists in the fundamentals of functional occlusion in order to achieve excellent patient care. Functional occlusion is what makes orthodontics a health science and not just a cosmetic service. This webinar introduction includes: instrumentation, cone beam computed tomography (CBCT) imaging, soft tissue cephalometric analysis, and collaboration with the general dental field in interdisciplinary cases. “Todd Metts, Dentsply GAC’s director of professional services, introduced me to the concept of these webinars and started the process, resulting in the two webinars that I have developed so far, ‘Orthognathic Surgery’ and ‘Interdisciplinary Dentistry.’ I hope to add more webinars on techniques for functional occlusion in the future. “Orthodontics is more than just straightening the front teeth, but some orthodontists and the public often do not understand the functional occlusion aspect. The clinician can straighten the teeth, but that does not necessarily mean that it will work with the muscle system, the joint system, and the nervous system. We measure these parameters with five goals: joint, face, perio, teeth, and function. By knowing these, orthodontists can measure more precisely and do a proper diagnosis and a post treatment follow-up to check the results. “Functional occlusion also is based on three concepts — 1) Seated condylar position, 2) Do not believe what you see in the mouth, and 3) Quit trying the impossible. Orthodontists try to fix bite problems that are skeletal with tooth movement. But, if the problem is skeletal, the teeth cannot be moved far enough to correct the bite. So the patient and the orthodontist end up with a system that fails. Because the joints and teeth do not match, the patient has to do a lot of muscle splitting and what I call ‘jaw gymnastics’ to be able to function, resulting in a breakdown of the system. “A very beneficial way to gain more information on the patient’s dentition is with cone beam computed tomography (CBCT), also known as 3D imaging. I was Orthodontic practice 47


Dr. Theodore Freeland — Director of Advanced Education in Orthodontics

EDUCATION EXPLORATION a pioneer in using this imaging method and have been using it for approximately 9 years. With these 3D images, the practitioner can detect pathology and joint problems from degenerative joint disease and joint positioning. From one scan, the doctor is able to create 2D films, cephalometrics, tomograms, APs, frontals, cross sections, and do nerve analysis. You can’t beat it. No other imaging system can achieve that amount of detailed information with the least amount of radiation. We can also relate the imaging to the functional analysis that we do on articulators. By using the natural head position, the true vertical line, and the axis horizontal plane, the orthodontist can actually coordinate articulator models and the imaging. “Another part of the seminar involves working with the restorative dentist, the oral surgeon, the periodontist, and the prosthodontist. If the orthodontist

understands the dentist’s language, this can result in increased patient referrals. If the dentist and the orthodontist understand the basics of functional occlusion, then they are talking the same language. The orthodontist will be able to show the restorative dentist what can be achieved orthodontically, and it will also be apparent what the restorative dentist can do with the altering of the occlusal surfaces. By working together on this level, the orthodontist is looked on by the dental profession as a prime helper in their restorative cases. Working with the oral surgeon on the basis of functional occlusion — making sure the joint is seated during surgery and following the outcomes along with functional occlusion — greatly increases the benefit for the patient. “These webinars introduce the basic instruments, techniques, and concepts. But, as we say in extreme skateboarding,

‘don’t try this at home’ unless you have the proper teaching. For that, I teach a course called Advanced Education in Orthodontics (AEO). This course is comprised of seven 4-day sessions, over a period of 2 years. Drs. Bob Frantz, Scott Anderson, Michael Goldman, Stan Crawford, and Dipak Chudasama help me teach the Advanced Education in Orthodontics course. It is a commitment to growth in orthodontic knowledge and patient health. Dentsply has helped with our marketing, and they also were kind enough to include us in GCARE. We have a very good working relationship — they supply a superior bracket product and wire system, both of which enhance the patient’s finished case. The AEO group purchases these products like the rest of the profession. It is not that they are giving us a product to sell. We use it because it works better than anything else out there.” OP

Visit Email Call 1.866.579.9496

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Volume 4 Number 1


Objet hosts WKE 2012 Annual Orthodontic Conference

“All speakers addressed solutions and technological topics related to today’s top orthodontic treatment trends, dilemmas, tools, and technology advances.”


he majority of the WKE orthodontic members traveled from different states nationwide to attend the WKE Orthodontic conference held on November 2-3, 2012 in Atlanta, Georgia. “We’re always trying to stay at the cutting edge of all of the latest technologies by attending and hosting continuing education courses,” says Don Inman from Inman Orthodontic Lab Inc. The meeting featured lectures on different topics from world-class experts, including Volume 4 Number 1

Objet, 3Shape, ESM Digital Solutions, and easyrx. Keynote speaker of the conference, Avi Cohen, Head of Medical Solutions at Objet, added, “All speakers addressed solutions and technological topics related to today’s top orthodontic treatment trends, dilemmas, tools, and technology advances.” The meeting was designed to share new technological solutions on variety of processes in digital orthodontics

from scanning, software design of orthodontic appliances, 3D printing, data storage, and management. “We also believe that gathering orthodontic lab owners and professionals from around the country, who will bring with them their expertise, experience, and wisdom, will be of particular significance in expanding and supporting the need for orthodontic care that is rapidly growing throughout the world” added Mr. Cohen. OP Orthodontic practice 49


Observations on growing an orthodontic practice: part 1

Chris Bentson offers tips for growing a practice in a competitive economy


s valuation and transition consultants, we have the duty to analyze a practice for sale or purchase with great scrutiny. When performing a practice valuation study, we analyze the last 3 years of a practice’s financial performance and operational performance for each practice. This provides us not only the revenue and expenses, but the patient flow, the conversion ratios from new patient exams to starts, the fee structure, the marketing plan, etc. More importantly, when visiting each practice, we observe the physical facility, fixed assets in service, staff, location within the practice’s drawing area, competitors’ location(s), and so on. We also perform a detailed demographic analysis of the patient drawing area. Needless to say, we end up with a great deal of data on each practice; and have the opportunity to

Chris Bentson, president, Bentson Clark & Copple, LLC of Greensboro, North Carolina, has been working with orthodontists regarding the business aspects of their practices for more than 23 years. He also serves as editor-in-chief of the Bentson Clark reSource, a quarterly newsletter focused on the business aspects of running a successful orthodontic practice. He is a frequent guest lecturer and has personally visited over 1,000 orthodontic practices in the United States, Canada, and Australia. He can be reached at 1-800621-4664 or via email at

50 Orthodontic practice

see practices in every geographic region of the country. Taken together, we see practices that are declining at various rates, practices that are maintaining a relatively flat “status quo” with regards to growth, and practices that are growing at various rates. We see these practices in all areas of the country, in all environments, generally battling a similar competitive and economic environment. We would like to provide a partial summary of common threads we have observed in practices that are growing versus ones that are not over the last several years. We hope to offer some ideas, habits, and choices that doctors/owners have made to grow a practice in a very slow-growing economy, with increasing scrutiny by consumers who are largely feeling an economic pinch. Parents are looking to save money where they can, including the investment in orthodontic care for themselves or more to the point, their children. Before discussing the elements of growth, below are a few necessary comments regarding general practice growth. 1. Not all practices can grow. There are many contributing reasons as to why a practice cannot grow: competitive environment, demographic environment,

geographic limitations, and so on; however, our observation of the number one reason practices cannot grow is because they do not currently operate with efficient systems. Systems, as we will discuss later in this article, are perhaps the key foundation to growth and without them, a practice in chaos will experience greater chaos as it makes decisions and tries to grow, ultimately imploding under the weight of poor systems. Some examples can be the following: • If patients are not seated on time, adding growth to a practice will only exacerbate the problem. • If cases are not finishing on time, growth presents real problems as chairs fill up with unhappy zero contract balance patients. • If the highest level of customer service cannot be currently offered, then providing the same average, predictable, run-of-the-mill, mediocre service inhibits growth. • If the staff is turning over at an accelerated rate, and there is gossip, backstabbing, and an ununified team that is just getting by, growth is not in a practice’s future. • If there is poor direction and leadership from the owner, counting on the staff to pick up the leadership role and Volume 4 Number 1

2. Not all practices should grow, even if they can. What? We have seen many practice owners who are professionally and financially satisfied with the practice just the way it is. These owners are wired a certain way and like a predetermined pace and flow. Growing their practice would invite things into their lives they don’t want — more time at the practice, more problems, more staff, more of this or that. Growth for these owners can come with a price they do not want to pay or they are not well suited for. As one doctor put it to me years ago, “I take a set off every day, I put a set on every day; that is just the way I like it and have been doing it for 20 years.” Only grow if one desires to deal with what comes with growth. 3. Growth is a choice. Unlike certain time periods in the last 20 years when we observed practices growing just because they existed year after year, today practice owners must choose to grow. Growth is intentional. It is planned for. It is measured and monitored. It requires investment and risk of capital and time. It requires leadership.

Growth is intentional. It is planned for. What have we perceived in practices that are growing, and what observations do we have regarding growth? We are seeing multiple strategies and paths to achieve growth. There is no silver bullet, no one, sure fire, can’t miss strategy. While we could discuss dozens of ideas, we will center on seven areas for practice owners to consider as they develop a growth strategy for their practice. These areas are: 1. Fee analysis 2. Increasing referrals 3. Starting more patients 4. Finding more patients 5. Product mix 6. Buying a competitor 7. Opening a satellite Fee analysis: Regardless of the price being charged, fees should be examined in three areas. 1. Am I collecting what I’m charging? 2. Am I raising my fees annually? 3. Am I flexible with my fees?

One of the easiest ways to grow the top and bottom line is to collect the highest percent possible of the fees charged. Insurance can be a bit of a wild card and requires a higher level of expertise, but with current practice management software, this can be handled efficiently and correctly. However, one of the biggest changes in collection procedures in the last decade has been automatic payment. Roll back the orthodontic tape to the early 1980s, and most practices were seeing patients on a 4-to-6 week interval and giving hand-punched coupon books to patients for payment reminders. Patients often associated payment with visit. Fast forward to the 1990s, and by the end of the decade, we went from the handwritten ledger card bin to almost 90% of practices being computerized, meaning daily aging reports were easy to obtain, monthly statements were printed or sent electronically to patients, and a raft of collection reports were available as tools to assist financial coordinators in collection of fees due. Over the past 10 years, most practices are now using automatic payment draft of the monthly payment. Companies such as OrthoBanc and Vanco services are being used. Local banks can provide this service in most communities,

$950,000 in Annual Collections, Assuming Fee Increases of: Amount of Time




5 Years




10 Years




15 Years




20 Years




Volume 4 Number 1

Orthodontic practice 51


grow the practice is likely not going to occur.

PRACTICE MANAGEMENT and many practice management systems have not only the functionality to auto draft payments but also an interface via the web for patients to make payments. Our observation is that growing practices exhibit extraordinarily high levels of collections and low delinquency rates in part by invoking technology to auto draft a monthly payment, giving financial coordinators time to work the tough ones and deal with the insurance companies. A suggestion made by many practice management consultants is to raise practice fees each year. This is one of the best ways to hedge profits against increasing overhead. While we have been living in an environment of almost unprecedented low interest rates and inflation rates, there is a common belief among economists that these low levels are not permanent, and some increases in these areas will occur. When and if they do, practice owners that are not annually increasing fees will feel a lighter weight in their wallets and find it difficult to catch up in one big move. In fact, practice owners leveraged on fixed fee insurance plans may find it against policy to make an upward price in their services above a certain threshold annually. A best practice is to monitor the economy and make fee increases annually that are near or just below the economic growth rate (for the last several years this has been anemic and under 3%). The chart on the previous page shows the effect of small fee increases over a career. The chart assumes annual collections of $950K per year (the mean collection rate as reported in The Journal of Clinical Orthodontics (JCO) Orthodontic Practice Study), assumes no growth over 20 years for the practice and shows the affect of a 1%, 2%, or 3% price increase to a practice owner at 5-year intervals for 20 years. Flexibility with fees is perhaps the greatest tool implemented by growing practices. Growing practices have a system in place to access risk and make it easy for the consumer to do business. A practice that is married to “x”% down and the balance ratably paid over “x” number of months needs to realize other options in the market are available to consumers. While the level of risk and how much flexibility should be granted can be debated, a prudent approach of appropriate credit risk analysis, coupled with excellent communication and collections systems, can allow many practices to allow more flexible options and still have a high 52 Orthodontic practice

probability of collecting fees. Consumers do not and should no longer associate visit with payment, and as this relationship is uncoupled in a practice, and more flexible payment options are afforded, it is likely for the practice to get to “yes” more frequently in the new patient process.

handling dismissing patients, or dealing with multidisciplinary cases. Offering opportunities to educate, whether on orthodontic modalities or small business issues, are valuable to both parties and helpful in strengthening a referring doctor relationship.

Increasing referrals: Gaining, asking for, and in some cases, rewarding a general dentist or pediatric dentist for professional referrals of patients is a time-honored tradition within the orthodontic profession. Yet over the past several years, orthodontists have seen fewer referrals from this group than ever before. The JCO’s Orthodontic Practice Study, published biannually, shows a decrease of almost 10% over the last 8 years. Still necessary and viable, growing practices have a two-pronged approach to their communication with referring practices: 1. Doctor-to-doctor 2. Practice-to-staff Doctor-to-doctor communication is, and always will be, an important marketing element of most orthodontic practices. While the golf outings, sporting event tickets, and holiday gifts can still be a component, the following approach helps the doctor-to-doctor relationship turn into more patient referrals:

C. Be an escape valve. If a referring doctor is providing orthodontic services, it can be a great relationship builder to get him/her out of a problem case he/she should not have accepted in the first place. It does not always come full circle, but there are a great many orthodontists who can testify to an increase in referrals after bailing out a poorly progressing case from another dentist.

A. Ask how? Most orthodontic practices communicate with all referrals in the same manner. Each referral receives the same letter, the same form, the same everything. We have seen doctors, especially new and younger, asking referring general practitioners how they want to be communicated with (electronic or paper). They also inquire what information they want to receive, demonstrating the ability to deliver specifically what the referral wants, ultimately leading the relationship ahead. This level of customization requires asking first versus telling, listening well, and then having the ability to execute and “customize” how to communicate to each referring general practitioner or pediatric dentist. B. Focus on education. Focusing communication with referring doctors on educational matters is often viewed as superior to “gifting.” Most small business owners and dentists share some common problems, such as: meeting CE requirements, human resource issues,

Perhaps just as important to the doctorto-doctor relationship is the relationship a practice develops with the referring doctors’ staff. This goes beyond donut and bagel runs. A. Know them. Start with first and last names, positions, children, birthdays, and staff anniversary dates. Have staff assigned to knowing the front desk and the hygienists in the general dental offices. Recognize significant events. Just like the television show Cheers theme song, you want to be “where everybody knows your name.” B. Include them. Visiting the referring doctors’ offices is not just to provide a nice holiday gift to the doctor, but provide something to the staff. A growing practice has a calendar with visit dates outlined over the full course of the year. Whether it is lunch, lip gloss, gift cards, game tickets, or invitations to events for the community the practice is sponsoring, be sure to include the referring doctors’ staff. C. Treatment. This one is all over the map, and there are many opinions. Decide if any treatment discounts or options will be available for referring staff, their spouse, or children. It is difficult to pass out three referring orthodontic cards at the front desk and successfully dodge the “Who’s your orthodontist?” question if the front desk person is an active orthodontic patient in your practice. OP Part 2 of “Observations on growing an orthodontic practice” will appear in the March/April issue. Volume 4 Number 1


Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims


s small business owners, a category in which most of us as dentists fall, there are many rules and regulations we must follow. One area of importance that is rarely discussed has to do with our general liability to protect our patients, our staff, and our personal assets. Let’s explore other areas of risk aside from malpractice claims that may help keep you out of trouble.

Innocent chores – major risk Many practitioners find it convenient to have an employee run chores for them. These tasks range from making bank deposits to picking up supplies to transferring patient charts from one office to another. Some utilize the services of their assistants,

secretaries, and office managers rather often. If possible, it is best to avoid any and all of these types of requests. Here is a scenario involving an auto accident that takes place every day in one city or another all around the country. Mary is riding to the bank to make your daily deposit when a dog runs into her path (hopefully she wasn’t texting). She veers off the street, onto the curb at the school bus stop where she kills three children, and four others are paralyzed to varying degrees; an unimaginable tragedy! The families will sue Mary, and since she was acting as your agent when the accident occurred, they will sue you as well and win.

Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from The University of Pennsylvania in 1976. He taught at Temple University and The University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging and health issues, and fiction with a medical bent. You can read about all of Dr. Fleisher’s methods to improve bedside manner in his book Bedside Manner - How to Gain Your Patients’ Respect, Love & Loyalty. www.bedsidemanner. info. Dr. Fleisher can be reached at:

There is much temptation to use others to run chores, but try to do them yourself if at all possible. If an employee does have to run errands, make sure he/she has a valid license and automobile insurance of his/her own. Make sure whoever runs chores for you is responsible, not driving under the influence or distracted by his/her cell phones. You must make sure you have liability insurance as well since, as noted, you will be sued, too. Purchasing an umbrella liability policy provides a large amount of coverage for little cost. Your umbrella policy should be between 5 and 10 million dollars. Get as much coverage as you can reasonably afford to protect yourself as best as you can in an unreasonable climate. Your umbrella policy is usually applicable to your home and offices as well, giving you an extra boost of protection against a lawsuit.

Personal liability While your homeowner’s and automobile insurance policies protect you from most personal injury claims, the bigger worries are the catastrophic claims that require the umbrella policy noted above. People slip and fall all the time. They often try to find

Volume 4 Number 1 Orthodontic practice 53


an excuse for their misfortune by blaming others and exaggerating the claim. There are some protective measures that will keep your personal and business properties less risk-prone, and reduce the chance for a fall in the first place. Tour your properties periodically to look for potential problems like defective pavements, potholes, loose carpeting, defective waiting room chairs, sharp edges, heavy objects on flimsy shelving, and any potential threats to the safety of visitors to your home and practice. Parking lots should be well lit and properly paved with safe and easy access to your building. Periodically have a serviceman check the stability of your overhead lights and X-ray equipment. Equipment falling onto your patient can result in considerable damage and grief for all involved. If you practice in a colder climate, make sure that icy conditions are managed appropriately with application of salt or sand, snow is removed in a timely manner, and any water that may result in slippery surfaces is attended to. Assign someone on your staff to be in charge of safety, and make sure that he/she develops a list that documents that he/she is doing the inspections regularly. Discuss your accident prevention program with your staff, and stress the importance of safety. Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. Rather than running around in panic mode, each person should have a responsibility that allows for attending to the patient and a prompt call for emergency personnel. During an emergency, it is not the time to run around looking for your emergency kit or checking the dates on the contents. With a well-run emergency program in place, there should be no sign of panic, and most other patients in your office will not realize that an emergency has occurred until the ambulance pulls up to your door. Having periodic emergency drills will allow you to handle most emergency problems in a professional and discreet manner. The last thing you want is chaos, considering there will likely be several witnesses to what took place during an emergency. You don’t want the plaintiff to show the jury how you were not prepared, and the resultant panic delayed timely and appropriate care resulting in further injury.

54 Orthodontic practice

Vicarious liability Anyone who works for you can pose a threat by any and all of his/her actions. This is called vicarious liability – liability incurred due to the actions of others. These actions can include having your secretary or assistant making suggestions for managing postoperative pain to an associate who provides patient care. The rationale for vicarious liability is based on the legal concept respondeat superior. This model was developed many years ago and means that the master is responsible for the acts or omissions of the servant. This states that you are responsible for the negligent actions of your staff members, including associates and possibly even independent contractors who offer services in your practice. To reduce your liability, it is imperative to define and control all work-related procedures, and supervise all staff

contractor. However, remember you are going to be held responsible for any of your regular associates if the plaintiff can prove that you should have been aware of the poor quality of the associate’s work. How hard is it to subpoena several charts of patients your associate worked on to show a pattern of poor quality? Get rid of anyone who doesn’t practice quality care. Make sure you have vicarious liability insurance coverage. Require a certificate of insurance from all professional employees, and make sure you check yearly that they have paid up policies. You should be listed as an additional insured on their policy just as your associates should be listed as an additional insured on your policy. Examine all educational credentials of any employees requiring licensure, and make sure they have valid licenses. Check references on job applications to make sure they are legitimate. Get

Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. members. Make sure you script exactly what you want your staff to tell patients regarding postoperative care and sequelae as well as any instructions you have auxiliary staff provide to patients. Having written handout information is the best way to make sure you control instructions to patients, and it makes it much easier for your staff to learn the exact contents of the handouts. This allows them to offer the same instructions verbally when queried by the patient. A patient who sees your associate, the independent contractor, will likely sue you as well if a claim of malpractice arises unless you inform the patient of the independent status. Without this notification, the patient has good reason to believe that the associate is an employee under the supervision of the owner of the practice, and therefore, making the owner liable for the actions of the associate. A notification of the independent status of the associate, on the patient registration/ informed consent form that the patient signs, will help to reduce your vulnerability from the actions of the independent

written permission to contact an applicant’s references, and have the applicant sign a release form authorizing former employers to provide references. Call all the names on the reference list, not just the top ones. Any question you ask a reference must abide by all non-discrimination laws. It’s easy to be lazy about hiring, but the liability consequences can be enormous. Do your homework! Protect yourself by employing these ideas. They will help make you bulletproof to lawsuits. Many people and lawyers are just waiting for the opportunity to file a claim. Don’t let yourself remain vulnerable. Most of all, consult with your lawyer and insurance agent to help you properly institute the ideas contained herein. OP This article is an excerpt from Dr. Fleisher’s soon to be published, From Waiting Room to Courtroom – How Doctors Can Avoid Being Sued.

Volume 4 Number 1


rthoMetrics is the leading provider of real-time practice analytics for orthodontists. Designed to be an easyto-use analysis framework that simplifies collecting and generating key practice information, OrthoMetrics continues to deliver meaningful statistics month after month. Recent concerns about possible marketplace confusion with other similarly named companies recently led the OrthoMetrics team to change their name and their look. OrthoMetrics is now Gaidge, and they have recently reintroduced themselves in a big way to the orthodontic community.

Gaidge Practice Performance Tool Gaidge is all about helping doctors finetune their practice. The Gaidge logo was designed to be reminiscent of a tachometer you might see on the dashboard of a highperformance vehicle with the needle in the optimal zone. A true “aid” to any practice, Gaidge provides the visual instrument to help a practice monitor performance, spot trends, and adjust their speed. Gaidge is an essential practice performance analysis tool for doctors who understand that you can only improve your position by first knowing where you stand. Gaidge provides the insight needed to make informed, strategic decisions without complicated, manual, time-consuming processes so you can accelerate your practice.

How does Gaidge help a practice accelerate its performance? • Key Practice Management Information: Crucial practice management information is identified and delivered immediately in meaningful charts and graphs with very little staff involvement. More than 30 charts are available. • Dynamic Practice Management Benchmarks: Gaidge benchmarks allow practices to compare their information to industry standards determined by leading consultants. This helps a practice to set and achieve goals. • Regional and National Comparison Volume 4 Number 1

Data: Comparison data is also available through Gaidge so a doctor can view practice information in comparison to industry trends on a regional or national level. This information is not available anywhere else.

Industry experts join the pit crew Katie Odegard recently joined the Gaidge sales and marketing team. Katie brings 13 years of industry knowledge and relationships with her. Nine of those years were spent with OrthoTrac in sales and development, and 4 of those years were spent with The Agency, a former Orthodontic advertising agency of TeleVox software. Shannon Brockway also joined the Gaidge team. Shannon has worked in orthodontics since 1995 as a clinical assistant, treatment coordinator, practice administrator, imaging and practice management trainer, and consultant. Through collaboration with the sales team and networking with industry leaders and consulting colleagues, Shannon is able to enhance Gaidge’s integration with leading practice management software companies. Product development and client integration/engagement are Shannon’s primary responsibilities at Gaidge.

Gaidge currently available for OrthoTrac and Dolphin Management users Gaidge is currently accessible for OrthoTrac users on version 11.3 and also for Dolphin Management users on version 5.0 or greater. Gaidge collects data from these platforms for Gaidge users and compiles this information for regional and national comparisons. Again, this comparison data is only available to Gaidge users. Look for other integrations coming soon. The Gaidge team can be contacted by calling 800-287-3396 or on the web at OP

Gaidge believers “OrthoMetrics is the most valuable resource that I utilize on a daily basis for managing my practice. The easy access from home or office, for me or my staff, keeps my practice at its best. I no longer keep comparative spreadsheets from past years to monitor my practice. Most of all, it takes the ‘human element’ out of my numbers comparison. The data is straight from the software I utilize. I just log on to the website!” Richard E. Boyd, DDS, MS Richard Boyd Orthodontics Columbia, South Carolina “Gaidge is the lifeline to my practice. I have been spoiled with the easy-to-use graphic design. I review it every day to retrieve ‘pulse of the practice’ statistics. My team and I discuss areas that need to improve – we can take immediate action without sorting through mountains of paper. My team is focused on the importance of accurate information. This focus has changed our performance.” Todd S. Bovenizer, DDS, MS Bovenizer Orthodontics Cary, North Carolina “The Gaidge tool identifies trends, confirms them, and allows owner/doctors the chance to ‘manage’ through this resource faster than anything available. This realtime identification should give Gaidge clients an advantage — as if they have night vision goggles versus the rest.” Chris Bentson Bentson Clark & Copple Orthodontic Transition and Valuation Services

Greensboro, North Carolina “Gaidge gives me the ability to monitor the pulse of our practice from any mobile device or computer. I get a quick snapshot or, when desired, a detailed picture of how my practice is doing. I can also compare my practices to others with a similar profile. The visible benchmarks allow me see our successes and failures, thus helping to identify areas that need attention. I can’t imagine practicing without it!” James D. “Tripp” Leitner, III Thomas and Leitner Orthodontics Rock Hill, South Carolina

This information was provided by Gaidge.

Orthodontic practice 55


OrthoMetrics takes on a new name and a new look

Hu-Friedy launches new Ortho Lingual Instrument Collection

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT llllllllllllllllllllllllllllllllllllllllllllllllll

Hu-Friedy, a global leader in the manufacture of dental instruments and products, introduced the new Ortho Lingual Collection, consisting of 10 instruments that feature optimal intraoral access, ideal visibility for the clinician, enhanced comfort for the patient, and more time savings per procedure. The new Ortho Lingual Collection includes cutters, pliers, and lingual ligature directors, designed specifically for patient and clinician ease, comfort and accessibility. Each cutter and pliers feature a distinctive gold plated handle, longer handles that allow for easier access and orbit formed box joints that are 14% to 29% thinner than standard Hu-Friedy orthodontic products. For more information about the Ortho Lingual Collection, call 1-800-HU-FRIEDY or visit

Biocryl Form-X CT radiographic stent material


Biocryl Form-X is a radiographic stent material that allows tooth position communication on CT scan images, simplifies the stent fabrication process, and trims easily and quickly. Form-X is designed for use in a Biostar® or MiniSTAR® positive pressure thermal-forming machine, and adapts to a replica of the diagnostic wax-up model or directly to a composite mock-up. Once thermalformed and trimmed, the appliance is inserted in the patient’s mouth, and a CT scan is taken. The scanned image reveals crisp and distinct outlines, contours, and embrasures to help determine proper implant angle and emergence to conform within the planned prosthesis for optimal restorative outcome. For more information, contact Great Lakes product customer service at 800-828-7626 or visit

The OrthoVend is a fully automated inventory system that is small enough to fit on just about any counter. It can hold up to a years’ worth of inventory and will automatically reorder product once it reaches a pre-designated reorder point and nothing is charged to your account until it is dispensed. The OrthoVend system includes an online inventory management module and free shipping for refill products. The safe, secure storage will eliminate the possibility of ever running out of product, stock shrinkage, waste, and mix-ups. The OrthoVend is also available with fully customizable graphics to match your office décor. For more information, please visit the Ortho Classic website, or call 866-752-0065

ClearCorrect announces treatment options for 2013

VIDAR Dental Film Digitizer

The new Limited 6 covers up to 6 sets of clear aligners (single or dual arch). It also includes a treatment setup, Phase Zero (initial passive aligners), and retainers. The Limited 12 includes up to 12 steps of clear aligners, plus a treatment setup, Phase Zero, and retainers. There’s no fee for revisions, as long as the case stays under 12 total aligners. The Unlimited, is the most flexible and predictable option. The doctor gets as many aligners as needed, until the case is closed, including unlimited revisions for up to 3 years and replacements for any aligner at no extra cost. For more information, call 888-331-3323 or visit www.

56 Orthodontic practice

VIDAR’s Dental Film Digitizer is specifically tailored for dental applications and is the only digitizer that meets U.S. and European guidelines for dental applications. Digital images can now legally replace the original x-ray film. The Dental Film Digitizer is designed to accurately render the full grayscale data with minimal noise throughout the specified grayscale density range, and has a unique ADC (Automatic Digitizer Calibration) feature that ensures excellent grayscale reproduction. For more information, call toll-free: 1-800-471-7226, phone, 1-703-471-7070, fax 1-703-471-7665 or visit

Volume 4 Number 1


Orthodontic Practice US Magazine, the January / February 2013 issue