clinical articles • management advice • practice profiles • technology reviews

July/August 2016 – Vol 7 No 4

PROMOTING EXCELLENCE IN ORTHODONTICS

Airway orthodontics the Facial asymmetries

new paradigm: part 2, Dr. Bradford N. Edgren
a vision for the future
Dr. Barry Raphael

Reframing
orthodontics:
Ortho 3.0
Dr. Rohit C.L. Sachdeva Is your retirement
plan strategy due for
an annual checkup?
Tom Zgainer

Corporate profile
3Shape Digital Orthodontics

Practice profile
Dr. Blair Adams

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1. Fracture Strength of Ceramic Bracket Tie Wings Subjected to Tension Gerald Johnson, DDS;
Mary P. Walker, DDS, PhDb; Katherine Kula, DDS, MSc Angle Orthodontist, Vol 75, No 1, 2005
2. G. Scuzzo, MD, DDS, K. Takemoto, DDS, PHD, Y. Takemoto, DDS, G. Scuzzo, DDS, L. Lombardo, DDS.
“A New Self-Ligating Lingual Bracket with Square Slots”, Journal of Clinical Orthodontics, Volume XLV,
No. 12 (2011): 682 - 683.
3. John. H. Hickham, D. M. (1993). Predictable Indirect Bonding. Journal of Clinical Orthodontics, 215-218. © 2016 Ormco Corporation
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INTRODUCTION

Indirectly speaking July/August 2016 - Volume 7 Number 4

EDITORIAL ADVISORS
Lisa Alvetro, DDS, MSD

I
Daniel Bills, DMD, MS
f you know me, you’ll know that I’m not shy. I say what I think — admittedly sometimes
Robert E. Binder, DMD
too soon — but rarely with regret. I will say that “I’m sorry” has become a key phrase in the
S. Jay Bowman, DMD, MSD
longevity of my marriage. Just keep moving forward.
Stanley Braun, DDS, MME, FACD
That’s why some of you who know me in our world of orthodontics are often surprised Gary P. Brigham, DDS, MSD
that I’m a firm practitioner of digital indirect bonding. George J. Cisneros, DMD, MMSc
“It’s a hassle.” Jason B. Cope, DDS, PhD
“It takes to much chairtime.” Neil Counihan, BDS, CERT Orth
“I never really have gotten the hang of it.” Bradford N. Edgren, DDS, MS
Yes, I’ve heard it all, and yet, I persist. It’s all or nothing when it comes to bonding for me. Eric R. Gheewalla, DMD, BS

“Why?” you ask. Dan Grauer, DDS, Morth, MS

Mark G. Hans, DDS, MSD
The answer is simple. It’s the most precise way I know to position brackets on my
William (Bill) Harrell, Jr, DMD
patients’ teeth. Today’s technology gives me 3D automation that makes it possible for me
John L. Hayes, DMD, MBA
to quickly evaluate and adjust bracket placement. That means that I’m able to simulate
Paul Humber, BDS, LDS RCS, DipMCS
bracket placement digitally prior to placement and get each and every bracket just where I Laurence Jerrold, DDS, JD, ABO
want it on the teeth. Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS,
I just can’t convince myself that placing one bracket at a time is more pleasant for the FFD, FAMS
patients, either. Mine frequently express their surprise at how easy it was. They regard me Marc S. Lemchen, DDS

as an artist — in my mind, anyway. Edward Y. Lin, DDS, MS

Thomas J. Marcel, DDS
You are probably thinking that there has to be a downside. Yes, there is lab work involved
Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth
in preparing the setup, which can take 10 days to get back. You’re thinking that all that kid’s
RCS, DOrth RCS
parents have to do is drive down the street to the next office and get some brackets on their Mark W. McDonough, DMD
kid’s teeth right away. You’ll never see them again. Randall C. Moles, DDS, MS
But that’s not how it works, at least, not for me. Every patient or parent of a patient who Elliott M. Moskowitz, DDS, MSd, CDE
sets foot in your office wants the best treatment possible. The placement accuracy, the Atif Qureshi, BDS
comfort of the process, and the reduced office visits — it’s an easy case to make. (Don’t Rohit C.L. Sachdeva, BDS, M.dentSc

take this personally, but most of my patients would rather be someplace else than in their Gerald S. Samson, DDS
Margherita Santoro, DDS
orthodontist’s office.) To my knowledge, I’ve never lost a patient because I use indirect
Shalin R. Shah, DMD (Abstract Editor)
bonding. Not one.
Lou Shuman, DMD, CAGS
I think perhaps the most powerful aspect for the patient of digital indirect bonding is the
Scott A. Soderquist, DDS, MS
technology. I know it is for me. The simulation software gives me the ability to anticipate
Robert L. Vanarsdall, Jr, DDS
potential interferences before they happen, puts the brackets perfectly where I want them, John Voudouris (Hon) DDS, DOrth, MScD
and still allows for adjustable bracket and tooth positioning. Neil M. Warshawsky, DDS, MS, PC
My suggestion is that you try a digital indirect case or two. I think that both you and your John White, DDS, MSD
patients will be pleased. Larry W. White, DDS, MSD, FACD

CE QUALITY ASSURANCE ADVISORY BOARD

Dr. Alexandra Day BDS, VT
Julian English BA (Hons), editorial director FMC
Dr. Paul Langmaid CBE, BDS, ex chief dental officer to
the Government for Wales
Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-
chief Private Dentistry
Dr. Chris Potts BDS, DGDP (UK), business advisor and
ex-head of Boots Dental, BUPA Dentalcover, Virgin
Dr. Harry Shiers BDS, MSc (implant surgery), MGDS,
MFDS, Harley St referral implant surgeon

Edward Y. Lin, DDS, MS, is a partner of Orthodontic Specialists of Green Bay (OSGB), a private group
practice in Green Bay, Wisconsin. Dr. Lin received both his dental (DDS) and orthodontic (MS) degrees
from Northwestern University Dental School. OSGB is a completely digital practice and has been
utilizing suresmile® for 10 years at three different practice locations. Dr. Lin converted his practice to a
100% suresmile practice in February 2007 and has not looked back. With more than 3,000 suresmile
and suresmile lingual cases completed, OSGB was recognized for Top Case Finishes in 2014.
© FMC 2016. All rights reserved. FMC
is part of the specialist publishing group
Springer Science+Business Media. The
publisher’s written consent must be obtained before any part of this publication
may be reproduced in any form whatsoever, including photocopies and
information retrieval systems. While every care has been taken in the preparation
of this magazine, the publisher cannot be held responsible for the accuracy of
the information printed herein, or in any consequence arising from it. The views
expressed herein are those of the author(s) and not necessarily the opinion of
either Orthodontic Practice US or the publisher.

2 Orthodontic practice Volume 7 Number 4

Practice
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MTM® Clear•Aligner can be used for making cosmetic

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preparing for restorative procedures and/or finishing
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* Proffit, W. (1998). Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey.
International Journal of Adult Orthodontics and Orthognathic Surgery, 13(2), 97-106. **Initial treatment plan and first refinement, if needed.
RTE-004-16 Issued 1/16
TABLE OF CONTENTS
Practice profile
Blair Adams, BSc, DDS
Enjoyable, efficient, effective, excellence
8 Case study
Corporate profile 14
3Shape Digital Orthodontics
Digital solutions for the orthodontic practice
4 Orthodontic practice Volume 7 Number 4
Financial focus
Is your retirement plan strategy
due for an annual checkup?
Tom Zgainer discusses the benefits
of reviewing your 401(k) plan on a
regular basis.....................................18
Early intervention in a case of
severe mandibular retrusion
Drs. German O. Ramirez-Yañez and
Carlos M. Mejia-Gomez discuss
intercepting developing malocclusions
as early as possible to reduce the risk
of more complicated treatments
.......................................................20
Orthodontic concepts
Reframing orthodontics:
Ortho 3.0
Dr. Rohit C.L. Sachdeva discusses the
eight major forces shaping the future
of orthodontics.................................22
The Mastery of Movement
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TABLE OF CONTENTS

Continuing education
Airway orthodontics the
new paradigm: part 2,
a vision for the future
Dr. Barry Raphael discusses how
Continuing education
Facial asymmetries
Dr. Bradford N. Edgren discusses the importance of diagnosis and treatment
28
added exercise protocols can help
of facial asymmetries
correct common problems related
to facial and oral function..................35

Abstracts
Abstracts Product profile
• Accuracy and reliability of Dolphin 3M — A system of PUBLISHER | Lisa Moler
3D voxel-based superimposition proven products Email: lmoler@medmarkaz.com

• Screw-type device diameter and
orthodontic loading influence
adjacent bone remodeling
• The effects of corticotomies on
frontonasal suture expansion and
A beautiful smile throughout treatment
....................................................... 46
Product profile
GENERAL MANAGER | Alan Lobock
Email: alobock@medmarkaz.com
EDITOR IN CHIEF | Mali Schantz-Feld, MA
Email: mali@medmarkaz.com | Tel: (727) 515-5118
MANAGING EDITOR | Lou Shuman, DMD, CAGS
Email: lou@medmarkaz.com

bone modeling in mature rabbits Avex® CX2 brackets by ASSISTANT EDITOR | Elizabeth Romanek
....................................................... 40 Opal® Orthodontics Email: betty@medmarkaz.com

....................................................... 48 NATIONAL ACCOUNT MANAGER | Adrienne Good

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Step-by-step CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver

Scanning with CEREC Ortho Materials & Email: amanda@medmarkaz.com

for clear aligner treatment equipment.........................50 WEBSITE MANAGER | Anne Watson-Barber

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Dr. Peter Gardell outlines the steps in a E-MEDIA PROJECT COORDINATOR | Michelle Kang
process for taking digital impressions Email: michellekang@medmarkaz.com

for use with clear aligners................ 42 Industry news................52 FRONT OFFICE MANAGER | Theresa Jones
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6 Orthodontic practice Volume 7 Number 4

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PRACTICE PROFILE

Blair Adams, BSc, DDS

Enjoyable, efficient,
effective, excellence

What can you tell us about your

background?
I have a busy, single-doctor orthodontic
practice in the eastern suburbs of Ottawa,
Canada, a mere 5 miles from where I grew
up as a child. When I was young, I was
always fascinated by science. I read biog-
raphies of great scientists such as Newton,
Galileo, Einstein, and da Vinci, and I used
my chemistry set to create large smells and
small explosions.
In grade school, my best friend’s father
was a periodontist. He encouraged us to
consider dentistry as a career, so that option
was always somewhere in the background of
my career planning. Also, my high school ski-
racing coach was a dental student. When he
told me, “Hey Blair, you know, dentists take
Fridays off to go skiing,” that was enough for
me! Done deal; sold to the highest bidder!
It may seem a frivolous way
to have chosen a career,
but these personal consid-
erations are often the points
on which destiny turns.
After doing an honors
BSc in Biochemistry at
Dr. Blair Adams
Ottawa’s Carleton Univer-
sity, I found myself in dental
school at Western University I had received a letter image of her new baby! We’re going to be
in London, Ontario. (Sadly, accepting me to the Grad- grandparents!
no skiing to be had there!) uate Orthodontic Program at We had a wonderful time in Boston. Dr.
In dental school the course Tufts University, 3,000 miles Everett Shapiro, head of the Tufts Ortho-
that interested me was orthodontics. Much away, in Boston. And Joselyn had been given dontics Department, was loved and
of my free time was spent observing things the wonderful news that she was pregnant! respected by all and ran a very happy
at the Orthodontic Graduate Department. We were stunned! We went out to a nice program. Joselyn was not eligible for a
But a larger part of my free time was restaurant and just sat there in shock! What work visa, so she spent her time learning
spent with a wonderful girl named Joselyn. to do? Reluctantly, we sold the cute little early childhood education — Boston has so
The day after my dental school graduation, house we really loved and moved to Boston. many great resources for that.
Joselyn and I were married in Oakville, her Boston was a big surprise. We didn’t My message to young people having
hometown just outside of Toronto. know much about it, so we didn’t know what children — get Burton White’s book, The
For our honeymoon, we spent 2 weeks to expect. First Three Years of Life.
driving to Vancouver, where I worked as a Boston is a wonderful city with so much At the end of each chapter, there’s a
general practice dentist and Joselyn, a kine- culture and history, and the people are so cheat sheet for fathers. I found it extremely
siology grad, worked in the Vancouver fitness nice. We loved it! helpful.
industry. We spent as much time as possible I started the Ortho grad program at The spring before I graduated, we had
skiing at Whistler. (Are you starting to notice Tufts in August. In October, our wonderful so much rain in Boston that we decided not
a theme here?) baby, Nicola, was born. Nicola is our only to go back to Vancouver. Some people feel
Two years later, just after we had bought and most favorite child. She is now a it rains excessively in Vancouver. Instead, we
our first home, each of us arrived home with third-grade teacher. As I am writing this, chose to go to my home town, Ottawa, so
some big news. Nicola has just sent me the ultrasound we could be closer to Nicola’s grandparents.

8 Orthodontic practice Volume 7 Number 4


Orthodontics is an immensely rewarding
career. It involves the right brain and the left
brain. Smile design is art and architecture.
Creating harmonious occlusion is the science
of applied biophysics, an engineering project
in miniature.
Spiritually, as the Buddha advised, it
is “Right Occupation.” We help people to
get what they want, and we spread the
joy of smiles around the world. Our love of
our profession and the patients we serve
encourages us to continuously pursue the
path of mastery. The joy of watching our
young patients grow in confidence as we
sculpt their beautiful new smiles is truly
heartwarming.
What do you think is unique about
your practice?
Digital diagnostics — we are the only
Ottawa orthodontic practice using computer-
scanning technology to straighten the teeth
“in the computer world” before we put on
the braces. Image-guided orthodontics,
combined with 3D treatment planning, is like
the GPS in your car. It allows me to predict
and avoid potential pitfalls that could occur
in treatment. We achieve our treatment goals
more directly and quickly, with less stress
and more comfort.
What systems do you use?
Let me start by answering this at the macro
level. I am a firm believer in “systems-based”
thinking. When systems are implemented in
any process, the power of teamwork is ampli-
fied to produce superior patient care that is
consistent and patient-centric.
Now, at the micro level, if we are thinking
of systems of “orthodontic therapeutic
devices,” I use self-ligating .022 brackets.
I’ve been using these exclusively in my prac-
tice for the last 10 to 12 years.
In about 70% of patients, I use active
clip brackets like the DENTSPLY GAC In-
Ovation®, American Orthodontics Empower®,
and Ormco Nexus™. I like the way the active
clip controls rotations and allows me to
correct torque.
We use passive self-ligation such as the
Ortho Classic H4™ and Ormco’s Damon®
brackets in about 30% of our cases. The
low-friction mechanics and early use of
light elastics allow me to achieve beautiful
non-extraction, nonsurgical treatment no
one would have dreamed of 20 years ago.
We also use these techniques in our Phase
I cases to create amazing, beautiful non-
extraction changes for 7- to 9-year-olds.
Volume 7 Number 4 Orthodontic practice 9
As a side note, I am beta testing an
entirely new self-ligating bracket and archwire
system developed by Dr. Rohit Sachdeva,
and I hope to present the results shortly.
What training have you undertaken?
I am a committed lifelong learner. Also,
I encourage the ethos of a learning organi-
zation in my team. I am an ardent believer
and practitioner of reflective learning as well.
As recently shared with me by Dr. Rohit
Sachdeva, this zest for learning is best
described in the words of Ryan Hoover —
“It’s the wanting that makes you a learner.
That’s what absorbs you. That’s what makes
you lose track of time, overcome fear, build
grit, knowledge, and grow. Learning happens
when you are not aware of it. It’s the wanting
that makes you a mother, an inventor, a
friend, a learner. When you look back at
yourself 6 months from today and don’t
Adams Orthodontics in Ottawa, Canada
PRACTICE PROFILE
feel embarrassed by your naiveté, there’s a
problem. That means you’re not learning,
growing …” Any learning that make me a
better person or a better doctor allows me to
make a difference in my patients’ lives. Their
orthodontic care experience is improved.
That will always be worth my investment in
time and effort.
I love to visit an excellent clinician who
gives a course in his/her own office for a few
days. When you can spend time in someone
else’s own environment and hangout in the
evening having informal, far-ranging discus-
sions long into the night, that’s when the
real learning takes place. That is the way I
learned the Herbst techniques of Dr. Terry
Dischinger, which have been indispensable
for many years. This allowed me to dispense
with using the “headgear,” something that
always gets a huge vote of appreciation from
patients and their parents.
Dr. Bill Arnett’s in-office surgery course
is one of the best courses I’ve ever taken.
I persuaded our own surgeon, Ottawa’s Dr.
Kevin Butterfield, to take this course, and
now, together, we produce beautiful, stable
results for our patients with more severe
problems that can only be dealt with by
combining orthodontics with facial surgery.
I am also trained to provide care for those
suffering from sleep apnea.
Who has inspired you?
Recently, we were in Toronto, listening
to a speaker talk about gratitude. We have
so much to be thankful for. We get caught
up in our daily lives and rarely take time to
appreciate what we have.
At the same time in Toronto, we were
watching the unfolding tragedy of the burning
of Fort McMurray.
PRACTICE PROFILE
We were inspired to be thankful for the
wonderful neighbors we have, the depend-
able team we work with, and the people we
serve and care for on a daily basis. We were
inspired to be grateful for having clean water
and a place to sleep. Not everyone has that.
It’s not automatic. Creating beautiful smiles
is a favorite conversation topic with our
patients and their parents. The techniques
I’ve learned from Drs. Tom Pitts and Duncan
Brown in their Masters Continuum course
have made differences that people really
notice. They love the results.
Dr. Rohit Sachdeva is my coach. If Wayne
Gretzky could benefit from
having a coach, I believe
every high-level profes-
sional can benefit from
having a coach. Over
time, daily routines can
lead to complacency and
overconfidence. Rohit’s
insightful perspectives on
life in general and ortho-
dontics in particular have
awakened my awareness
of new horizons in patient
care and practice manage-
ment. Our intensive, weekly, Adams Orthodontics staff
2- to 3-hour Skype sessions
dissect every facet of patient care in my
practice.
Rohit has shown that solutions to the
most complex problems can be found by
investing time in proactive planning. The key
lies in reduction of complex interactions to
the fundamentals of applied biomechanics.
Rohit fondly calls this the “pre-mortem.” I
truly believe he has awakened hidden talents
within me.
What is the most satisfying aspect
of your practice?
Watching our patients grow up and go
out into the world armed with one of the best
success tools you can give someone — a
beautiful smile. We know many of them from
age 7 to 17. It’s wonderful.
And then 10 or 15 years later, they’re
back with their own little 7-year old. The circle
of life.
Pretty cool, n’est ce pas?
Professionally, what are you most
proud of?
Adams Orthodontics is a team of skilled
professionals dedicated to “Patient First”
care, guided by the principles of servant
leadership. We are known for providing
empathetic care and designing personalized
10 Orthodontic practice Volume 7 Number 4
We made custom mouth guards for this patient’s hockey team.
His father told me that, as a result, the players could commu-
nicate more clearly as they were playing. He felt this played
a significant part in helping them to win their division for the
season
smiles for our patients by using the best of
the newest in image-guided orthodontic
technology. Last year, we won both the
Consumer’s Choice award and Faces
Magazine Award for best orthodontic office
in Ottawa and surrounding area.
It just wouldn’t be possible to do this
without our team. They are truly indispensable.
Eleven years ago, we built a beautiful
5,000-square-foot orthodontic care center,
expressly designed to have a homelike atmo-
sphere. We spend a large proportion of our
time there, and we wanted our patients and
their families to feel as though they have been
invited into our home.
I am truly blessed to have this great team
creating gorgeous smiles with me in such a
beautiful environment.
What has been your biggest
challenge?
Like most orthodontists, I’m sure, our
biggest challenge is assembling an outstand-
ingly talented team. Training and retaining
wonderful people who can routinely deliver
memorable patient care experiences is a
constant, daily project. Everyone has indi-
vidual strengths and weaknesses. Nurturing
the strengths and finding others to fill in for
the weaknesses can be like conducting a
symphony orchestra.
What would you have become if
you had not become a dentist?
Architect or engineer. My parents’ worst
nightmare was ski bum!
What is the future of orthodontics
and dentistry?
There have always been and always will
be issues that raise concerns with regard to
the integrity of dentistry as a whole and the
safety of the public. As the French say, the
more things change, the more they stay the
same. Personal integrity, mastery of clinical
skills, and systems that provide service
excellence are the keys to success and
fulfillment in any field. Focus on the pursuit
of excellence.
We strive to provide “An Experience of
Enjoyable, Efficient, Effective, Excellence.”
There will always be clients who seek out
and appreciate this level of service. There
will always be those who seek the best in
esthetic results and long-term healthy func-
tion. These are the people we want to serve.
This is what makes us feel good at the end
of the day.
Research into why people don’t
adequately plan for their retirement dis-
covered that many people have a “discon-
nect” between their “present selves” and
their “future selves.” Subjects who were
shown an image of themselves that had been
aged to look as they would far in the future
consistently increased the amount of money
they intended to save for their retirement. The
researchers concluded that subjects who
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MANY OPTIONS & CHOICES

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PRACTICE PROFILE
felt more “connected” to their “future selves”
demonstrated more responsible behavior.
Achievement of beautiful, healthy ortho-
dontic results requires the full participation
of a committed, educated patient who has
a supportive, helpful family. Orthodontics is a
Top 10 favorites
1. My brilliant, beautiful wife and
daughter and Quito our 6-year-old
Sheltie.
2. Skiing in deep snow. My daughter
tells me I’m a snow snob.
3. Continuing education. I love
learning new techniques I can use
to create better smiles.
4. Hiking up a mountain or cycling
down a mountain on a beautiful,
sunny, cool day.
5. Spending time with brilliant thinkers.
Learning from the best in my
profession has given me a network
of deep friendships that brings fulfill-
ment and support.
6. Music — rock, classical, folk, jazz,
country. Good music stirs the soul.
7. Photography — never leave the
house without a camera!
8. Reading. Thirty minutes with a great
book at the end of the day takes me
to a different world.
9. Mont Tremblant any time of year
except the month of May — bug
season!
10. That beautiful smile on the faces of
our patients and their parents when
the braces come off. It’s fun to get
braces, but it’s way more fun to get
‘em off.
ESLO dinner at Lake Como. (left to right) Dr. Ron Roncone, his wife, Elizabeth; Dr. Blair
Adams,his wife, Joselyn; Dr. Bren Bankhead, and his wife
12 Orthodontic practice Volume 7 Number 4
team sport. There will always be those who
don’t plan for the future and merely wish to
avoid pain and expense in the here and now.
These are not people we can count on to be
part of the team. There is a place in the world
for “emergency dentistry.” There is no “emer-
gency orthodontics.” (Except for crossbites
and associated cr-co shifts that are causing
gingival destruction.)
What are your top tips for main-
taining a successful practice?
• Let your patients and their families
know that you and your team are
there for them.
• Do “whatever it takes” to provide a
first-class experience and first-class
results.
• Keep your facility up-to-date. Provide
a warm, welcoming environment for
your patients, their families, and your
team.
• Train, train, train. Help your team
learn to provide a consistently excel-
lent customer service experience.
Read the book The E-Myth Physi-
cian by Michael E. Gerber.
• Stay current on the “best of the
newest” in orthodontic techniques
and technology.
• When hiring staff, hire for “nice.” You
can train people to make appoint-
ments and bend wires. You can’t
train people to be nice. People are
“born nice.”
Joselyn and daughter Nicola and Dr. Adams. Nicola sings with the Ottawa Bach Choir, a
world-class choir. We were in Italy for the European Society of Lingual Orthodontics meeting
What advice would you give to
budding orthodontists?
When I told my family dentist that I had
been accepted into dental school, he told
me — “Don’t make patients of your friends.
Make friends of your patients. Get to know
them and their families.”
You won’t be busy from Day One. Go out
and meet every single dentist within 10 miles.
Find out what kind of dentistry they want
their patients to have, and how they want
their patients to be treated.
Communicate on a regular basis with
all dentists who trust you to care for their
patients. They are the contractors; we are the
sub-contractors. They need to know what’s
happening.
Take photos of every patient at every
visit. Get into this habit before you get busy. It
will save you years of chairtime. When things
go off track — and they will — these photos
will tell you when it happened, and how to
prevent it from happening again. Experience
is the ability to recognize a mistake when you
make it again. We all make mistakes. Get
over it, and learn from them.
You can’t provide excellent customer
service without learning to manage a
business.
Dr. Ron Roncone’s JSOP Orthodontic
Management course is the best there is.
Take it.
Dr. David Sarver’s facial esthetics course
is the best. It doesn’t happen often. Grab it!
Invest in a clinical coach to sharpen your
focus on the pursuit of excellence. I have
found Dr. Rohit Sachdeva to be one of a rare
breed. He has transformed my approach to
orthodontics and my perspective on life.
What are your hobbies, and what
do you do in your spare time?
Spare time? What’s that?
See favorites list. OP
SMPP587Rev062116
CORPORATE PROFILE

3Shape Digital Orthodontics

Digital solutions for the orthodontic practice

O rthodontics is racing into the digital era

faster than most anticipated. Industry
professionals agree that the trend will only
accelerate.
There are many reasons. The clinical
and patient benefits of going digital have
become so well documented that the only
reason not to use the technology is lack of
resources, which is understandable. But for
orthodontists and orthodontic labs alike, ROI
studies and testimonials from colleagues
and patients should help offset financial
concerns.
When Italian orthodontist, Dr. Santiago
Isaza Penco, discussed CAD/CAM’s impact
on his practice, he summed it up: “Now
anything is possible!”

Creating the digital patient

Digital technology provides doctors and
labs with a unique, all-encompassing, and
predictive view of their patients. In essence,
you now create the digital patient.
Using software like 3Shape Ortho
Analyzer™, orthodontists and lab techni-
cians can merge CT/CBCT data, intraoral
scans, X-ray panoramics, cephalometric
tracings, and photos with digital models.
Enabling professionals to take what were
once separate steps in the workflow and
melt them into a more comprehensive single
step and process: digital patient analysis,
treatment planning and monitoring, and
orthodontic appliance production — are all
achieved onscreen.
Choose treatments like Invisalign®
with just a click
And because you are now working digi-
tally, your team shares treatment analysis,
planning, monitoring, and even appliance-
production effortlessly between the lab,
orthodontist, and when relevant, the patient.
For example, doctors using TRIOS®
who choose an Invisalign treatment for their
patients can simply just pick Invisalign from
the drop-down menu list of orthodontic solu-
tion providers in TRIOS’ software and click
to send the case. This is synergy driven by
digital technology that makes the entire ortho-
dontic workflow more efficient and more
TRIOS Battery-Powered Cart model
effective. TRIOS case submissions to Invis-
align will be available from Q4 2016.
Digital improves your workflow
When discussing the clinic-to-lab work-
flow benefits of going digital, the aforemen-
tioned Dr. Penco says, “Communication
between a lab and orthodontist is very,
very important. In Italy, labs must build all
orthodontic appliances, so the cooperation
between the two is extremely important. In
the old days, our lab partner would come
to my office every 2 days from hundreds of
miles away to pick up and check models
and design appliances. Now this is no
longer necessary — everything is done in
real time, digitally.  discovered, if I switch off the lights, the chil-
“Just 2 years ago, we were still sending
traditional impressions. It would take 3 to 4
weeks to have the appliance designed and
shipped back. Now it only takes 2 to 3 days
for a retainer. This is a tremendous change!”
Digital promotes patient buy-in
Achieving patient buy-in is obviously
important to any orthodontic practice. But
an interesting and rarely discussed benefit of
using digital technology is its impact on young
people: an orthodontist’s biggest customer.
As Dr. Penco points out, “The majority of
my patients are young people, which is great
because they are also the best for marketing
our work. They go on our Facebook page or
website and watch the videos. They want to
see our intraoral scanner (3Shape TRIOS)
because they have seen videos about it.
“With children, it has always been diffi-
cult to take traditional impressions. Having
TRIOS has made it much easier. I also
dren watch the screen when I scan. It’s a
show. We both can relax and take our time.
Like adults, it is important for children to see
everything. In that way, they are convinced
about the treatment from the start.”

14 Orthodontic practice Volume 7 Number 4


Brazilian orthodontist, Dr. Carlo Marassi,
elaborates: “Digital orthodontics makes it
easier for us to communicate with patients.
It’s great to have a 3D image of the patient’s
occlusal situation and to show this to the
patient during clinical examinations. Showing
the 3D model makes it much easier to
describe problems and treatments because
most people do not know what occlusion
means or have never even seen their own
posterior teeth.
“Patients don’t know what a crossbite,
or other orthodontic problems, look like.  the reason they accept it is because of digital
When you can show the patient a 3D image,
including occlusion already from the first visit,
it helps their understanding of the problem
and its treatment options. This understanding
also helps motivate them towards taking the
next step in treatment.”
Italy’s Dr. Penco agrees: “Patient compli-
ance is very important in orthodontics
and medicine, in general. When you are
convinced that you need an orthodontic
treatment, you cooperate. But you need
tools to explain the treatment with. That’s
where the TRIOS intraoral scans are invalu-
able. They make it easy. When your patient
understands what you can do to solve the
problem, they cooperate. Communication is
key. In fact, with the scans and software, I
can simulate my proposed treatment. I can
TRIOS Pod model
Volume 7 Number 4 Orthodontic practice 15
even bring the parents in during diagnosis,
show the scans, and describe the treatment.
Patients believe that because I am using new
technology when I demonstrate the treat-
ment, I will deliver better results. When the
patient understands where we can put the
tooth to achieve the best results, it becomes
very important information for them. It makes
the patient’s decision easier and the whole
process go faster. They can go home and
make a decision based on knowing what
the treatment will entail. They accept it. And
scans and treatment simulation.”
Young people are digital by nature; it
make sense to involve them digitally in their
treatment.
TRIOS® digital color impressions
The tagline — making a great first impres-
sion — may apply to orthodontics more than
any other branch in dentistry.
There are numerous benefits to using
intraoral scans within orthodontics. The
Austin Journal of Orthopedics & Rheuma-
tology recently listed what it considered the
advantages were in an article, “Intra-oral
Scanners: A New Eye in Dentistry.”
For the orthodontist, advantages of
digital scanning include improved diagnosis
and treatment planning, increased case
CORPORATE PROFILE
acceptance, faster records submission to
laboratories and insurance providers, fewer
retakes, reduced chair time, standardiza-
tion of office procedures, reduced storage
requirements, faster laboratory return,
improved appliance accuracy, enhanced
workflow, lower inventory expense, and
reduced treatment times.
Benefits to the patient include an
improved case presentation and a better
orthodontic experience with more comfort
and less anxiety, reduced chair time, and
easier re-fabrication of lost or broken appli-
ances, as well as potentially reduced treat-
ment time.
The advantages of intraoral scanning are
exactly what make 3Shape’s TRIOS intra-
oral scanner your right choice too. TRIOS
separates itself from the pack because
of the award-winning intraoral scanner’s
documented accuracy, speed, RealColor™
digital color impressions, automatic occlu-
sion capture in real time, and never a need
for powder.
Plus TRIOS and 3Shape Orthodontics
continue to create more and more inte-
grations with global orthodontic solution
providers like Invisalign®, Incognito, and
many more, making it easy for orthodontists
and GPs to pick and choose the right treat-
ment for their patients from TRIOS’ long list
of partner integrations. And because the inte-
grations are cloud-based, doctors can share
cases with solution providers and TRIOS®
Ready labs with just a click from within the
TRIOS software.
Digital model production
The practice of digital model-making is
surging forward as better digital impression
systems, new CAD software, and improved
manufacturing technologies create digital
model-making solutions at lower costs with
higher accuracy and increased efficiency.
For orthodontic labs, providing digital
model-making as well as digital archiving
services have now become revenue genera-
tors. As orthodontists are required by law to
keep models of their patients, digital models
provide them with a regulatory compliant,
space, and cost-saving alternative to storing
gypsum models.
Dr. Carlo Marassi discusses what digital
model-making has meant to his practice,
“I have been practicing orthodontics for
more than 20 years now, and by law, we
have to keep our case records for 10 years.
We rent another office just to store all our
gypsum models. 3Shape technology is now
enabling us to digitize all our models and
CORPORATE PROFILE
close our special storage rooms. This will
save us money, not to mention the time and
manpower it takes to maintain a physical
storage system.”
He adds, “Gypsum models are typically
fragile and can break, and then you simply
lose the case information. This can’t happen
with digital models. Naturally, we back up our
digital archives like any critical IT system.  But
the option to create digital models makes
the whole matter of archiving cases cheaper,
more efficient, and more robust.”
3Shape orthodontic solutions enable you
to create digital study models from alginate
impressions and plaster models as well as
digital intraoral scans.
CAD-designed digital appliances
CAD-designed orthodontic appliances
are nothing new. Global orthodontic solution
providers use state-of-the art digital tech-
nology to create treatment solutions on an
assembly line scale. Up until recently, that
amount of programming power and connec-
tivity was unavailable to ordinary orthodontic
labs — at least not at an affordable price.
The development of our Ortho Analyzer™
and Appliance Designer™ solutions have
made analysis, treatment planning and appli-
ance design simpler, repeatable, faster, and
affordable for smaller labs.
Orthodontic labs using CAD/CAM soft-
ware like Appliance Designer can now design
and manufacture with the same accuracy
and efficiency as the global orthodontic
solution providers. From clear aligners, night
guards, and retainers to splints, Herbst appli-
ances, and more, labs can essentially design
any type of orthodontic appliance.
Depending on their CAM equipment,
they can manufacture the appliance them-
selves or outsource the production. This cuts
delivery time down from weeks to days and
hours. And it makes it possible for smaller
orthodontic labs to offer competitive services
to global orthodontic solution providers.
Throw into the mix new generation 3D
printers that make it affordable to print 3D
models as well as fabricate orthodontic appli-
ances, including retainers, metal appliances,
aligner technology, and indirect bonding, and
it makes CAD/CAM an indispensable asset
for orthodontic labs.
“Digital being better would be
stating the obvious”
According to Australian orthodontic lab
owner, Ari Sciacca, “CAD/CAM has enabled
my lab to do things virtually and streamline
and/or eliminate laborious processes like
16 Orthodontic practice Volume 7 Number 4
Digital technology provides doctors and
labs with a unique, all-encompassing, and
predictive view of their patients. In essence,
you now create the digital patient.
duplicating models, cutting out teeth, and
doing them in wax.” He adds, “Digital being
better would be stating the obvious.”
Italian Orthodontic Laboratory, Team
Orthodonzia Estense’s owner, Stafano
Negrini agrees, saying, “CAD/CAM has
enabled us to compete against bigger
labs. We can provide everything from
digital study models, digital archiving, to
planning and manufacturing. And we can
do it quickly. Going digital means that the
work we do is now virtual. We can edit,
save, share, and even remake a patient’s
appliance with just a click. It’s a much more
effective way to work.”
Digital treatment monitoring
Perhaps no other area in orthodontics
benefits more through digital technology than
patient treatment monitoring. Intraoral scans
can be compared side-by-side to precisely
monitor and document tooth movement, the
oral situation, and the treatment plan.
Digital technology also enables ortho-
dontists and labs to virtually debond brackets
and compare the current patient situation
with their treatment plan. Because of this,
more and more orthodontists and labs are
using 3Shape orthodontic software to digi-
tally remove and place brackets on virtual
models to save their patients visits and to
better ensure that treatment plans stay on
the right track.
Doctors and labs can simulate ortho-
dontic treatments like extractions, inter-
proximal reductions, the constraints, and
full details of tooth movement digitally. If you
combine this with using virtual articulators to
optimize occlusion in real time, the benefits
of digital technology are just too powerful an
opportunity for professionals to ignore.
Digital technology has changed the way
we live. Orthodontics maybe its greatest
benefactor. While not practicing in the ortho-
dontic branch, leading prosthodontist and
3Shape-user, Dr. Jonathan L. Ferencz, sums
up the digital advantage best: “My patients
get it. My staff gets it. I get it. Go digital!”
Orthodontic solutions for practices
TRIOS® digital color impression solution
TRIOS® intraoral scanner features Real-
Color™ intraoral photographs to enable
orthodontists to create high-quality digital
impressions in lifelike colors as well as
capture the bite automatically in real time.
TRIOS’ speed and accuracy helps ortho-
dontists to save time, see more patients, and
digitally archive cases to save storage space.
TRIOS is integrated with many leading ortho-
dontic solution providers like Invisalign®. The
easy-to-use digital color impression solution
features a removable autoclavable tip and
comes in a pen grip design, handle grip, and
chair-integrated versions.
3Shape orthodontic treatment planning
and analysis software enables orthodontists
to integrate all patient data, including IO and
CBCT scans, to improve diagnostics, patient
comfort, and treatment acceptance
Orthodontic solutions for labs
3Shape orthodontic treatment analysis
and planning and appliance-design soft-
ware help labs to attract new customers and
expand the services they offer. Coupled with
3Shape’s complete range of lab scanners,
orthodontic labs can now create and archive
digital study models as well as digitally plan
treatment and design and manufacture orth-
odontic appliances.
3Shape orthodontic lab scanners
3Shape delivers a full range of ortho-
dontic lab scanners from the industry’s most
powerful, R2000 all-in-one scanner with
simultaneous two-model scanning, to the
entry-level R500. All 3Shape lab scanners
are ISO-documented accurate and provide
industry-leading speed. Importantly, lab
scanners are the perfect tool for digitizing
orthodontic gypsum study models. For
example, this enables labs to lease their lab
scanners to orthodontic practices for digi-
tizing models. OP
This information was provided by 3Shape.
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FINANCIAL FOCUS
Is your retirement plan
strategy due for an
annual checkup?
Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis
R egular maintenance regarding our
health, be it a twice a year teeth cleaning
or an annual physical, allows the experts to
determine if we are as fit as we think we are,
or see if there might be some issues under
the hood that need attention. Likewise,
each April, we are reminded of whether our
tax planning is sufficient or perhaps needs
a tuneup. Similarly, your retirement plan
strategy is worth reviewing with a pension
plan expert as well.
Often the original plan and strategy you
implemented get away from your intended
individual and corporate goals. Your
employee populace may experience turn-
over, the actual age demographics of your
staff may take on a different makeup, and
by the way, you are now a year closer to
retirement. You can find these changes limit
your personal contributions due to required
employer contributions or, more positively,
open up new opportunities to design a plan
that accelerates your personal contributions.
Retirement plans — whether a 401(k),
profit-sharing plan, a defined benefit, or
Tom Zgainer is CEO of America’s Best 401(k).
He has helped over 2,800 businesses obtain
a new or improved retirement plan over the
past 13 years with a focus on strategic plan
design to help achieve individual and corporate
objectives. You can learn more at www.
americasbest401k.com.
18 Orthodontic practice Volume 7 Number 4
a cash balance plan — all require some
give-and-take. For owners, principals, key
associates, or partners to take advantage
of the opportunity to maximize annual contri-
butions, you’ll need to give a proportional
amount that passes all the required compli-
ance tests to eligible employees.
These employer contributions at first
might not be palatable to you and your
bottom line. However, utilizing a long vesting
schedule — for example up to 6 years — can
help ensure an employee needs to stay and
contribute to your practice that long to earn
any 1 year’s contribution. Plus, you receive
the tax deduction benefit of the full amount
of employer contributions in the tax year of
the contribution, up to 25% of gross payroll.
A great reason to go through an annual
plan design checkup is to see if there is a
better plan type option for you. As you get
closer to retirement, generally over age 45,
plan types, such as a new comparability
profit-sharing plan, a cash balance or defined
benefit plan, can be paired with a 401(k) to
rapidly accelerate your personal contribution
objectives.
For 2016, you can defer $18,000 into a
401(k) plan, with a $6,000 catch-up provi-
sion if over age 50. That’s generally the best
first thing to try and accomplish. If your plan
Receive your retirement plan checkup here: http://americasbest401k.com/medmark.
demographics are suitable, meaning staff is
younger than the owners, principals, or part-
ners (HCEs), and you are over age 45, a new
comparability profit-sharing plan can provide a
maximum benefit for a select employee group,
while providing the lowest possible contribu-
tion to non-key groups allowed by law. This
plan design can help you add to your deferrals
and get up to the $53,000/$59,000 maximum
annual limits from combined employee and
employer contributions.
To really accelerate your contribu-
tions, consider looking into adding a cash
balance or defined benefit plan to the 401(k).
Maximum contributions for these plans range
from $102,000 at age 45 to $237,000 at age
62. When added to the 401(k)/profit-sharing
contributions, it’s like squeezing 20 years of
retirement saving into 10, not to mention the
significant reduction to your tax liability that
you will enjoy.
Just as you might make an appoint-
ment with your physician or CPA, this is a
great time of year to get a retirement plan
checkup as well. It’s easy and painless, as a
census with your current firm demographics
will enable a experienced pension specialist
or actuary help determine if there is a better
way to proceed into the years ahead for your
retirement planning. OP
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CASE STUDY

Early intervention in a case of severe

mandibular retrusion

Drs. German O. Ramirez-Yañez and Carlos M. Mejia-Gomez discuss intercepting developing malocclusions
as early as possible to reduce the risk of more complicated treatments

Abstract
A clinical case is presented showing a
non-syndromic child born with a severely
retruded mandible and deep bite. An early
intervention permitted improvement of the
sagittal and vertical relationships between
both maxillaries before the patient enters
into the mixed dentition. This clinical case
supports the idea that developing maloc-
clusions in children should be intercepted as
early as possible in order to reduce the risk Figures 1A-1E
of more complicated treatments in the future,
as well as preventing other problems that
can associate with a deviated or diminished
craniofacial growth and development.

Introduction
At birth, the mandible is positioned
distal to the maxilla in a sagittal relation.1
The mandible presents a high growing rate
over the first year of life,2 improving the
sagittal, transverse, and vertical relationships
between both maxillaries.3,4 Some children
are born with a severely retruded mandible,
which makes their face appear as if they had
Pierre Robin syndrome but without the cleft
palate and glossoptosis characteristic of that
congenital malformation.
The higher potential for mandibular
and maxillary growth has been reported
to happen over the first 5 years of life.2,5
Even more, a distocclusion at the primary
dentition is going to perpetuate or even
worsen through the mixed dentition.6,7
Also, a retruded mandible is associated
with a retrusive tongue position.8,9 A child
with those conditions is at higher risk of
developing sleep-related breathing dis-
orders,10 and therefore, an early intervention
in a child with a retruded mandible may be
German O. Ramirez-Yañez, DDS, Pedo Cert, MDSc, MSc, PhD,
is an adjunct professor at the College of Dentistry, University of
Manitoba, and is in private practice in Aurora, Ontario, Canada.
Carlos M. Mejia-Gomez, DDS, Ortho Cert, is the chairman of
the Craniofacial Abnormalities Unit for the Fundacion Abrazar in
Colombia.
Figures 2A-2B
beneficial, as it may reduce the severity of
the problem and its detrimental effects on
the oral functions.6,11
This paper reports a clinical case of a
non-syndromic child born with a severely
retruded mandible and deep bite. An early
intervention permitted improvement of the
sagittal and vertical relationships between
both maxillaries before the patient enters into
the mixed dentition.
Case report
The patient was initially seen at 10 months
old since the mother was concerned that he
had a small mandible with no chin and was
sleeping with the mouth open and breathing
noisily. The medical history was not relevant,
and he was naturally delivered with no compli-
cations. The patient was receiving respiratory
therapy. Breastfeeding happened over the first
4 months, and then the mother gave up as
she did not produce enough milk. She had
been feeding him with formula since then.
The first clinical exam revealed a distal
position of the mandible (8 mm), associated
with deep bite (OB 100%). The patient had
hyperactivity of the mentalis muscles at swal-
lowing and lips unsealed at rest. The initial
position of the mandible and the dental occlu-
sion are shown in Figures 1A, 2A, and 3A. At
this age, myofunctional therapy was initiated
in order to stimulate lip seal. The mother was
advised to exercise this area by maintaining
the lips together with her fingers for 5 minutes
for 3 to 5 times per day. That exercise was
practiced over a 3-month period. At 14
months old, the patient was maintaining a
lip seal most of the time (Figure 1B).
After maintaining lip seal, the mother was
instructed to add other exercises, such as
massage on the tongue to stimulate an ante-
rior movement of the tongue and massage
on the incisive papilla and mandibular trac-
tion with her fingers, bringing the mandible
forward. These exercises were also recom-
mended 3 to 5 times per day. Besides that,

20 Orthodontic practice Volume 7 Number 4


the mother was instructed to slowly harden
the diet by progressively introducing food
with fiber, such as carrots, crackers, and
meats, into his diet.
At 36 months old, the patient showed
some improvement in the sagittal relationship
between the maxillaries and the profile (Figure
1C). Another exercise was introduced at this
stage. The mother was instructed to place a
piece of paper on the side of his mouth and
ask the child to bite toward that side.
The Planas Direct Tracks (PDTs) were
built up when the patient was 42 months
old. They were built up on the first primary
molars as described by Ramirez-Yañez for
disto-occlusion.12 The patient was followed
up over the next 12 months, adjusting
the PDTs in order to stimulate a forward
displacement of the mandible. The overjet
and overbite were within normal limits at
48 months old (Figure 2B). Since then, the
patient has been wearing a functional remov-
able appliance, the Indirect Planas Tracks,
as a retainer waiting for the eruption of the
first permanent molars. The patient was
instructed to wear the latest appliance 24
hours per day, removing it only for eating. At
5 years old, the patient is showing a normal
sagittal, transverse, and vertical relationship
for his age (Figure 2B). Also, his profile has
improved with the treatment (Figures 1A-1D
and Figures 3A-3B).
Discussion
A disto-occlusion diagnosed in the
primary dentition does not improve with
natural growth. A longitudinal study reported
that conversely, the developmental problem
is going to be present in the mixed denti-
tion or even become worse.6 Furthermore,
that developmental problem can associate
with sleep-breathing disorders,10 which may
further affect the growth and development
of the child.13
The case presented here was intercepted
at an early age in the primary dentition, so
growth and development of both maxil-
laries were stimulated during the period of
his life when they expressed the highest
growth potential.2,5 In that context, the
developmental problem was successfully
intercepted, and the mouth was brought to
a situation where growth and development
can continue within normal limits.11,14
The patient was initially treated with
myofunctional exercises and diet guidance,
which help to improve the relationship
between the maxillaries. Also, that treat-
ment improved the activity of the mastica-
tory and facial muscles, making them able
Volume 7 Number 4 Orthodontic practice 21
Figures 3A-3B
to hold the mandible in a centric position.15
The improvement in the maxillaries’ relation-
ship was associated with an improvement
in the oral functions, such as swallowing, lip
seal, and tongue posture at rest16,17, which
can make the results of the treatment more
stable.18 Later, when the patient was more
cooperative, a simple, fixed technique was
designed for primary dentition. The PDTs
were introduced to further stimulate the rela-
tionship of the maxillaries in a sagittal and
vertical way, with the intent of guiding the
craniofacial growth and development.
In this case, early treatment improved
the relationship between both maxillaries and
guided the craniofacial growth and develop-
ment. Thus, all the tissues composing the oral
system can continue expressing their highest
growing potential over the following stages.
In other words, the message received by the
trigeminal nerve through the mechanorecep-
tors in the periodontal ligament is sent to the
brain, which in turn will change the activity
of the mandibular and facial muscles. This
produces better loading of the craniofacial
bones, including both maxillaries.14,19,20
In conclusion, the clinical case presented
here supports the idea that developing maloc-
clusions in children should be intercepted as
early as possible in order to reduce the risk
of more complicated treatments in the future,
as well as preventing other problems that
can associate with deviated or diminished
craniofacial growth and development, such
as sleep-breathing disorders. OP
REFERENCES
1. Smartt JM Jr., Low DW, Bartlett SP. The pediatric mandible:
I. A primer on growth and development. Plast Reconstr
Surg. 2005;116(1):14e-23e.
2. Liu YP, Behrents RG, Buschang PH. Mandibular growth,
remodeling, and maturation during infancy and early child-
hood. Angle Orthod. 2010;80 (1):97-105.
CASE STUDY
3. Kobayashi HM, Scavone H Jr., Ferreira RI, Garib DG. Rela-
tionship between breastfeeding duration and prevalence of
posterior crossbite in the deciduous dentition. Am J Orthod
Dentofacial Orthop. 2010;137(1):54-58.
4. Westover KM, DiLoreto MK, Shearer TR. The relationship
of breastfeeding to oral development and dental concerns.
ASDC J Dent Child. 1989;56(2):140-143.
5. Laowansiri U, Behrents RG, Araujo E, Oliver DR, Buschang
PH. Maxillary growth and maturation during infancy and
early childhood. Angle Orthod. 2013;83(4):563-571.
6. Baccetti T, Franchi L, McNamara JA Jr., Tollaro I. Early
dentofacial features of Class II malocclusion: a longitudinal
study from the deciduous through the mixed dentition. Am
J Orthod Dentofacial Orthop. 1997;111(5):502-509.
7. Ovsenik M, Farcnik FM, Korpar M, Verdenik I. Follow-
up study of functional and morphological malocclusion
trait changes from 3 to 12 years of age. Eur J Orthod.
2007;29(5):523-529.
8. Bacon WH, Turlot JC, Krieger J, Stierle JL. Cephalo-
metric evaluation of pharyngeal obstructive factors in
patients with sleep apneas syndrome. Angle Orthod.
1990;60(2):115-122.
9. Yılmaz F, Sağdıç D, Karaçay S, Akin E, Bulakbası N. Tongue
movements in patients with skeletal Class II malocclusion
evaluated with real-time balanced turbo field echo cine
magnetic resonance imaging. Am J Orthod Dentofacial
Orthop. 2011;139(5):e415-e425.
10. Guilleminault C, Akhtar F. Pediatric sleep-disordered
breathing: New evidence on its development. Sleep Med
Rev. 2015;24:46-56.
11. Ovsenik M. Incorrect orofacial functions until 5 years of
age and their association with posterior crossbite. Am J
Orthod Dentofacial Orthop. 2009;136:375-381.
12. Ramírez-Yañez G. Early treatment of malocclusions:
prevention and interception in primary dentition. 2009;
2nd ed:www.kidsmalocclusions.com. Accessed May 27,
2016.
13. Huang YS, Guilleminault C. Pediatric obstructive sleep
apnea and the critical role of oral-facial growth: evidences.
Front Neurol. 2013;3:184.
14. Sohn BW, Miyawaki S, Noguchi H, Takada K. Changes
in jaw movement and jaw closing muscle activity after
orthodontic correction of incisor crossbite. Am J Orthod
Dentofacial Orthop 1997;112(4):403-409.
15. Maffei C, Garcia P, de Biase N, et al. Orthodontic interven-
tion combined with myofunctional therapy increases elec-
tromyographic activity of masticatory muscles in patients
with skeletal unilateral posterior crossbite. Acta Odontol
Scand. 2014;72(4):298-303.
16. Korbmacher HM, Schwan M, Berndsen S, Bull J, Kahl-
Nieke B. Evaluation of a new concept of myofunctional
therapy in children. Int J Orofacial Myology. 2004;30:39-52.
17. Schievano D, Rontani R, Bérzin F. Influence of myofunctional
therapy on the perioral muscles. Clinical and electromyo-
graphic evaluations. J Oral Rehabil. 1999;26(7):564-569.
18. Smithpeter J, Covell D Jr. Relapse of anterior open bites
treated with orthodontic appliances with and without
orofacial myofunctional therapy. Am J Orthod Dentofacial
Orthop. 2010;137(5):605-614.
19. Forwood MR. Mechanical effects on the skeleton:are there
clinical implications? Osteoporos Int. 2001;12(1):77-83.
20. Frost HM. A 2003 update of bone physiology and Wolff’s
law for clinicians. Angle Orthod. 2004;74(1):3-15.
ORTHODONTIC INSIGHTS
Reframing orthodontics: Ortho 3.0
Dr. Rohit C.L. Sachdeva discusses the eight major forces shaping the future of orthodontics
T he development of the orthodontic
specialty has generally followed the
cultural, scientific, and technological evolu-
tion of society, although it has not neces-
sarily always been in step. The historical
transformation of our society to the present
time has clear footprints. The agrarian soci-
ety was symbolized by the farmer with the
plough and the industrial society by the as-
sembly-line worker. Today’s “knowledge”
worker can best be characterized by the
computer. Similarly, the orthodontic profes-
sion has witnessed a transformational pro-
cess that I describe as Ortho 1.0, 2.0, and
3.0. Ortho 1.0 typically defined the ortho-
dontist’s role as a craftsman whose skills lie
in manual dexterity and the use of a plier
to bend wire and provide personalized care.
In some ways, this was no different than a
farmer in an agrarian society whose skills
lay in tilling the land to provide for his fam-
ily. Ortho 2.0 extended the orthodontist’s
role into that of a manager leading a team
of chairside assistants and support staff to
provide care to a broader base of patients
with the use of standardized and modular
orthodontic appliances. Again, one can
clearly visualize parallels of this environment
with that of the Henry Ford model of mass
production in the early 20th century and the
introduction of prefabricated modular parts
assembled by a labor force. Furthermore,
both the agrarian and industrial models
Rohit C.L. Sachdeva, BDS, M Dent Sc, is
a consultant/coach with Rohit Sachdeva
Orthodontic Coaching and Consulting, which helps
doctors increase their clinical performance and
assess technology for clinical use. He also works
with the dental industry in product design and
development. He is the co-founder of the Institute
of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder
and former Chief Clinical Officer at OraMetrix, Inc. He received
his dental degree from the University of Nairobi, Kenya, in 1978.
He earned his Certificate in Orthodontics and Masters in Dental
Science at the University of Connecticut in 1983. Dr. Sachdeva
is a Diplomate of the American Board of Orthodontics and is
an active member of the American Association of Orthodontics.
In the past, he has held faculty positions at the University of
Connecticut, Manitoba, and the Baylor College of Dentistry, Texas
A&M. Dr. Sachdeva has over 90 patents, is the recipient of the
Japanese Society for Promotion of Science Award, and has over
160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog
on http://drsachdeva-conference.blogspot.com. Please contact
improveortho@gmail.com to access information.
22 Orthodontic practice Volume 7 Number 4
represented an authoritarian “closed sys-
tem” of management with the manager oc-
cupying a privileged position at the apex of
the pyramid. Both Ortho 1.0 and 2.0 can
be characterized by a hierarchical model
of care delivery; i.e., a “doctor–centered”
model with little participation from patients
in defining their personal treatment wants
or needs.
Today, we are at the beginning of an
orthodontic care revolution driven by the
following eight major forces poised to re-
define the practice of orthodontics as we
know it, including the following consider-
ations of their impact on the profession.
Eight major forces poised to redefine
the practice of orthodontics
1. Health information technology and
health literacy
2. Computer-aided design and manu-
facturing and “omics” technologies/
bioinformatics
3. Public policy
4. Direct-to-consumer marketing and
social networks
5. The rise of the expert non-expert
6. The shift in patient demographics
7. The rise of dental tourism
8. Do-it-yourself (DIY)/IKEA ortho-
dontics in the era of cognitive
computing
Figure 1: Growth of dental management group practices. Source: http://www.dentalcarealliance.net/wp-content/uploads/
2012/01/infographic-why-dental-service-organizations-are-here-to-stay-1000.png
Health information technology and
health literacy
Developments in healthcare informa-
tion technologies support almost instant
connectivity and communication between all
stakeholders in the healthcare system. The
ability to transfer massive amounts of data
on demand, the enablement of cost-effective
data-warehousing and data-mining resources,
is driving the genesis of a healthcare informa-
tion exchange that is accessible to all. The
increased porosity of information exchange
is breaking the traditional communication
barriers between patients, doctors, hospitals,
academia, and industry. Healthcare is being
democratized rapidly through the rise of the
informed patient. This new dynamic is already
leading to the reframing of the traditional roles
and relationships between doctor and patient.
Computer-aided design and manu-
facturing and “omics” technologies/
bioinformatics
The development of computer-aided
design and manufacturing technologies,
coupled with the biological revolution in
the “omics” arena — namely, genomics,
proteomics, and metabolomics — has the
potential to provide unprecedented abilities
to the orthodontist in designing and delivering
personalized and targeted care to patients.
Public policy
Western economies are crumbling
under the weight of high healthcare costs,
 ORTHODONTIC INSIGHTS
especially in the United States. Public policy,
driven by government agencies, the insur-
ance industry, and the patient communities
at large, is demanding high fidelity and quality
care. In other words, care delivery is effective,
efficient, patient-centered, safe, affordable,
and value-driven (Figures 3 and 4). Addi-
tionally, the pressures from these agencies
are requiring the doctor to be more trans-
parent and accountable for the care given
to patients. Finally, in the race to provide
value-based care through the economies
of scale, we are witnessing a proliferation
of managed-care dental practices that are
challenging the role of the solo practitioner
(Figures 1 and 2).

Direct-to-consumer marketing and

social networks
Figure 2: Growth of dental management group practices. Source: http://www.dentalcarealliance.net/wp-content/uploads/
Bypass marketing efforts by industry are 2012/01/infographic-why-dental-service-organizations-are-here-to-stay-1000.png
challenging the traditional role of the doctor
as the legitimate source of healthcare-
related information to patients (Figures 5
and 6). Furthermore, the rapid proliferation of Ortho 3.0 seeks transformational leadership, new
support groups on the Internet is extending
their reach and influencing the mind-set awakenings through patient participation, interprofessional
of patients through conversations of “real-
world” care experiences and disease-specific and transdisciplinary collaborations, and new learning that
resources of information.
will redesign the orthodontic care system.
The rise of the expert non-expert
The rise of the generalist dental practi-
tioner is upsetting the traditional role of the
specialist orthodontist in providing ortho-
dontic care. Adding to the fuel is the almost
pervasive lack of recognition by patients

Figure 3: Interest in affordable care. Source: Kath-

leen Irwin. “An Untapped Revenue Opportunity.” http://
profitable-practice.softwareadvice.com/dental-tourism-an-
untapped-revenue-opportunity-0914/. The Profitable Prac-
tice. Published September 10, 2014. Accessed May 31,
2016.
Figure 4: Regional interest. Source: Kathleen Irwin. “An Untapped Revenue Opportunity.” http://profitable-practice.softwaread-
vice.com/dental-tourism-an-untapped-revenue-opportunity-0914/. The Profitable Practice. Published September 10, 2014.
Accessed May 31, 2016.

Volume 7 Number 4 Orthodontic practice 23

ORTHODONTIC INSIGHTS

Figure 5: Pharma’s spending on direct-to-consumer TV advertising (DCTA).

Source: http://pharmamkting.blogspot.com/2016/01/is-direct-to-consumer-
tv-advertising.html

regarding the professional capabilities of

the specialist orthodontist. Furthermore, the
generalist is equipped to address the needs
of a patient as a “whole,” with comprehen- Figure 6: Consumers’ response to multiple channels; global averages. Source: http://www.nielsen.com/us/en/insights/
news/2012/consumer-trust-in-online-social-and-mobile-advertising-grows.html
sive dental treatment adding to the conve-
nience of care under “one roof.” All these
factors unfortunately bring into question the
value of specialist education.

The shift in patient demographics

In the western world, we are witnessing
a significant decline in birthrates and,
concurrently, a rise in the aging population
as well as growth in the immigrant popula-
tion. These dynamics represent a shift in the
patient population base and demand that
the specialist attune his practice to deal with
patients whose needs and aspirations for
orthodontic care are very different from the
traditional teenager. The demand of care for
the geriatric population is generally limited
in nature, and furthermore, many of these
patients are afflicted with chronic diseases
requiring a total healthcare approach
in managing them effectively. The first-
generation ethnic population is generally not
as well acquainted with the benefits of ortho-
dontic care and require novel approaches in
communication to encourage their participa-
tion in care (Figure 7).

Rise of dental tourism

The “repackaging” of dental care as
an esthetic need rather than a health need
in the western world, combined with cost
Figure 7: The Great Shift, the Browning of America. Orthodontic practices must understand the various cultures within their
pressures and globalization of expertise, are patient base and make some accommodations for the changing demographics of their communities (such as having some
defining new channels for affordable patient bilingual staff members). Source: Passel, Jeffrey and D’Vera Cohn. 2008. “U.S. Population Projections: 2005-2050.” Washington,
care. It is highly conceivable that patients D.C.: Pew Hispanic Center, February; Census Bureau 2011 population estimates. Pew Research Center

24 Orthodontic practice Volume 7 Number 4

 ORTHODONTIC INSIGHTS
will have access to orthodontic care from
orthodontic practitioners “beyond borders,”
especially when it comes to providing limited
care with aligners. And such a model could
easily be offered under the auspices of
dental tourism. In fact, the more the clinician
relies upon outsourcing planning of care by
external agencies (laboratories) for patients,
especially in the arena of digital orthodontics,
the greater the likelihood of such a model
gaining a foothold (Figures 3, 8, and 9).

Do-it-yourself (DIY)/IKEA ortho-

dontics in the era of cognitive
computing
We are rapidly approaching the era of
Figure 8: Dental destination advertisement. Source: https://cancundentistdentaris.wordpress.com/tag/cosmetic-dentistry-mexico/ cognitive computing driven by transforma-
tional developments in the area of artificial
intelligence (Figures 10, 11, and 12). A real-
world product of this technology is Google’s
autonomous car. I believe in the next couple of
decades, it will be possible to use the power
of machine intelligence through input provided
directly by the patient to design a care plan.
Orthodontic appliances would be directly
manufactured in the “home lab” with the
use of computer-aided manufacturing such
as 3D printing. And patients could manage
their personal care by scanning themselves
periodically and matching their response
against a guidance or tracking system based
upon patient-matched data. This “DIY/IKEA
Figure 9: Health-tourism.com website. Source: https://www.health-tourism.com/dental-braces/ orthodontics” is a real possibility. In fact, the
ability to design and manage one’s own care

Figure 11: IBM Watson. Source: http://www.slideshare.net/

AndersQuitzauIbm/watson-join-the-cognitive-era. Copyright
Figure 10: Defiition of cognitive computing. Source: http://www.slideshare.net/ViperVarunT/cognitive-computing-33845238 2013 International Business Machines Corporation

Volume 7 Number 4 Orthodontic practice 25

ORTHODONTIC INSIGHTS

was recently demonstrated by a design

student, Amos Dudley1 (Figure 13).
The orthodontic profession is at a
crossroads. The dilemma lies in recog-
nizing the new realities “on the ground”
and the need to evolve into an environ-
ment that is more system-based. This will
undoubtedly come at a price and loss of
some professional autonomy in order to
achieve greater good.
Furthermore, the orthodontist will
need to commit to acquiring new knowl-
edge and skills through personal drive
in order to harness the promise of new
learning and technologies to improve
patient care, to increase its accessibility Figure 12: Enablement of cognitive computing; the cost of computing power. Source: John Hagel III, John Seely Brown (JSB), Tamara
while remaining mindful of the cost and, Samoylova & Michael Lui. From exponential technologies to exponential innovation. Deloitte University Press. http://dupress.com/
most importantly, to maintain professional articles/from-exponential-technologies-to-exponential-innovation/.
dignity and be the font of empathy for Published October 4, 2013. Accessed May 31, 2016.
every patient.
Ortho 3.0 defines this “New Look” for our practices of a learning/teaching organiza- Ortho 3.0 can only gain a foothold
profession, moving beyond the monolithic tion, to employ evidence-based clinical prac- through a spirit of collective professional
symbolism of the computer and the image of tices, to offer highly reliable organization and resolve that is supported by the backbone
the orthodontist practicing in solitude behind care management, to support and advance of professional antifragility. This mandates
a desktop, always distanced from patients patient healthcare literacy, and engagement, growth through deliberate experimentation
by cyberspace. as well as achieving truly connected care. fueled by intelligent failure.
Ortho 3.0 places the patient at the Ortho 3.0 challenges conventional
Yes, in some ways, it is a departure from
epicenter of the care-delivery model with all models and ways of thinking of orthodontic
the past. Yet in many ways, it retains the core
other actors and agencies coalescing within care delivery, while seeking transforma-
values, belief systems, and some of the prac-
a system designed to serve the patient as tional leadership, new awakenings through
tices of conventional orthodontics. To state
an individual. It is designed around system- patient participation, interprofessional and
based thinking that continuously strives transdisciplinary collaborations, and new it explicitly: “patients matter.” This does not
to improve patient care, to enhance both learning that will redesign the orthodontic and will not change.
personal and community care through the care system. Aeger Primo, patients first. OP

Figure 13: Student Amos Dudley designs his DIY aligners using $60 and a 3D printer. Source: http://www.mnn.com/health/healthy-spaces/blogs/student-designs-his-own-braces-using-3d-printer

REFERENCE
1. Fiona MacDonald. A college student has 3D-printed his own braces for less than $60. Science Alert. http://www.sciencealert.com/a-college-student-has-3d-printed-his-own-braces-for-less-than-60.
Published March 21, 2016. Accessed May 31, 2016.

26 Orthodontic practice Volume 7 Number 4

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CONTINUING EDUCATION
Facial asymmetries
Dr. Bradford N. Edgren discusses the importance of diagnosis and treatment of facial asymmetries
Abstract
The most important key to any successful
orthodontic treatment is a proper and thor-
ough diagnosis. The same is true for the diag-
nosis and treatment of facial asymmetries. If a
patient’s facial asymmetry is not initially diag-
nosed, the risk of treatment failure increases,
especially in cases with inappropriate/irrevers-
ible permanent tooth extraction and/or treat-
ment mechanics. This is especially important
in children because facial asymmetries in
these young patients generally become more
severe with growth and time; therefore, early
recognition is imperative. Improper early inter-
ceptive orthodontic treatment can accentuate
the asymmetry rather than improve it. This
includes the underdiagnosis and consequent
lack of treatment of upper airway obstruc-
tions, enhancing the development and degree
of facial asymmetries.1
Introduction
Ideal bodily symmetry in all organisms
rarely, if ever exists. Consequently, subtle
asymmetries are common in all patients
and considered normal. However, the point
where the subtle facial asymmetry falls
outside the range of normal and becomes
aberrant/divergent is not as easily delineated.
Often it is the patient’s perception of the lack
of facial symmetry, as well as the degree of
the imbalance, that determines the necessity
and the extent of treatment warranted.2 The
investigation of McAvinchey, et al., into the
perception of facial asymmetries reported
that recognition of an asymmetry was depen-
dent upon the profession of the observer and
the severity of the anomaly. Findings of their
layperson group classified an asymmetry of
Bradford N. Edgren, DDS, MS, earned
both his Doctorate of Dental Surgery, as
Valedictorian, and his Master of Science in
Orthodontics from the University of Iowa,
College of Dentistry. He is a Diplomate,
American Board of Orthodontics, and a
member of the Southwest Component of
the Edward H. Angle Society. Dr. Edgren has
presented nationally and internationally to
numerous orthodontic groups on the importance of orthodontic
diagnosis, early interceptive orthodontic treatment, CBCT, and
upper airway obstruction. He has been published in AJO-DO,
the American Journal of Dentistry, as well as other orthodontic
publications. Dr. Edgren currently has a private practice in
Greeley, Colorado.
28 Orthodontic practice Volume 7 Number 4
Educational aims and objectives
This article aims to discuss some ways that early orthodontic treatment can successfully
improve and resolve facial asymmetries in young patients.
Expected outcomes
Orthodontic Practice US subscribers can answer the CE questions on page 34 to
earn 2 hours of CE from reading this article. Correctly answering the questions will
demonstrate the reader can:
• Realize the importance of diagnosis and treatment of facial asymmetries.
• Identify various etiologies of skeletal asymmetries.
• Recognize important aspects of the clinical exam for proper evaluation of asymmetries.
• Identiify the radiographic techniques necessary to determine facial asymmetries.
• Realize the different treatment modalities for distinct types of asymmetries.
5.6 mm ± 2.7 mm at the chin to be “normal.” single malpositioned tooth preventing proper
They also reported that orthodontists were intercuspation, can develop into permanent
found to be far more conscious of the pres- deformities following the cessation of growth.
ence of an asymmetry than the layperson.3 Functional shifts of the occlusion can accen-
Treatment of dental asymmetries due to tuate or even mask structural asymmetries
premature deciduous tooth loss, tooth size underscoring the importance of a thorough
discrepancies, and/or missing teeth is more clinical exam.4 Young patients exhibiting true
easily addressed compared to structural, functional asymmetries can be successfully
skeletal asymmetries. Orthodontic treatment treated with early interceptive dentofacial
techniques to regain space loss, permanent orthopedic treatment, including maxillary
tooth replacement, and asymmetrical extrac- expansion and orthodontics.
tions are often employed to successfully treat Etiologies of skeletal asymmetries vary
dental asymmetries. and fall into three basic categories, including
Significant skeletal asymmetries require congenital, environmental, and develop-
a combination of orthodontics, dentofacial mental.4 Congenital and genetic causes
orthopedics, and possible future ortho- of facial asymmetries include cleft lip and
gnathic surgery after the finalization of palate, hemifacial microsomia, unilateral
growth in adolescents. Adults with skeletal craniosynostosis6, and zygomaticotemporal
anomalies require orthodontics and surgical synostosis.7
considerations, unless the patient dictates Infection, tumors, and trauma are exam-
certain compromises before the initiation of ples of environmental or acquired etiologies
treatment,2 necessitating the importance of of facial asymmetry. Growth of benign and
informed consent. Even though facial asym- malignant tumors can distort the dentofacial
metries can present in Class I malocclusions, architecture, misshaping the dentoalveolar
they are more often associated with Class arches and jaw bones, resulting in signifi-
II and Class III malocclusions.4 Severt and cant facial asymmetries. Early trauma to the
Proffit reported that clinically apparent facial temporomandibular joint can result in anky-
asymmetries were most often recorded at losis, unilateral condylar hypoplasia, and/or
the level of the chin in 74% of patients, and subcondylar fracture, precipitating the onset
midface asymmetries were documented in of facial deformities. Age of onset of an
roughly a third (36%). Interestingly, they also acquired etiology will determine the severity
noted that when a transverse deviation of of the asymmetry. Often the earlier the onset,
the chin occurred, there was a predilection the greater the facial deformity due to growth.
to the left. An exception was with long-faced Asymmetries that are developmental in
patients where there was an equal distribu- nature are relatively uncommon. Develop-
tion between left and right asymmetries.5 mental asymmetries are non-syndromic,
Functional asymmetries, which often idiopathic, non-congenital, and gradually
result from the mandible deflecting to one develop over time, becoming apparent
side due to maxillary constriction or even a during adolescence.4

Diagnosis and radiographic tech-
niques
A thorough evaluation, including clinical
assessment, panoramic imaging, submento-
vertex radiography, and a complete cephalo-
metric survey with analyses are all important
for diagnosis of patients with facial asym-
metries. The clinical exam should include
an evaluation of dental midlines, Angle clas-
sification, open bites, functional shifts, and
the presence of anterior and posterior cross-
bites. Unilateral posterior crossbites can be
an indication of a bilateral maxillary constric-
tion with a functional shift to the affected side
resulting in a functional asymmetry. A uni-
lateral posterior crossbite can also be indica-
tive of a midface skeletal asymmetry.
Lateral cephalograms, though useful for
evaluation of anteroposterior and vertical
evaluations of the jaws and dentition rela-
tive to the cranial base, are less reliable for
assessment of asymmetries. Superimposition
of left and right structures as well as magnifi-
cation errors can mask skeletal asymmetries.4
Posteroanterior radiographs do not result in
superimposition or the unequal magnifica-
tion of the left and right halves of the face
and are an important tool in the diagnosis of
Figure 1: Diagnostic photos of a 8-year 5-month-old female
with a functional facial asymmetry resulting in a unilateral right
posterior crossbite
Figure 3: Diagnostic lateral CBCT image
Volume 7 Number 4 Orthodontic practice 29
asymmetries.2 Routine use of the postero-
anterior cephalogram and frontal cephalo-
metric analysis can reduce the risk of missing
skeletal asymmetries, especially in the young
patient who possesses a mild, incipient facial
asymmetry that hasn’t been fully expressed
because of remaining, future growth.
Submentovertex imaging is another
valuable radiographic technique that can
be used to assess the shape and symmetry
of the inferior border of the mandible, zygo-
matic arches, and relative position of the
condyles. A facial asymmetry that is detected
on a posteroanterior cephalogram can be
diagnosed as a functional asymmetry when
evaluated by the submentovertex radio-
graph because the left and right inferior
borders of the mandible are determined to
be symmetrical.
The panoramic radiograph is a conve-
nient image for an initial evaluation of the
dentition, maxilla, mandible, pathology, and
gross asymmetries. However, it is not as
valuable a tool for determination of skeletal
asymmetries due to the inherent distortions
of this radiographic technique because of
patient positioning.8 Observed differences
between the left and right halves, unless
Figure 2: Initial panoramic CBCT image acquired by an i-CAT Next Generation scanner
Figure 4: Initial frontal CBCT image with right posterior crossbite and facial asymmetry
CONTINUING EDUCATION
overt between the temporomandibular joints,
ramuses, and the bodies of the mandible,
should be interpreted with discretion.
Cone beam computed tomography
(CBCT) has neither the magnification errors
nor the complications of superimposition of
anatomical structures that traditional radio-
graphic techniques possess. Consequently,
CBCT imaging is a valuable tool when evalu-
ating facial asymmetry patients.
Patient therapies
Early interceptive treatment of patients
diagnosed with functional asymmetries
includes a combination of dentofacial
orthopedics and orthodontics. This 8-year
5-month-old female presented with a right
functional shift of the mandible resulting in a
lower facial asymmetry, posterior crossbite,
and a lower dental midline discrepancy of
4.5 mm (Figure 1). Panoramic CBCT imaging
reveals dental crowding (Figure 2). The lateral
CBCT image shows no evidence of an
asymmetry since both lower borders of the
mandible are coincident (Figure 3). The frontal
CBCT image demonstrates a significant facial
asymmetry to the right (Figure 4). Cephalo-
metric analysis of the frontal image revealed
CONTINUING EDUCATION
Figure 5: Frontal cephalometric analysis
a skeletal lingual crossbite pattern due to the
maxilla (Figure 5). Axial CBCT images of the
patient demonstrate relatively good symmetry
of the inferior border of the mandible but with
a functional deviation to the right (Figures 6
and 7). The patient was treated with a bonded
maxillary expander and orthodontics. Early
interceptive treatment time was 31 months.
Her maxillary constriction and right poste-
rior crossbite were corrected, and her facial
symmetry significantly improved as well
(Figures 8, 9, and 10).
Treatment of patients with structural
craniofacial asymmetries is more challenging
than those with functional asymmetries.
Younger patients can benefit from early inter-
ceptive treatment, lessening the severity of a
facial asymmetry and therefore reducing the
extent of future orthognathic surgery. This
7-year 9-month-old female presented with
right-sided hemifacial microsomia (Figure
11). The panoramic CBCT image displays
ectopic maxillary lateral incisors and signifi-
cant crowding (Figure 12). Her frontal volume
rendering image discloses a hypoplastic right
30 Orthodontic practice Volume 7 Number 4
maxilla and mandible manifesting in signifi-
cant middle and lower face asymmetries
(Figure 13). Frontal cephalometric analysis
reveals a notable occlusal cant with the right
side superior to the left (Figure 14). The axial
image exhibits a misshapen inferior border of
the mandible with the right half being notably
more underdeveloped than the left (Figure 15).
This young patient’s treatment included
maxillary expansion with a bonded expander
to stimulate maxillary development and
orthodontics. Treatment time was approxi-
mately 30 months resulting in a nice Class
I occlusion and improvement in her facial
asymmetry (Figure 16). Her panoramic image
following early interceptive treatment demon-
strates acceptable root parallelism and
proper eruption of the permanent dentition
(Figure 17). Frontal and axial images exhibit
improvement in facial asymmetry and lower
borders of the mandible (Figures 18 and 19).
A boost in self-esteem was an added benefit
of early treatment for this patient. The extent
of future orthognathic surgery has been
reduced, if desired, for this patient.
Figure 6: Axial CBCT image
Figure 7: Volume rendering of axial CBCT image displays
relative symmetry between the right and left inferior borders
of the mandible
Adult patients generally require a combi-
nation of orthodontics and orthognathic
surgery to correct significant facial asymme-
tries. This 27-year 6-month-old adult female
fractured her mandible at the age of 5 (Figure
20). At the time, the left subcondylar neck
fracture was treated with closed reduction.
She suffered from chronic headaches and left
jaw joint pain. Intraoral photographs demon-
strate a 5 mm lower dental midline deviation
to the left, a right-sided Class I malocclusion,
and a Class II malocclusion on the left. The
panoramic image discloses a complete adult
dentition with the exception of the previously
extracted third molars (Figure 21). Frontal
and axial CBCT images display a significant
left-sided facial asymmetry and severely
misshapen mandible (Figures 22 and 23).
A sectional axial image at the level of the
condyles shows a significant alteration in the
morphology of the left condyle secondary to
the subcondylar fracture at age 5 (Figure 24).
 CONTINUING EDUCATION
Figure 9: Panoramic CBCT image at interim deband demonstrating reduction in dental crowding

Figure 8: Interim deband photos demonstrating correction of posterior crossbite and

functional facial asymmetry

Figure 10: Frontal CBCT image at interim deband showing significant improvement Figure 11: Diagnostic photos of a 7-year 9-month-old female with hemifacial microsomia and right
in facial symmetry facial asymmetry

Figure 12: Panoramic CBCT imaging displaying significant crowding Figure 13: Frontal CBCT imaging revealing a hypoplastic right maxilla and mandible

Volume 7 Number 4 Orthodontic practice 31

CONTINUING EDUCATION
Figure 14: Frontal cephalometric analysis demonstrating canted occlusal plane and significant facial asymmetry
Figure 16: Interim deband photos show improvement in
dental midlines and facial symmetry
Figure 18: Frontal CBCT image at interim deband demon-
strating improvement in facial symmetry with early
interceptive treatment
32 Orthodontic practice Volume 7 Number 4
Figure 15: Axial CBCT image illustrating the difference in the size and
shape of the inferior borders of the mandible
Figure 17: Interim deband panoramic image
Figure 19: Axial image at interim deband
Splint therapy was initially employed to
resolve her left temporomandibular joint pain
and tension headaches. Following cessation
of her joint pain and headaches, the patient
was treated with comprehensive ortho-
dontics and orthognathic surgery to improve
her alignment, stability, and jaw function.
Surgical correction included a LeFort I oste-
otomy, bilateral sagittal split osteotomy, and
genioplasty to correct her maxillofacial skeletal
and dental anomalies. Post-surgical extraoral
and intraoral photos show notable improve-
ment in facial symmetry and dental midline
alignment (Figure 25). The post-surgical frontal
CBCT image displays significant improve-
ment in her maxillofacial skeleton, especially
in mandibular shape and form (Figure 26).
 CONTINUING EDUCATION
Figure 20: Diagnostic photos of a 27-year 6-month-old female
with a history of a left subcondylar fracture at age 5 Figure 21: Panoramic CBCT imaging demonstrating a gross difference in the size between the right/left ramuses and condyles

Figure 22: Frontal CBCT image illustrating left-sided skeletal Figure 23: Axial CBCT image revealing severe difference in Figure 24: Sectional CBCT image at the level of the condyles.
asymmetry size and shape of the inferior border of the mandible Note the significantly misshapen and displaced left condylar head

Conclusion
Appropriate early orthodontic treatment
can successfully improve and resolve, espe-
cially functional, facial asymmetries in young
patients. Early treatment requires time to
take necessary advantage of growth to be
successful. Surgical intervention is some-
times required for these patients as adults;
however, the extent of surgical intervention
can be reduced with proper early treatment.
Adult patients with facial asymmetries require
a combination of orthodontics and ortho-
gnathics. Careful diagnostic evaluation is
essential for successful outcomes. OP
Figure 25: Post-surgical photos reveal significantly improved Figure 26: Post-surgical CBCT frontal image demonstrating
facial symmetry significantly improved skeletal symmetry

REFERENCES
1. Edgren BN. Upper airway obstruction – poor function becomes poor form (CE). Orthodontic Practice US. 2013; 4(2):34-37.
2. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review. Angle Orthod. 1994;64(2):89-98.
3. McAvinchey G, Maxim F, Nix B, Djordjevic J, Linklater R, Landini G. The perception of facial asymmetry using 3-dimensional simulated images. Angle Orthod. 2014;84(6):957–965.
4. Cheong YW, Lo LJ. Facial asymmetry: etiology, evaluation, and management. Chang Gung Med J. 2011;34(4):341–351.
5. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg. 1997;12(3):171-176.
6. Arvystas MG, Antonellis P, Justin AF. Progressive facial asymmetry as a result of early closure of the left coronal suture. Am J Orthod. 1985;87(3):240-246.
7. Rogers GF, Greene AK, Oh AK, Robson C, Mulliken JB. Zygomaticotemporal synostosis: a rare cause of progressive facial asymmetry. Cleft Palate Craniofac J. 2007;44(1):106-111.
8. Rondon RH, Pereira YC, do Nascimento GC. Common positioning errors in panoramic radiography: A review. Imaging Sci Dent. 2014;44(1):1-6.

Volume 7 Number 4 Orthodontic practice 33

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Facial asymmetries
EDGREN

1. Often it is the _____ that determines the neces- unilateral craniosynostosis (Arvystas MG), and 8. Routine use of the ___________ can reduce
sity and the extent of treatment warranted. zygomaticotemporal synostosis. the risk of missing skeletal asymmetries,
a. patient’s perception of the lack of facial a. Congenital and genetic causes especially in the young patient who possesses
symmetry b. Environmental causes a mild incipient facial asymmetry that hasn’t
b. degree of the imbalance c. Developmental causes been fully expressed because of remaining,
c. parents’ request d. Insignificant types future growth.
d. both a and b a. 2D FMX
5. Infection, tumors, and trauma are examples b. posteroanterior cephalogram
2. Treatment of dental asymmetries due to of __________ of facial asymmetry. c. frontal cephalometric analysis
________ is more easily addressed compared a. developmental causes d. both b and c
to structural, skeletal asymmetries.
b. environmental or acquired etiologies
a. premature deciduous tooth loss
c. congenital causes 9. _____________ is/are a convenient image for
b. tooth size discrepancies
d. anomalies an initial evaluation of the dentition maxilla,
c. missing teeth
mandible, pathology, and gross asymmetries.
d. all of the above
6. Asymmetries that are _______ in nature are a. The panoramic radiograph
relatively uncommon. b. Submentovertex imaging
3. Severt and Proffit reported that clinically
apparent facial asymmetries were most often a. developmental c. Lateral cephalograms
recorded at the level of the chin in ______ b. congenital d. Posterioanterior cephalograms
of patients, and midface asymmetries were c. environmental
documented in roughly a third (36%). d. acquired 10. _________ has/have neither the magnification
a. 30% errors nor the complications of superimposi-
b. 45% 7. A unilateral posterior crossbite can also be tion of anatomical structures that traditional
c. 74% indicative of a ___________. radiographic techniques possess.
d. 82% a. hemifacial microsomia a. Submentovertex imaging
b. subcondylar fracture earlier in life b. Cone beam computed tomography (CBCT)
4. ___________ of facial asymmetries include c. midface skeletal asymmetry c. Lateral cephalograms
cleft lip and palate, hemifacial microsomia, d. unilateral condylar hypoplasia d. Panoramic radiographs

34 Orthodontic practice Volume 7 Number 4


Airway orthodontics the new paradigm: part 2,
a vision for the future
Dr. Barry Raphael discusses how added exercise protocols can help correct common problems related to
facial and oral function
A lex checks in for his after-school
appointment. Instead of going to the
operatory, he takes his activity scorecard
and exercise mouthpiece to the Activity
Center. The Activity Center has no dental
chairs, no lights to shine in his eyes, and
no scary handpieces or pliers sticking
up from racks. Instead Alex walks into a
fun-looking room with video screens and
mirrors on the walls surrounded by cartoon
characters with word balloons saying, “Are
you breathing through your nose?” and “Is
your tongue on the spot?”
He sees Sara, his health coach, who
greets him with a big smile. Sara is a college
graduate with an interest in health and well-
ness. Sara has a clean approach to diet and
exercise and loves to work with younger kids.
She inquires, “So how did you do this week?”
“I got up to 40 paces, but I had some
trouble wearing my trainer every day,” Alex
confesses as though he was talking with
a teacher about his homework. “But I can
definitely breathe through my nose better,
and my soccer coach said I’m doing better
on the team.”
“Fantastic,” says Sara encouragingly. “So
let’s see what your obstacles are with your
wear time and get you moving forward.” And
so they sit at a video monitor and review
his exercises for that week. “Paces” teaches
nasal breathing and makes it easier for Alex
to keep his mouth closed and his tongue on
the palate. The two spend about 15 minutes
together before Sara assigns a video on nutri-
tion and gives the next exercise prescribed
by the orthodontist. Then Alex heads for the
orthodontic operatory.
Barry Raphael, DMD, is a practicing
orthodontist in Clifton, New Jersey, for over
30 years. His transition to airway thinking
came 25 years into practice so as he says, “I
know what it takes to make the transition.”
He teaches these concepts at the Mt.
Sinai School of Medicine in New York City.
He is the owner of the Raphael Center for
Integrative Orthodontics and the founder of
the Raphael Center for Integrative Education.
Volume 7 Number 4 Orthodontic practice 35
CONTINUING EDUCATION
Educational aims and objectives
This article aims to discuss natural physiological competencies that are required for
optimal growth and development.
Expected outcomes
Orthodontic Practice US subscribers can answer the CE questions on page 39 to
earn 2 hours of CE from reading this article. Correctly answering the questions will
demonstrate the reader can:
• Identify certain natural physiological “competencies” required for the optimal growth
and development of the occlusion, the jaws, the joints, the airway, and the cranium.
• Realize some habits that cause the alveolar processes to deform and prevent the teeth from easily erupting
into place.
• Realize that certain common problems with facial and oral function must be corrected by training patients
with certain exercises facilitated by a health coach.
• Recognize the parts of a comprehensive myofunctional treatment plan.
• Realize some steps to becoming a myofunctional orthodontic practice.
When he sits in the chair, the orthodontic Trainer? Training?
assistant asks about the comfort of the light So what is behind these added protocols
wire expander he is wearing to develop his that are being introduced into the modern
upper arch and checks for hygiene and orthodontic office? While most orthodontic
breakage. Then the orthodontist comes over, techniques focus on taking cooperation out
removes the expander, makes adjustments, of the hands of the patient, why in the world
and replaces it. He/she also asks Alex, “So would we want to be bringing “exercises” of
how does your trainer fit? Is there anything all things back into our treatment program?
I can do to make it more comfortable? Are The patient illustrated above is typical
you making sure you are keeping your lips of what we see every day in practice. Most
together even when you’re not wearing all children with malocclusions have some
your trainer?” degree of soft tissue dysfunction.1 Unless
Of course, Alex gives a shy nod. He there are congenitally missing or extra teeth
knows that he has always had a problem or premature loss due to caries or trauma,
keeping his lips together and hates the way most malocclusions are to some degree
it makes his face look. Someone once teased acquired — or at very least exacerbated by
him for looking like Napoleon Dynamite. It’s — habits that cause the alveolar processes
been hard changing his habits, but it’s hard to deform and prevent the teeth from easily
playing soccer too, sometimes. He knows it’s erupting into place.
paying off, though, because not only is his Muscle influence on genetically pro-
stamina improving, but his teeth are getting grammed eruption sequences, especially
straighter, too! during resting oral postures, herds the teeth
“You’ll see Sara again in 2 weeks and me into places they don’t belong, and malocclu-
again in a month,” his orthodontist smiles. sion is the result. The maxilla, being one of
the most malleable bones in the growing face,
“Keep up the good work. You look great!”
And Alex is off to soccer practice. is especially susceptible to distortions of the
Author’s first note: Now guess what? functional matrix (or spatial matrix) in all three
planes of space becoming not only narrower,
This is what my practice looks like now, and
the future is here. but falling down and back under the cranial
base.2 Then the mandible has to compensate
——————————————————— resulting in a variety of occlusal schemes.3
CONTINUING EDUCATION
Although the orthodontic literature has
known about the influence of habit and
function on the growing face and jaws for a
long time,4,5,6,7,8 there has been inconsistent
effort in developing scientifically validated
protocols that reliably and consistently miti-
gate the effects of function on form. It is too
simplistic to declare that “function follows
form,” as many orthodontic philosophies do,
so that we only have to pay attention to one
part of what is actually an unending cycle of
form and function and form and function,
ad infinitum. (What adult even asks which
came first?)
Addressing function, which is invariably
the result of a behavior, is certainly harder
to do in an orthodontic practice than the
mechanics required for “form treatments.”
But as a society, we do address behav-
ioral issues all the time with teaching and
coaching. We do it in schools. We do it in
sports and the arts. We do it with psycho-
logical and social guidance. And, by and
large, we do it well. Certainly, kids are able
to accomplish things today that children of
past generations never could. Have you been
to a cheer competition, dance festival, martial
arts class, or track meet lately? When there is
a will to change behavior — on both the part
of the child and the parents — miraculous
things can happen.
What do we have to train?
Behind the idea that function is an etio-
logical component in a majority of malocclu-
sions9 is a recognition of certain common
problems with facial and oral function that
must be corrected for the teeth to come in
straight, or to stay straight if they had to be
corrected orthodontically. (Each of these has
ample evidence behind them). There are
certain natural physiological “competencies”
that are required for the optimal growth and
development of the occlusion, the jaws, the
36 Orthodontic practice Volume 7 Number 4
joints, the airway, and the cranium. They are
the following:
1. Upper airway patency and nasal
breathing. While there has been
much controversy over the influence
of mouth breathing on the influence
of facial growth in the orthodontic
literature, nasal and pharyngeal
airway obstruction is a damaging
influence to the growing (and aging)
face not because of the change in
respiratory mode but because of
the change in oral rest posture that
results from it.10,11,12,13
The human being is supposed to
breathe primarily through the nose.
Otherwise we couldn’t nurse as an
infant. Unfortunately, something —
inflammation, allergy, metabolic chal-
lenge, injury, etc. — can induce a
change to chronic oral breathing, and
the mouth begins to hang open. This
will, over time, change the trajectory
of the growing maxilla for children
just as surely as it did for Harvold’s
monkeys.14,15,16
2. Lip competency. The ability to keep
the lips closed at rest is critical for
several reasons:
• It assures that breathing will be
through the nose.
• It seals the mouth during chewing
and swallowing to keep contents
from spilling out and air from
getting in (as in aerophagia).
• It allows for the third major
competency, which is having
the tongue rest on the palate.
Good lip seal should be accom-
plished without strain or tension
of the orbicularis oris or mentalis
muscles. These muscles, when
active during function, place a
significant molding force on the
anterior arch form, crowding or
flattening the arch as the teeth
make their way into the mouth.
3. Tongue-to-palate resting position.
Of all the molding influences on the
growing maxilla, this is probably the
most important and least appreci-
ated.17,18 While many people attribute
narrow palates to genetics or “mouth
breathing,” it is the lack of tongue
presence on the palate that lets the
bone collapse in all three dimensions
of space. Just like the brain is the
scaffold for the growing calvaria,
and the eyeball is the scaffold for the
growing orbit, the tongue is the scaf-
fold around which the palate takes its
shape. In fact, the tongue creates its
entire nesting area based on its size,
shape, tonus and, most importantly,
resting position. The collapse of the
maxilla (in all three planes of space)
is perhaps the most common feature
of modern malocclusion. The specific
arrangement of the teeth reflects just
what the tongue has been doing all
day and night long. If the tongue is
a bear, then the teeth are the bear
tracks: an impression left by the pres-
ence of a being that leaves the place
orderly or wreaks havoc.
4. A quiet swallow without use of
CN VII. In the infant, the facial nerve
efferents participate in suckling with
an “infantile” swallow but should
become inactive when we transi-
tion to a mature, tongue-to-palate
swallow when the primary teeth
come in. When this transition fails
to occur, we learn to use our lips,
chin, cheeks, and neck musculature
to counter the remaining forward
or lateral “thrusting” motion of the
tongue. In this way, we get beyond

drooling and dribbling, but the bad
habit remains. A telltale sign of a soft
tissue dysfunction during swallowing
is the appearance of any contrac-
tion of the facial muscles. When the
tongue has been properly trained to
rest and function on the palate, those
facial dysfunctions will disappear.
Then there are competencies that also
influence facial growth that go beyond the
teeth attached to the child and on to the child
attached to the teeth.
1. Efficient breathing using the
diaphragm. Optimal minute/volume
(low and slow) ensures proper gas
exchange and the best delivery
of oxygen to target tissues. The
diaphragm also is the pump for the
upper body lymphatic system helping
infection drain from swollen tonsils.
2. A nourishing (not challenging) diet
requiring masticatory fitness. Much
of what we eat contains elements
not recognized as food by our
bodies. We have to work extra hard
to eliminate, destroy, or sequester
these non-nutritional materials (e.g.,
preservatives, antibiotics, pesticides,
colorants, fertilizers, etc.).
3. Proper posture of the head and
body against gravity. Holding the
head forward may open the airway,
but it puts excessive strain on lingual,
suprahyoid, infrahyoid, and cervical
strap muscles in a chain that leads
down to the feet.
4. Restorative, refreshing sleep. More
than the teeth, the quality of our sleep
suffers the most from the morpho-
logic changes to the airway that occur
from the poor habits listed above.
The above competencies can be encour-
aged in the orthodontic office but may require
referral to appropriate healthcare providers.
Incompetence and compensation
Each of these eight competencies were
part of our evolutionary upbringing and were
at the root of our survival. Anthropologists tell
us that “recent” changes in our environment
(i.e., modern civilization) have challenged
these competencies with chronic stressors
such as changes in our bodily actions
(posture, sitting, activity levels, soft diet, etc.);
changes in our exposures (quality of food, air,
water, skin contacts, etc.); and changes in
our attitude (our reactions to chronic mental
frustrations and challenges).19,20,21
We have had to make a variety of
compensations to deal with these changes.
Volume 7 Number 4 Orthodontic practice 37
Unless there are congenitally
missing or extra teeth or premature
loss due to caries or trauma,
most malocclusions are to some
degree acquired — or at very least
exacerbated by — habits that
cause the alveolar processes to
deform and prevent the teeth from
easily erupting into place.
For one of thousands of examples, if our
bodies are unable to process or tolerate a
certain food (dairy or wheat) and we activate
immune system functions to combat them
(swollen tonsils and adenoids), making nasal
breathing (the first competency) difficult. We
compensate by opening our mouths to
breathe. As noted above, the consequence
of that new “habit” is maxillary collapse and
hence, malocclusion.
This principle is at the heart of Evolu-
tionary Medicine (and Darwinian Dentistry,
per Boyd) and explains in great measure
not only the increasing incidence of mal-
occlusion but also all the other chronic
non-communicable diseases of civilization
(lifestyle diseases) that plague us (including
caries and sleep apnea among many others
like heart disease, obesity, diabetes, osteo-
porosis, certain cancers, and so on).22,23
In other words, chronic disease like
malocclusion is the result of something
we do (compensations), and hence can be
changed by something we do (foster compe-
tencies). Since these are behaviors, then the
solution must be behavioral as well. Much
to the chagrin of orthodontists who have
been inventing and implementing numerous
ways to eliminate cooperation as a variable
CONTINUING EDUCATION
in our treatments, there is no way around
it anymore. We must ask our patients to
change their habits in order to change their
health. As they say, “If nothing changes,
nothing will change.”
Doing form and function
Orthodontics is quite proficient in
changing form and has long argued that if
you “change the form, function will follow.”
We must now see this as an incomplete
approach to the problem. While it may be
perfectly suitable in any one case to begin
with a “form” treatment (i.e., maxillary arch
development), it must be followed by func-
tional treatment to break the spiral and
prevent relapse. Other patients may need
only functional treatment to set growth on a
better trajectory. Most importantly, the ortho-
dontic practice of the future must handle
both form and functional deficiencies with
modalities appropriate to each.
In general, a comprehensive myo-
functional treatment plan includes the following:
1. A complete assessment. Mal-
occlusion is only the tip of the
iceberg. We have to start asking
“why?” and looking for the etiolo-
gies of the problem. That means
learning to see and looking for soft
tissue dysfunctions and their side
effects. Look for where the major
competencies are lacking, and realize
that the Angle classification is only a
symptom, not a diagnosis.
2. Foster competencies. The ulti-
mate in preventive orthodontics is
when you can change outcomes by
changing behaviors. Of course, this
means starting very early. It means
talking with moms about their infants
and toddlers. It means looking for the
habits (blocked airway, lip incompe-
tence, low tongue posture, aberrant
swallow, etc.) that create the prob-
lems before the problems take hold.
If we continue to wait for “braces
age” or continue to argue that Phase
II treatment is adequate for aligning
the teeth, we completely miss the
opportunity to assist facial growth.
In many ways, the teeth are not the
problem at all, rather a symptom of
an imbalance elsewhere.
3. Relieve the compromises. This
means reversing the damage already
caused by the dysfunctions and not
just in the transverse dimension.
Maxillary shape has to be, if possible,
reconstituted in four dimensions of
CONTINUING EDUCATION
space: width, sagittal, vertical, and
cant. This is where orthodontics can
be most helpful, and it is why we
must be involved in this field. Many
of our current techniques have limita-
tions (i.e., they tend to be retractive
of an already deficient maxilla), but
alternative treatments do exist. As
specialists, we need to expand our
repertoire to include modalities that
help the face grow forward, create
more tongue space, and preserve
or enhance the nasopharyngeal
airway.24,25,26,27,28
4. Reduce compensations. To re-
iterate, changing form is not enough.
If you don’t correct the reason the
malocclusion started in the first
place, why should it be stable at all?
Splinting incisors together and calling
a case stable are no longer a satis-
factory endpoint unless you started
treatment too late. We have to teach
and foster the good habits — as
noted previously — that will not only
keep our orthodontic results more
stable but also lead to better health
all around for our children.
Becoming a myofunctional ortho-
dontic practice
There are a few necessary steps to take
in upgrading an orthodontic practice to deal
with a bigger picture of health. There are
protocols to change, techniques to adopt,
and some simple changes to the office
environment. But most important of all is to
establish the position of a Health Educator
on your staff. You, the orthodontist, are much
too busy with the form treatments to have the
time to sit and educate your patients. While
you will soon "talk the talk" to each of your
patients and parents about the importance
of good health habits, you will need someone
by your side to actually do the teaching. The
analogy is the dental hygienists (who, by the
way, are naturally great educators) who stand
by the side of the general or perio practitioner
to support his/her efforts. What dental prac-
tice today doesn’t have a hygienist doing
what the GP doesn’t need to do?
The orthodontic practice of the future
will similarly have an adjunctive professional
position to complete the care model. This
person will augment your assessment and
record taking. He/she will help spot some of
the problems the children have (it’s amazing
what you can see in the reception area) and
be able to explain your program to the moms.
He/she will run the education program, track
38 Orthodontic practice Volume 7 Number 4
the progress of the patients, and trouble- ———————————————————
shoot the cooperation and motivation issues
of each child. In short, health educators take Health Coach Sara greets Alex again the
care of the work for you. next month and sees he’s got a sparkle in his
The transition into a myofunctional, eye. “I did it!”, crows Alex, “I wore my trainer
airway-aware orthodontic practice takes every day, and look at my teeth! They’re
work, time, training, and a lot of commit- getting straighter!”
ment. But it can be done and needs to be The two sit down at the video screen
done if our profession is going to rise above and go over the next set of exercises and
the fray of people looking to do orthodontics set his goals for next time. His ortho-
faster, cheaper, and easier. More importantly, dontist is amazed to see the open bite
our children are suffering from a whole host closing on the right side and breathes a
of chronic diseases that orthodontics can sigh of relief. “Boy, that makes life easy,” he/
favorably affect since their origin is within she thinks.
our scope of concern — the stomatognathic Author’s second note: Now give this
system. We need to regain our position as article to the one person on your staff who
physicians of the face and nurture a new is sharp and might be excited about this
generation into better health. concept, and see what he/she says. OP
REFERENCES
1. Bakor, SF, Enlow DH, Pontes P, De Biase NG. Craniofacial growth variations in nasal-breathing, oral-breathing, and tracheoto-
mized children. Am J Orthod Dentofacial Orthop. 2011;140(4):486-492.
2. Boyd K. Darwinian Dentistry part 1: an evolutionary perspective on the etiology of malocclusion. JAOS. 2011;11(3):34-39.
3. Bronson, J. Case Report: rapid improvement of enlarged tonsils following treatment with and ALF (Advanced Light Force)
appliance. Journal of Gnathologic Orthopedics and Facial Orthotropics. 2013;5-7.
4. Corruccini RS, Flander LB, Kaul SS. Mouth breathing, occlusion, and modernization in a north Indian population. Angle Orthod.
1985; 55(3):190-196.
5. Graber, TM. The “three M’s”: muscles, malformation, and malocclusion. AJO-DO. 1963; 49(6):418-450.
6. Guilleminault C, Huang YS, Montero PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-
disordered breathing. Sleep Med. 2013;14(6):518-525.
7. Gungor A, Turkkahraman H. Effects of airway problems on maxillary growth: a review. Eur J Dent. 2009;3(3):250-254.
8. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372.
9. Huang YS, Quo S, Berkowski JA, Guilleminault C. Short lingual frenulum and obstructive sleep apnea in children. 2015;1:1-4.
10. Lieberman, D, The Evolution of the Human Head. Harvard University Press, 2011.
11. Lieberman, D. The Story of the Human Body: Evolution, Health, and Disease. Pantheon Press, 2013.
12. Mew JR. The postural basis of malocclusion: A philosophical review, Am J Orthod Dentofacial Orthop. 2004;126(6):729-738.
13. Mew J. ibid.
14. Mew, M. Craniofacial dystrophy. a possible syndrome? Br Dent J. 216(10):555-558.
15. Moss ML, Rankow RM. The role of the functional matrix in mandibular growth, Angle Orthod. 1968;38(2):95-103.
16. Nesse R, Williams G. Why we get sick: the new science of Darwinian medicine. Vintage Books, 1994.
17. Ovsenik, M. Incorrect orofacial functions until 5 years of age and their association with posterior crossbite. Am J Orthod Dento-
facial Orthop. 2009;136(3):375-381.
18. Ramirez-Yañez G, Sidlauskas, Junior E, Fluter J. Dimensional changes in dental arches after treatment with a prefabricated
functional appliance. J Clin Pediatr Dent. 2007; 31(4):279-283.
19. Ramirez-Yañez GO, Farrell C. Soft tissue dysfunction: a missing clue when treating malocclusions. Int J Jaw Func Orthop.
2005;1:483-494.
20. Rogers AP. A restatement of the myofunctional concept in orthodontics. Am J Orthod. 1950;36(11):845-855.
21. Seeman J, Kundt G, and Stahl de Castrillon F. Relationship between occlusal findings and orofacial myofunctional status in
primary and mixed dentition, J Orofac Orthop. 2011;72(1):21-32.
22. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morpho-
metrics. Cranio. 2007;25(2):84-89.
23. Singh GD. Spatial matrix hypothesis. Br Dent J. 2007;202(5):238-239.
24. Singh GD, Griffin TM, Chandrashekhar R. Biomimetic oral appliance therapy in adults with mild to moderate obstructive sleep
apnea. Austin J Sleep Disord. 2014;1(1):5.
25. Timms DJ, Tremouth MJ. A quantified comparison of craniofacial form with nasal respiratory function. Am J Orthod Dentofacial
Orthop. 1988;94(3):216-221.
26. Vig K, Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. Am J Orthod Dentofacial Orthop.
1998;113(6):603-611.
27. Woodside DG, Altuna G, Harvold E, Metaxaz A Primate experiments in malocclusion and bone induction. Am J Orthod.
1983;83(6)460-468.
28. Woodside, DJ, Linder-Aronson S, Lundstrom A, McWilliam J. Mandibular and maxillary growth after changed mode of breathing.
Am J Orthod Dentofacial Orthop. 1991;100(1):1-18.
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Airway orthodontics the new paradigm: part 2, a vision for the future
RAPHAEL

1. Most all children with malocclusions have 4. The ability to keep the lips _______ is critical a. and should remain just as active
_________ associated with them. for several reasons. b. but should become inactive
a. some degree of soft tissue dysfunction a. moist c. and should strengthen
b. supernumerary teeth b. open at rest d. and should be exercised
c. severe trauma c. closed at rest
d. congenitally missing teeth d. slightly parted 8. Holding the head forward may open the
airway, but it puts excessive strain on ______
2. Unless there are ______, most malocclusions 5. Just like the brain is the scaffold for the growing and cervical trap muscles in a chain that leads
are to some degree acquired — or at very calvaria, and the eyeball is the scaffold for the down to the feet.
least exacerbated by — habits that cause the growing orbit, _____ is/are the scaffold around a. lingual
alveolar processes to deform and prevent the which the palate takes its shape. b. suprahyoid
teeth from easily erupting into place. a. mentalis muscles c. infrahyoid
b. the tongue
a. congenitally missing teeth d. all of the above
c. the teeth
b. extra teeth
d. orbicularis oris
c. premature loss due to caries or trauma 9. Look for where the major competencies are
d. all of the above lacking, and realize that the Angle classifica-
6. The collapse of the maxilla (in all three planes
tion is _________.
of space) is perhaps ________ of modern
3. While there has been much controversy over a. only a diagnosis, not a symptom
malocclusion.
the influence of mouth breathing on the influ- a. the most common feature b. neither a diagnosis nor a symptom
ence of facial growth in the orthodontic litera- b. the most uncommon feature c. only a symptom, not a diagnosis
ture, ________ is a damaging influence to the c. a very painful result d. both a symptom and a diagnosis
growing (and aging) face not because of the d. an unusual result
change in respiratory mode but because of the 10. The ultimate in preventative orthodontics is
change in oral rest posture that results from it. 7. In the infant, the facial nerve efferents partici- when you can change outcomes by _______.
a. TMD pate in suckling with an “infantile” swallow a. changing behaviors
b. nasal airway obstruction ________ when we transition to a mature, b. encouraging the use of expanders
c. pharyngeal airway obstruction tongue-to-palate swallow when the primary c. testing for allergies before orthodontics
d. both b and c teeth come in. d. enforcing mouth breathing

Volume 7 Number 4 Orthodontic practice 39

ABSTRACTS
Accuracy and reliability of Dolphin 3D voxel-based
superimposition
Mohamed Bazina, DDS, MSD
Background
Superimposition of
cephalograms has many
uses in orthodontics,
including growth evalu-
ation and outcome assessments, but
cephalograms are distorted and show
incomplete two-dimensional data. Cone
beam computed tomography (CBCT)
provides a three-dimensional, undistorted,
and more complete analysis of our patients.
Superimposition of 2 CBCTs is possible by
using landmarks, surfaces, or density infor-
mation (voxel-based). Voxel-based super-
imposition is automated and uses the most
image content, providing the most accurate
result. Until recently such superimposition
was extremely laborious, but a user-friendly
voxel-based superimposition has recently
been introduced.
40 Orthodontic practice Volume 7 Number 4
Abstracts
Aim
To evaluate the accuracy and reliability
of Dolphin 3D voxel-based superimposition.
Methods
This was a retrospective study using
existing scans of 31 surgical orthodontic
patients. The sample included 19 females
and 12 males with a mean age of 21. Each
patient had a pre-surgical (T1) and a post-
surgical (T2) scan taken within 12 months.
Surgical patients were used due to lack of
expected growth to reduce outcome bias.
The volumes were superimposed using voxel-
based methods from Dolphin Imaging Systems
and the accepted method used by Cevidanes,
et al. The Cevidanes method, considered as
the gold standard, uses two different open-
source programs and takes about 3 hours
to complete, while the Dolphin method takes
under 5 minutes. T2 was superimposed on T1
cranial base. T2 registrations for both methods
were compared to each other using the abso-
lute closest point color map, with emphasis on
7 regions (Nasion, A point, B point, bilateral
zygomatic, and bilateral gonion).
Results
Intraclass correlation showed excel-
lent reliability (0.96). The mean differences
between the two methods were less than
0.21 mm (voxel size = 0.38). The least differ-
ence was in the left zygomatic area with 0.09
mm ±0.07, while the largest was in the right
gonion region with 0.21 mm ±0.13.
Conclusion
Dolphin 3D voxel-based superimposition,
a fast and user-friendly method, is accurate
and reliable.

Screw-type device diameter and orthodontic loading
influence adjacent bone remodeling
J. Christian Francis, DDS, MS, University of Kentucky
Background
Utilization of screw-
type devices for ortho-
dontic anchorage con-
tinues to increase. These
screws have been designed progressively
narrower to allow for interradicular place-
ment, but failure rates are significantly
higher than those of wider endosseous
implants. Bone remodeling adjacent to these
anchorage screws is critical to maintaining a
healthy bone-screw interface and sustaining
orthodontic forces.
Purpose
The purpose of this study was to
evaluate the effect of diameter and ortho-
dontic loading of a screw-type device on
supporting bone remodeling.
The effects of corticotomies on frontonasal suture
expansion and bone modeling in mature rabbits
Brittany M. Wright-Graves, DDS, MS
Background
Although expansion
of complex adult sutures
with continuous forces
has been shown to
be possible, the amounts of expansion
obtained were limited. Whether the bony
sutural interface can be altered to enhance
sutural separation has not been experimen-
tally investigated.
Purpose
This split-skull study was designed to
evaluate whether corticotomies enhance
bone modeling and reduce the resistance
of sutural articulations during expansion in
mature rabbits
Materials and Methods
Nine adult female rabbits, 8 to 9 months
old, had miniscrew implant (MSI) supported
Volume 7 Number 4 Orthodontic practice 41
Research Design
Anchorage devices (n = 70) with 1.6 mm,
2.0 mm, 3.0 mm, and 3.75 mm diameters
were placed into edentulous sites in skel-
etally mature beagle dogs following premolar
extraction and healing. In a split-mouth
design, devices on one side were loaded
(2N) utilizing calibrated coil springs. Epifluo-
rescent bone labels were given i.v. prior to
sacrifice. Bone-implant sections (~ 70 µm)
were prepared using undecalcified methods.
Bone formation rate (BFR, %/yr) and other
histomorphometric variables were assessed
using imaging software.
Results
The BFR varied by jaw. The mean BFR
ranged from 10.93%/yr. to 38.91%/yr. The
BFR was significantly (p <0.05) lower in bone
adjacent to the 1.6 mm diameter screws
compared to bone adjacent to the 2.0 mm,
expansion devices with 150 g open-coil
nickel-titanium springs placed bilaterally
across the frontonasal sutures. Corticoto-
mies were performed, anterior and posterior
to the frontonasal suture, on one randomly
chosen side. The other side served as the
control. Sutural separation was measured
bi-weekly for 7 weeks. Using µCT scans of
each specimen, bone material density and
bone volume fraction were measured. Quali-
tative histologic analyses of the tissues were
performed using H&E staining.
Results
Most (94.4%) of the MSIs remained
stable throughout the experiment. There
was significantly (p <.05) more sutural
separation on the corticotomy side (3.73
mm) than the control side (2.83 mm). Bone
volume fraction was 5.1% less, and bone
density was 1.6% less on the corticictomy
ABSTRACTS
3.0 mm, and 3.75 mm diameter screws. BFR
was lower adjacent to loaded 1.6 mm screws
compared to non-loaded 1.6 mm screws
(p <0.01) or loaded 2.0-3.75 mm diameter
screws (p <0.01). No significant differences in
BFR were noted, regardless of loading condi-
tion, between the 2.0 mm, 3.0 mm, and 3.75
mm diameter screws.
Conclusion
We detected a dramatic reduction in a
critical biologic parameter, bone remodeling,
in a controlled experimental design. While
orthodontic loading of 2N did not alter bone
remodeling associated with screws of 2.0
mm diameter or larger, it did decrease bone
remodeling adjacent to the 1.6 mm screws.
2.0 mm diameter or larger machined screws
may be more likely to maintain a healthy
bone-implant interface under typical ortho-
dontic forces.
than control side. The amount of expansion
that occurred was negatively correlated (R =
.860; p = <.001) with bone density. Blinded
histological evaluations showed increased
numbers of osteoblasts along the bone
fronts on the corticotomy side. Compared
to the control side, the sutural margins
on the corticotomy side exhibited greater
numbers of elongated Sharpey’s fiber inser-
tions, greater amounts of immature woven
bone, and more osteocytes.
Conclusion
Mature sutures expanded with adjunc-
tive corticotomies undergo 31% more
separation than sutures expanded without
corticotomies, with the amount of expan-
sion that occurs being inversely related to
bone density. OP
Abstracts are courtesy of DENTSPLY GAC.
STEP-BY-STEP

Scanning with CEREC Ortho for clear aligner

treatment
Dr. Peter Gardell outlines the steps in a process for taking digital impressions for use with clear aligners

F or years now, I’ve been using the

CEREC Omnicam for intraoral scanning
and ClearCorrect’s clear aligner system
for orthodontics. Now that CEREC Ortho
has arrived, I can use my Omnicam to
take digital impressions for use with clear
aligners and finally get rid of PVS material
once and for all.
About CEREC Ortho
CEREC Ortho is a newly released soft-
ware that has made capturing high-quality
full-arch digital impressions much faster than
was previously possible. It does this by using
a well-defined imaging pattern, in which the
software guides the clinician through step
by step.
When doing full-arch scans, I have found
two items that help with the scanning process:
1. The Isolite® retraction system offers
control of the patient’s soft tissue and
control of saliva, which can interfere
with the imaging process. Half of the
arch can be scanned, and then the
Isolite Mouthpiece can be reposi-
tioned and the rest of the dentition
captured.
2. The OptraGate® from Ivoclar Viva-
dent® is indispensable for efficient
imaging. I love this product to be in
place when taking the photographic
Peter Gardell, DDS, graduated from New York University College of Dentistry with honors. He has received numerous
awards for clinical excellence. Dr. Gardell has attained faculty and clinical mentor positions at some of the most
prestigious educational institutions in the United States. He has written articles and lectured extensively on many of the
technologies he has implemented in his office. Dr. Gardell is a member of the American Academy of Cosmetic Dentistry.
Disclosure: Dr. Gardell acknowledges having received no compensation from ClearCorrect.
records as well. It retracts the lips and
keeps the buccal mucosa away back
to the first molar. It does this comfort-
ably for the patient, so leaving it in
place during the visit is acceptable
and speeds up the entire process.
Before you get started with the scanning
process, special attention should be paid
to ensure that all embrasures of the teeth
are captured, and at least 2 mm of gingiva
should be captured as well.
Full-arch scanning
When scanning, you will image the mouth
in a set, specified manner. You will start by
positioning the camera over the mandibular
second right molar and holding it still for a
few seconds. The camera will activate, and
an audio signal will alert the operator that
imaging has commenced. Roll the camera
to the lingual surfaces, and be sure to move
the camera anterior in a smooth and steady
manner. Do not move the camera distal at
this point. Once you are in the area of the
lower left lateral and canine, again hold the
camera steady for a few seconds. An audio
tone will then signify that this sweep has
been completed.
Return the camera to the occlusal of the
right mandibular second molar, and again
wait for the audio signal. Move the camera
anterior, capturing the occlusal surfaces of
the teeth. As you move forward over the lower
incisors, the camera will beep indicating that
you have completed your second sweep.
Next, bring the camera back to the
occlusal of the second molar. Wait for the
audio cue, and then rotate the camera to
the buccal side. Move the camera forward
until a beep is heard, signifying that the third
sweep has been completed.
To complete the imaging, one more
sweep is required to tie the buccal, lingual,
and occlusal sweeps together. You should
look for any unclear areas on the digital
model, which can be filled in where needed.
(These areas will be displayed in yellow.) Hold
the camera over an area that has already
been captured, and wait for the camera to
activate. Now you can fill in any existing holes
freehand. There is no set imaging protocol
for this (if this step is needed at all).
You will then repeat this entire process
for the upper jaw.
Buccal-bite scanning
The next step is the most exciting for
seasoned CEREC users — capturing the
dual buccal bite. Capturing the buccal bite
has proven to be difficult for many doctors
who were previously scanning in CEREC
Connect. This is yet another reason why
CEREC Ortho is superior for full-arch scan-
ning. Similar to the scanning of the arches,
the buccal scan is done in a well-defined
process, which the software will guide the
clinician through. It is very important to
explain to the patients to bite firmly and to
keep their teeth together as you image one
side, followed by the opposing side.
When the buccal scan begins, there will
be a start point displayed on the screen.
Hold the camera steady on the mark (which
is in the area of the first and second maxil-
lary premolar), and wait for the audio signal.
Move the camera down toward buccal
surfaces of the mandibular teeth trying to
overlay the camera placement with the
target on the screen. Repeat the process
on the contralateral side. Once both sides
have been scanned, the models will auto-
articulate (or “snap”) into position, which will

42 Orthodontic practice Volume 7 Number 4

 STEP-BY-STEP
conclude the imaging phase of the CEREC
Ortho software. Videos of this process are
available to view at www.Cerecdoctors.com.

Advantages
There is an immediate advantage of
scanning with CEREC Ortho as compared
to scanning with CEREC Connect — the
first being dramatically decreased file sizes.
There are also significant advancements
with CEREC Ortho in the processing of
virtual models: Unwanted and unnecessary
soft tissue and artifacts will be automatically
removed by the software. All of this adds up
to a crisper and cleaner virtual model for the
orthodontist to evaluate and for ClearCorrect
to fabricate the aligners from.
and photos can easily be uploaded. Once need to waste money on PVS materials and
Case submission the case has been submitted, a case number shipping fees, and even better — the clini-
After the scan has been submitted, will be assigned. This number will be used cian will receive the treatment setup from
the orthodontist will need to access Clear- to identify this case from start to finish. ClearCorrect in as quickly as 24 hours.
Correct doctor’s portal in order to submit ClearCorrect will then amass all the informa- When using traditional PVS impressions, the
the corresponding case to ClearCorrect tion submitted, including the scans, and in impressions would likely still be at the ship-
(dr.clearcorrect.com). Basic patient informa- short order will send a confirmation of receipt. ping carrier’s sort facility after 24 hours, likely
tion will be entered, and a checklist will be filled And that’s it — all of the patient’s records not arriving to the lab for days! Patients are
out on the desired treatment and movements. have been submitted to ClearCorrect, with- sure to be thrilled with the expedited treat-
There is even a section where radiographs out having to mail a single thing to the lab. No ment they’ll receive. OP

Quality.We’ve been making clear

aligners for almost ten years.
We’ve gotten very good at it.

Free Limited 6 Case

Use promo code OPRAC2
when you sign up for free at clearcorrect.com/doctors

Volume 7 Number 4 Orthodontic practice 43

LABORATORY LINK

Digital indirect bonding

James Bonham describes how CAD technology

delivers precision bracket placement

C omputer-aided design (CAD) software

enables engineers and architects to
design, inspect, and manage engineering
projects within an integrated graphical
user interface (GUI). Computers are proven
to enhance the precision and efficiency
of creation, modification, and analysis of
any design. Dental professionals currently
use CAD technology every day to design
appliances like implant surgical guides,
crowns and bridges, and tooth aligners to
name a few. More recently, CAD technology
is assisting orthodontists with treatment
planning and precision bracket placement.
3DiB (three-dimensional indirect bonding)
is the latest bracket-placement CAD tech-
nology from ARCAD Digital Lab (the software
developer) and Specialty Appliances ortho-
dontic laboratory. 3DiB has many unique
features, including an online communica-
tion portal, a web-based approver soft-
ware, and an extensive bracket file library.
The advanced CAD software simulates the
patient’s ideal posttreatment finish derived
from the doctor’s treatment plan, and then
identifies the exact bracket location for effi-
cient straight-wire tooth alignment. Ortho-
dontists have the flexibility to quickly view,
edit, and approve their cases from almost
any Windows®-based computer. Instead
of forcing clinicians to use an unfamiliar
appliance, 3DiB allows them to select their
preferred bracket system for each individual
orthodontic case.
Every orthodontic bracket has a unique
prescription of torque, tip, and angulation
built into the bracket. 3DiB software under-
stands how the bracket’s prescription is
expressed when attached to the tooth and
engaged with the doctor’s finishing archwire.
Using this knowledge, the software finds the
best bracket location on each tooth’s unique
anatomical surface that will perfectly align the
archwire slots and achieve the doctor’s ideal
treatment finish.
James Bonham is a partner at Specialty Appliances
and manages sales and marketing. He has spent
the past 12 years in orthodontics with a strong
focus on the integration of digital technology into
orthodontic practices.
Once the ideal setup is completed and
checked for quality by experienced tech-
nicians, the orthodontist is notified through
3DiB’s secure communication portal. Clini-
cians can log into their portal and have full
control to adjust either teeth in the ideal
setup, or bracket location on the pretreat-
ment malocclusion model. If they decide to
adjust the posttreatment setup, brackets
automatically adjust to their new location
on the pretreatment malocclusion. To the
contrary, doctors can also choose to move
brackets on the pretreatment malocclusion
and instantly witness the adjusted tooth posi- the doctors’ approved ideal placement of
tion on the posttreatment setup. This easy their brackets.
approval process usually takes 5 minutes Transfer trays can be sectioned or
or less of the doctors’ valuable time. When delivered in whole to each arch by a single
doctors are happy with their case setup, they orthodontic chairside assistant. Specialty
simply click on the approve button, and the Appliances recommends a chairside
case gets forwarded to Specialty Appliances delivery system using a light-cured flowable
for indirect tray fabrication. composite. This reliable delivery system has
Specialty Appliances then reviews the proven results of excellent bond strength
doctor-approved setup and prints the mal- and minimal to no adhesive flash. In-
occlusion model. Using a proprietary system direct bonding training materials and on-site
to capture the doctors’ ideal bracket posi- training are available through Specialty Appli-
tion, the lab places the brackets on a printed ances’ upon request.
malocclusion model. Specialty then manu- Excellent bracket placement has always
factures an indirect transfer tray with custom been a sure way to move teeth efficiently,
adhesive bases on each bracket pad. This decreasing orthodontic treatment time. 3DiB
process ensures a perfect custom fit of each is a fine use of CAD technology to help ortho-
bracket to the tooth’s enamel surface. 3DiB’s dontists achieve greater precision in bracket
indirect transfer trays will efficiently deliver placement. OP

44 Orthodontic practice Volume 7 Number 4

 CUSTOM CLASS II
FIXED APPLIANCES

Specialty’s M4™ MiniScope® Herbst is known for durability and patient

comfort. The compact design offers room for orthodontic bracket therapy
while simultaneously correcting the class II malocclusion. M4 also delivers the
greatest range of motion, allowing 40 degrees of lateral movement and
a maximum incisal opening of 64mm.
Request Applecore Screws for any herbst design
and we will provide them at no additional charge!

Specialty’s custom M.A.R.A. is a simple and predictable

appliance for mandibular advancement on class II patients.
The appliance is attached to the first molars, or the deciduous
second molars, with crowns or Specialty’s ROC crowns.
Adjustments are achieved by adding shims and/or bending
the removable upper elbow. Expansion can be incorporated
into each arch as needed.

Specialty Appliances is a full service orthodontic laboratory, manufacturing more than 250 premier products.

800.522.4636 • SpecialtyAppliances.com
4905 Hammond Industrial Drive, Suite J • Cumming • Georgia 30041
PRODUCT PROFILE
3M — A system of proven products
A beautiful smile throughout treatment
Y our patients look to you to enable their
most beautiful smile, even while they’re
undergoing orthodontic treatment. While
esthetics might begin with ceramic brackets
with clear or colored ligatures — it doesn’t
end there. Class II correction is an everyday
part of your practice, and it’s a process that
can be esthetic too. 3M has put years of
science to work to develop a system of
proven products that allows your patients to
be comfortable, happy, and confident while
you’re correcting their Class II malocclusion.
A brilliant system
Patient-pleasing esthetics begins with
the leading ceramic system. Clarity™
ADVANCED Ceramic Brackets provide
exceptional esthetics and strength in a small
size, with smooth surface uppers and lowers
that resist staining and discolor-
ation throughout treatment. These
ceramic brackets are proven —
offering predictable debonding
and enhanced patient comfort.
Clarity ADVANCED brackets are
the first step to truly esthetic Class
II correction.
Adding efficiency and time-
savings, APC™ Flash-Free
Adhesive provides an improved
patient bonding experience.
The system eliminates the
flash removal step completely,
reducing bonding time, and
there is no compromise in
bond strength. Early users have
reported less than a 2% bond
failure rate. The adhesive on the
tooth after bonding has been
shown to protect enamel under
the adhesive, further contrib-
uting to a beautiful smile after
treatment.
Designed with extensive user
input, Victory Series™ Superior Fit
Buccal Tubes eliminate the need
to band molars. They feature a
complex-contour curvature base
for superior fit, are easy to place
and handle, and offer a sleek,
low-profile, and tapered body for
patient comfort. Availability with Actual patient wearing Clarity™ ADVANCED Brackets and Forsus™ Class II correctors
46 Orthodontic practice Volume 7 Number 4
APC Flash-Free Adhesive coating means
increased efficiency at placement and supe-
rior strength.
Treatment for Class II malocclusion has
traditionally been limited to products that are
easy to install, but require patient compliance,
or products that are fixed but difficult to work
with. Many appliances are worn outside the
mouth. With Forsus™ Class II correctors,
treatment becomes both hidden and fixed
— but without the hassle. Forsus Class II
correctors can be added at any time, without
molar bands. Cheek bulges are
eliminated, and the device remains
in place 24/7 without the need for
patient compliance. Today, Forsus
Class II correctors have been used
in the treatment of more than
1-million patients.
The result?
Simply beautiful
For you and your practice, this
intelligent system works around the
clock to speed progress and help
ensure optimal, esthetic results.
External hardware is eliminated,
with no headgear, face bow, or
elastics that can be embarrassing
for patients of all ages; and compli-
ance issues are no longer a threat
to effective treatment. Pairing
this with brilliant, patient-pleasing
esthetic brackets and more efficient
application means you can spend
more time with patients and more
time building a successful practice.
To see how 3M can make a
difference for you, visit 3M.com/
Aesthetics, and get your compli-
mentary samples. Or call 3M at
800-423-4588. OP
Complimentary samples are for U.S. doctors.
This information was provided by 3M.
Beautiful,
together.

Your patients trust you to provide them a beautiful smile

throughout treatment. Trust 3M for proven solutions to achieve your
desired end result. Together with 3M Science, you can deliver beautiful smiles
throughout treatment, even when correcting Class II malocclusion — and as an end result,
have a happier, more confident patient.

The answer is proven products that work beautifully together — together with you —
to deliver a beautiful smile.

Forsus™ Correctors — used in treatment

by more than 1 million patients!

Call to see how 3M can

make a difference for you.
(800) 423-4588 | 3M.com/ortho

© 3M 2016. All rights reserved. 3M, APC, Clarity, Forsus, and Victory Series are trademarks of 3M. Used under license in Canada.
PRODUCT PROFILE

Avex® CX2 brackets by Opal® Orthodontics

P atients seeking a world-renowned

orthodontic prescription that doesn’t
compromise esthetics or their confident
smile need look no further than the recently
introduced Avex® CX2 brackets. Avex CX2
brackets are the newest part of the world-
renowned McLaughlin Bennett System
4.0™ and are available exclusively through
Opal® Orthodontics.
Designed to help give patients confi-
dence throughout every step of their ortho-
dontic treatment, Avex CX2 brackets blend
naturally with tooth enamel and resist
staining, thanks to each bracket’s unique
polycrystalline-material makeup. The small,
low-profile design also provides maximum
patient comfort throughout treatment. Avex
CX2 brackets offer predictable, reliable results
allowing patients to reach their treatment
goals in less time.

Each Avex CX2 bracket features purchase

points on the tie wings that enhance patient
comfort and make ligation easier. Addition-
ally, generous undercuts on the tie wings Avex CX2 brackets offer predictable,
enable double tying of ligatures and chains
throughout orthodontic treatment. Preci-
sion wire slots on each bracket are true to
reliable results allowing patients to reach
specified dimensions, providing optimum
torque control, and the universal color iden- their treatment goals in less time.
tification markings correspond with the rest
of the Avex® Suite — making a complete
and compatible system from start to finish.
Color indicators in the wire slots also provide
an effective visual reference for precise Opal Orthodontics crafts each and every precision with which each and every bracket
positioning. Avex CX2 bracket with control and predict- is manufactured.
Additionally, mesial and distal pockets ability in mind and has even improved the To learn more about the Avex CX2
on each Avex CX2 bracket provide greater base of each bracket for simplified, easier brackets or the Avex Suite — part of
interbracket distance, reducing wire force bonding. The new compound contoured the McLaughlin Bennett System 4.0 —
while offering improved patient comfort. True base also ensures maximum bracket-to- please visit opalorthodontics.com, or call
torque in the base of the bracket delivers tooth fit. 888-863-5883. OP
optimal positioning and minimal occlusal Furthermore, the features of the Avex
interference while the base ridge enables Suite enable clinicians to treat to board
better handling. standards more efficiently, thanks to the This information was provided by Opal® Orthodontics.

48 Orthodontic practice Volume 7 Number 4

 Clearly
Confident.
With esthetic braces from Opal,
your patients can smile with confidence.

To purchase Avex CX2, call 888.863.5883 or visit

opalorthodontics.com to learn more.

Zara Guinard
Professional Triathlete, Coach, and Model opalorthodontics.com | 888.863.5883
© 2016 Ultradent Products, Inc. All rights reserved.
M AT E R I A L S
lllllllllllll & lllllllllllll
EQUIPMENT
3Shape and Ormco announce TRIOS® integration with
Insignia™ Advanced Smile Design™
TRIOS® — 3Shape’s digital color impression solution — is now
integrated with Insignia™ Advanced Smile Design™, a sophisticated
computer-designed treatment planning and custom-fabricated appli-
ance software system by Ormco, a manufacturer and provider of
advanced orthodontic technology and services. The timesaving
workflow integration enables orthodontists to send TRIOS intraoral
scans with just a click to Ormco for the planning and delivery of its
Insignia™ bracket treatment system. For orthodontists using TRIOS,
the integration eliminates the steps of having either to take an analog
PVS impression or to manually upload a large and bulky intraoral scan
file to a server. Now orthodontists can just choose Insignia from their
3Shape Communicate™ account to submit the case and send the
TRIOS digital color impression file to Ormco, which then uses the
intraoral scan to create its customized digital orthodontic treatments.
For more information, visit the Ormco website at http://www.
ormco.com/. For information about 3Shape, visit www.3shape.com.
Americo Dry Mouth Nightguard System
New from Great Lakes, the Americo Dry Mouth Nightguard
System is designed to protect teeth from the effects of abnormal
dry mouth and prevent permanent periodontal damage during sleep.
The custom-made upper and lower appliance trays are fabricated
to fit comfortably and hold a specially formulated gel that increases
salivary flow to protect tooth enamel. The Dry Mouth Nightguard
Gel contains xylitol, an anti-cariogenic agent that consistently main-
tains moisture around the teeth and gums throughout the night,
reduces dental decay, plaque formation, and bacteria growth and
decreases the risk of oral infection. The Americo System, invented
by Dr. Americo Fernandes of Winnipeg, Canada, includes an upper
and lower appliance tray, Dry Mouth Nightguard Gel, appliance case,
and application brush.
For more information about the Americo Dry Mouth Night-
guard System, contact Great Lakes laboratory customer service
at 800-828-7626, or visit GreatLakesOrtho.com.
50 Orthodontic practice Volume 7 Number 4
Steripod® now available at CVS and Walgreens
Bonfit America, Inc., maker of products
for living well, recently doubled distribu-
tion for its market leading Steripod® clip-on
toothbrush protector, which is now avail-
able in 30,000 stores across the United
States, including for the first time 6,000
CVS and 6,000 Walgreens stores. Addi-
tionally, Steripod added 200 Meijer stores,
Shopko Wisconsin locations, and will roll
out to approximately 1,000 Kroger Co.
stores nationwide later this year. Steripod is
a clip-on protector that fits any standard or
electric toothbrush and keeps it fresh and
clean for up to 3 months using a patented
vapor shield of thymol — used in many mouthwashes and oral anti-
septics. Simply clip Steripod on an electric or manual toothbrush,
and it goes to work; no cables or batteries are needed.
Learn more at GetSteripod.com.
Ormco announces commercial availability of Alias™
Lingual Bracket System
Ormco announced the commercial availability of its Alias™
Lingual Bracket System, the world’s first straightwire, passive self-
ligating, square-slot lingual bracket. Ormco worked closely with
world-renowned lingual leaders and product inventors, Drs. Kyoto
Takemoto and Giuseppe Scuzzo, to develop this advancement in
lingual orthodontics that utilizes passive self-ligation and light forces,
provides excellent torque and rotational control, and facilitates easy,
fast, and comfortable wire changes.
With passive self-ligating technology, Alias features brackets
designed for optimized movement — the unique .018 vertical
square slot keeps the archwire properly engaged, allowing for more
precise treatment and greater rotational and torque control. The
Alias Lingual Bracket System is designed around three product
pillars: simplicity, efficiency, and comfort.
To learn more about Ormco, visit www.ormco.com.
New shopping cart from DGS Ortho
DGS Ortho, a Bristol Pennsylvania-based supply company, is
proud to announce its new shopping cart.
Visit DGSortho.com, and view hundreds of money-saving items.
The new site is easy to navigate and very easy to place orders. Email
with any questions: dgsortho@gmail.com.
 Turn Complex Class II and Class III
Patients into Simple Class I Patients

Class llI Appliance

Pre-treatment In-treatment Post-treatment

Class ll Appliance

Pre-treatment Corrected in 3 months, 20 days Post-treatment - 13 Months

CARRIERE MOTION™ APPLIANCES

®

Motion Appliances shorten overall treatment time by correcting Class II

and Class III malocclusions at the beginning of treatment, prior to bracket
placement, when patient motivation is highest.

Learn more about the Motion Appliance

at 888.851.0533 or visit HenryScheinOrtho.com

© 2016 Ortho Organizers, Inc. All rights reserved. PN M900 7/16

U.S. Patent 7618.257,6,976,839. 7,238,022, and 7,985,070 B2.
Foreign Patent Nos. 2,547,433, 1723927, and 2006202089
M AT E R I A L S
lllllllllllll & lllllllllllll American Orthodontics announces enhancements to
PowerScope™ 2 Class II Corrector
American Orthodontics announced two new features on its

EQUIPMENT PowerScope™ 2 Class II Corrector. PowerScope 2 now features

a magnetic sleeve that slides onto the hex head driver, ensuring a
secure hold on the appliance during installation and stabilizing the
attachment nut when seating it on the wire. In addition, PowerScope
2 has new activation lines that provide a clear visual cue during
activation. The three distinct lines are spaced 2 mm apart and refer-
ence the level of appliance activation, ranging from no activation to
partial to full. The appliance also includes an improved attachment
nut to increase durability and ease of installation.
PowerScope 2 is a one-size-fits-all appliance that requires no
lab setup or special band assemblies. It attaches wire to wire for
quick and easy chairside installation and features an internal NiTi
spring mechanism that delivers 260 grams of force for continuous
Ortho Technology showcases Plaque HD™ at AAO activation during treatment.
Ortho Technology’s recent partnership with Plaque HD™ put For more information, visit www.americanortho.com, or call
the company’s booth in a green spotlight, revealing a new hygiene 1-800-558-7687.
approach to customers and passersby alike. Plaque HD, a new
toothpaste, has green disclosing agents that color and identify
plaque — proven to help consumers remove up to 4 times more
plaque than standard toothpaste, according to its makers, with
published results in the International Journal of Dentistry and Oral
Science. Ortho Technology also launched two other well-established
products that proved popular — Chewies™ Aligner Tray Seaters and
ComfortBrace™ Dental Brace Protective Strips, a wax alternative
that offers superior protection, esthetics, and longevity.
For more information on Tampa, Florida-based Ortho Tech-
nology, call 1-800-999-3161.

INDUSTRY NEWS llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

DDS Solution offers digital study models and interactive Great Lakes Orthodontics wins ethics award
communication tools Great Lakes Orthodontics was recently named as the winner
DDS Solution is an of the 2016 Buffalo Niagara Business Ethics Association (BNBEA)
innovative orthodontic lab Award in the large business category. The BNBEA recognizes
that specializes in digital Buffalo Niagara companies that exemplify the highest standards
study models and inter- of ethical behavior and business practices.
active communication Great Lakes Orthodontics, an employee-owned company
tools. The lab can take the founded in 1967 and located in the Buffalo, New York, suburb
orthodontist’s impressions of Tonawanda, provides products, laboratory services, and both
or exported intraoral scans in-house and online appliance fabrication training to members of
and turn them into finished the orthodontic, prosthodontic, restorative, and general dental
study models that are imbedded in interactive PDF reports. These professions worldwide.
documents allow the orthodontist to share patient study models, To learn more, visit greatlakesortho.com.
both before and after, with the referring dentist, the patient, and any
other specialist or team member who needs to see them, without
requiring specialized software. Using Adobe Reader, which is found
on most computers, these PDFs are accessed and manipulated.
Adobe Reader includes built-in measurement and annotation tools
useful in visually communicating treatment options and plans.
For more information, call 719-347-1188, or visit http://www.
ddssolution.com.

52 Orthodontic practice Volume 7 Number 4

AUTHOR GUIDELINES
Orthodontic Practice US is a peer-reviewed,
bimonthly publication containing articles
by leading authors from around the world.
Orthodontic Practice US is designed to be read
by specialists in Orthodontics, Periodontics,
Oral Surgery, and Prosthodontics.
Submitting articles
Orthodontic Practice US requires original,
unpublished article submissions on orthodontic
topics, multidisciplinary dentistry, clinical cases,
practice management, technology, clinical updates,
literature reviews, and continuing education.
Typically, clinical articles and case studies
range between 1,500 and 3,000 words.
Authors can include up to 15 illustrations.
Manuscripts should be double-spaced, and
all pages should be numbered. Orthodontic
Practice US reserves the right to edit articles
for clarity and style as well as for the limitations
of space available.
Articles are classified as either clinical,
continuing education, technology, or research
reports. Clinical articles and continuing educa-
tion articles typically include case presentations,
technique reports, or literature reviews on a clin-
ical topic. Research reports state the problem
and the objective, describe the materials and
methods (so they can be duplicated and their
validity judged), report the results accurately
and concisely, provide discussion of the find-
ings, and offer conclusions that can be drawn
from the research. Under a separate heading,
research reports provide a statement of the
research’s clinical implications and relevance
to implant dentistry. Clinical and continuing
education articles include an abstract of up
to 250 words. Continuing education articles
also include three to four educational aims and
objectives, a short “expected outcomes” para-
graph, and a 10-question, multiple-choice quiz
with the correct answers indicated. Questions
and answers should be in the order of appear-
ance in the text, and verbatim. Product trade
names cited in the text must be accompanied
by a generic term and include the manufacturer,
city, and country in parentheses.
Additional items to include:
• Include full name, academic degrees, and
institutional affiliations and locations
• If presented as part of a meeting, please
state the name, date, and location of the
meeting
• Sources of support in the form of grants,
equipment, products, or drugs must be
disclosed
• Full contact details for the corresponding
author must be included
• Short author bio
• Author headshot
Volume 7 Number 4 Orthodontic practice 53
Pictures/images
Illustrations should be clearly identified,
numbered in sequential order, and accompa-
nied by a caption. Digital images must be high
resolution, 300 dpi minimum, and at least 90
mm wide. We can accept digital images in all
image formats (preferring .tif or jpeg).
Tables
Ensure that each table is cited in the text.
Number tables consecutively and provide a
brief title and caption (if appropriate) for each.
References
References must appear in the text as
numbered superscripts (not footnotes) and
should be listed at the end of the article in their
order of appearance in the text. The majority
of references should be less than 10 years
old. Provide inclusive page numbers, volume
and issue numbers, date of publication, and
all authors’ names. References should be
submitted in American Medical Association
style. For example:
Journals:
(Print)
Greenwall L. Combining bleaching techniques.
Aesthetic & Implant Dentistry. 2000;1(1):92-96.
(Online)
Author(s). Article title. Journal Name. Year;
vol(issue#):inclusive pages. URL. Accessed
[date].
Or in the case of a book:
Greenwall L. Bleaching techniques in
Restorative Dentistry: An Illustrated Guide.
London: Martin Dunitz; 2001.
Website:
Author or name of organization if no author
is listed. Title or name of the organization if
no title is provided. Name of website. URL.
Accessed Month Day, Year. Example of Date:
Accessed June 12, 2011.
Author’s name:
(Single) (Multiple)
Doe JF Doe JF, Roe JP
Permissions
Written permission must be obtained by
the author for material that has been published
in copyrighted material; this includes tables,
figures, pictures, and quoted text that exceeds
150 words. Signed release forms are required
for photographs of identifiable persons.
Disclosure of financial interest
Authors must disclose any financial interest
they (or family members) have in products
mentioned in their articles. They must also
disclose any developmental or research rela-
tionships with companies that manufacture
products by signing a “Conflict of Interest
Declaration” form after their article is accepted.
Any commercial or financial interest will be
acknowledged in the article.
Manuscript review
All clinical and continuing education
manuscripts are peer-reviewed and accepted,
accepted with modification, or rejected at the
discretion of the editorial review board. Authors
are responsible for meeting review board
requirements for final approval and publication
of manuscripts.
Proofing
Page proofs will be supplied to authors
for corrections and/or final sign off. Changes
should be limited to those that are essential for
correctness and clarity.
Articles should be submitted to:
Mali Schantz-Feld, editor in chief
mali@medmarkaz.com
Reprints/Extra issues
If reprints or additional issues are desired,
they must be ordered from the publisher when
the page proofs are reviewed by the authors.
The publisher does not stock reprints; however,
back issues can be purchased.
Checklist for article submissions:
3 A copy of the manuscript and figures,
captions, including all pictures (low res)
necessary for reviewers
3 Manuscript: double-spaced including
separate references, figure legends, and
tables
3 Abstract, educational objectives, expected
outcomes paragraph
3 References: double-spaced, alphabetical,
American Medical Association style
3 Tables: titled and cited in the text
3 Mandatory submission form, signed by
all authors
Please contact Mali Schantz-Feld, editor in
chief, with any questions via email:
Mali@medmarkaz.com
INDUSTRY NEWS
KaVo Kerr Group Imaging announces second annual
Dental 3D University event
Registration is open for the second annual Dental 3D University
(3DU), hosted by KaVo Kerr Group imaging brands Gendex™,
NOMAD™, SOREDEX™, and Instrumentarium™. 3DU is a one-of-
a-kind 2-day event that offers dental professionals an educational
environment dedicated to cone beam 3D (CBCT) solutions that
will enhance their practices and put them in full control of treat-
ment outcomes. 3DU will be held October 7-8, 2016, in Boston,
Massachusetts.
Welcoming doctors, staff, and dental students, 3DU gives
attendees the opportunity to earn up to 12 CE credits courtesy of
world-class speakers and industry experts, including:
• Christine Taxin on medical billing and insurance re-
imbursement
• Lou Graham, DDS, on his journey to 3D
• Kaveh Ghaboussi, DMD, on using 3D for implant planning
and more
• Lisa Koenig, BCHD, DDS, MS, offering anatomy and
pathology review
• Lou Shuman, DMD, CAGS, on social media and online
marketing 2016: search engine optimization, website and
mobile
Visit dental3DU.com/win for details and additional information
about the event.
OrthoBanc announces winners of $3 Billion Collected
Contest
After announcing Bourne Orthodontics of Marysville, Wash-
ington, as the first-prize winner of their $3 Billion Collected Contest,
OrthoBanc paid off the remaining balance of two deserving respon-
sible parties chosen by Bourne. One of the selected recipients is
a single dad who serves in the armed forces, and the other is a
single mom who has been diligent about paying on her balance.
OrthoBanc announced their $3 Billion Collected Contest last
August. “We were getting close to collecting nearly $3 billion in
payments for our valued customers, so we decided to use that
milestone as a chance to give something back to our customers
and also to a few deserving patients,” said Marla Merritt, Director
of Sales and Marketing for OrthoBanc.
For more information about OrthoBanc, visit orthobanc.com,
or call 888-758-0585, option 2.
54 Orthodontic practice Volume 7 Number 4
OrthoAccel® granted three new patents
OrthoAccel® Technologies,
Inc., has been granted two new
patents from the United States
Patent and Trademark Office,
and one international patent from the State Intellectual Patent Office
of the People’s Republic of China, in the category of vibrating dental
devices. The new patents protect key design elements and ranges
of parameters for AcceleDent. To use AcceleDent, patients bite
down on the product mouthpiece for 20 minutes daily while gentle
vibrations from its patented SoftPulse Technology™ accelerate
bone modeling and remodeling in the craniofacial region.
To learn more, visit AcceleDent.com.
LED Dental Inc. announces international VELscope® Vx
distribution agreement with major dental technology
provider in China
LED Medical Diagnostics Inc. reports that its wholly owned
subsidiary, LED Dental Inc., has signed an exclusive distribution
agreement with Biocare Health Supply Ltd. for the sale and distri-
bution of its award-winning VELscope® Vx system in China and
Hong Kong.
The VELscope Vx Enhanced Oral Assessment System is utilized
by dentists and health-care providers as an adjunct to the tradi-
tional comprehensive oral examination. The VELscope Vx’s tissue
fluorescence technology enhances the visualization of oral mucosal
abnormalities that many not be apparent or visible to the naked eye,
such as oral cancer and premalignant dysplasia. The VELscope Vx
is also intended to be used by surgeons to aid in the identification
of diseased tissue around a clinically apparent lesion, thus assisting
in the determination of the appropriate margin for surgical excision.
For more information, visit http://www.velscope.com/.
Brace yourself for Bracees
Dr. Sy Viet Nguyen, a dentist from
Ohio and the creator of Bracees
accessories for your mouth, is
launching his new company, Bracees
LLC. The company projects that his
patent-pending product will be the
next “it” thing for kids for years to
come. He came up with Bracees while
working on his orthodontic patients.
Initially, kids are very excited to get
braces, and then in the middle of treatment, he usually hears,
“When do I get my braces off?” He thought there has to be a better
way to get kids more excited about braces than just colored rubber
bands, so he created Bracees.
Bracees will allow kids to customize their braces daily — they
can wake up in the morning and pick out Bracees to match their
daily outfits. They can also show people their true personality
through their braces.
To find out more, visit www.bracees.com.
Address the Orthodontic Complexities You Face Everyday with...

clinical articles • management advice • practice profiles • technology reviews

July/August 2016 – Vol 7 No 4

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SMALL TALK
Practice integrity: fulfilling the promise
Dr. Joel Small discusses a strategy to create and maintain long-term success
H ave you ever stopped to consider the
enormous amount of time and effort
spent in the healthcare profession trying
to identify the secret to long-term success
for our clinical practices? Today there is a
continually growing abundance of courses,
journals, and consultants dedicated to
teaching us any number of techniques
or tricks of the trade to guarantee our
successful longevity. Perhaps this is an
indication that today’s healthcare providers
are coming to the realization that technical
skill, although a key factor, is not the only
determining factor of our overall success.
With all of this diverse information coming
at us from all directions, wouldn’t it be helpful
if there was one overarching theme that
consolidated this information into a single
concept that allowed us to better focus
and gain clarity with regard to a long-term
“success” strategy?... a theme that provided
for us a clear line of sight between where we
are now and where we need to be to ensure
years of prosperity and fulfillment?
One school of thought maintains that
BRANDING is this overarching theme, and
yes. Branding is important. Unfortunately,
the idea that a brand is created through
marketing is a common misconception that
actually hurts rather than helps our strategic
plan for success. Marketing, for all of its
hype, is simply a means of presenting our
message to prospective patients and refer-
rers. All marketing messages contain both
stated and implied promises that we make to
patients and referral sources. What we often
fail to realize is that it is our ability to deliver
Dr. Joel C. Small is a practicing endodontist
and the author of Face to Face: A Leadership
Guide for Healthcare Professionals and
Entrepreneurs. He received his MBA, with an
emphasis in healthcare management, from
Texas Tech University. He is a graduate of the
University of Texas at Dallas postgraduate
program in executive coaching and limits his
coaching practice to motivated healthcare professionals. He is
a nationally recognized speaker on the subjects of leadership
and professional development. Dr. Small is available for speaking
engagements and for coaching healthcare professionals who
wish to experience personal and professional growth while
taking their practices to a higher level of productivity. Dr. Small
can be reached at joel@joelsmall.com. Readers can sign up for
his blog at www.leadfaceface.com.
56 Orthodontic practice Volume 7 Number 4
on these promises that
creates our brand and
the environment for
long-term success in the
service industry. It is my
opinion that marketing
campaigns consistently
fail, not because the
message was not ideally
crafted, but rather the
underlying promise is
not kept.
I would like to submit
that the overarching
theme that drives our
success is not simply branding but what I
call Practice Integrity. So, what is practice
integrity and why is it so vital to our success?
Before answering this question, let me begin
by asking you to consider what qualities
you personally admire most in those people
who have positively influenced your life. I’ve
asked this question to literally hundreds of
our colleagues, and invariably many if not
most of us say that it is these influencer’s
ability to exhibited impeccable honesty and
a consistent willingness and ability to fulfill
their commitments that we admire most.
Interestingly, this same concept of honesty
and fulfillment of commitment is the found
in the definition of integrity, and whether it
is applied to a personal or professional rela-
tionship, it still holds true. Practice Integrity
knows no boundary. Whether we have a
small solo practice or a large multi-doctor,
multi-office practice, it is our practice integrity
that both creates and maintains our long-
term success.
So here’s an exercise that I would like
to suggest … one that I believe you will
find to be very beneficial in helping you and
your team find clarity and direction when
designing your strategic plans and creating
your brand. First, ask your referral sources
what they expect from you with regard to
your patient care and interaction with their
office. Meet with their staff if necessary to
gain a clear understanding of their expecta-
tions and needs. Next, survey or ask your
patients what their expectations might be.
Dig deep to go beyond the superficial expec-
tations. Once you have accumulated this
information, gather your team together, both
doctors and staff, to have a frank discussion
regarding your Practice Integrity. Create a list
of both the implied and stated promises you
make to your referral sources and patients.
Does your promise match their expecta-
tions, and more importantly, are you able
to fulfill your promise. Again, it is important
to dig deep … to go beyond the superficial
obligatory responses to the deeper more
meaningful answers. Identify the universal
expectations expressed by the vast majority
of your patients and referrers. Determine if
and how you are meeting those expecta-
tions. Next look for those unique expecta-
tions expressed by specific referral sources.
Ask yourself and your team if collectively you
are willing to extend the promise of consis-
tently meeting these expectations, and if so,
how will this best be accomplished? Finally,
let your referral sources know that you will
periodically check in with them to ensure that
you are fulfilling your promise to them and
their patients.
Once we clarify these expectations and
develop a reputation for consistently deliv-
ering on our promise, the word will spread
from our satisfied referral sources, and we
will find that our reputation becomes a
magnet for attracting other referral sources.
Furthermore, as these word-of-mouth refer-
rals increase to critical mass, our practices
will eventually reach a tipping point from
which we will experience exponential growth
through lasting professional relationships that
ensure our long-term success even in the
most competitive environments. OP
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