Ortho Tribune U.S.

Rotated teeth — effective ortho treatment utilizing the lingual technique (entree) / Orthodontic education needs ‘fresh young blood’ / Rotated teeth — effective ortho treatment utilizing the lingual technique / A new year and a new mission / Dr. Hardy’s referral marketing creates record number of starts / The TRAINER System in the context of treating malocclusions (part1) / The TRAINER System in the context of treating malocclusions (part2)

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ORTHO TRIBUNE
The World’s Orthodontic Newspaper · U.S. Edition

November/December 2009

www.ortho-tribune.com

Vol. 4, Nos. 11 & 12

Educating the future

Time to evaluate

Checking in

Why orthodontics is
in a state of flux

Start next year off with a
new mission statement

Starts are up for
Dr. Hardy. Find out why.

uPage

Help give
low-income
kids, teens a
better smile
By Fred Michmershuizen, Online Editor

miles Change Lives (SCL),
a nationwide program that
provides access to orthodontic treatment for children from
low-income families, is expanding its service areas into new
states and regions. The program,
which is supported by 3M, is
seeking low-income children
and teenagers, ages 11–18, with
severely crooked teeth and misaligned jaws.
SCL’s growth is possible
because of the efforts of dedicated orthodontists who are working to establish SCL programs
in their communities and who
agree to treat qualified, motivated SCL patients in their offices.
“I’ve been so pleased with
this program,” said Dr. Randall
Markarian of St. Louis, an SCL
program leader. “Every SCL
patient assigned to my practice
has been a pleasure. I’ve had
moms in my office in tears when
I put their child’s braces on. With
SCL, I know that I’m helping the
kids who need me the most.”
g OT page 2

uPage

Rotated teeth — effective
ortho treatment utilizing
the lingual technique
By Rubens Demicheri, DDS, MD

oday, more and more adults
seek orthodontic treatment. In
the realm of orthodontic therapy, the lingual technique has steadily expanded.1,2 The biomechanical
principles to move teeth are independent whether the brackets are
bonded on the labial or lingual.
Nevertheless, there are differences
with the force action and jacking
position.
For some tooth movements with
the lingual (in principle, also for
labial) technique, the position of a
bracket’s slot has a critical influence regarding the effectiveness of

Fig. 1

orthodontic treatment.
As in labial orthodontics, leveling
is perhaps the most important task.
It must be achieved with light forces
quickly, accurately and effectively.
Leveling requirements:
• vertical movement,
• in–out movement or buccal–
palatal movement,
• angulation movement,
• rotation.
g OT page 3

Fig. 2

Fig. 1: Start of treatment
(July 2007).
Fig. 2: Progress of leveling
(October 2007).

OT Study Club explores periodontal health
Dr. Robert Boyd will present Webinar on Jan. 21

ecent literature indicates that
small but significant overall
periodontal liability occurs
with fixed appliances during orthodontic treatment. However, studies also point out these problems

Dr. Robert Boyd
can be overcome almost completely
with the use of established preventative dentistry measures employed
before, during and after treatment.
At 7 p.m. (EST) on Jan. 21, Dr.
Robert L. Boyd, chairman of the
Department of Orthodontics at the
Arthur A. Dugoni School of Dentistry of the University of the Pacific
in San Francisco, will discuss these

matters in his OT Study Club Webinar, “Improving Periodontal Health
Through Orthodontic Treatment.”
Boyd, who holds degrees in both
orthodontics and periodontics,
will present a review of currently
available oral-health products for
orthodontic patients evaluated in
light of FDA and ADA approvals for
claims. He will use this information and also review the current
dental literature to determine what
toothpaste, toothbrushes, rinses
and other plaque-removal aids have
been shown to be the most efficient and effective for orthodontic
patients with fixed appliances.
The Webinar, sponsored by Procter & Gamble, will last 60 minutes
with a 30-minute question-andanswer session at the end. The
course is free, and you can register
at OTStudyClub.com. Attendees will
earn one C.E. credit. For more information, contact Julia Wehkamp at
julia.wehkamp@dtstudyclub.com. OT

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[2] =>

From the Editor

Ortho Tribune | Nov./Dec. 2009

Orthodontic education
needs ‘fresh young blood’
By Dennis J. Tartakow, DMD, MEd, PhD,
Editor in Chief

rthodontic education may be in
a state of flux with a daunting
outlook for the future. Recruitment, retention and increased
faculty vacancies of full-time,
board-certified faculty members in
postgraduate orthodontic programs
are issues of critical importance
when perceived through the lens of
educational leadership and social
justice.
Historically, these issues have
been emergent problems in dental
education since the early 1990s;
they have the potential of impacting
people, communities and society as
well.
For more than two decades, orthodontic programs have been losing
full-time faculty members without
new orthodontists filling their positions. Prior to 1990, there was neither concern for the future of academic orthodontics nor worry that

f OT page 1

According to SCL, families who
turn to it for assistance cannot afford
the average cost of braces for their
children. With the current economic downturn, more families now
qualify for SCL due to a change in
the program’s financial guidelines,
which include a broader spectrum
of low-income families.
SCL is actively seeking qualified
applicants in Missouri, Minnesota,
Kentucky, Virginia, Florida, San

‘If education and
research can become a
reasonable choice
to compete with
clinical practice as a
career option, the
specialty will maintain
its high standards.’
these issues would ever materialize; most postgraduate orthodontic
programs were not in short supply of full-time faculty members.
However, since the 1990s, increased
apprehension for the future of academic orthodontics has surfaced
regarding these unfilled position
vacancies across the country.
Besides the natural progression
of age, sickness or retirement, there
are reasons why many seasoned
faculty members are leaving academics for clinical practice; it has
to do with money and economics.
Newly graduated orthodontists have
been groomed to replace older,
retiring faculty members but not
many choose academe over clinical practice; they have tremendous
financial debts from years of education that just about precludes consideration for a career in education.
In addition to, and as a result of,
these problems facing the specialty
of orthodontics, there are social justice implications of virtue ethics
and community obligation that may
begin to emerge. The most important of these human rights possibilities include: (a) poorly trained

Diego, Colorado, North Carolina,
Massachusetts, Wisconsin, New Jersey, Illinois, Philadelphia, Kansas,
Texas and Long Island, N.Y. SCL
plans to expand into more states and
regions in 2010.
The organization was founded in
1997, and since then it has assisted
more than 1,200 patients. Orthodontists who wish to get involved or get
more information are invited to contact the organization at (888) 9003554, info@smileschangelives.org,
www.smileschangelives.org. OT

orthodontic graduates who may not
serve the public with the expertise
that is expected, (b) reduced dental services currently provided to
the community from dental school
clinics and off-campus outreach
facilities, and (c) diminished health
care for individuals who rely upon
universities and hospitals for their
personal medical and dental needs.
Orthodontic education is in need
of addressing full-time faculty shortages with “fresh young blood” — it
is a dilemma that resonates with
inadequacies and consequences.
Student financial obligations make
it difficult, if not impossible, to
attract young doctors to consider
a career in education; the salary
differential alone makes academe
a non-competitive issue with clinical practice taking into consideration debt service, starting a family,
beginning life after school, etc.
Survival of the specialty is at
stake. Transformative thinking and
decision-making is most important
for safeguarding tomorrow’s orthodontists and orthodontic leaders.
The AAO leadership is taking the
attitude of carpe diem — seize the
day — and making the changes that
are necessary for reducing full-time
faculty vacancy positions.
If education and research can
become a reasonable choice to
compete with clinical practice as a
career option, the specialty will
maintain its high standards and
continue to graduate well-educated
orthodontists — the essence of a
force for change. OT

Corrections

Ortho Tribune strives to maintain
the utmost accuracy in its news and
clinical reports. If you find a factual error or content that requires
clarification, please report the details
to Managing Editor Kristine Colker at
k.colker@dental-tribune.com.

Image courtesy of Dr. Earl Broker.

ORTHO TRIBUNE
The World’s Orthodontic Newspaper · U.S. Edition

Publisher & Chairman
Torsten Oemus
t.oemus@dental-tribune.com
Vice President Global Sales
Peter Witteczek
p.witteczek@dental-tribune.com
Chief Operating Officer
Eric Seid, e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Ortho Tribune
Prof. Dennis Tartakow
d.tartakow@dental-tribune.com
International Editor Ortho Tribune
Dr. Reiner Oemus
r.oemus@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dental-tribune.com
Managing Editor/Designer
Implant & Endo Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Online Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Product & Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Product & Account Manager
Mark Eisen, m.eisen@dental-tribune.com
Marketing Manager
Anna Wlodarczyk
a.wlodarczyk@dental-tribune.com
Marketing & Sales Assistant
Lorrie Young, l.young@dental-tribune.com
C.E. Manager
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Dental Tribune America, LLC
213 West 35th Street, Suite 801
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Phone: (212) 244-7181, Fax: (212) 244-7185

Published by Dental Tribune America
© 2009, Dental Tribune International GmbH.
All rights reserved.
Dental Tribune makes every effort to report
clinical information and manufacturer’s
product news accurately, but cannot assume
responsibility for the validity of product claims,
or for typographical errors. The publishers
also do not assume responsibility for product names or claims, or statements made by
advertisers. Opinions expressed by authors are
their own and may not reflect those of Dental
Tribune International.

OT Editorial Advisory Board
Jay Bowman, DMD, MSD
(Journalism & Education)
Robert Boyd, DDS, MEd
(Periodontics & Education)
Earl Broker, DDS
(T.M.D. & Orofacial Pain)
Tarek El-Baily, BDS, MS, MS, PhD
(Research, Bioengineering & Education)
Donald Giddon, DMD, PhD
(Psychology & Education)
Donald Machen, DMD, MSD, MD, JD, MBA
(Medicine, Law & Business)
James Mah, DDS, MSc, MRCD, DMSc
(Craniofacial Imaging & Education)
Richard Masella, DMD (Education)
Malcolm Meister, DDS, MSM, JD
(Law & Education)
Harold Middleberg, DDS
(Practice Management)
Elliott Moskowitz, DDS, MSd
(Journalism & Education)
James Mulick, DDS, MSD
(Craniofacial Research & Education)
Ravindra Nanda, BDS, MDS, PhD
(Biomechanics & Education)
Edward O’Neil, MD (Internal Medicine)
Donald Picard, DDS, MS (Accounting)
Howard Sacks, DMD (Orthodontics)
Glenn Sameshima, DDS, PhD
(Research & Education)
Daniel Sarya, DDS, MPH (Public Health)
Keith Sherwood, DDS (Oral Surgery)
James Souers, DDS (Orthodontics)
Gregg Tartakow, DMD (Orthodontics)
& Ortho Tribune Associate Editor

[3] =>

Trends

Ortho Tribune | Nov./Dec. 2009
f OT page 1

Leveling mechanics is due to the
application of:
• adequate inter bracket distance,
• light and elastic force,
• preformed memory arch wire.
One of the advantages of nickel titanium (NiTi) and super elastic arch wire is that we can fill
the bracket slot earlier during the
course of the treatment plan.
In lingual orthodontics compared
to labial orthodontics, rotational
movement to level a single rotated
tooth is not easy to achieve.3
There are several points to consider.

Movement mechanics
of a rotated tooth

The only force system that can produce pure rotation (a moment with
no net force) is a couple, which is
two equal and opposite and parallel
forces, but non-collinear.4
The
rotational
movement
depends on the moment of the forces. The moment of the force is
equal to the magnitude of the force
applied, multiplied by the perpendicular distance of the line of action
to the center of resistance.
These forces applied to the tooth
should produce efficient rotation.
However, in buccal orthodontics,
rotation movement of rotated teeth
can be accomplished even without
an exact application of this force
system.
Memory-shaped
pre-formed
arches in large cross-sections, filling the slot of the bracket, have
good control of the tooth movement
and can perform this task within a
short amount of time.
In labial orthodontics, leveling seems to be easier and can be
resolved in less time. Reference the
clinical case (Figs. 1 and 2).
In the lingual technique, the arch
wire could move the teeth in the lingual direction.5 That is the reason
why some movements are difficult
to achieve, as they are in the labial
technique.
The problems are:
• During the rotational movement,
teeth are moved lingually into
a shorter length of the arch,
with less space for movement
(Fig. 3).
• The small size of the arch and
subsequent short inter-bracket
distance (Fig. 4).
• Less control of the arch in the
bracket slot.
The short inter-bracket distance
necessarily means that any moment
produced across a given bracket
will be decreased due to the short
lever-arm to the center of rotation.
This is more significant in the
mandible dental arch because it is
more constricted than the maxillary
and the incisor mesial-distal width,
which is less than the maxillary
incisors (Fig. 4b).5
Depending on the available space
for de-rotation, it can be necessary
to open space as the first step. The
second step is the de-rotation.

Slot position
If we consider de-rotation as an isolated step, then we know the power
applied works on the horizontal
plane. In principle, by all brackets
with horizontal slots, the arch wire
can slip off (Fig. 5). Two factors can
avoid this problem.
The ligature holds the arch wire
into the slot. This effect can support
the force direction.6
But this effect can be eliminated
if the force direction pulls the arch
wire out of the slot. This can happen very frequently with the lingual
technique.
Using light forces and also small
diameter arches make it more difficult and almost impossible to derotate a rotated tooth at the moment
of leveling.
Contingent on the various force
g OT page 4

Fig. 3

Fig. 4a

Fig. 3 (above): Rotated teeth move
lingually into the shorter length
of the arch, with less space for
movement.
Figs. 4a, 4b (right): The interbracket distance is short with the
lingual technique, especially in the
lower jaw (b).

Fig. 4b
AD

[4] =>

Trends

Ortho Tribune | Nov./Dec. 2009

f OT page 3

action and jacking position of a labial or a lingual arch wire, the position of the bracket slot has different
consequences. The horizontal slot
makes fewer problems in labial, as
in lingual, technique.
Today, the majority of the lingual brackets in the market offer
horizontal slots. With this particular orientation of the slot, only the
ligature contains the arch. Thus, the
points of the applying forces are not
firm when elastic ligature is used,
even with steel ligation and full
engagement of the arch wire in the
bracket slot.
Even slight rotations of the tooth
are difficult to be solved completely in this way with stainless steel
ligature. The use of copper-nickel
titanium arch wires will slightly
increase the effectiveness because
the arch has a tendency of sliding
out of the lingual slot.
What is the solution? For derotation, the slot needs to be close to
force direction (Fig. 6). In principle,
a tube would solve all problems.
However, to use tubes on all teeth
makes it impossible to insert the
wire.
When the leveling stage requires
de-rotation of a single tooth, the
vertical slot is an alternative. During de-rotation, the arch wire is in
contact with the bracket body or
metallic framework (Figs. 6, 7 and
9). Therefore, the power from the
arch wire will transfer completely
to the tooth.
However, a vertical slot instead of
a horizontal slot is also not enough
because some of the movements in
this stage (leveling) might be affected, and it may not be very efficient
with this orientation of the slot.
For example, any vertical movements, especially intrusion movements, are difficult with a vertical
slot. In principle, this is the same
problem with a horizontal slot and
de-rotation as described.

Fig. 7: Magic brackets provide a
vertical slot for the posterior teeth.
(Photo/Dentaurum)

Fig. 5: With an open lingual horizontal slot, the arch wire can slip off the
bracket.

Fig. 8: Magic brackets provide a
vertical entrance for the anterior
teeth. (Photo/Dentaurum)

Fig. 6: The closed lingual horizontal slot with a vertical entrance provides
excellent rotational control. (Photo/Dentaurum)

The clever solution
To find a satisfactory reply for the
outlined problems, an ideal lingual
bracket would need a vertical and
a horizontal slot. This is a technical
challenge because, on one hand,
lingual brackets need to be small in
all directions.7 On the other hand,
they should have many features.
A good compromise is the magic®
lingual bracket system.*
For front teeth, magic brackets
have a horizontal slot (Fig. 8), but

Fig. 9a

Fig. 9b

the insertion of the arch wire is vertical.8 When the arch wire is in position, it is held into the horizontal
slot and cannot slide in the direction
of the force because the metal wall
of the bracket body does not allow
it (Fig. 9).
This special design will achieve
most of the movements that derotation requires and is effective
in realizing the necessary vertical,
in–out and angulations movements
that leveling requires. In the posterior teeth, the situation is identical
because of the vertical slot design of
the brackets (Fig. 7).
These are the advantages of a
vertical slot (not only for lingual
brackets): better torque control,
rotation and “en-masse” retraction
(Fig. 10). Additionally the arch wire
is easy to insert because there is a
direct view into the slot.
Effective control with rotation
and torque require brackets with
a long mesial-distal distance (Fig.
11).9
Naturally, the issues of a short
inter-bracket distance can be solved
or minimized with the use of memory-shaped arch wires and, especially, super elastic arches.
In order to accomplish those
movements effectively, it is important to consider indirect bonding
to place and position lingual brackets. Indirect bonding significantly
reduces rotation deviation with
irregular proximal contact points.10

Conclusion

Figs. 9a, 9b: The arch wire cannot
slip off during tooth rotation.
(Photos/Dentaurum)

In comparison to labial orthodontics, rotational movement is difficult
to achieve in lingual orthodontics.
There are many reasons for this,
but one of the most important is
the use of brackets designed with a
horizontal slot.

[5] =>

Ortho Tribune | Nov./Dec. 2009
The results of this design specific
to de-rotation of a single tooth, or
a group of teeth, are very poor and
require a lot of time.
Magic lingual brackets are
designed with a special slot. In these
brackets the arch wire will not disengage the slot, and the leveling
forces are very effective in achieving
all the movements efficiently. OT

Trends

5

Fig. 10b: Intra-year the space is
nearly closed.

* (Dentaurum, Turnstr. 31, 75228 Ispringen, Germany; www.dentaurum.de)

References

1. Ye, L. and Kula, K.S.: Status of lingual orthodontics, World J Orthod.
7:361–368, 2006.
2. Geron, S. and Ziskind, D.: Lingual forced eruption orthodontic
technique: clinical considerations
for patient selection and clinical
report, J Prosthet Dent. 87:125–
128, 2002.
3. Sander, C., Sander, F.M. and
Sander, F.G.: The derotation of
premolars and canines with NiTi
elements, J Orofac Orthop. 67:117–
126, 2006.
4. Smith, R.J. and Burstone, C.J.:
Mechanics of tooth movement, Am
J Orthod. 85:294–307, 1984.
5. Geron, S.: Rotated teeth in lingual
orthodontics: problems and solutions, Lingual News. 1:2002.
6. Bednar, J.R. and Gruendeman,
G.W.: The influence of bracket
design on moment production during axial rotation, Am J Orthod
Dentofacial Orthop. 104:254–261,
1993.
7. Nidoli, G., Macchi, A., Lazzati,
M. and Casagrande, V.: [Lingual
appliances], Mondo Ortod. 14:23–
30, 1989.
8. Sorel, O.: Creation of the magic
bracket, Rev Orthop Dento Faciale.
41:39–58, 2007.
9. Matasa, C.G.: Bracket angulation as a function of its length
in the canine distal movement,
Am J Orthod Dentofacial Orthop.
110:178–184, 1996.
10. Shpack, N., Geron, S., Floris, I., et
al: Bracket placement in lingual
vs labial systems and direct vs
indirect bonding, Angle Orthod.
77:509–517, 2007.

OT About the author
Dr. Rubens
Demicheri
received
his DDS in
1983 from
the Universidad de la
República
(UDELAR)
in Uruguay
and then
went on to
complete
his postgraduate studies at Nagasaki
University in Japan. Demicheri has
been an associate professor in the
Department of Pediatric Dentistry at
UDELAR, a visiting lecturer at the
University of Alfonso X el Sabio in
Spain and a lecturer on lingual orthodontics in South America and Europe.
Contact him by e-mail at demicheri@
odon.edu.uy.

Fig. 10a: Mini-screws (tomas®-pin, Dentaurum) provide efficient en-masse
retraction. (Photos/Dr. Papadia and Dr. Isaza Penco, Italy)

Fig. 11: For rotation and torque,
brackets with a long mesial-distal
distance are the best choice. (Photo/
Dentaurum)

AD

[6] =>

Practice Matters

Ortho Tribune | Nov./Dec. 2009

A new year and a new mission
By Scarlett Thomas, President,
Orthodontic Management Solutions

s we approach the New Year,
it’s important to take the time
to evaluate where you currently are as a business, where you
want to be as a business and how
you plan on achieving these goals.
In order for your orthodontic
practice to be successful, you have
to have a clear mission that informs
the general public about why it
would be beneficial to do business
with you. Having a mission statement is essential, as it will represent your vision of how you would

like to be seen by your patients.
Although a mission statement and
a company description are separate
concepts, they often are combined.
Why? Because your mission statement expresses your philosophy,
motivation and goals with regard
to your business. Your company
description, in contrast, presents
your ideas and concepts. They are
equally important.
In addition, an ideal mission
statement should be inspiring to
employees. The statement brings
a certain focus to the staff members as the purpose of their work
becomes clearer and they are able
to see the value of their contribu-

tion. Few things in life are as fulfilling as the knowledge that you
are contributing something greater
than yourself. The mission statement should allow each employee
to see his or her own personal role
in the orthodontic practice.
Patients will be reassured when
they are exposed to the mission
statement as they will be able to see
the practice is committed to their
purpose. Patients can also sometimes form a connection with the
practice if the values outlined are
ones they share. People like to work
with others who they like and agree
with; it’s a natural human instinct.
When you sit down to write your

mission statement, there are several
things you should keep in mind.
First, who are your patients and
what are their needs and desires?
Second, how do you fulfill those
needs and desires? What values do
you currently have? What values do
you want to have? Are you all working together with a similar purpose
or are employees of the practice
constantly veering off course?
A mission statement is best written in collaboration. All staff members should sit down and talk about
their thoughts and how they want
to represent the practice to the public. Ideas should be brainstormed
among everyone and then voted on.
Most companies display their
mission statements on their Web
sites; some have their mission statements incorporated into their logos,
ads and stationary. You may want to
visit a variety of Web sites and read
the mission statements of different
companies, particularly those in the
orthodontic field.
After you’ve brainstormed all
your ideas, write them on a chalkboard and play with them. Combine
and try out different phrases. Say
them out loud. When working in
a group, maintain the guideline of
accepting, not rejecting, all suggestions. After all the suggestions have
been noted, take a break.
The final refinement of your mission statement may not be achieved
immediately. Give yourself time to
contemplate a few ideas before you
finalize it. And remember, your mission statement need not and should
not be regarded as forever final.
Depending on changes in your business, trends and any unexpected
shifts in the economy, you may want
to modify your mission statement at
some point in your career.
To learn more regarding mission
statements or other managementrelated topics, register for an
upcoming Webinar at orthoconsult
ing.com. Registration can be found
under events and seminars. OT

OT About the author
Scarlett Thomas
is an orthodontic
practice
consultant who
has been in the
field for more
than 23 years,
specializing in
case acceptance,
team building,
office management and marketing. As a speaker and practice
consultant, she has an exceptional
talent to inform, motivate and excite.

OT Contact
Scarlett Thomas
Orthodontic Management Solutions
Phone: (858) 435-2149
scarlett@orthoconsulting.com
www.orthoconsulting.com

[7] =>

[8] =>

Practice Matters

Ortho Tribune | Nov./Dec. 2009

Dr. Hardy’s referral marketing
creates record number of starts
referrals and which are not.
• Developing referral sources from
non-referring dentists who have
the potential to begin referring.

By Kevin Johnson & Emily Ely

r. Brian Hardy has much to be
happy about — he recently set
a record for the most starts ever
in a single month since he opened
his practice nearly three years ago.
Production is up 33 percent for the
calendar year and was up 63 percent for the summer months. All of
the practice’s efforts are paying off
with impressive dividends.
The first Total Ortho Success™
Practice Makeover winner and his
team are delighted with this breakthrough success. One key reason for
the jump in numbers is the result
of implementing Levin Group’s Science of Referral Marketing™.

One team member makes
all the difference

Even before Dr. Hardy began his
consulting programs with us, he
knew his marketing efforts had not
generated the results he wanted. As
it turned out, Hardy Orthodontics
needed to add one critical team
member to its practice — a professional relations coordinator (PRC)
— to realize its referral-marketing
goals.
Shortly after beginning his practice makeover, Levin Group counseled Dr. Hardy to create a PRC
position, and his referral-marketing
efforts finally took off.
The PRC is crucial to making
referral marketing successful. Most
orthodontists do not have the time,
knowledge or interest to implement
or maintain a comprehensive referral-marketing program.
With a PRC, Dr. Hardy has a
dedicated team member whose job
is to focus on marketing, build the
practice and dramatically increase
referrals, allowing Dr. Hardy more
time to concentrate on providing
optimal orthodontic care.
The PRC runs 95 percent or more
of the entire marketing program.
Her responsibilities include creating the referral-marketing strategies, designating timelines to carry
them out, implementing the strategies, tracking results and adding
new strategies.
This individual’s job is to continAD

From left, Emily Ely, Kevin Johnson
and Dr. Brian Hardy.

Total Ortho Success

Pr actice

ually find ways to increase referrals
from patients and referring doctors using Levin Group’s systematic
method.
Referral
marketing
is
an
advanced science that will deliver
a predictable result if it is implemented and carried out consistently
using the appropriate systems. The
PRC should be thought of as a professional who will need to learn the
Science of Referral Marketing. With
the right training and guidance, a
PRC can help generate hundreds of
new patient referrals every year.

Understanding referral
marketing

The key to an excellent referralmarketing program is consistency. Levin Group recommended to
Dr. Hardy that his practice design
a multi-year marketing plan that
consists of multiple ongoing strategies designed to boost referrals. He
focused on:
• Maintaining his relationship with
top-level referrers.
• Turning mid-level referrers into
top-level referrers.
• Determining which low-level
referrers are prospects for greater

Practices should carefully devise
a marketing plan that will roll out
over the course of a year. An ortho
marketing plan, such as Dr. Hardy’s,
will likely include the following:
• Doctor lunches
• Shared hobbies (golf, sailing, etc.)
• Full-day seminars
• Other personal contacts
• Doctor visits/phone contacts
• Lunch-and-learns
• Community activities
• PRC visits/lunch for referring
office
• Evening seminars
• Correspondence
• Fact sheets
• Food deliveries
To be completely successful,
each of these contact opportunities
must include well-produced support materials, including training
scripts for the PRC and staff and
professionally printed materials.
As strategies are implemented,
orthodontists need to keep in mind
that their competitors are aggressively marketing their ortho practices as well. Consequently, referral
marketing needs to be consistent
and of the highest quality to ensure
the greatest return on investment.
In the competitive world of orthodontic practices where comparison
shopping abounds, it’s necessary to
solidify the practice’s referral base
and expand it continuously. Referral marketing is the cornerstone of
maintaining a steady flow of referrals.

The state of the practice
At Hardy Orthodontics, the practice
is enjoying its new direction. The
PRC’s referral-marketing efforts
have yielded the following impres-

sive results:
• Converted two “B” offices (steady
referrers) to “A” offices (top referrers); converted four “C” offices
(occasional referrers) to “B” offices (steady referrers).
• Encouraged 16 new clinicians to
send patients.
• Staged a patient picnic — the most
well-attended marketing event in
the practice’s history.
As these results show, a strong
referral-marketing program is a
necessity, not an option. Orthodontic practices that consistently and
effectively engage in referral marketing will become the production
and profitability leaders in their
area.
As Dr. Hardy and his staff moves
into the final phase of their Total
Ortho Success Management and
Marketing Year 1 programs, they
are:
• Brainstorming future referral
events.
• Completing a new patient orientation packet designed to increase
starts.
• Creating a new practice brochure
that reflects the current practice
mission and goals.
Join us in our next installment
when we detail some of Dr. Hardy’s
end-of-year results and recap Hardy
Orthodontics’ year of consulting
with Levin Group.
To jumpstart your own Total
Ortho Success Practice Makeover,
come experience Dr. Roger Levin’s
next Total Ortho Success Seminar on
Jan. 28 and 29 in Las Vegas. Ortho
Tribune readers are entitled to
receive a 20 percent courtesy. To
receive this courtesy, call (888) 9730000 and mention “Ortho Tribune”
or e-mail customerservice@levin
group.com with “Ortho Tribune
Courtesy” in the subject line. OT

OT About the authors
Levin Group Senior Consultant
Kevin Johnson has spent the last
eight years working as a Levin
Group orthodontic management
and marketing consultant. He
manages a team of consultants
and is a frequent lecturer at the
Levin Advanced Learning Institute. Johnson earned his degree
from Towson University in 1996.
With many years of marketing experience, Levin Group Consultant Emily Ely joined Levin
Group in 2005. Ely uses her unique
knowledge and experience to provide
marketing solutions for orthodontic
practices. She earned her degree in
business from Towson University.
Both Ely and Johnson are members
of the Ortho Expert Team, a specialized
group of consultants who are trained in

the needs of orthodontic practices.
For more than two decades, Levin
Group has been dedicated to improving the lives of orthodontists. Visit
Levin Group at www.levingrouportho.
com. Levin Group also can be reached
at (888) 973-0000 and by e-mail at
customerservice@levingroup.com.

[9] =>

Industry Clinical

Ortho Tribune | Nov./Dec. 2009

The TRAINER System in the
context of treating malocclusions
By German Ramirez-Yañez, DDS, MDSc, PhD

Part three

nother effect reported with the
TRAINER System™ Appliances
is transverse development of
the dental arches. All the Frankellike appliances, which have a buccal shield in their structure, move
the cheeks away from the buccal
aspect of the upper and lower posterior teeth. This action produces
two effects on the craniomandibular
system (CMS).
First, the presence of the buccal
shields releases a force produced
by the buccinators (muscles of the
cheeks) on the buccal aspect of the
posterior teeth, which normally is of
about 2.7 g/cm2, but can increase up
to 20 g/cm2 in patients with a digital
sucking habit or tongue thrust.
In the same way, these buccal
shields in the appliance release
excessive force (up to 80 g/cm2) that
can be produced at the corner of the
mouth on the cuspid teeth, which
can be present in those patients
with the same habits. Such a force
tends to reduce the inter-canine
distance, badly affecting the shape
of the dental arches and crowding
the dentition (Lindner and Hellsing
1991; Mew 2004).
Second, the presence of the buccal shields in the appliance stretches the buccinators and orbicularis
oris (muscles of the lips), creating a
tension zone at the area of insertion
of those muscles.
As it has been extensively
explained in the literature (most
orthodontics and cranio-facial
growth books), on the tension zone
there is bone apposition (Frost
2004). Therefore, by creating a tension zone by stretching the muscles (buccinators and orbicularis)
through the buccal shield in the
appliance, there is an increase in
bone apposition at the maxilla and
mandible. The presence of the buccal shield at the anterior area of the
mouth encourages the patient to
produce a better lip seal, which will
be explained later.
Be aware that this effect is higher
in the MYOBRACE®. As explained
in part two, one of the assets of
the MYOBRACE is the inner-core
embedded in the buccal shields.
This inner-core provides more
resistance to the appliance and
counteracts the force released by
the buccinators and orbicularis
muscles when they are hyperactive.
The first effect referred to above
permits that the force produced by
the tongue on the lingual aspect
of the posterior teeth (about 1 g/
cm2) stimulates the development
of the dento-alveolar units of those
teeth toward buccal. Due to this,
there is no force counteracting in

an opposite way as it has been neutralized by the presence of the buccal shields. In this way, transverse
development is stimulated.
The other effect regarding creating a tension zone at the insertion
area stimulates bone apposition at
the borders of the mandible and
maxilla, thus stimulating further
development of the jaws with bone
formation that will give more space
for tooth alignment.
g OT page 11

Fig. 4: Patient, age 7.
In this case, there is also
a mandibular advance
and an improvement
in the inclination
of the upper incisors.
Furthermore, a
significant improvement
in lip seal (right side)
can be observed in this
patient after treatment
during 14 months with
a TRAINER Appliance
(T4K).
AD

[10] =>

[11] =>

Ortho Tribune | Nov./Dec. 2009

Industry Clinical 11
Fig. 5: Cephalic lateral X-rays of a
5-year-old patient. The left X-ray shows
the patient before treatment, the X-ray
in the middle shows the patient at the
end of treatment, and the X-ray on the
right shows the patient one year after
treatment with the mandible correctly
positioned and with an ideal overbite
and overjet for his age. This patient
used the TRAINER Appliances for 15
months, starting with the T4I and then
switching to the T4K when the first
permanent molars erupted.

f OT page 9

An additional effect to stimulate transverse development of the
dental arches with the Trainers is
changing the posture of the tongue.
When relaxed, the tongue stays in
a physiological position (Fig. 4),
which is encouraged by the lingual
tab located on the upper-lingual
side of all the appliances of the
TRAINER System, including the
MYOBRACE.
It has been scientifically proven
that the TRAINER System Appliances stimulate transverse development of the dental arches. A paper
published in the Journal of Clinical
Pediatric Dentistry (Ramirez-Yañez
et al. 2007) shows the results of a
study of the effect of the T4K on
the dimensions of the dental arches
of 60 children with Class II, Div 1.
These results show that there is a
significant increase in the intercanine, inter-premolar and intermolar distances when treatment
was performed with the TRAINER
Appliance.
This effect is produced by posturing the tongue in a more physiological position and by the buccal
shields in the appliance releasing
the force produced by the muscles
of the cheeks and lips. In other
words, the effect with the TRAINER
is similar to that reported in patients
treated with the function regulator
appliance (Frankel R. 1977).

Vertical growth and
development

Clinically, the TRAINER System
Appliances produce an improvement in the vertical relationship
between the upper and lower
teeth (overbite) in patients that
have either a deep or an open bite.
This has been scientifically demonstrated in two studies (Usumez
et al. 2004; Ramirez-Yañez et al.
2007) — one where it was reported
that patients with deep bite have
a significant increase in the vertical dimension (Fig. 5) and another
where patients with open bite have
a significant reduction in the negative overbite (Fig. 6).
To explain the effect of the
TRAINER System Appliances on the
vertical development, it is necessary to use concepts from the physiology of the CMS. Furthermore, it is
necessary to explain separately how
the Trainers work to correct each of
these problems, as the same appliance works in a different way when
there is a deep bite or an open bite.

Deep bite
When the mouth is closed, the masticatory muscles, particularly the
masseters (deep masseter) and temporalis (posterior fibers), increase
their activity when the first teeth
contact occurs. This is a physiological response that permits a higher
force to move the teeth closer and
smash any piece of food that may be
between them. Patients with a deep
bite have stronger muscles closing the mouth (Farella et al. 2003),
and some reports have shown that
deep-bite patients have more type

II fibers in the masseter muscle
(Rowlerson et al. 2005), which has
been associated with an increase in
the average of bite force (Ringqvist
1973).
The presence of the TRAINER
in the mouth does not permit tooth
contact because of the silicon surface between the upper and lower

components of the appliance, which
avoids contact between the teeth.
As there is no contact between the
teeth and maximum intercuspation is not reached, the increase in
muscular activity when closing the
mouth does not occur, reducing the
loading at the teeth and their dentoalveolar units at maximum inter-

cuspation. As the loading at maximum intercuspation is reduced, the
dento-alveolar units can develop
and teeth can come to that plane
given by the occlusal surfaces of the
appliance. Thus, an occlusal plane
(Spee curve), which is generally
g OT page 12
AD

[12] =>

Industry Clinical

Ortho Tribune | Nov./Dec. 2009

f OT page 11

Fig. 6: Patient,
age 8. She had an
open bite, which
closed after 20
months treatment
with a TRAINER
Appliance (T4K).
Lingual thrust
present at the
beginning of
treatment was
corrected, and her
occlusion is stable
after two years
of treatment
without using
any retention.

curved in deep-bite patients, tends
to flatten, improving the vertical
dimension (Fig. 5).

Open bite
On the other hand, open bite closes
when treatment is performed with
the appliances of the TRAINER System (Ramirez-Yañez et al. 2007). To
understand how these appliances
can produce a positive effect when
treating open bites, it is necessary
to understand the physiology of
tongue posture.
First, it is important to remember the tongue, the mandible and
the hyoid bone are linked through
a muscular system and work as a
team.
When the tongue is relaxed, its
tip positions on the incisal papilla
at the anterior part of the palate,
which is its natural position when
relaxed. With the tip of the tongue
in this position, the dorsum of the
tongue runs at the cervical third of
the crowns and roots of the upper
premolars. The base of the tongue
goes downward at the molars, leading to insert at the hyoid bone.
When the tongue is relaxed,
the hyoid bone, where the anterior digatric muscle inserts, is positioned approximately between the
third and fourth cervical vertebras,
and antero-posteriorly, about the
middle of the body of the mandible (Rocabado 1983; Tallgren and
Solow 1987). The anterior digastric
muscle, which is located between
the mandibular symphysis and the
hyoid bone, plays an important role
in the growth and orientation of the
mandible (Spyropoulos et al. 2002),
as it loads the anterior area of the
mandible.
In patients with tongue thrust,
the tongue is protruded. Therefore,
the tip of the tongue is positioned
forward and downward (the dorsum of the tongue comes downward and the base of the tongue
moves forward). This causes the
hyoid bone to move backward and
upward (Ono et al. 1996; Haralabakis 1993), which stretches and
increases the muscular activity of
the anterior digastric muscle.
Increasing the muscular activity
of the anterior digastrics increases
the pulling produced by that muscle
on the anterior area of the mandible,
pulling the mandibular symphysis
backward and downward, stimulating a clockwise rotation of the mandible aggravating the open bite.
AD

Fig. 7: The lingual tab on the T4K is
a key feature of each appliance as it
stimulates the tip of the tongue and
repositions the tongue in its physiological position.

Fig. 8: T4K in place, assisting tongue
positioning and lip seal and reducing mentalis activity.
Thus, the effect observed when
open bites are treated with the
TRAINER System Appliances is produced in part by stimulating reeducation of the tongue posture,
which is encouraged by the lingual
tab located in the upper lingual area
of these appliances. When the appliance is in the mouth, the lingual tab
stimulates the tip of the tongue (Fig.
7). It does not position between the
incisors or even downward, but at
the area of the incisal papilla. As
previously explained, when the tip
of the tongue is at its physiological
position, its dorsum and base tend
to reposition at their physiological positions as well, with the base
descending at the molar area.

In this context, the hyoid bone
locates in a better position, decreasing the activity in the anterior digastric muscle. Reducing the pulling at
the anterior area of the mandible
by the anterior digastric muscle,
the mandible is not stimulated to
rotate backward and downward
anymore, and the muscles elevating the mandible may stimulate a
counter-clockwise rotation, which
help to close the open bite (Fig. 6).
These significant results when
treating open bite patients with
the TRAINER System Appliances
were explained by Usumez and colleagues (Usumez et al. 2004). They
found a significant reduction in the
angles FH-MP (frankfort/mandibular plane) and SN-GoGn (sella-nasion/gonion-gnathion), which means
the Trainers produce in some way
a counter-clockwise rotation of the
mandible.
Another effect contributing to the
closure of open bites with the Trainers is that the appliance does not
allow the tongue to position between
the incisors teeth. This allows the
teeth that are under-erupted to reerupt (secondary eruption process)
with development of their dentoalveolar units at the anterior area of
the mouth. Thus, the appliance of
the TRAINER System helps to treat
an open bite by re-educating the
tongue to position in a more physiological pattern, therefore permitting a counter-clockwise rotation of
the mandible as well as stimulating
or permitting development at the
dento-alveolar units at the incisors.

Lip seal
One of the problems associated with
mouth breathing and teeth crowding is unsealed lips. This is caused
by a low muscular activity in the lip
muscles (orbicularis).
There is an antagonism between
the orbicularis and the mentalis
muscles; when the lip muscles
reduce their activity, the mentalis muscles increase their activity
and vice versa (Tosello et al. 1999;
Lowe and Takada 1984). In patients
who do not maintain a correct lip
seal, the mentalis muscles maintain
higher activity. So, the muscular
activity at the orbicularis is very low
or even non-existent.
Lip seal is reached through

increasing the activity at the mentalis muscles, which pushes the
lower lip up to reach the upper lip,
which is generally short because of
a lack in development of the upper
orbicularis muscle.
The TRAINER System Appliances
have some elements on the anteroinferior area of the buccal shield
that touch the internal mucosa of
the lower lip when the lip is being
raised by the mentalis muscles (Fig.
8). When the mucosa of the lower
lip is stimulated by any element,
the activity in the mentalis muscles
is inhibited (Stavridi et al. 1992).
Reducing the activity of the mentalis
muscles increases the activity of
the orbicularis due to the antagonism explained previously (Tosello
et al. 1999). This way, development
of the lip muscles is stimulated to
produce a better and permanent lip
seal through the activity of the lip
muscles rather than the activity of
the mentalis muscles (Fig. 4).

Conclusions
The various appliances of the
TRAINER System work similarly,
improving the muscular activity of
the masticatory and facial muscles
as well as re-educating the tongue
to sit in a more physiological position when relaxed. By maintaining
the mandible in a forward position
during a period of approximately
10 hours per day, there is a change
of the mandibular posture, which
improves the sagittal aspect in those
patients with a disto-occlusion.
Through their action on the muscles of the cheeks and lips, the
TRAINER System Appliances produce transverse development of the
dental arches. Finally, through their
action on the muscles closing the
mouth and their action on the posture of the tongue, these appliances
can improve the vertical aspect in
those patients with either deep or
open bite.
Thus, it can be concluded that
the appliances of the TRAINER System (including the MYOBRACE) are
a valid alternative to treat malocclusions, as they improve the sagittal
and transverse development of the
maxilla and mandible as demonstrated by scientific research. These
appliances also improve the muscular activity of the masticatory and
facial muscles, as well as the posture of the tongue, as it has been
shown in successful cases treated
with the Trainers as well as published in the literature.
There is ongoing research with
the appliances of the TRAINER System to evaluate their action on the
muscular activity of the muscles in
the CMS, an action that has been
already demonstrated with other
functional maxillary orthopedics
(FMO) appliances (Stavridi et al.
1992; Sessle et al. 1990).
All changes produced in the
mouth and the CMS by the Trainers
permit the teeth to have more space
and position better in the dental
arches — in other words, to have
better tooth alignment. The MYOg OT page 14

[13] =>

[14] =>

Products

Ortho Tribune | Nov./Dec. 2009

Avex CXi
Made from polycrystalline alumina, Avex CXi Ceramic Brackets offer translucence without sacrificing bracket integrity, bond strength or patient comfort.
Bracket features include mesial and distal “pockets” that provide greater
inter-bracket distance, reducing wire forces and improving patient comfort;
metal slot liners to enhance strength and reduce friction; and purchase points
on the tie wings that have a patented shape that is both round for comfort and
pointed for easy ligation.
The universal color identification marking and the same in/
out dimensions for each tooth as the Avex MX Stainless Steel Brackets,
make the brackets completely interchangeable — an industry first.
Opal Orthodontics
(888) 863-5883
www.opalorthodontics.com

f OT page 12

BRACE appliance maintains all the
characteristics and elements of the
Trainers. Therefore, it can produce
the same effects reported by other
Trainers as these effects are the
result of the elements found in all
TRAINER System Appliances.
By stimulating development of
the dental arches, there will be
more room for the teeth, and the
MYOBRACE can guide the teeth to
align in a correct position through
the tooth channels included in the
appliance. This is one of the features that differentiates the MYOBRACE from the other Trainers.
Based on all evidence presented
here, it can be stated that the TRAINER System Appliances (including the
MYOBRACE) are a viable and scientifically proven alternative to treat
those patients who require treatment for malocclusions but who do
not want treatment with fixed appliances such as brackets. OT

References
1.

3.
4.

Farella M, Bakke M, Michelotti A,
Rapuano A, Martina R. Masseter thickness, endurance and exercise-induced
pain in subjects with different vertical
craniofacial morphology. Eur J Oral
Sci 2003; 111:183–188.
Frankel, R. The Frankel appliance.
In: TM Graber, B Newmann (Eds).
Removable Orthodontic Appliances.
Philadelphia: W.B. Saunders; 1977.
p.526–66.
Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians.
Angle Orthod. 2004 Feb;74(1):3–15.
Fujiki T, Inoue M, Miyawaki S, Nagasaki T, Tanimoto K, Takano-Yamamoto
T. Relationship between maxillofacial
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movement in patients with anterior
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Orthop 2004; 125: 160–167.

Haralabakis NB, Toutountzakis NM,
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in adult individuals with open bite and
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6. Kanao A, Mashiko M, Kanao K. Application of functional orthodontic appliances to treatment of Mandibular
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7. Lindner A, Hellsing E. Cheek and lip
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8. Lowe AA, Takada K. Association
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Am J Orthod 1984; 86:319–30.
9. Mew JR. The postural basis of malocclusion: a philosophical overview. Am
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10. Ono T, Lowe AA, Ferguson KA, Fleetham JA. Associations among upper
airway structure, body position,
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patients with obstructive sleep apnea.
Am J Orthod Dentofacial Orthop. 1996
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11. Petrovic A, Stutzmann J, Lavergne J,
Shaye R. Is it possible to modulate the
growth of the human mandible with
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1991; 29(1-2): 3–8.
12. Quadrelli C, Gheorgiu M, Marcheti,
C, Ghiglione V. Early myofunctional
approach to skeletal class II. Mondo
Orthod 2002; 2:109–22.
13. Ramirez- Yañez GO, Farrell C. Soft
Tissue Dysfunction: A missing clue
in orthodontics. International Journal
Jaw Functional Orthopedics 2005; 1:
351–9.
14. Ramirez- Yañez GO, Sidlauskas A,
Junior E, Fluter J. Dimensional changes in dental arches after treatment with
a prefabricated functional appliance.
Journal of Clinical Pediatric Dentistry
2007; 31:287–91.
15. Ramirez- Yañez GO, Faria P. Early
Treatment of a Class II, Division 2
Malocclusion with the Trainer for Kids
(T4K): A Case Report. Journal of Clinical Pediatric Dentistry 2008; 32:325–30.
16. Ringqvist M. Fiber sizes of human masseter muscle in relation to bite force. J

Neurol Sci 1973; 19:297–305.
17. Rocabado M. Biomechanical relationship of the cranial, cervical, and hyoid
regions. J Craniomandibular Pract.
1983 Jun-Aug;1(3):61–6.
18. Rowlerson A, Raoul G, Daniel Y, Close
J, Maurage CA, Ferri J, Scioteg JJ.
Fiber-type differences in masseter
muscle associated with different facial
morphologies. Am J Orthod Dentofacial Orthop 2005; 127: 37–46.
19. Sessle BJ, Woodside DG, Bourque P,
Gurza S, Powell G, Voudouris J, Metaxas A, Altuna G. Effect of functional
appliances on jaw muscle activity. Am
J Orthod Dentofacial Orthop. 1990
Sep;98(3):222–30.
20. Spyropoulos MN, Tsolakis AI, Alexandridis C, Katsavrias E, Dontas I. Role of
suprahyoid musculature on mandibular morphology and growth orientation in rats. Am J Orthod Dentofacial
Orthop. 2002 Oct;122(4):392–400.
21. Stavridi R, Ahlgren J. Muscle response
to the oral-screen activator. An EMG
study of the masseter, buccinator, and
mentalis muscles. Eur J Orthod. 1992
Oct;14(5):339–49.
22. Stutzmann JJ, Petrovic AG. Role of the
lateral pterygoid muscle and meniscotemporomandibular frenum in spontaneous growth of the mandible and
in growth stimulated by the postural
hyperpropulsor. Am J Orthod Dentofacial Orthop. 1990; 97(5): 381–92.
23. Tabe H, Ueda HM, Kato M, Nagaoka K,
Nakashima Y, Matsumoto E, Shikata N,
Tanne K. Influence of functional appliances on masticatory muscle activity.
Angle Orthod. 2005 Jul;75(4):616–24.
24. Tallgren A, Christiansen RL, Ash M Jr,
Miller RL. Effects of a myofunctional
appliance on orofacial muscle activity and structures. Angle Orthod. 1998
Jun;68(3):249–58.
25. Tallgren A, Solow B. Hyoid bone position, facial morphology and head posture in adults. Eur J Orthod. 1987
Feb;9(1):1–8.
26. Tosello DO, Vitti M, Berzin F. EMG
activity of the orbicularis oris and mentalis muscles in children with malocclusion, incompetent lips and atypical
swallowing — part II. J Oral Rehabil
1999; 26:644–9.
27. Usumez S, Uysal T, Sari Z, Basciftci F,
Karaman A, Guray E. The Effects of
Early Preorthodontic Trainer Treatment on Class II, Division 1 Patients.
Angle Orthod 2004; 74: 605–609.
27. Van der Linden, Frans P. G. M. and
Proffit, William R. Dynamics of Orthodontics (Vol 4): Orofacial Functions.
Quintessence Pub.

OT About the author
Dr. German Ramirez-Yañez, DDS,
MDSc, PhD, is an assistant professor
on the faculty of dentistry, Department of Preventive Dental Science
at the University of Manitoba in
Winnipeg, Canada. Contact him at
german@myoresearch.com.

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[cover] => Ortho Tribune U.S.

[toc] => Array ( [0] => Array ( [title] => Rotated teeth — effective ortho treatment utilizing the lingual technique (entree) [page] => 01 ) [1] => Array ( [title] => Orthodontic education needs ‘fresh young blood’ [page] => 02 ) [2] => Array ( [title] => Rotated teeth — effective ortho treatment utilizing the lingual technique [page] => 03 ) [3] => Array ( [title] => A new year and a new mission [page] => 06 ) [4] => Array ( [title] => Dr. Hardy’s referral marketing creates record number of starts [page] => 08 ) [5] => Array ( [title] => The TRAINER System in the context of treating malocclusions (part1) [page] => 09 ) [6] => Array ( [title] => The TRAINER System in the context of treating malocclusions (part2) [page] => 14 ) ) [toc_html] =>

Table of contents

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