Cover / Editorial / Content / Clinical and diagnostic advantages of 3-D imaging systems in dental specialties / The business of private practice orthodontics in the United States / 52 weeks of social media posts in less than five minutes / Lingual you will love / SENTALLOY: The story of superelasticity / What is UOBG and why should you be a part of it? / Sesame Communications appointed to UOBG Preferred Partner Program / Submissions / Imprint
Cover
01 - 01 viewEditorial
02 - 02 viewContent
05 - 05 viewClinical and diagnostic advantages of 3-D imaging systems in dental specialties
06 - 10 viewThe business of private practice orthodontics in the United States
11 - 16 view52 weeks of social media posts in less than five minutes
17 - 22 viewLingual you will love
24 - 27 viewSENTALLOY: The story of superelasticity
30 - 44 viewWhat is UOBG and why should you be a part of it?
46 - 47 viewSesame Communications appointed to UOBG Preferred Partner Program
48 - 49 viewSubmissions
50 - 50 viewImprint
55 - 55 viewArray
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[1] =>
ortho
issn 2161–7228
the international C.E. magazine of
North America Edition • Vol. 1 • Issue 1/2012
orthodontics
1
2012
_earn c.e. credit
Clinical and diagnostic advantages of 3-D imaging systems in dental specialties
_practice matters
The business of private practice orthodontics in the United States
_techniques
Lingual you will love: Capturing the incremental patient with lingual orthodontics
[2] =>
I editorial_ ortho
Welcome
to ortho
The goal of this quarterly magazine is twofold. First, it seeks to share practical orthodontic knowledge
that can be put to use in your day-to-day practice. Second, it is a vehicle to help you chip away at your
continuing education (C.E.) requirements.
The amount of new information available in the orthodontic field about new products, techniques and
research data is astounding. Running a practice and seeing patients leaves little time for catching up on
the latest clinical news and product information. Thus, we hope ortho will not only be a welcome respite
for those rare chunks of time you can devote to leisurely reading, but one that provides a practical return
on your investment by providing information that you can actually put to immediate use.
In addition, we know that taking time away from the practice to pursue C.E. credits is costly in terms
of lost revenue and time. As a quarterly magazine, ortho is here to help you chisel at least four C.E.
credits per year out of your already busy life without the lost revenue and time away from your practice. To that end, every edition of ortho will include at least one hour of ADA CERP-certified C.E. credit
where readers can answer questions about the materials at www.dtstudyclub.com to earn this credit.
Annual subscribers to the magazine ($50) need only register at the Dental Tribune Study Club website to
access these C.E. quizzes free of charge. In fact, even non-subscribers may take the C.E. quiz after registering on the DT Study Club website and paying a nominal fee.
If you are a practitioner with a penchant for words, it might also interest you to know that authors of
the C.E.-accredited articles receive 15 percent of the fees collected from the non-subscribers who take the
C.E. quiz online. The C.E. quiz for the articles in this edition will be available online on May 1.
Dental Tribune America is part of the largest dental publishing network in the world, Dental Tribune
International (DTI), which consists of 23 license partners around the globe. The DTI network publishes a
variety of dental publications that are distributed in more than 90 countries. Please visit us online at www.
dental-tribune.com to see the variety of publications we offer and at www.dtstudyclub.com to see the
complete list of online and offline C.E. opportunities available. In the meantime, we hope you enjoy the
first edition and welcome your feedback.
Sincerely,
Torsten Oemus
Publisher
02 I ortho
1_ 2012
Torsten Oemus
Publisher
Dental Tribune International
[3] =>
[4] =>
[5] =>
content _ ortho
I
page 11
page 06
page 17
I c.e. article
I about the publisher
06 Clinical and diagnostic advantages of 3-D
imaging systems in dental specialties
50
55
_submissions
_imprint
_Dan McEowen, DDS
I practice matters
11 The business of private practice orthodontics
in the United States
_Chris Bentson, President, Bentson, Clarke & Copple
17 52 weeks of social media posts in less than five
minutes
_Rachel Mele, Director of Business Development,
Sesame Communications
I technique
24 Lingual you will love: Capturing the incremental
patient with invisible orthodontics
_Ronald Roncone, DDS, MS
ortho
issn 2161–7228
the international C.E. magazine of
30 SENTALLOY: The story of superelasticity
_Albert Teramoto, DDS
1
North America Edition • Vol. 1 • Issue 1/2012
orthodontics
2012
I UOBG
46 What is UOBG and why should you be a part
of it?
_Lindsay Peach, UOBG Program Director
_earn c.e. credit
Clinical and diagnostic advantages of 3-D imaging systems in dental specialties
_practice matters
The business of private practice orthodontics in the United States
_techniques
48 Sesame Communications appointed to UOBG
Preferred Partner Program
_Gib Snow, DDS
page 24
Lingual you will love: Capturing the incremental patient with lingual orthodontics
I on the cover
__ORCE012012.indd 1
4/20/12 4:10 PM
Cover image provided by DENTSPLY GAC
page 46
page 30
ortho
I 05
1
_ 2012
[6] =>
I C.E. article_ application of 3-D imaging
Clinical and diagnostic
advantages of 3-D imaging
systems in dental specialties
Author_Dan McEowen, DDS
_c.e. credit article
This article qualifies for
C.E. credit. To take the
C.E. quiz, please log on to
www.dtstudyclub.com. The quiz
will be available on May 1.
Fig. 1_Saggital CBCT MPR showing
bone defect at point of dehiscence of
the implant coating.
(Photos/Provided by Dr. McEowen)
Fig. 2_Periapical does not show the
sinus anatomy or the width of the
bone.
Fig. 3_MPR showing post-op of
sinus graft and implant placement.
Fig. 1
_For nearly 100 years, dentists have relied on 2-D
radiographic imaging for diagnosis and treatment
planning. With the 1999 introduction of cone-beam
computed tomography (CBCT), all dentists now have
tools available for more accurate diagnosis and treatment.1 The ability to look at a tooth in any direction
and orientation, as well as in 3-D, eliminates much
of the guesswork commonly experienced with 2-D
radiographs.
We have been limited in most cases to only a
buccal-lingual view provided by periapicals, bitewings and panoramic radiographs with the occasional axial view of an occlusal film. Medical CT
scans and images began in the early 1970s and were
sometimes used by dentists, offering our first multiplaner views.2
The adoption of 3-D cone-beam imaging is appropriate and has important advantages for all modalities of dentistry. From every specialist to the general
dentist, the increased amount of radiographic information as well as increased accuracy will aid in the
most sound diagnosis possible.
Fig. 2
06 I ortho
1_ 2012
_CBCT description
CBCT is a single or partial rotation of an X-ray
source around the head, capturing X-rays on various
flat panel arrays and sensors. The information is converted to a series of axial slices by computed tomography and stored as virtual anatomy in the computer.
With the use of sophisticated software, the
dentist is able to view information in several different views, including: axial slices (head-to-toe
orientation), coronal slices (front-to-back orientation), saggital slices (side-to-side orientation) all
known as multiplaner reconstructions (MPR). The
thickness of each slice can be varied to include more
or less information.
Because the voxels (volumetric pixels 3-D) are
isotropic, other MPR images can be generated by
slices drawn at any angle, curve or thickness through
the scan to view areas critical to the final diagnosis.3,8
The final view offered by CBCT is a 3-D view that
can be rotated and viewed in any direction.
Once again through software manipulation, 3-D
Fig. 3
[7] =>
C.E. article_ application of 3-D imaging
Fig. 5
Fig. 4
images can be viewed as conventional radiographs,
maximum intensity projections (MIP), soft-tissue
projections and a variety other views.
This nearly endless ability to manipulate the data
aids in the diagnosis and identification of disease,
nerve canals, sinus morphology, dental caries, bone
density, fractures, endodontic pathology, implant
placement criteria, periodontal defects, bone pathology, fractured teeth, iatrogenic trauma, TMJ
morphology and disease, third-molar position and
many more healthy or diseased conditions.
_Early CBCT adoption with implants
The first and primary use of CBCT for early adopters
was implant placement. As the scope and the value
of the information became better known, dentists of
all branches began to see the value of MPRs and 3-D
renderings including periodontics, endodontics, oral
surgery, treatment of TMJ, orthodontics, implantology and general dentistry.1,7,8
Clinical periapical and panoramic radiographs for
the placement of implants can be misleading with
elongation, foreshortening, superimposition and
geometrically incorrect data.7,8 A look at the implant
in the periapical shows no obvious disease to an existing integrated implant. Clinically, a buccal fistula was
present with exudate and slight pain. The CBCT scan
(Fig. 1) reveals a more accurate view showing a buccal defect on a saggital MPR. A surgical flap revealed
a dehiscence of the coating of the implant. Removal
of the foreign body resulted in an asymptomatic and
healthy patient
The evaluation of the available bone for the initial
I
implant placement can be crucial for the long-term
success of the case. If there is inadequate bone
available, grafting may be a necessity. CBCT studies
render the most accurate information available at a
low radiation dose. The periapical shows an obvious
lack of bone height, but does not show the buccallingual dimensions or an accurate view of the sinus
morphology (Fig. 2).
The MPR view of the CBCT shows all necessary
measurements to perform the sinus lift and grafting
with the immediate placement of the implant fixture
(Fig. 3). Three-dimensional views show the floor of
the sinus and any soft-tissue pathology (Fig. 4). Having accurate measurements in all dimensions is an
advantage of CBCT scanning.
Fig. 4_The 3-D CBCT showing
anatomy of the maxillary sinuses.
Fig. 5_Axial MPR showing mesial
buccal roots in first, second and third
molars.
_CBCT and endodontics
Endodontics is a field that is rapidly adopting
the use of CBCT and for good reason. The inherent
geometric deficiencies of 2-D radiographs make
the CBCT scan a valuable adjunct to investigate the
root morphology in both 3-D and MPR. The typical
periapical will show superimposed canals in the
anteriors, bicuspids and molars as well as unwanted
bone densities both buccal and lingual to the affected
tooth, making the image quality poor.
The ability to view MPR slices in cross-section,
long axis and oblique directions gives the ability
to follow all canals in any direction and show their
relationship and measurements from other known
structures. This virtual tour of the root morphology
is a great benefit to the final treatment outcome
(Fig. 5).3,4
ortho
I 07
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[8] =>
I C.E. article_ application of 3-D imaging
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 6_Periapical showing minimal
pathology with no radiolucency.
Fig. 7_Coronal MPR showing a
short fill on the mesial lingual and
radiolucency.
Fig. 8_Saggital MPR showing
unfilled canal and radiolucency.
Fig. 9_Periapical showing a normal
fill with a radiolucency.
Fig. 10_Coronal MPR showing the
superimposed lingual root unfilled.
Fig. 11_Coronal MPR showing nerve
between roots
of the third molar.
08 I ortho
1_ 2012
Post root-canal infection can be difficult to diagnose with the standard periapical. The endodontic
fills may appear to be normal even though other clinical findings and symptoms are abnormal. The patient
presents several months post root-canal treatment
with pain on palpation and pressure and avoids this
side of the mouth.
A periapical radiogragh shows minimal pathology (Fig. 6). The roots appear to be filled and a small
puff of sealer extends through the apex of the mesial
roots. The distal root structure and fill appear normal.
There is little indication of periapical radiolucency
only a widening of the periodontal ligaments of the
mesial roots.
A CBCT scan reveals a completely different picture.
The coronal MPR reveals a short fill near the apex of
the mesial lingual root and a large radiolucency (Figs.
7, 8) not visible on the periapical radiograph (Fig. 6).
Missed canals are difficult to see in a buccallingual projection of the periapical radiograph as one
canal is superimposed on the other (Fig. 9). Often, as
viewed in this radiograph, we see periapical pathology with an apparent normally filled canal. CBCT
scans allow dentists to look for pathology in MPR
planes to identify the actual problem before invasive
procedures are performed on the patient. The axial
view shows a lingual canal exists and is untreated. The
coronal view confirms the diagnosis and treatment
can be completed (Fig. 10).
Today’s endodontists, as well as general dentists,
are benefiting from the diagnostic capabilities of
the high-resolution CBCT scanners available over
conventional 2-D periapical.5,6
_Oral surgery
Oral surgery, with its inherent invasive nature, can
be better served using CBCT with MPR as well as 3-D
images. The ability to perform virtual surgery is a benefit to both the doctor and the patient. Doctors have
the advantage of seeing morphology and landmarks
in real time and space with accurate measurements,
and patients will gain a better understanding of the
problems and the solutions their doctors are offering
them.
Third-molar extractions can be risky based on
2-D and panoramic radiographs. These radiographs
can often superimpose nerves and sinuses over root
structures. Dentists using 2-D radiographs must often rely on experience to assess the risks of iatrogenic
[9] =>
C.E. article_ application of 3-D imaging
Fig. 12
trauma. The use of CBCT with MPRs and 3-D images
reduces any guessing as well as the chance for any
permanent damage to the patient. With the adoption
of CBCT, the judgment is based on solid evidence and
the risk will decrease.
A panorex of the superimosed third molars gave
no solid evidence the canal lies between the roots. It is
only with the use of CBCT and the MPRs that the nerve
can accurately be seen traversing between the mesial
buccal and mesial lingual root (Fig. 11).4,5
Other surgical advantages include the identification and the position of supernumerary or impacted
teeth. The images show accurate positions and show
definitive morphology that will aid in removal of the
proper teeth (Fig. 12). Knowing the exact position of
many of these teeth is a benefit to both the doctor and
patient. It will lead to the most precise surgical path
and the least invasive procedure.
_Periodontics
The explanation of periodontal problems are
often misunderstood by the patient. As doctors,
we talk about pockets, point to X-rays and propose
treatment only to have patients refuse treatment
because they do not understand what we are clinically describing. Using the 3-D portion of the CBCT
scan can improve the understanding and acceptance
of treatment plans.
The images are a picture of the problem that is
owned by that patient and much easier to understand
by the layperson. Illustrating periodontal defects and
pockets allows the patient to better participate in the
process (Fig. 13).
I
Fig. 13
The MPRs and the 3-D projections aid in surgical
planning for periodontists, allowing for accurate
measurements and bone analysis prior to osseous
surgery that doctors cannot get using the periapicals
or panoramics.
Studies have shown that CBCT images are more
accurate than panoramic radiographs. For the periodontist placing implants, the ability to measure bone
density and avoid important anatomy is important.4,5
Fig. 12_The 3-D rendering showing
supernumersary teeth and positions.
Fig. 13_The 3-D rendering with
periodontal defects and calculus
bridge.
_Orthodontics
Orthodontists are beginning to adopt large fieldof-view CBCT. Recent studies show that linear
measurements of bony structures are more accurate
using CBCT and have less distortion than current
methods of measurement: lateral cephalometric,
posteroanterior (PA) and submentovertex (SMVT).5
Accurate measurements of tooth volume and tooth
position can aid in accelerated treatment times and
more precise treatment.
Along with tooth position, density of bone and
size of arches, the orthodontist also has an accurate
evaluation of the temporomandibular joint and
position of the condyles. Impacted teeth are easily
identified and position, either buccal or lingual can
be confirmed prior to movement or removal.
Both MPRs and 3-D projections give the clinician a
complete picture of the problems and the treatment
course.
With a single CBCT scan, orthodontists can produce all of the information they need: panoramic,
cephalometric, PA, SMVT, tooth size and volume,
crowding evaluation in any plane, TMJ evaluation
ortho
I 09
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_ 2012
[10] =>
I C.E. article_ application of 3-D imaging
‘With a single CBCT scan, orthodontists can
produce all of the information they need:
panoramic, cephalometric, PA, SMVT, tooth
size and volume, crowding evaluation in any
plane, TMJ evaluation and airway analysis, all
with both soft-tissue and skeletal information.’
and airway analysis, all with both soft-tissue and
skeletal information.5,7
_Conclusion
We treat our patients in 3-D, and now, with conebeam computed tomography, we are changing the
way we diagnose from 2-D to 3-D. The addition of
this technology will increase your diagnostic skills
with better and more complete information at your
disposal. As with any type of invasive diagnostic tool,
clinicians should weigh the risk to benefit in using
CBCT scans.
Judicious use of CBCT and knowledge of patient’s
lifetime doses should always be a consideration
as well as the availability of other diagnostic tests
appropriate for the problems of the patient. When
adopting new technology, training is paramount.
Along with training comes the responsibility of the
doctor to read and diagnose information from CBCT
scans.
Do not avoid CBCT from lack of knowledge;
instead, take this opportunity to become a better diagnostician and radiologist. As you review radiology
and pathology, your use of CBCT will aid in making
the most accurate diagnosis and the most complete
treatment plans._
References
1. Ziman E, DDS, JD; White SC, DDS, PhD; Tetradis
S, DDS, PhD. Legal Considerations in the Use of
Cone Beam Computer Tomography Imaging.
CDA Journal. 2010;138:49–56.
2. No specific author listed. For the Patient (history
of X-ray), JADA, Nov 2004; vol.135:1643.
3. Patel S, Dawood A, Whaites E, PittFord T. New
Dimension in Endodontic Imaging: Part 1. Conventional and Alternative Radiograpic Systems.
International Endodontic Journal. 2009;1–16.
4. Lezingera I, Dudicb A, Giannopoulouc C, Kiliar-
10 I ortho
1_ 2012
idis S. Root Contact Evaluation by Panoramic
Radiography and Cone-Beam Computed Tomography of Super High Resolution. Am J Orthod
Dentofacial Orthop. 2010;137:389–392.
5. Hilgers ML, Scarfe WC, Sheetz JP, Farman AG.
Accuracy of Linerar Temporomandibular Joint
Measurements with Cone Beam Computed
Tomography and Digital Cephalometric Radiography. Am J Orthod Dentofacial Orthop.
2005;128:803–811.
6. Stavropoulos A, Wenzel A. Accuracy of cone
beam dental CT, intraoral digital and conventional film radiography for the detection of
periapical lesions. An ex vivo study in pig jaws.
Clinical Oral Investigations. 2007;11:101–106.
7. Scarfe WC, Levin MD, Gane D, Farman AG. Use
of Cone-Beam Computed Tomography in Endodontics. International Journal of Dentisty.
Volume 2009 (2009), Article ID 634567, 20 pages.
_about the author
ortho
Dan McEowen, DDS, is
a 1982 graduate of Loma
Linda School of Dentistry
and has been in private
practice for 26 years. He is
a founding member of the
World Clinical Laser Institute, achieving a mastership
level of proficiency.
He has been active in the
FDA approval of oral surgery
techniques using erbium
lasers. McEowen has lectured and trained internationally
in techniques using lasers in general and specialty dental
fields. He a member of the ICOI and is active in implantology. McEowen has been involved in cone-beam technology
for more than five years and owns 3D Imaging Center in
Maryland.
[11] =>
practice matters_ staying competitive
I
The business of private
practice orthodontics
in the United States
Author_Chris Bentson, President, Bentson, Clark & Copple
_Private practice orthodontic ownership in America is and will continue to be one of the best income
producing vocations in all of dentistry and medicine.
However, running a successful practice is increasingly complex and the path leading to financial success seems steeper than past years.
The winds of change and challenge vary in direction and intensity, but are relentless as they push
practice owners to learn, adapt and implement the
ideas, strategies and products necessary to stay
competitive and clinically relevant.
This article will look at the current orthodontic
market in the United States from the perspective of
the practice owner. We’ll glance back at past norms,
look at where we are now and discuss a few of the
trends we’re seeing in the profession looking forward. Put your seat belt on, this can be a bumpy ride.
_Doctor demographics
The U.S. Census Bureau reports there are about
312 million people living in the United States. To serve
the dental needs of this population, the U.S. Department of Labor’s Occupational Outlook Handbook
reports there are currently about 136,000 general
dentists working in the United States. Orthodontists
are the largest dental specialty group with a force of
about 9,500.
Of the 65 orthodontic residency programs in the
United States, the total resident enrollment at any
given time is about 975, with about 360 residents
graduating each year. Program length varies between 24 and 36 months.
Currently, 17 programs offer 24 months, 15
programs offer 30 months and 33 programs are in
the 36-month range (each of these are ranges as
some programs are 26 months or 33 months, as an
example).
Growth in the number of programs, and therefore
residents, has substantially increased in the last decade. Primarily, programs at Jacksonville, Denver and
Las Vegas each started with an original class size of
about 14 residents, though the University of Nevada
has recently dropped back down to four residents
per class.
In addition to these three large programs, the
University of Southern Nevada in Henderson began
in late 2008 and offers an MBA along with an orthodontic certificate, accepting 10 residents per year.
Seton Hill University, in Greensburg, Pa., began a new
orthodontic program in July 2010 and will graduate
its first class of six in December.
Collectively, these new programs produce about
54 new orthodontists per year, an 18 percent increase
in the number of orthodontists coming out per year
compared with a decade ago.
This increase in the number of new orthodontists
is currently intersecting with a larger number of
pediatric dental offices bringing orthodontics inhouse and an increasing number of dental clinics and
corporate-managed dental offices adding orthodontics into their business model. In addition, recent
economic times have caused many orthodontists to
extend their careers, giving investment portfolios
and retirement funds time to rebound, resulting in
fewer practice owners retiring.
These factors have resulted in an aging orthodontic profession. According to the 2011 Journal of Clinical Orthodontics 2011 Practice Study, the current
mean age of an orthodontist is 54, and he/she has
been practicing for 23 years. Both of these statistics
are 30-year highs.
As the profession ages, opportunities for practice
purchases have remained scarce. One measurement
of supply and demand is the AAO Practice Opportunities Services (POS), which reported 143 opportunities
ortho
I 11
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_ 2012
[12] =>
I practice matters_ staying competitive
(Photo/Vladimir Mucibabic,
www.dreamstime.com)
for purchase or employment and 464 doctors seeking
opportunities for purchase or employment at the end
of last year. This roughly 3:1 ratio of buyers to sellers
has moved down from a ratio of 5:1 in 2009 and 4:1
in the last half of 2010, as reported by the AAO POS.
Young orthodontists are necessarily seeking
work where they can find it, often as an associate/
employee of a general dental clinic or pediatric dental
practice.
We expect the supply and demand of buyers
and sellers to continue to move toward levels that
are more equal over the next several years, thus improving the prospect for buyers to find orthodontic
practices for sale.
After years of caution following the stock market’s
financial crisis swoon, the wealthy returned to
luxury brands, benefiting retailers such as Saks, Inc.
and Nordstrom Inc.
At the lower end, dollar stores and discount
chains profited as prolonged unemployment and
economic uncertainty spurred the middle class to
trade down.
That created a barbell effect, as companies that
traditionally cater to middle-class consumers suffered. Gap Inc.’s profit declined 27 percent….and
department store chain J.C. Penny Co. flipped to a
$65 million loss for the first nine months of the year
(2011).”1
_The economy and census data
The recent 2011 JCO Practice Study seems to agree
with the analysis above, as mean net collections for
orthodontic practice owners reported a $10,000 drop
from the 2009 study; from $960,000 to $950,000.
Median case starts also decreased from 220 in 2009
to 200 in the 2011 study. Both of these drops were
the first decreases in these measurements since the
studies began in 1983.
These drops in means reflect the middle class
struggle to get back on their feet. We have seen
value-positioned practices grow and high-end boutique practices do well in the most recent year ended,
furthering the idea that the current economic pain
for the orthodontist is hitting the middle market
practitioner.
Current U.S. Census Bureau data does reveal an
expected increase in the population, which may
provide some solace to orthodontic practice own-
The recession that started in December 2007 and,
according to economists, ended in May 2009, has
been over for almost three years. However, the crawl
out has been slow at best. Gross domestic product
(GDP) posted an anemic 2.8 percent growth in 2010
and was backed up by another tepid performance of
just under 3 percent in 2011.
While we have been technically out of a recession
since mid 2009 and have thus far avoided a doubledip, consumers are more conservative, saving more
and looking for a bargain, especially the middle class.
The Wall Street Journal, in an article describing
current consumer sentiment in January of this year
stated:
“Retailers and consumer-goods companies alike
grappled with a disappearing middle class in 2011.
12 I ortho
1_ 2012
[13] =>
[14] =>
I practice matters_ staying competitive
ers. Particularly of interest to orthodontists are the
4,058,000 children born in 2000, the highest number
of births since 1992.
These millennial babies are turning 12 this year,
prime candidates for full phase adolescent treatment. Total U.S. population growth is predicted at
8.7 percent through 2020 and 8.3 percent from
2020–2030 with significantly high percentages of
this growth concentrated in the Hispanic, Asian
Pacific Islander and African American ethnic groups.
_Financial lending
Even with little organic orthodontic practice
growth and the increasing educational debt of
residents, money is available for practice purchases
or start-ups for young doctors. Local banks that are
primarily asset lenders often have trouble underwriting orthodontic practice purchases.
But an array of cash-flow lenders that focus on
dental transaction lending for both start-ups and
acquisitions have teams that are aggressively seeking
out and lending to young orthodontists.
Why? Because the performance of these loan
portfolios is superior to most other types of loans
these institutions underwrite. Orthodontics does
and will continue to provide doctor/owners with an
exceptional return on investments, and certain lenders understand and want to participate in this return
in today’s market.
Money for practice purchases for young doctors
typically requires no down payment, repayment over
seven to 10 years, with some programs being longer
and often with a fixed interest rate.
Larger practice loans often require the seller to
carry some of the purchase price in a note with many
lenders agreeable to refinancing the seller portion
after a year or two of timely payments and monitored
practice performance of the new owner, thus allowing the seller to be fully cashed out within several
years of the change of ownership.
_Trends in orthodontics
Decrease in GP and dental specialty referrals
Several trends currently in process divert from the
norms seen over the last 30 years. Chief among them
is a decrease in the number of referrals from general
dentists or other dental specialties.
According to data published by the JCO on practice studies completed from 1983 to 2011, general
dental referrals accounted for 50 percent or greater
of the total referrals for orthodontic practice owners
for the years 1983–1999.
Since that time, this referring source has steadily
declined, representing 41 percent of total referrals in
the 2009 practice study and 40 percent in the recently
14 I ortho
1_ 2012
published 2011 study. Referrals from other dental
specialists also declined from 2 percent over the years
from 1983–2009 to 1 percent of total referrals in the
latest 2011 study.
This is believed to primarily be a result of the
increase of pediatric dentists bringing orthodontic
treatment into their practices.
Increase in internal marketing programs
As a result of a decrease in referrals form other
dental professionals, practices have aggressively
employed ideas and strategies to generate internal
referrals. Patient referrals increased from 30 percent
in the 2007 JCO Practice Study to 35 percent in both
the 2009 and 2011 studies.
Our observation is that generating a program
to increase internal referrals is a learned skill and
demands a system or process that includes the entire
orthodontic team to be most effective.
This is most easily accomplished by employing a
consultant to help the practice learn how to generate
referrals and implement a systematic approach to
seek referrals from patients.
Increase in use of website and social media
A derivative of the drive to generate patient referrals is a push to increase the effectiveness of the
practice website and communication with patients
and prospective patients by using social media and
networking tools.
Not so many years ago, having a website was the
goal; today, practices that have learned to leverage
their websites and other social media tools tend to
show higher new-patient flow than those that do not
and often higher numbers of case starts.
Abbreviated treatment times
For years, the average treatment time for fullphase orthodontic treatment stayed very close to 24
months. This length coincided well with payments
that fit nicely within the family budget. In recent
years, adoption of certain treatment modalities
has resulted in a decrease in the average number of
months in treatment for patients.
The 2009 JCO Practice Study reported average
treatment times of 22 months, down from the traditional 24 months for the first time. Many practices
report treatment times in the 15–18 month average range with the use of certain newer treatment
modalities.
New approaches to fees and payment methods
With some practices experiencing shorter treatment times and some treatment modalities associated with per-case lab fees or higher cost of goods,
treatment fees posted an increase of only three
percent between 2009 and 2011, according to the
[15] =>
[16] =>
I practice matters_ staying competitive
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Reference
1. Lublin, S. Year of the Oops: Firms
Spent 2011 in Reverse. Wall Street
Journal. January 2012.
16 I ortho
1_ 2012
JCO practice studies, which is the smallest increase
in 30 years.
Additionally, the current economic environment
is making it difficult to increase fees while asking
the consumer to pay for the fee in an abbreviated
amount of time. The use of automatic monthly payment services has greatly increased over the last
five years, and some practices are choosing to allow
patient contract lengths to extend beyond estimated
treatment lengths if certain requirements are met
(often either a credit check and/or the insistence of
automatic payment method).
There are certainly a number of other trends currently occurring in orthodontics. As the landscape
evolves, practice owners are well served to stay ahead
of the curve wherever they can.
Our observations are that consultants are a great
help to practice owners. Consultants see dozens
and sometimes hundreds of practices per year and
can bring transferrable concepts that owners can
implement as they address a changing consumer
and market.
It is also more important than before for practice
owners to monitor key operational and financial
metrics with more scrutiny than perhaps they have
in the past. This effort will help identify areas in
the practice that need attention and allow practice
owners to make better and earlier decisions as they
operate in the current environment.
As stated at the beginning of this article, “Private
practice orthodontic ownership in America is and
will continue to be one of the best income producing
vocations in all of dentistry and medicine.”
Stay focused, be aware of the trends and changes
and keep your seat belt on. The ups and downs of
practice ownership are not for the lazy or faint of
heart, but the results are enormously rewarding._
_about the author
ortho
Chris Bentson has been
working with orthodontists
regarding the business aspects of their practices for
more than 23 years.
He is currently the president
of Bentson Clark & Copple
based in Greensboro, N.C.
Bentson also serves as editor
in chief of the Bentson Clark
reSource, a quarterly newsletter focused on the business
aspects of running a successful orthodontic practice.
He is a frequent guest lecturer, most recently presenting
at the invitation of the AAO at the 2011 AAO Transition
Seminar in Chicago. He has personally visited more than
1,000 orthodontic practices in the United States, Canada
and Australia. He may be reached at (800) 621-4664 or via
e-mail at chris@bentsonclark.com.
[17] =>
practice matters_ social media
I
52 weeks of social
media posts in less
than five minutes
Author_Rachel Mele, Director of Business Development, Sesame Communications
_Somewhere along the way, Facebook stopped
being social. Oh, you can still go there, chat with your
friends and plan your weekend. You can still “like”
pictures of your neighbor’s new puppy and stay upto-date with your high school friends.
However, you can also go there, chat with suppliers and plan your next major purchase. You can
“like” that secret sale your favorite store is having
and stay up-to-date with the companies your high
school friends are now running. Right before our
eyes, Facebook grew up.
To anyone who’s paying attention, it’s obvious
that Facebook has transcended the concept of “social
media” and has in reality become “business essential.”
The facts bear this out. Facebook now has 845 million users1, including more than 60 percent of active
online U.S. consumers2 spending an average of seven
hours a month on the site.3
This is the type of reach and frequency that marketers would have killed for in the past. These figures
emphasize the power of social media to create interactive dialogue.
It’s no secret that running an orthodontic office,
and actively engaging with patients on Facebook,
can be challenging without support. Nevertheless,
the new business landscape and reach of Facebook
make it essential.
To lend a helpful hand, here are 52 weeks of
Facebook orthodontic posts for your practice.
You can use these posts to start or enhance the
conversation with your patients online. Remember
to personalize each Facebook post and include a link,
photo or video to support the topic.
1) January 24 is Parent’s Day. Dr. [insert name]
would like to thank [his/her] parents for all they have
done. Tell us why you are thankful for your parents.
2) In-Ovation® C clear braces are a great way to get
your teen excited about correcting his/her bite and
teeth alignment issues. Because they’re clear, friends
and family won’t even notice they have braces on!
Give us a call at [insert telephone number] to learn
more.
3) Join us today for our 4th annual [insert practice
name] blood drive. We donate because we believe it’s
the right thing to do. Why do you give blood?
ortho
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[18] =>
[19] =>
[20] =>
I practice matters_ social media
4) It’s Valentine’s Day. The average woman smiles
approximately 62 times a day compared to men who
only smile 8 times a day.4 Guys, will you remember to
smile at your lady today?
5) Dr. [insert name] just got a haircut. What do you
think of the new style?
6) Congratulations to our patients [insert names]
on opening their new shop in town at [insert location/
address]. Can’t wait to stop by and check things out!
7) Celebrate National Children’s Dental Health
Month in February. We are giving away $100 gift card
to Toys “R” Us®. Tell us how your children take care of
their dental health and you could win.
8) [Insert practice name] tip of the day: Leave a
toothbrush at work in your desk so you can brush
your teeth after lunch. What’s your favorite way to
keep your mouth feeling fresh during the day?
9) Check out our page on www.realself.com at
[insert direct www.realself.com practice profile link]
to see what the discussion is all about as it relates to
orthodontic treatments.
20 I ortho
1_ 2012
13) Did you know we have a mobile-enabled
website? Check it out at [insert website address] on
your mobile phone to quickly get our dentist and
team bios, map to our office, important links or click
to call our office.
14) Have you flossed your teeth today?
15) Today we are featuring our Team Member of
the Month, [insert name], our [insert title]. [Insert
name] has worked in orthodontics for more than
[insert number] years and [insert he/she] ensures we
always provide top-quality care and customer service
to our patients. How have you interacted with [insert
name]?
16) Don’t forget! If you “Check In” at our office
on Facebook, you could receive a $20 Starbucks gift
card. Try it!
17) We have QR codes up in our office. Check them
out next time you are here and be sure to scan them
all. If you find the right one, you’ll be entered to win a
$100 shopping spree.
10) “A laugh is a smile that bursts.” ~ Mary H.
Waldrip
18) Our [insert staff member’s title] [insert staff
member name] just had a baby. Congrats to [insert
name] on [insert her/his] new bundle of joy, [insert
baby’s name]!
11) February 28 is National Tooth Fairy Day. Losing
baby teeth can be traumatic. There isn’t much that
can make it better than the smiling, caring Tooth
Fairy! What do you think the Tooth Fairy looks like?
19) For your convenience, our practice website
now offers secure online payment options. Just click
the “Patient Login” button on our website at [insert
link to patient login].
12) Guess whose [insert practice name] team
member smile this is. [insert image of a team member’s smile].
20) Would you like to be the face of [insert practice
name]? We’re producing a new TV commercial, and
we are looking for a patient to be the face of our
[21] =>
practice matters_ social media
I
Facebook has transcended the concept of ‘social media’
and has in reality become ‘business essential.’
practice. Just submit a video on our Facebook Fan
page telling us why you’d be the best. Videos must be
received before [insert date].
21) It’s Take Your Child to Work Day. Today Dr.
[insert name]’s [insert son/daughter] is shadowing
[insert his/her] [insert dad/mom] in our office. [Insert
he/she] wants to be an orthodontist one day. What
are you doing on Take Your Child to Work Day?
22) Would you rather have perfect: teeth, eyesight
or hair? According to Glamour Beauty, 44 percent
say teeth.5
23) What’s the best joke you know? One that
makes everyone smile. Post clean jokes only!
24) What are you smiling about this weekend?
According to a recent study, folks with big smiles
may actually live longer than those who don’t smile
as big.6
25) Moms help with our homework. They cheer
us on and fix our boo-boos. Moms can also be our
chauffeurs, our cooks, the one who picks up after our
messes and so much more!
We want to recognize one mom with a $100 gift
certificate to [insert name of local spa]. Tell us why
your mom deserves this day of pampering by [insert
date] to win (for your mom that is!).
26) We know our patients prefer different methods to help them remember their appointment. For
your convenience, we offer e-mail, SMS text and/or
voice reminders (or all three). You can even manage
your preferences through our website at [insert link
to patient login].
27) We recommend that a toothbrush be kept
at least six feet away from a toilet to avoid airborne
particles resulting from the flush.8 Where do you keep
your toothbrush?
28) Did you know Dr. [insert name] is a member
of the American Association of Orthodontics and a
board-certified orthodontist? AAO member professionals stay one step ahead of their peers by keeping
informed of market trends.
They learn how the latest products and technologies benefit the patient. By selecting a board-certified
orthodontist, you know you’re receiving the most up-
to-date and best orthodontic care available.
29) We are putting together care packages for
overseas military. We’ll be including toothbrushes,
floss, toothpaste and more. If you’d like to include
anything in our care packages, please let us know.
30) Today Dr. [insert name] and [insert his/her]
spouse, [insert name], are celebrating [insert number]
years of marriage. Congratulations! Anyone else celebrating a birthday or anniversary this month?
31) “If you see a friend without a smile, give him
one of yours.” ~ Proverb
32) Our office now offers a massaging chair, aromatherapy and warm towels during your appointment. What do you think of that?
33) Floss picks or traditional floss?
34) Today is National Junk Food Day! Don’t forget
to brush and floss your teeth, and don’t forget to
wash away the junk food stuck between your teeth.
35) Click “Like” if you brush your teeth after lunch!
36) In France, the Tooth Fairy is a mouse!
37) We’re having a website scavenger hunt. Go to
our website at [insert website address] and find the
answers to these four questions:
A) [insert question] B) [insert question] C) [insert
question] D) [insert question]. Send your answers to
us at [insert email address] and you could win a $25
gift card.
38) Are all braces the same? No way! Read why
Dr. [insert name] chooses to use In-Ovation® System
braces for you and your family [insert link to web
page].
39) We use environmentally friendly methods
and materials wherever possible, while minimizing
waste and energy. Our toothbrushes are even made
of recycled yogurt containers! What do you do to stay
environmentally friendly?
40) It’s Halloween, and we want to buy your candy!
Our goal is to collect 300 pounds. We’ll be accepting candy all week long. $1 per pound of unopened
ortho
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_ 2012
[22] =>
I practice matters_ social media
candy. We’ll be sending all candy to service people
overseas.
41) This month, we are pleased to present [insert
patient name] as our Smile of the Month. Visit our
blog to learn how [insert his/her] smile was transformed with Invisalign, the clear way to straighten
your teeth [insert link to onsite blog].
42) Did you know we always have someone on
call in case an orthodontic emergency arises? Just
call our practice at [insert telephone number]. We are
here to help.
46) The Go-To Mom, Kimberly Blaine, educates us
on how the Invisalign treatment helps you achieve
that perfect smile.9 Get the facts in less than four
minutes.
47) Believe it or not, smiling boosts your immune
system!10 See more interesting facts about smiling at
www.pickthebrain.com.
_about the author
44) According to a study at DePauw University in
Indiana, people who smile often are more likely to
have healthy marriages!8 Do you agree or disagree?
45) We’re celebrating Silly Hat Day. Wear your silliest hat to the office today, and you could win a $25
Starbucks gift card!
48) We’d love to wish you happy birthday on your
special day with an e-mail greeting. Be sure to send
us your email address so we can remember your
special day.
49) Has your experience with our office been
great? Leave a review for us on Google! It only takes
a minute, and we greatly appreciate your feedback
[inset link to Google places listing].
50) We just hit [insert number] fans here on Facebook. Hoorah!
51) See what Wikipedia has to say about “orthodontist.”
52) You are never too old to have a beautiful smile,
and we can help. Make it a New Year’s resolution by
calling our office at [phone number].
1_ 2012
_References
1. Facebook.com/press/info.php?statistics
2. “Facebook Users Average 7 hours a month in
January as Digital Universe Expands,” Nielsen
2/16/2010.
3. “Social Networks/Blogs Now Account for One in
Every Four and a Half Minutes Online,” Nielsen,
June 2010.
4. www.deltadentalok.org/oralhealth/funfacts.
asp
5. “Would You Rather: Have Perfect Teeth, Perfect
Eyesight or Perfect Hair?” Glamour Beauty.
6. “Life span may be as wide as your smile,” Los
Angeles Times.
7. www.funfactz.com/health-facts/dentistshave-recommended-that-toothbrush-bekept-1688.html
8. DePauw University Study by Dr. Hertenstein.
9. www.facebook.com/invisalign/
posts/10150285818424022
10. www.pickthebrain.com
43) Today is our 10th annual food drive. We are in
need of pasta, cereal, peanut butter, baby food, toilet
paper, canned tomatoes, vegetables or anything you
have that is not perishable. Thank you for helping us
feed our hungry neighbors.
22 I ortho
To download 365 days
of Facebook posts,
please visit
www.goo.gl/cWMWp
ortho
Rachel Mele is
the director of business development
at Sesame Communications. As a
member of the
Sesame Speakers
Bureau, she speaks
and writes regularly
on Internet technologies, including
search optimization,
social media and
effective web marketing.
Mele’s data-rich presentations make the complexities of
dentistry in the digital age easier to understand and manage. Mele is an accomplished Toastmaster and the VP of
public relations for her local club in Wallingford, Conn. Mele
can be reached at rachel@sesame communications.com.
[23] =>
[24] =>
I technique_ lingual ortho
Lingual you will love
Capturing the incremental patient with invisible
orthodontics
Author_Ronald Roncone, DDS, MS
_Lingual orthodontics is not new in the world of
orthodontics. Crude attempts at lingual orthodontics
were tried many years ago. The first true lingual began almost simultaneously about 1980 with Dr. Kurz
of California and Dr. Fujita of Japan.
Patients around the world were hungry for an
appliance that would give them straight teeth but
could not be seen. Because of the potential commercial windfall, various companies entered the
marketplace.
In the United States, many orthodontists immediately jumped into this new area only to realize that
working with braces on the inside of teeth was not
nearly as easy as it was when they were attached to
the outside surfaces of teeth.
Due to the steep learning curve, the general acceptance of braces by U.S. citizens and the improvement in clear braces, lingual orthodontics disappeared, with a few notable exceptions. Meanwhile,
those orthodontists outside of the U.S. worked on
mastering lingual and making slow and steady improvements to the various techniques.
Some common statements arose from the initial
experience with lingual orthodontics.
Fig. 1_In-Ovation ‘L’ Closed
Fig. 2_MTM No•Trace Closed
Fig.3_MTM No•Trace side view
(Photos/Provided by Dr. Roncone)
• Lingual orthodontic treatment takes longer.
• Results of lingual treatment are not as good as
labial treatment.
• Lingual treatment is too hard on the orthodontist because of the poor postural positions required.
Fig. 2
Fig. 1
24 I ortho
1_ 2012
• Patients do not speak well with lingual braces.
• Tongue irritations are a constant problem for
lingual patients.
• Patient visits take substantially longer with
lingual braces.
• The time required to master lingual treatment is
not worth the effort.
• It is too difficult to tie-in archwires.
Each of these statements has some element of
truth in them, yet all can be refuted. This article will
attempt to address all of these statements. However, even if they could not be totally refuted, one
overriding factor remains: Patients want “invisible”
orthodontics!
For many years, the most-used bracket in lingual
orthodontics was the Kurz bracket (Ormco). It was
a solid, well-conceived bracket that went through
seven generations. The bracket basically remains
the same as it was nearly 20 years ago. Other lingual
brackets have been developed over the years, but
most of the improvements have come in the area of
precision placement of the brackets. Clinicians such
as Takemoto, Scuzzo, Fillion, Wiechmann and others
have made significant contributions in this area.
Several years ago, the biggest leap in development
was the size of brackets conceived by Drs. Takemoto
and Scuzzo. The bracket was very small and targeted
the anterior teeth commonly referred to as the “social
six.” Interest is again building for use of the lingual
Fig. 3
[25] =>
technique_ lingual ortho
I
Dr. Roncone MTM No•Trace Case
Fig. 4a_Pre-treatement.
Fig. 4b_Initial placement.
Fig. 4c_At 12 weeks.
Fig. 4a
Fig. 4b
Fig. 4c
bracket as part of an orthodontist’s offerings to his
or her patients due to the high demand for an invisible solution.
Yet, with all the improvements, lingual orthodontics remained difficult. For the patient, speech problems could be overcome, but it was not a quick or easy
adjustment. Patients also took a long time getting
used to the tongue irritations. Gingival hyperplasia
was also a common problem.
Even when the orthodontist mastered the “mechanics” of lingual, it was still difficult to ligate
the wire to the brackets. Wire tying stainless-steel
ligatures to each bracket or using special ties, such
as the “double over” tie, were very time consuming
and difficult. With these thoughts in mind, the next
stage of lingual treatment necessarily led to lingual
self-ligation.
Several years ago, in conjunction with GAC, we
began the development of the In-Ovation “L.” It
is currently in use in many areas of the world. The
bracket is small: 1.5 mm in thickness and 2.2 mm in
width. The clip is very easily opened and closed, which
eliminates the difficult and time-consuming task of
wire tying or placing elastomeric modules.
The same basic philosophy of light wire treatment
that is part of the In-Ovation “R” and “C” protocol
can be used on the lingual. With all of these advancements in technology, the highest degree of quality
still requires indirect procedures for full lingual. Many
excellent methods of indirect are currently available.
As an offshoot of this self-ligating bracket (SLB),
it is very easy to treat simple cases requiring no basic
changes in occlusion with the MTM® No•Trace (MTM
= minor tooth movement) System. Mild to moderate
crowding of the anterior teeth can be easily treated in
a matter of weeks. All of the cases that our office has
treated have been completed within the six-week to
4.5-month period. Most of these are under 10 weeks.
MTM No•Trace utilizes a reduced base size and is
designed to address these simple cosmetic cases. The
ortho
I 25
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[26] =>
I technique_ lingual ortho
Fig. 6
Fig. 6_MTM No•Trace series from
closed to open.
AD
26 I ortho
1_ 2012
reduced base allows the clinician to place the bracket
near the incisal/occlusal edges of teeth, thereby
eliminating any gingival irritation problems. It allows clinicians to correct minor misalignments with
minimal office and chair time, incorporating only a
simple round-wire treatment.
Almost every day, a patient’s parent expresses his
or her desire to have straight teeth, but expresses that
he or she does not want to show braces and doesn’t
want it to take very long. Some of these patients had
braces years ago, did not continue to wear retainers and subsequently developed crowding of the
anterior teeth. Most of these people have good to
excellent posterior occlusions.
Others never had braces but have continued to get
crowding of teeth over the years. In the past, I would
[27] =>
technique_ lingual ortho
I
‘MTM No•Trace is meant as
a cosmetic alternative only’
attempt to correct these problems with retainers. The
problem was that most people did not wear these
retainers enough to obtain the results desired.
Their treatment would continue on for many
months. This was frustrating both for the patient
and me. The treatment also became a financial disadvantage.
While clear aligners have become popular, this
was not the answer for me because of the excessive
amount of time it takes at the computer planning for
relatively simple treatment.
In addition, the expense of the aligners was also
a concern that ultimately led me to look for a better
solution.
In my opinion, the use of MTM No•Trace System
has many advantages over retainers and aligners:
• Truly invisible.
• Very tiny (1.5 mm thick), which virtually eliminates tongue irritation.
• Minimal speech problems.
• They are not dependent on patient cooperation
(other than proper brushing).
• Because they are placed near the incisal/occlusal edges of teeth, there is little gingival problem.
• They can be placed directly, therefore no labo-
_about the author
ratory fees are involved. For those who routinely do
their own indirect bonding, you can continue the
process if you so desire.
• Chair time is minimal at each appointment.
There are no “re-ties.” The light round wire continues
to align teeth if left alone.
• 80 percent of patients require only one wire.
• The clips open and close easily with the tool
provided or with an explorer (my choice).
• Depending on the country, province or state
laws, placement and removal of archwires is easily a
task that can be delegated to auxiliaries.
Certainly not all those who desire MTM No•Trace
treatment are good candidates. Case selection is important. MTM No•Trace is meant as a cosmetic alternative only. Those patients whose correction requires
root torque or uprighting are not good candidates.
However, those who desire alignment only, who
might obtain “better” treatment if full-bonded appliances were placed, may still choose a compromise
result if their current malocclusion is not worsened.
These patients must understand the unstable
nature of the result and agree to lifetime retention.
In addition, these patients should be fully informed of
the limitations of such treatment and sign a potential
risk and liability disclosure form._
ortho
After receiving his undergraduate degree from Marquette University, Ronald Roncone,
DDS, MS, pursued graduate study in physiology and neuroanatomy at the Marquette School
of Medicine while simultaneously earning his dental degree from the same university. His
CV includes postdoctoral certificates from the Harvard School of Dental Medicine and the
Forsyth Dental Center.
Roncone’s practice in San Diego, Calif., specializes in adult treatment (esthetics, surgical and
TMD) as well as early treatment for children. He is a respected and frequent lecturer, having
taught more than 500 seminars around the globe. His impressive list of technical innovations
include long (eight to 12 weeks) intervals between patient appointments, which he introduced
in 1989 through the use of titanium wires and the development of a unique prescription for
bands and brackets.
He is widely known in the orthodontic community as the “Guru of Marketing.” Please visit him
online at www.ronconeorthodontics.com or e-mail info@ronconeorthodontics.com.
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SENTALLOY: The
story of superelasticity
Author_Alberto Teramoto, DDS
_Part I: History and basic concepts
Fig. 1_Metallurgist William J.
Buehler
Fig. 2_A multicrystaline metal
sample of NITINOL. Each pattern
represents a different grain of
random size, shape and orientation
of the atom lattice. The blow-up
on the right shows the structure of
the austenite phase of the NITINOL
atomic lattice called ‘body-centered
cubic.
Fig. 3_The cubes are intertwined
such that the each corner is in the
center of another cube. The distance
of the center of a cube from a
corner is shorter than the distance
to a neighboring corner. Thus the
‘nearest neighbors’ of each nickel
atoms (white balls) are titanium
atoms (blue balls), not other nickel
atoms and vice versa.
Fig. 1
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Introduction
Since the days of Angle, many technological
advances in archwires have enhanced our specialty,
increased our efficiency, reduced our chair time, and
as a result, increased our profitability. However, because of the great number of nickel-titanium alloys
that actually exist, it is important to understand the
historical background as well as basic concepts about
them in order to visualize and recognize the clinical
potential they have in orthodontics. Although nickeltitanium alloys appear to be the same, there are many
small differences in their composition and manufacturing process, which inevitably make the difference
between ordinary and extraordinary NiTi archwires.
The beginning of NITINOL
Nickel-titanium alloys have been found to be the
most useful of all shape-memory alloys (SMAs): They
are metals that demonstrate the ability to return to
some previous shape or size when subjected to an
appropriate thermal procedure. In other words they
“remember” their original shapes. Other shape memory alloys include copper-zinc-aluminum-nickel and
copper-aluminum-nickel, but they do not possess
the combined physical and mechanical properties of
nickel-titanium alloys.
NiTi is unique because of the force levels expressed
when heated, its corrosion resistance, its biocompatibility, the ease with which the TTR can be set and
the reasonable cost of fabricating a precise alloy. A
Fig. 2
metallurgist, Dr. William J. Buehler, doing research at
Naval Ordnance Laboratory (NOL) in White Oak, Md.,
discovered the unique shape memory properties of
this alloy. NITINOL is an acronym used to describe a
generic family of nickel-titanium alloys. It represents
the two main elements of this alloy — nickel and
titanium (NiTi) — and contains a reference to where it
was devoloped in NOL, Naval Ordnance Laboratory.1
In 1958, Buehler was looking for a change in his
professional career. An aerodynamics project at NOL
was searching for the appropriate material for the reentry nose cone of the SUBROC missile. Jerry Persh,
the project manager, put Buehler to work assembling
known property data on selected elemental metals
and alloys that might be feasible.
Early in the developmental stages, secondary
research on nickel-titanium alloys led to a significant
application by Raychem Corporation. The produced
a product called Cryofit, which was a hydraulic line
coupler for the U.S. Navy’s F-14 aircraft. However,
this was just the beginning of a wide range of new
and exciting applications in medicine, dentistry and
diverse engineering areas. Buehler retired from NOL
in 1974 but remained involved in the development of
NITINOL until 2005, at which time he moved to New
Bern, N. C.
How NITINOL works
Exactly what made these metals “remember” their
original shapes was in question after the discovery
of the shape-memory effect. George Kauffman
(Department of Chemistry of University of Fresno)
Fig. 3
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Fig. 5
Fig. 4
Fig. 10
describes this process as follows: In a non-memory
metal, the strain of deformation is absorbed by rearrangement of the crystals, and it is impossible to
get the crystals back into the original position. On the
other hand, in an alloy such as NITINOL the crystals
stay in place: The atoms within the metal crystals
rearrange themselves and the distorted objects revert to its original shape. There is no visible change
in shape of the metal; all the changes occur at the
atomic level.2
NITINOL had phase changes while still a solid;
these phase changes are named martensite (low
temperature) and austenite (higher temperature).
The range of transition temperature (TTR) varies for
different compositions from about -50°C to 166°C by
varying the nickel titanium ratio or ternary alloy with
small amounts of other metallic elements. Under the
transition temperature, NITINOL is in the martensite
phase. In the martensite phase, this alloy can be bent
into various shapes; the crystal structure is disordered body-centered cubic. To fix the “parent shape”
(austenite phase), the metal must be held in position
and heated to about 500°C.
The high temperature “causes the atoms to arrange themselves into the most compact and regular
Fig. 6
Fig. 7
Fig. 9
Fig. 8
Fig. 11
I
Fig. 12
Fig. 13
pattern possible” resulting in a rigid cubic arrangement known as the austenite phase; the crystal structure becomes that of an “ordered” cubic, frequently
called a cesium chloride (CsCl) structure. Above the
transition temperature, NITINOL reverts from the
martensite to the austenite phase, which changes it
back into its parent shape.
NITINOL is a conglomeration of tiny regions of
single crystals, called grains, all of random size, shape
and orientation (Fig. 2). In the austenite phase the
atoms of the grains adopt an atomic structure in
which each nickel atom is surrounded by eight titanium atoms at the corners of the cube and each titanium atom is likewise surrounded by a cube of nickel
atoms (Fig. 3). In the martensite phase, when the wire
cools below its TTR, the grains changes, which means
that the nickel and titanium atoms assume a different
and more complex three-dimensional arrangement
(Fig. 4).
NITINOL in orthodontics
Another early application and probably the most
important for the orthodontic world was the introduction of NITINOL into orthodontics as an archwire.
In 1968, Dr. George F. Andreasen (Fig. 5) read
Fig. 4_Crystals with good neighbors.
A, B and C) NITINOL wire is treated
at high temperature to set the parent
shape. D) When NITINOL is cooled,
the phase changes from austenite
to martensite because martensite
crystals are slightly flexible, they can
deform to accommodate bending of
the wire. E) They remain attached to
neighboring crystals. F) Martensite
crystals revert to their undeformed
shape, and wire magically unbends.
Fig. 5_Dr. George F. Andreasen
joined the Iowa dentistry faculty
in 1963 and was professor and
chairman of the department of
orthodontics at the University of Iowa
(1965–1975).
Fig. 6_Dr. Fujio Miura, professor and
chairman of the First Department
of Orthodontics of the Tokyo
Medical and Dental University from
1962–1991.
Fig. 7_Dr. Fujio Miura, left, and Dr.
Masakuni Mogi, head of the Group of
Dental Materials, first department of
orthodontics (TMDU).
Fig. 8_SENTALLOY, super elastic
nickel-titanium alloy.
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Fig. 14
Fig. 15
Fig. 16
Fig. 17
an account of a strange alloy discovered at the
Naval Ordnance Laboratory (now the Naval Surface
Weapons Center). He contacted Buehler, who sent
Andreasen a number of different NITINOL composition in different processing conditions. Andreasen
did extensive clinical research and found one of these
alloys worked most effectively; he called this alloy
the “memory wire” because it returned to its original
shape after being bent. Andreasen’s 1978 article was
the first to use the terms “shorter treatment times,”
“less patient discomfort” (light forces) and “fewer
archwire changes.” The wire was commercialized
by Unitek Corporation and trademarked as NITINOL,
identical in name to what Buehler had called it.
The first commercially available wire was 50/50
percent nickel to titanium and was a shape memory
alloy in composition only. Cold working by more than
8 to 10 percent suppressed the shape memory effect.
Nevertheless, what made it attractive compared to
the competitive wires available at that time was its
light force (about 1/5 to 1/6 the force per unit of deactivation)4, and its increased working range allowed
it to be used in more severely maloccluded cases
without taking a permanent set.
Andreasen reported his research on the thermal
dynamic effects of NITINOL in the Angle Orthodontist
in April 1985. Andreasen’s work on NITINOL earned
him the 1980 Iowa Inventor of the year Award. He
died in 1989 at the age of 55. This was the very beginning of nickel-titanium wires for orthodontics.
SENTALLOY: The first superelastic NiTi alloy
In the meantime in Japan, Dr. Fujio Miura (Fig. 6),
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who is the most famous orthodontic professor in
Japan’s history, was making basic research on the
biology of tooth movement with the objective to
establish the “ideal concept of tooth movement.” He
was looking for a material or device that could deliver
a constant and continuous force, and research was
initiated to find a material that would satisfy this
requirement.
In 1982, Miura and his university team made an
offer to TOMY Incorporated (manufacturer of orthodontic products) and Furukawa Electric Co. (supplier
of wire material) to do joint research on a new superelastic wire (Fig. 7). This new wire was characterized by
its ability to generate optimal force for tooth movement and about 8 percent stress-induced martensitic
transformation (superelasticity). This new NiTi alloy
was launched in 1985 under the trade name of SENTALLOY (superelastic nickel-titanium alloy) (Fig. 8).
SENTALLOY had the features of superelasticity
and shape memory. Miura5 describes these unique
properties as follows.
Shape memory
Phenomenon occurring in an alloy that is soft
and readily amenable to change in shape at low
temperature but can easily be reformed to its original
configuration when heated to a suitable transition
temperature.
Superelasticity
A phenomenon that occurs when the stress
value remains fairly constant up to a certain point of
wire deformation. This is produced by stress, not by
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I technique_ archwire
Fig. 20
Fig. 18
Fig. 19
Fig. 21
Fig. 22
temperature, and the phenomenon is called stressinduced martensitic transformation
Miura said that SENTALLOY allows a constant
force to be delivered over an extended portion of the
deactivation range and is therefore more likely to
generate physiologic tooth movement and greater
patient comfort. Using the body temperature to
transform this alloy, SENTALLOY can address tooth
movement resistance during an orthodontic treatment without causing trauma to surrounding dental
tissues.
Miura believed that the discovery of the “superelastic” properties of SENTALLOY wires and its use
in osteoclast recruitment was a significant scientific
breakthrough for the orthodontic specialty. The use
of superelastic wire established a new standard of
biologic treatment in clinical orthodontics.6
_Part II: SENTALLOY historical overview
For more than two decades, SENTALLOY archwire
ha found wide applicability in orthodontics and has
developed products around the philosophy of applying physiological force for tooth movement.
• 1958, Dr. William J. Buehler began experimental
work on NITINOL at U.S. Naval Ordnance Laboratory
(Fig. 1).
• 1976, Dr. George Andreasen develops first NiTi
alloy in orthodontics (Fig. 5).
• 1986, Dr. Fujio Miura develops SENTALLOY the
first Super-elastic nickel-titanium alloy (Fig. 6).
• 1987, GAC International introduces the first
superelastic open and close coil springs. (Fig. 9).
• 1988, DERHT method for bending SENTALLOY
wire was developing under the trade name of ARCHMATE (Fig. 10).
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Fig. 23
• 1990, NEOSENTALLOY appears, and it was the
first time that was possible to use a full-size rectangular wire as initial wire that generates 100, 200 or
300 grams (Fig. 11).
• 1992, BIOFORCE is introduced as the only superelastic wire that starts with low, gentle force for
anteriors and increases to the posteriors (Fig. 12).
• 1993, GAC International creates Bioforce and
NEOSENTALLOY IonGuard, a new nickel-titanium
wire that underwent an ion implantation process
(Fig. 13).
• 1993, SENTALLOY MOLAR MOVER is created for
molar distalization (Fig. 14).
• 1995, TOMY Inc. introduces SENTALLOY STLH, a
static termoactivity low-hysterisis, nickel-titanium
wire (Fig. 15).
• 2000, GAC PAKs enhances clean storage and
dispensing of each wire (Fig. 16).
• 2008, high esthetic archwires: SENTALLOY and
Bioforce. Providing the same outstanding performance as standard wires, a rhodium process provides
low reflectivity for reduced visibility (Fig. 17).
_Part III: Evaluation of mechanical and
physical properties of SENTALLOY
There are basically three types of laboratory tests
— bending, tension and torsion — used to study the
mechanical properties of orthodontic wires. Two
more tests are used to evaluate physical properties:
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I technique_ archwire
Fig. 24
Fig. 25
Fig. 26
Fig. 27
Fig. 28
Fig. 29
differential scanning calorimeter (DSC) and X-ray
diffraction.
Although these tests do not necessarily reflect
the clinical situations to which wires are usually
subjected, they provide a basis for comparison of
these wires with others NiTi wires. And in all of the
tests, SENTALLOY has proved its efficiency as the only
biologically correct archwire. Some of this examples
are next.
A) Three-point bending test
In order to demonstrate the difference between
the first NITINOL wire (3M Unitek) and the superelastic nickel-titanium alloy (SENTALLOY) in 1986, a
three-point bending test was introduced by Miura.5
This test was designed to clarify the relationship
between the loading and deflection by determining the nature of the force being delivered during
orthodontic treatment. This method is acceptable to
demonstrate the springback properties.
During cantilever bending, the wires of good
springback property will increase the length and
the angle of the specimens, so a superelastic-like
property appears even if the wire does not possess
this feature. Instead, a three-point bending test was
designed because this would accurately differentiate
the wires that do not possess superelastic features.
At the same time, the three-point bending test
actually simulates the application of wire force on
the teeth in the oral cavity. The deformation of NiTi
alloys is induced with martensitic transformation;
this can be reversed by heating the alloy to return to
the austenite phase and is transformed by reversing back to the previous shape; this is produced by
temperature.
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Materials
Wire specimen of 0.016 round wires was selected:
stainless-steel, Co-Cr-Ni, work-hardened and NiTi
SENTALLOY. In order to simulate oral cavity environment the wires and the steel poles were set in a chamber at 37°C. The midpoint of the wire was deflected 2
mm at speed of 0.1 mm/min, under a pressure from a
metal pole 5 mm in diameter (Figs. 18, 19).
Findings
Both stainless-steel and Co-Cr-Ni wires showed
a linear relationship when the amount of deflection
was 2 mm and the load was around 1300 g (Fig. 20).
As the deflection was removed, both of them
showed a permanent deformation. NITINOL load deflection curve was almost linear; when the deflection
of 2.0 mm was reached the load was 790 g (Fig. 21).
When SENTALLOY wire load-increasing ratio was
2.0 mm, the load was 650 g. However, when the deflection was decreased 1 mm from 1.6 to 0.6 mm, the
load was decreased by only a small amount, namely,
values around 250–350 g (Fig. 22).
By evaluating the test results, SENTALLOY wire
showed superelastic property and was physiologically compatible to the tooth movement because it
provided continuous force for a long period of time
during deactivation.
B) Tensile test
According to Miura, superelasticity can be produced by stress, not by temperature difference, and
is called stress-induced martensitic transformation.
Uniaxial tensile testing was performed all specimens
were stretched using an Instrom universal testing
machine.
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I
Fig. 32
Fig. 30
Fig. 31
Fig. 33
Fig. 34
Materials
Wire specimen of 0.016 round wire stainless-steel,
Co-Cr-Ni, work-hardened and NiTi SENTALLOY were
selected; they were attached to a steel plate with
epoxy resin at 37ºC. In this figure, Y-axis represents
the force generated by the wire and X-axis shows the
strain that the specimens were stretched (Fig. 23).
Findings
For the stainless-steel and Co-Cr-Ni wires, the
elastic modulus was 17–22 KG/mm2x10. Showing very
high values and a stress-strain curve to be almost
straight during activation and deactivation phase.
The elastic modulus of work-hardened NITINOL was3
5-6 KG/mm2x10 and a stress-strain curve to be almost
straight. Finally, in contrast, SENTALLOY showed a
stress-strain curve of great significance that illustrates clearly the superelastic property.
When the wire was stretched it showed a straight
curve. But when it reached 2 percent of its original
length, it produced stresses of 55 to 58 Kg/mm2 keeping those values until the strain was induced nearly
to 10 percent (A to B). This diagram shows how the
martensitic transformation begins at the 2 percent
strain level and the transformation continues up to
the 8 to 10 percent (Fig. 24).
When the martensitic transformation is completed, the whole specimen is transformed into
the martensitic phase. When this occurs, the stress
increases because of the elastic deformation. When
the strain is removed (B to C), the stress decrease is
linear because the elastic deformation occurs in the
martensitic phase (Fig. 25).
Later, the martensitic transformation occurs
again in the direction of the austenite phase generate
in a continuous force (C to D) (Fig. 26). In the final step,
the martensitic transformation is completed and
the wire is again in the austenitic phase (D to E). This
elastic deformation occurs in the austenite phase and
the stress decrease is linear (Fig. 18).
The preceding metallurgical analysis indicates
that SENTALLOY possesses superelastic properties
(A to B range) and in the stress-strain curves (C
to D range) (Fig. 19). The deformation of NiTi alloys and temperature changes induce martensitic
transformations. These transformations are either
stress (deformation) related or temperature related.
Heating the alloy will induce the martensitic change
(martensite to austenite) and removal of heat, cooling, (austenite to martensite) will return the wire to
its original shape.
Bioforce
Miyazaki8 reported that a specific type of heat
treatment (unlike the moderate temperature
changes noted above) of SENTALLOY at 500°C would
permanently and significantly alter the force plateau
during unloading on a three-point bending test. This
procedure created the possibility to manufacture
SENTALLOY with three different levels of force. This
same technology allowed a single wire size to have
three different force levels. The optimal superelastic
wire now offered light forces in the anterior section,
medium force in the bicuspid area and a heavier force
in the molar region.
In a three-point bending test, the superelastic
properties of the wire become apparent in the molar region above a loading of 280 g (Fig. 29). At the
premolar segment, the load/deflection curve reached
a load of 180 g (Fig. 30). And the anterior segment the
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Fig. 35
Fig. 37
Fig. 38
Fig. 36
wire demonstrated a superelastic plateau of 80 g (Fig.
31). It is possible to alter the superelastic characteristics of the wire in any desired section and apply an
optimal force to each tooth with a single archwire.
This creates the possibility to obtain with a single archwire, the specific biological force to move
specific teeth, with no patient trauma and fewer
archwire changes (Fig. 32).
Bioforce IonGuard
To minimize friction, DENTSPLY GAC created a
nickel-titanium wire that underwent an ion implantation process but did not affect the unique superelastic properties of Bioforce and NEOSENTALLOY.
Ion implantation was originally developed for use in
semiconductor applications. At low temperature, a
high energy beam of ions are used to modify the surface structure and chemistry. The ion implantation is
not a layer on the surface, therefore, it does not affect
the dimensions or properties of the material and can
be applied to virtually any material. Ion implantation improves wear resistance, surface hardness,
resistance to chemical attack and, most importantly,
reduces friction (Fig. 33).
Ryan9 showed that the ion-implantation process
does reduce the frictional forces produced during
tooth movement. This process tends to increase
stress-fatigue, hardness and wear, regardless of the
composition of the material.
The stainless-steel wire produced the least frictional force during in vitro tooth movement, followed
by treated nickel-titanium, treated beta-titanium,
untreated nickel-titanium and, finally, untreated
beta-titanium. There were statistically significant
differences in the amount of movement seen with
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the ion-implants wires compared with their untreated counterparts (Fig. 34).
Bedolla and Teramoto,10 in contrast with Ryan´s
study, in an in vitro study reported that Bioforce
IonGuard, which shows the smoothest surface (Fig.
35), generated the least frictional force, followed by
stainless-steel and untreated NiTi, and the combination of Bioforce IonGuard with In-Ovation® brackets
showed the less frictional forces (Figs. 36, 37).
Differential scanning calorimetry
Over the past decade, differential scanning calorimetry has been used to study nickel-titanium archwire alloys. In conventional DSC, two small pans, one
containing the material to be analyzed and the other
an inert reference material, such as indium are heated
at the same rate, typically 5°C or 10°C per minute.
The changes in the thermal power difference for
the two pans are related to changes in the heat capacity. It is useful for studying phase transformations in
the nickel-titanium archwire alloys.
There are important phase transformations for
nickel-titanium alloys: Temperatures at which the
transformation from cooling begins, martensitestart (Ms); temperature at which martnesite peaks or
is finished (Mp or Mf); temperature at which austenite begins, austenite start (As); and temperature at
which austenite peaks or is finished (Ap or Af).
In some cases, an intermediate R-phase (Rhombohedral crystal structure) may form during this
transformation process.
Bradley et al.11 to clarify the differences in the
phase transformation for major types of nickeltitanium wires, performed a DSC study, the results
of which follow.
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Material
Wires tested: Four different Upper
016X022 NiTi archwires were tested
— NITINOL-SE (3M UNITEK); CopperNiTi 35 (ORMCO); NEOSENTALLOY F
80 (DENTSPLY GAC International); Bioforce-SENTALLOY (anterior section)
(DENTSPLY GAC International)
Equipment
Differential scanning calorimeter
(DSC) for measuring the austenite transformation temperature (Af point) was
performed using a SII-DSC6220 Seiko
Instrument (Fig. 39) and a thermal analyzer LN2 vessel was connected to DSC
for cooling (Fig. 40).
Fig. 39 (top)
Fig. 40 (bottom)
Oral temperature
Sublingual temperature is routinely
used as an indicator of oral temperature.
It is approximately 37°C for most individuals, while not forgetting that many
factors have been shown to affect the
temperature in the oral cavity.
Temperature data should be considered during
the manufacture and clinical use of temperature sensitive orthodontic materials like the nickel titanium
wires. According to Moore12 if a single oral temperature were to be selected for the investigation of
the in- vitro properties of orthodontic wires, 35.5°C
would be more appropriate than 37°C.
Results
NITINOL SE
With NITINOL SE the complete transformation
to austenite (Af) occurs at about 60°C, which is
considerably above the temperature of the oral
environment.
ortho
_contact
Alberto Teramoto DDS,
Orth. Cert., maintains a
private practice devoted exclusively to orthodontics in
Mexico City, Mexico.
He received his certificate of
orthodontics from the First
Department of Orthodontics
of Tokyo Medical and Dental
University, Japan.
Presently he is an assistant
professor at the Universidad
Tecnologica de Mexico and
Editor in Chief of the journal
Ortodoncia Actual.
44 I ortho
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Copper NiTi 35
A single peak on the heating DSC curve, which
corresponds to the martensite to austensite transformation indicates that the Af temperature (29.1°C)
is under oral cavity temperature for copper NiTi 35.
NEOSENTALLOY
NEOSENTALLOY has a completely austenitic structure close to the temperature of the oral environment
(32.7°C). There is also considerable hysteresis for the
TTR in the forward and reverse directions for the
complete transformation (martensite to austenite).
Bioforce (anterior section)
Just like NEOSENTALLOY, in the anterior section of
Bioforce we see the complete transformation occurring very close to body temperature 32.5 °C.
Summary
SENTALLOY archwires were the first reported superelastic nickel-titanium archwire in orthodontics.5
They are body heat activated and are capable of
producing excellent treatment results because they
deliver a light and constant force for a long period of
time; which is considered physiologically desirable
for tooth movement. _
_References
1. Buehler WJ, Gilfrich JV, and Wiley RC. J. Appl.
Phys., Vol. 34, 1963, p 1475.
2. Kauffman G, Mayo I. The Story of NITINOL:
The Serendipitous Discovery of the Memory
Metal and Its Application. Chem. Edu.
1997. Abstract, Volume 2, Issue 2 (1997),
S1430–4171(97)02111-0
DOI
10.1333/
s00897970111a.
3. Andreasen GF, Hilleman TB. An evaluation of 55
cobalt substituted Nitinol wire for use in orthodontics. J Am Assoc, 1982, 1173–1375, 1971.
4. Kusy, Robert P. 1997: A review of contemporary archwires: Their properties and characteristics. The Angle Orthodontist: Vol. 67, No. 3,
pp. 197–207.
5. Miura F, Mogi M, Ohura Y, and Hamanaka H. The
super-elastic property of Japanese NiTi alloy
use in orthodontics. Am. J. Orthod. Dentofac
Orthop. 1986,90.1–10 .
6. Miura F. Reflections on my involvement in
orthodontic research. Am. J. Orthod. Dentofac
Orthop. 1993, 104. 531–538.
7. Teramoto A. SENTALLOY. The Inside History of
Superelasticity. 2005 GAC Books.
8. Miyazaki S, Ohmi Y, Otsuka Y, Suzuki Y, 1982.
Characteristic of deformation and transformation pseudoelasticity in Ti-Ni alloys. Journal
de Physique. Colloque C4 supplement au n12,
tome 43, Decembre:255–260.
9. Ryan R, et cols. The effects on ion implantation on
rate of tooth movement. An in vitro model. Am
J Orthod. & Dentofac Orthop 1997.112:64–68.
10. Bedolla V. and Teramoto A. Diferencia de fricción
generada entre arcos de NiTi y NiTi con Nitrógeno en comparación con acero en brackets
estándar y de autoligado activo. Ortodoncia
Actual 2008 Año 5 Vol;16,20–26 ( in Spanish).
11. Bradley T, Brantley WA, and Culbertson B. Differential scanning calorimetry (DSC) analyses
of superelastic and non superelastic nickeltitanium orthodontic wires. Am. J. Orthod
& Dentofac Ortop, 1996; 109: 589–597.
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I UOBG_ what and why
What is UOBG
and why should you
be a part of it?
Author_Lindsay Peach, UOBG Program Director
Below: The UOBG home page.
_Whoever said you can’t be all things to all people
obviously wasn’t a member of the UOBG. As the name
suggests, the United Orthodontic Buying Group is a
group of orthodontists who have united in order to
reap the benefits of group pricing.
Born of an orthodontic study group 25 years ago,
today the UOBG has become a real force in the orthodontic marketplace.
The UOBG prides itself on its ability to be different things to different people. Through its preferred
partnership program — at last count, 29 companies
strong, and growing — the UOBG is able to offer its
members a selection of practice-oriented programs
and products that are as diverse as they are distinguished.
Members can take advantage of discounts on
everything from practice transition consulting to
software and customized marketing materials from
www.GACpowered.com.
Recently the UOBG added three new preferred
partners to its portfolio of product and service providers. Typical of the UOBG’s strength in diversity
philosophy, each of these new members brings
something new and unique to the table.
_Passion for progress
If you’re not familiar with The Progressive Orthodontist (TPO) magazine, you’re missing out. This
relatively young publication is already on the “must
read” publication list of many orthodontists.
The magazine, and accompanying online forum,
offers fresh insights, new trends and best practices
for the business of orthodontics.
This includes articles about team building, practice development, marketing and social media, as well
as regular features geared specifically for residents
and new orthodontists.
Worth every dollar of its $189 annual subscription
price, UOBG members can redeem UOBG coupons for
a subscription to The Progressive Orthodontist.
A quarterly publication, it will hook you after the
first issue. If the whip-smart offerings in TPO have
captured the attention of the orthodontic community, then the online expertise of Sesame Communications has it buzzing.
_Be online and be in touch
A preferred partner since 2011, Sesame Communications is the leading provider of cloud-based
patient connection systems for the dental industry.
Sesame Communications’ strength is placing you
46 I ortho
1_ 2012
[47] =>
UOBG_ what and why
‘UOBG members can take
advantage of discounts
on practice transition
consulting, software and
custom marketing materials
where patients are today — online. Having evolved
from an appointment reminder service, Sesame
Communications is now a comprehensive supersource for all things online, including website development, SEO and SEM, plus online marketing and
social media management.
UOBG members enjoy special discounts, as well
as the option to use UOBG coupons on select Sesame
Communications online services.
_The right tools to succeed
A preferred partner since early 2011, the Pride
Institute offers UOBG members a unique and fully
customized approach to practice management that
is designed to maximize business potential.
The Pride Institute has been empowering the
dental community with proven business solutions
for more than 35 years. In partnering with them, the
UOBG has created one of the most valuable benefits
available to our members: the ability to gain access
to a wide range of professional consulting services to
help grow your practice.
Developed to meet the needs of the modern
orthodontic practice, Pride Institute programs help
you and your team in the business of orthodontics
and quality care, and ensure implementation and accountability through hands-on consulting.
These are just a few of the newest preferred partner benefits. There are more than 25 others that we
haven’t mentioned.
And here’s the thing: We haven’t yet touched on
the single most impressive aspect of the UOBG — the
price. The UOBG membership definitely has its privileges, and it doesn’t cost a thing.
For your free membership in the UOBG, point your
browser to www.UOBG.org to join. And then, let the
advantages begin._
I
ortho
_contact
You may contact Lindsay
Peach via e-mail at lindsay.
peach@dentsply.com or via
phone at (631) 419-1700. In
addition, please visit the UOBG
website at www.uobg.org for
more information.
AD
ortho
I 47
1
_ 2012
[48] =>
I UOBG_ preferred partner program
Sesame Communications
appointed to UOBG
Preferred Partner Program
Author_Gib Snow, DDS
Below: The Sesame
Communications home page.
48 I ortho
1_ 2012
_In late 2011, the United Orthodontic Buying Group (UOBG) announced a partnership with
Seattle-based Sesame Communications, a leader
in cloud-based patient communication systems.
Through this new preferred partner addition, the
UOBG will help orthodontists meet patients where
they are most likely to be found today — online.
UOBG members will receive special discounts as
well as the option to use UOBG coupons on select
Sesame Communications online services designed
to accelerate practice growth. Sesame Communications joins an already impressive stable of preferred
partners that the UOBG makes available to its growing membership.
The UOBG is dedicated to providing value to its
members through its enhanced Preferred Partner
Program. The Preferred Partner Program allows the
UOBG to create strategic relationships with leading
companies in orthodontics that offer quality prod-
ucts and enhance the value of the UOBG membership
through attractive pricing and value-added services.
The UOBG Preferred Partners offer exclusive opportunities for orthodontists, often creating unique
programs or services available only to UOBG members.
“UOBG Preferred Partners must meet stringent
requirements. We selected Sesame Communications
because of their extensive experience in online dental
marketing,” said John Kringel, managing director of
UOBG. “Sesame specializes in helping practices get
found, get chosen and stay connected through targeted, integrated online marketing strategies.
Whether a practice has an underperforming or
outdated website or no website at all, Sesame can
help create an online strategy to accelerate practice
growth.
Our members have found this partnership immensely rewarding. We are delighted to have Sesame
Communications as our newest Preferred Partner.”
An unchallenged leader in online behavior research, Sesame Communications is dedicated to
helping dental practices uncover what patients want
and what works best for them in a rapidly evolving
digital market.
Since 1999, Sesame Communications has evolved
into a top-flight, online marketing communications
technology services firm offering Web and mobile
site design, patient portals, search engine optimization, social media services including sweepstakes and
contests, online marketing and other strategic online
services to enhance practice growth.
Sesame Communications complements these
offerings with rich analytics to help better manage
practice growth.
In one of its most recent studies, Sesame Communications was able to identify the top 25 factors
that influence the ability of an orthodontist’s website
to attract new patients. Sesame uses this research to
[49] =>
UOBG_ preferred partner program
their doctors’ online presence and to help increase
new patient case starts.
“Our partnership with the UOBG solidifies our
leadership position and demonstrates our combined
commitment to the success of every orthodontic
practice,” said Diana P. Friedman, chief executive officer at Sesame Communications.
“Now it’s easy for an orthodontist to quantify ROI
on patient communications, patient engagement
and marketing investments. When you look at what
Sesame does and what the UOBG stands for, you can
see why this relationship makes so much sense. Sesame is honored to partner with the UOBG to offer this
best of class system to accelerate practice growth.”
In the few months that this program has been
available to UOBG members, we have seen unprecedented success and interest. UOBG members are
excited to be able to redeem their UOBG coupon
points for such a valuable investment in the future
of their business.
As a DENTSPLY GAC and UOBG practice, Drs.
Groesch and Longos of central Illinois are just one
of many practices taking advantage of the newest
UOBG Preferred Partner Program from Sesame Communications.
As a UOBG member, their office received a complimentary Online Effectiveness Evaluation with
Sesame Communications that uncovered why their
website was not performing as expected any longer.
Groesch and Longos were able to use the UOBG
coupons they accumulated toward the purchase of
their new website, mobile site and the In-Ovation®
_about the author
I
‘UOBG Preferred
Partners must
meet stringent
requirements. We
selected Sesame
Communications
because
of their extensive
experience
in online dental
marketing ...’
System Provider Package of Web content through
Sesame Communications.
“Just days after our new website went live, we
received several requests for new appointments via
e-mail. Our old website functioned, but the new one
is remarkably better,” said April, the office manager
for Groesch and Longos._
ortho
Gib Snow, DDS, of Lancaster, Calif., has been a Sesame member since 2001 and a UOBG member since 2008. Snow Orthodontics uses Sesame for all its online marketing, including its website, mobile site, search optimization, social media strategy,
patient portal and reminders.
Through the UOBG Preferred Partner Program, the practice had its website and mobile site redesigned by Sesame. Through their
Sesame marketing strategy, today Snow’s eight office locations receive an average of 463 calls per month with 88 patients per
month identified as new.
For more information on joining the UOBG, or the UOBG Preferred Partner offering visit www.uobg.org or speak with your
DENTSPLY GAC sales representative.
To learn more about Sesame Communications, visit www.sesamecommunications.com or call (877) 633-5193.
ortho
I 49
1
_ 2012
[50] =>
I about the publisher _ submissions
submissions
formatting requirements
Please note that all the textual elements
of your submission:
_complete article
_figure captions
_literature list
_contact info (e-mail addy please)
_author bio
must be combined into one Microsoft Word
document. Please do not submit multiple files
for each of these items. In addition, images
(tables, charts, photographs, etc.) must not
be embedded in the text document.
All images must be submitted separately, and details about how to do this
appear below.
If you are interested in submitting a C.E.
article, please contact us for additional instructions before you make your submission.
_Text length
Article lengths can vary greatly — from a
mere 1,500 to 5,500 words — depending on
the subject matter. Our approach is that if
you need more or less words to do the topic
justice, then please make the article as long or
as short as necessary.
We can run an extra long article in multiple parts, but this is usually discussing a subject matter where each part can stand alone
because it contains so much information. In
addition, we do run multi-part series on various topics. In short, we do not want to limit
you in terms of article length, so please use
the word count above as a general guideline
and if you have specific questions, please do
not hesitate to contact us.
_Text formatting
Please use single spacing and do not put extra
space between paragraphs. We also ask that
you forego any special formatting beyond the
use of italics and boldface, and make sure that
all text is left justified.
If you would like to emphasize certain
words within the text, please only use italics
50 I ortho
1_ 2012
(do not use underlining or a larger font size).
Boldface should be reserved for article headlines, headers and subheads please.
Please do not “center” text on the page,
add special tab stops or use underlines in your
text as all of this must be removed manually
before layout. If you require a special layout,
please let the word processing program you
are using help you to do this formatting
automatically rather than doing it manually.
If you need to make a list or add footnotes
or endnotes, please let the word processing
program do it for you automatically.
There are menus in every program that
will help you apoply all sorts of special formatting.
_Image requirements
Please number images consecutively by
using a new number for each image. If it is
imperative that certain images are grouped
together, then use lowercase letters to designate the images in a group (i.e., Fig. 2a, Fig.
2b, Fig. 2c).
Insert figure references in your article
wherever they are appropriate, whether that
is in the middle or end of a sentence, but
before the period rather than after. Our
preference is to have figure references noted
in the appropriate place within the text as it
helps the readers to orient themselves when
moving through the article. In addition,
please note:
_We require images in TIF or JPEG format
_These images must be no smaller than
4 x 4 inches in size at 300 DPI.
_Images should be 1 MB in size each
If you have an image that is greater than
1 MB, please do not bother “sizing it down”
to meet our requirements, but send us the
largest file size available. The larger the
starting image is in terms of bytes, the more
leeway the designer has in terms of resizing
the image to fill up more space should there
be room available).
Also, please remember that you should
not embed the images into the body of the
text document you submit. Images must
be submitted separately from the textual
submission.
You may submit images through a
zipped file via e-mail, unzipped individual
files via e-mail or post a CD containing your
images directly to us (please contact us for
the mailing address as this will depend upon
where you will be mailing them from).
Please do not forget to send us a head
shot photo of yourself that also fits the
image requirements noted above so that it
can be printed along with your article.
_Abstracts
An abstract of your article is not required.
However, if you choose to provide us with
one, we will print it in a separate box.
_Contact info
At the end of every article is a contact info
box with contact information along with a
head shot of the author.
Please note at the end of your article the
exact information you would like to appear
in this box and format it according to the
previously mentioned standards.
A short bio (50 words or less) may precede the contact info if you provide us with
the necessary text.
_Questions? Comments?
Please do not hesitate to contact us for our
International C.E. Magazine Author Kit or if
you have other questions/comments about
the article submission process:
Group Editor Robin Goodman
r.goodman@dental-tribune.com
Ortho Managing Editor Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor Fred Michmershuizen
f.michmershuizen@dental-tribune.com
[51] =>
[52] =>
[53] =>
[54] =>
[55] =>
about the publisher _ imprint
I
ortho
the international C.E. magazine of orthodontics
U.S. Headquarters
Dental Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com
Ortho Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com
List Manager
Robert Spencer
database@dental-tribune.com
Designer
Kristine Colker
k.colker@dental-tribune.com
Account Manager
Mark Eisen
m.eisen@dental-tribune.com
Director of International
Education
Christiane Ferret
c.ferret@dtstudyclub.com
Account Manager
Humberto Estrada
e.estrada@dental-tribune.com
Marketing Manager
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dental-tribune.
com
Group Editor
Marketing Assistant
Robin Goodman
r.goodman@dental-tribune.com Lorrie Young
l.young@dental-tribune.com
Managing Editor
Accounting
Fred Michmershuizen
Melissa Chan
f.michmershuizen
m.chan@dental-tribune.com
@dental-tribune.com
Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
Account Manager & Interactive
Gina Davison
g.davison@dental-tribune.com
International Account Manager
Jan Agostaro
j.agostaro@dental-tribune.com
Editorial Board
Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert
Dental Tribune America is the official media partner of:
ortho_Copyright Regulations
_the international C.E. magazine of ortho published by Dental Tribune America is printed quarterly. The magazine’s articles and illustrations are protected by copyright. Reprints of any kind, including digital mediums, without the prior consent of the publisher are inadmissible
and liable to prosecution. This also applies to duplicate copies, translations, microfilms and storage and processing in electronic systems.
Reproductions, including excerpts, may only be made with the permission of the publisher.
All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
holder and no other individual(s) or publisher(s) holds the copyright to the material. The editorial department reserves the right to review all
editorial submissions for factual errors and to make amendments if necessary.
Dental Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items
will be disposed of unread should they be received.
Dental Tribune strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Robin Goodman at r.goodman@dental-tribune.com. Opinions expressed by authors are their own and
may not reflect those of Dental Tribune America and its employees.
Dental Tribune cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not
assume responsibility for product names or statements made by advertisers.
The responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential
liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, and the legal venue is New York, N.Y.
ortho
I 55
1
_ 2012
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Editorial
02 - 02
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Content
05 - 05
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-
Clinical and diagnostic advantages of 3-D imaging systems in dental specialties
06 - 10
view
-
The business of private practice orthodontics in the United States
11 - 16
view
-
52 weeks of social media posts in less than five minutes
17 - 22
view
-
Lingual you will love
24 - 27
view
-
SENTALLOY: The story of superelasticity
30 - 44
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-
What is UOBG and why should you be a part of it?
46 - 47
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Sesame Communications appointed to UOBG Preferred Partner Program
48 - 49
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Submissions
50 - 50
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Imprint
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/ Editorial
/ Content
/ Clinical and diagnostic advantages of 3-D imaging systems in dental specialties
/ The business of private practice orthodontics in the United States
/ 52 weeks of social media posts in less than five minutes
/ Lingual you will love
/ SENTALLOY: The story of superelasticity
/ What is UOBG and why should you be a part of it?
/ Sesame Communications appointed to UOBG Preferred Partner Program
/ Submissions
/ Imprint
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