Ortho Tribune U.S.

Shooting straight about 3-D imaging (entree) / Quality improvement via systems thinking / PCSO - NESO focus on improvements - technology in their annual sessions / Shooting straight about 3-D imaging / What kind of impression is your practice making? / Make shoppers stop shopping / Analyzing the modus operandi of the trAinEr System Appliances / Financial relief for the holidays

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OrthO tribunE

SP
EC

the World’s Orthodontic newspaper · u.S. Edition

OCTOBER 2009

www.ortho-tribune.com

VOL. 4, NO. 10

PcSO and nESO

A good impression

new products

What you can expect
at the annual meetings

How to keep your
patients coming back

A Class II appliance,
a hand driver and more

Page

tooth decay
more common
in patients with
cleft lip, palate

atients with cleft lip and/or palate have a higher prevalence
of tooth decay and cavities, also
called dental caries, than their
siblings without clefts, according
to a report published in The Cleft
Palate–Craniofacial Journal.
In this study, conducted at
Damascus University of Syria,
53 patients with clefts ages 12 to
29 years were compared with 53
sex- and age-matched siblings
without clefts.
Eighty-five percent of the
patients with clefts exhibited a
moderate or high dental caries
score, compared with only 43
percent of the control subjects.
To read the entire article, visit
www2.allenpress.com/pdf/cpc
j-46-05-529-531.pdf. OT

Page

Pages

13, 14

Shooting straight
about 3-D imaging
An orthodontist
shares his views
By Bradford Edgren, DDS, MS

tudies on learning have shown
that visual images provide 80
to 90 percent of the information
that the brain receives. So it makes
sense that in the dental office,
details received from our radiological workups are imperative for precise diagnosis and communication
with patients.
Now, cone-beam technology has
brought 3-D imaging right into the
dental office, expanding the scope

Fig. 1: Superimposed molars
spotted on scan.

of treatment for my patients as well
as for other dental practitioners.
The greatest benefit of 3-D
imaging is the amount of information obtained from each scan. The
360-degree scan of the entire head
shows the maxillofacial complex in
a format that can be rotated or sliced
to achieve the best view of these
structures.
For oral surgeons, periodontists
or general dentists placing implants,
the opportunity to view the dentition
from any and all of these angles is of
great benefit during diagnosis and
planning.
g OT page 4

Enter now to win free practice makeover
Deadline to apply
extended to Oct. 30

f you are ready to grow your orthodontic practice, apply now to
win the second Levin Group Total
Ortho Success™ Practice Makeover.
The deadline to apply has been

extended to Oct. 30, which means
you still have time to win one full

year of a free Levin Group Total
Ortho Success Management and
Marketing consulting program.
When was the last time you took
a close look at your practice’s systems? Whether you are in the beginning stage of your career or already
experienced and successful, growth
is always within your reach — even
in this economy.
The winning orthodontist will
experience improvements in every
aspect of operating his or her practice. This free, one-year manage-

ment and marketing makeover will
be a customized approach based on
the orthodontic practice’s unique
needs, goals and potential.
To apply, go to www.levingroup
ortho.com or www.ortho-tribune.com.
For more information, contact Lori
Gerstley, professional relations manager at Levin Group, at (443) 4713164 or lgerstley@levingroup.com.
Check out how last year’s winner,
Dr. Brian Hardy, has grown his practice since he started the makeover
process at www.ortho-tribune.com. OT
AD

Dental Tribune America
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Suite #801
New York, NY 10001

PRSRT STD
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PAID
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Mechanicsburg, PA

[2] =>

From the Editor

Ortho Tribune | October 2009

Quality improvement
via systems thinking
By Dennis J. Tartakow, DMD, MEd, PhD,
Editor in Chief

e are trained to treat malocclusions and growth and
development problems. For
the one-on-one relationship with our
patients, most clinicians fulfill this
job successfully. However, the traditional role of a doctor is carried out
with a broader historical, organizational, social and political context —
where the diagnosis and treatment of
system failures can be as important
as clinical interactions with the individual patient.
In order to improve health-care
outcomes in our increasingly complex environment, clinicians must
confront greater understanding to
influence a wider framework. This
progression can be achieved by meeting such constraints within the growing science of quality improvement.
Many orthodontists perceive providing high quality care not only as
our professional responsibility but
our raison d’etre — our reason for
being! Our focus is first and foremost
on the patient in front of our eyes and,
occasionally, on similar populations
of malocclusions, concentrating on
clinical effectiveness, safety and frequently on wider proportions of treatment quality; this includes impartiality and fairness, patient-appreciation
and patient-responsiveness, as well
as access and synchronization with
others.
As a profession, we are encouraged to advocate and espouse a standards-based approach and regard
discrete phases of education as the
mechanism by which these standards
are delivered. We are trained as erudite scientists and, therefore, educat-

ed to regard a randomized, controlled
trial as the gold standard of evidence;
progress is then achieved by trial
findings, outcomes and assessments.
In the business arena, the science of quality improvement is well
established. As orthodontists, we
strive for delivering high standards
of care and recognize that we have
two jobs regarding clinical effectiveness: improving how we perform and
performing to our utmost ability. This
requires commitment to (a) influence
patients and populations, by accepting responsibility for other dimensions of quality; (b) standards, by
influencing the systems within which
care is provided, (c) bio-science, by
consigning ourselves to continuous
learning and to the creation of learning organizations, and (d) behavioral science, by understanding and
accepting the strengths and weaknesses of different forms of evidence
that apply to appropriate problems.
Quality improvement illustrates a
variety of recognized scientific disciplines, the core feature of which
is systems thinking. This requires
acknowledgement of variation and
recognition of behavioral sciences in
order to glean a broader appreciation
for what constitutes profound knowledge.
Systems thinking can occur at the
(a) practice level with our patients,
and (b) national level with our leadership. Orthodontists are well versed
in basic sciences and clinical application. By possessing the skills required
to transform profound knowledge
into practice, we bring together the
expertise in a way that allows optimization of the working environment
for the benefit of the clinician and
patient. This evolution is called praxis. We must employ these skills and
expertise to influence change in the
local, state and national level.
Education, of course, is the answer
to a lack of knowledge and the key
to success for improving multi-level quality improvement. There are
many approaches for developing initiatives of quality improvement, such
as those presented in previous editorials (learning to look, systems thinking and scenario planning). We must
have the desire to contribute at the

level required to produce prolonged,
system-wide improvements in quality. Education, incentives, leadership
and revalidation are key ingredients
for quality improvement to be omnipotent at all levels.
Quality improvement education
differs from traditional dental education in terms of philosophy, culture,
ethos, content and style. These are
adult learning principles, highlighting active learning, experimentation,
self-reflection and feedback. Existing educational programs must share
and evaluate quality improvement
in order to create effective evidencebased educational programs. Audits,
outcome assessments and professional re-accreditation are important components for expanding
and advancing the science of quality improvement; it is an explicit and
integrated expression of best orthodontic practice.
Many general dentists, orthodontists and other specialists are only
partially trained for future challenges, especially as our professional
roles evolve within the system and
our delivery of health care becomes
more complex. In order to promote
the science of quality improvement,
systems thinking and appreciation for
the praxis of theoretical explication
and practical optimization are
required to be applied. Academe, the
profession and clinicians must rise to
this challenge. OT
This editorial was inspired by an
original essay: Hockey, P.M., & Marshal, M.N. (2009). Doctors and quality
improvement. Journal of the Royal
Society of Medicine, 102, 173–176.

Corrections

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

Image courtesy of Dr. Earl Broker.

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

Publisher & Chairman
Torsten Oemus
t.oemus@dental-tribune.com
Vice President Global Sales
Peter Witteczek
p.witteczek@dental-tribune.com
Chief Operating Officer
Eric Seid, e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Ortho Tribune
Prof. Dennis Tartakow
d.tartakow@dental-tribune.com
International Editor Ortho Tribune
Dr. Reiner Oemus
r.oemus@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dental-tribune.com
Managing Editor/Designer
Implant & Endo Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Online Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
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Published by Dental Tribune America
© 2009, Dental Tribune International GmbH.
All rights reserved.
Dental Tribune makes every effort to report
clinical information and manufacturer’s
product news accurately, but cannot assume
responsibility for the validity of product claims,
or for typographical errors. The publishers
also do not assume responsibility for product names or claims, or statements made by
advertisers. Opinions expressed by authors are
their own and may not reflect those of Dental
Tribune International.

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

[3] =>

Ortho Tribune | October 2009

Event Preview

PCSO, NESO focus on improvements,
technology in their annual sessions
By Kristine Colker, Managing Editor

rthodontists on the West Coast
and the East Coast have a lot to
look forward to during the next
few weeks as both the Pacific Coast
Society of Orthodontists (PCSO) and
the Northeastern Society of Orthodontists (NESO) put on their annual sessions, both featuring a wide
range of educational opportunities,
social events and more.
The 73rd annual PCSO, which
will take place Oct. 22–25 at the
Phoenix Convention Center in
Phoenix, Ariz., is focusing this year’s
program on “kaizen,” the Japanese
word for improvement.
Meeting organizers promise
that this year’s session will build
on this theme by helping attendees explore new technologies
and refine current techniques to
achieve success in today’s changing
environment.
The meeting kicks off Thursday,
Oct. 22 with a new and younger
member program and reception,
but the real action gets under way
on Friday, starting with a joint doctor/staff lecture by Dr. Roger Levin.
He will discuss what you should
do to position your practice for the
future.
Other speakers that day include
Holly Armentrout on implementing
current technology, Lori Garland
Parker on new technologies and
their applications in a busy practice, Dr. Lysle Johnston on orthodontic education and its current
and future impact on the profession
and an interactive panel discussion
addressing TMJ, estradiol dysfunction and micro-implants.
Saturday’s topics will focus on
marketing, Web site development,
patient care, mechanics, facial harmony, self-ligating brackets, softtissue lasers and mini-implants.
Sunday’s staff portion features
two lectures: Carol Eaton on the
importance of the new patient experience and Jackie Dorst on TADS.
The clinicians’ program ends the
weekend with more emphasis on
technology and multidisciplinary
topics as Dr. Claude Boutin lectures
on the implication of the Internet on
your practice, Dr. Jerry Nelson talks
about multidisciplinary treatment
at the University of California, San
Francisco, and Dr. David Kennedy
leads a discussion on early treatment.
In addition, attendees will have
an opportunity during the weekend
to attend alumni receptions, tour
the exhibit hall and socialize with
friends and colleagues at the Rawhide Western Town welcome party
from 7–10 p.m. Friday.
In a re-created 1880s Western
town with a steakhouse, saloon,
shops and rodeo arena, attendees
will enjoy staged shootouts, country

music, a petting zoo, rock climbing,
a sundown cookout and a marshmellow roast around a bonfire. Tickets are $75, and transportation is
provided.
For more information on the
PCSO annual meeting or to register,
visit www.pscoortho.org.

NESO highlights
The NESO 88th annual meeting,
taking place Nov. 13–15 at the New
York Hilton in New York City, is centered around the theme “Something
for Everyone.”

There will be discussions on the
latest technology, including reports
on intraoral scanning, computeraided brackets and other new developments; discussions on when to
treat children, with opposing points
of view presented and debated; and
in a special joint session given by
Dr. Bill Arnett, there will be discussions on making soft tissue your
primary focus.
In addition, staff sessions will
focus on communication and conflict resolution, digital trends and
risk management.

When not attending the educational programs, attendees will be
able to have lunch in the exhibit
hall so they can visit with the exhibitors and see what’s new for their
practice.
On Friday night, Nov. 13, the
president’s reception will give
attendees the opportunity to meet
and greet friends, classmates and
colleagues before heading out on
the town.
For more information on the
NESO annual meeting or to register,
visit www.neso.org. OT
AD

[4] =>

Trends

Ortho Tribune | October 2009

f OT page 1

My cone-beam system has even
revealed supernumeraries, cysts
and foreign objects hidden within
standard radiographs.
When evaluating for implants,
3-D imaging allows the clinician
to determine the height and width,
as well as the quality, of the bone
in the implant area. Moreover, 3-D
provides the ability to precisely
evaluate the distance and angulation between roots of adjacent teeth
to avoid damaging said teeth during
implant placement.
Because implants are generally
the preferred restoration for the
missing single tooth, an orthodontist
can scan a patient prior to debanding to determine exactly how the
teeth are aligned within the bone
and make any necessary corrections.
It would be very disappointing for
a patient to anticipate receiving an
implant and crown only to realize
later that the orthodontist didn’t create enough space for the implant.
Three-dimensional imaging provides for more precise measurements than 2-D panoramic radiographs, which can be unreliable
because of distortion and superimposition. Cone beam offers true 1:1
anatomical measurements, eliminating geometric errors of projection and supporting accurate linear
measurements.
AD

Fig. 2: Scan
saves the patient
unnecessary
surgery.
Fig. 3: Precise
position of an
impacted central
incisor.
Fig. 4: Patient
educated on
pathology.

Fig. 2

Fig. 3

All of this improves surgical predictability for orthognathic surgery
cases. With 3-D, I don’t have to
calculate for magnification errors
when determining the amount of
surgical correction on these cases.
Prior to 3-D imaging, my orthodontic diagnostic records always

Fig. 4
included panoramic X-ray and lateral and frontal cephalograms. Now,
with one scan, I gain the panoramic,
lateral and frontal images, as well
as everything in between. Skeletal
asymmetries that may not be clearly
visible on 2-D head films are more
evident with a cone-beam scan. 3-D
makes it easier to determine the
buccal, lingual and vertical position
of impacted teeth.
Cone-beam imaging also helps
with informed consent. 3-D scans
reveal pathologies that may have
become lost in 2-D images because
of distortion, magnification and
the superimposition of anatomical
structures. I discovered a horizontal
root fracture on a patient and sub-

sequently referred him to an endodontist for evaluation. This patient
needed to be aware of the likelihood
that the tooth could be lost because
of previous trauma. Without this
insight, foreshortening of the root,
or even tooth loss, may have been
blamed on the orthodontic treatment.
For TMJ disorders, with one scan
that takes just a couple of minutes,
I get panoramic, frontal and lateral
views as well as corrected tomographs that would have taken me
an hour or more with 2-D methods.
After implementing cone beam,
I discovered some interesting
cases. In one case, we were waiting
patiently for the second permanent

[5] =>

Trends

Ortho Tribune | October 2009
OT Online
To register for and view Dr. Edgren’s
complete Webinar on 3-D imaging,
including a discussion of these cases
and others, check out the online
archives section of the brand new
Ortho Tribune Study Club at www.
OTStudyClub.com.

Fig. 5: Mysterious hearing issue
solved.
molars to erupt prior to initiating
phase II treatment. After the other
three second molars had already
erupted, as part of progress records,
the i-CAT® scan showed that an
impacted third molar was impeding
the eruption of the maxillary right
second molar (Fig. 1).
On previous “standard” pans,
the fourth third molar was perfectly superimposed with the second molar, and was not evident.
This second molar may never have
erupted, or worse yet, may have
been presumed to be “ankylosed.”
In another example, a patient
was referred from an oral surgeon
for an i-CAT scan. The referring
oral surgeon wanted to clarify diagnoses made at another office, based
upon previous digital pans, including a supernumerary, odontoma,
failure to erupt and/or ankylosed
deciduous second molar.
On the scan (Fig. 2), it was evident that it was just an ankylosed
deciduous second molar, eliminating the need for a previously
planned exploratory surgery. This
patient also owes her future nice
occlusion to 3-D imaging and diagnosis.
Our cone beam also gave us a
great view of another patient’s horizontally impacted maxillary central
incisor (Fig. 3). When treatment
started, the i-CAT machine aided
the oral surgeon in exposing and
placing a gold chain on the cen-

OT About the author
Dr.
Bradford Edgren
earned
a
doctorate of
dental
surgery
from
University of
Iowa, College
of Dentistry
and a master
of science in
orthodontics. He is
certified by the American Board of
Orthodontics, is a diplomate of the
American Board of Orthodontics and
is a member of the College of Diplomates of the American Board of
Orthodontics. He is also a member of
the American Association of Orthodontists, Rocky Mountain Society of
Orthodontists, Colorado Orthodontic
Association, The Edward H. Angle
Society of Orthodontists — Southwest
Component, American Dental Association, Colorado Dental Association
and Weld County Dental Association.

size of the cyst. The patient was so
impressed with the i-CAT scan that
he consequently set his daughter up
for orthodontic treatment.
One of my most unusual cases
involved a young patient who came
in for braces, but after the i-CAT
scan left with some clues that led to

an ENT solving the mystery of her
hearing loss (Fig. 5).
While some of these cases show
hidden pathologies, it is no secret
that 3-D imaging sheds light on our
more difficult cases and, no matter
what our specialty is, adds a new
dimension to our practices. OT
ADS

tral incisor for guided eruption. Her
impacted canine, detected on the
previous scan, has also since been
brought into place.
Regarding patient education, an
oral surgeon referred a patient for
an i-CAT scan to verify the position
of the mandibular canal in relationship to the impacted third and
dentigerous cyst prior to extraction
(Fig. 4). This helped the patient
visualize the extent of the third
molar impaction and appreciate the

[6] =>

Practice Matters

Ortho Tribune | October 2009

What kind of impression
is your practice making?
By Scarlett Thomas
President, Orthodontic Management Solutions

o my girlfriend calls me the
other day. Her son has been a
patient of a particular orthodontic practice for many years. Her
relationship with this practice has
always been pleasant, but nothing
special.
One day she walked in for her
son’s regular monthly appointment
to find things just didn’t go well
for seemingly no good reason. She
became extremely frustrated and,
as soon as she walked out the door,
she called me and in a strongerthan-normal voice said, “I really
dislike those people.”
This was a practice she had been
loyal to for many years, but because
of one negative exchange in a handful of minutes, the relationship and
years of working together quickly
turned sour. In a moment, the entire
practice was reduced to “those people.” Because of one person, she
now disliked them all.
Perhaps someone called in sick
and the rest of the staff was running
behind. Maybe the staff was training a new employee or possibly had
just received bad news regarding a
particular situation.
Who knows?
But at that moment, she realized
she no longer wanted to do business with that orthodontic practice
anymore. She was ready to end a
long-term affiliation because of a
brief encounter over nothing significant. It was at that moment I realized how fragile orthodontic patient
relationships really are.
The problem was that the orthodontic practice had not worked to
establish a strong emotional connection with my friend and/or her
family. It was just a group of people
in a building going through the
motions of handling daily affairs.
The situation was simply a generalized indifference, but when the
relationship was tested, it had no
significant strength to support it.
In business and in life, we too
often minimize or forget the impact
we really have on others. Our reach
is deeper and wider than most of us

‘No job is
insignificant or
exempt from
making an
important and
impressive impact
on the value and
experience an
orthodontic
practice delivers
to its patients.’
realize. Unfortunately, it can take
losing a valued patient to understand this.
Let this be a reminder to you
that your orthodontic practice, your
staff and you personally have a far
greater effect on your patients than
you could ever image.
No job is insignificant or exempt
from making an important and
impressive impact on the value and
experience an orthodontic practice
delivers to its patients.
To help your team understand its
individual effects on your practice
and patients, you must get specific.
Training, role-playing and communication are keys to a successful business. Just saying, “You play
an important role,” won’t tell the
employees what they need to do or
do differently every day.
Every decision, action and activity presents an impression. They
must understand that what they do
every day has a meaning far greater
than the tools they use, the items
they handle and the paper they deal
with.
In fact, your staff may be the
very reason patients do business
with your practice and/or the very
reason they don’t. This being said,
before the members of your team
can embrace the impact of each of
their respective actions, they must

understand the impact they have on
the practice as a whole.
They must be trained how to
communicate with patients. They
must operate with constant mindfulness about their ability to build or
destroy relationships in a heartbeat.
I recommend having regular
meetings to discuss the following:
• What is the real impact your staff
has on the well-being of your
patients?
• What recent negative situations
have come to the surface concerning your patients?
• How were these situations handled?
• What could have been done differently to resolve the issue?
• What effect on the patient does
it have when things go right? Or
when things go wrong?
• What does the staff need to know
and do regularly to make a great
impression with your patients?
Every staff member needs to be
focused on the impact he or she has
on the practice and the patients. It is
a key factor in the greater success of
your practice.
To learn more about the impact
employees have on your business,
please join the “4 Keys To Orthodontic Success” Webinar series. You can
register and find out more information by visiting orthoconsulting.com
and checking under events and seminars. OT

OT About the author

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

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

[7] =>

[8] =>

[9] =>

Practice Matters

Ortho Tribune | October 2009

Make shoppers stop shopping
By Roger P. Levin, DDS

ore than most dental specialties, orthodontics has always
had shoppers. However, the
down economy has made people
even more sensitive to price. As a
result, people are shopping around
for the lowest fee more than ever.
To turn ortho shoppers into starts,
orthodontists must recognize that
effective case presentation is essential to building patient trust.
Through our Total Ortho Success™ consulting program, Levin
Group has demonstrated that case
presentations by highly successful
ortho practices share five common
characteristics. All top-producing
ortho practices:
1. Use a dedicated treatment coordinator. An orthodontic treatment
coordinator allows the practice
to provide a better experience for
patients and parents without taking up too much of the clinician’s
time. A treatment coordinator can
improve customer service and
enhance case acceptance, but his
or her performance must be measured against results to ensure
optimal effectiveness.
2. Get to know the patient first.
Asking questions about the
patient’s background is key to
building a strong relationship.
Subjects of interest can be school,
athletics and extracurricular
activities.
3. Explain treatment. And that means
far more than simply mentioning the clinical details and the
timeline for treatment. Emphasizing the benefits of treatment is

OT About the author

Dr. Roger P. Levin is founder and
chief executive officer of Levin
Group, Inc., the leading orthodontic practice management firm.
Levin Group provides Total Ortho
Success™, the premier comprehensive consulting solution for lifetime success to orthodontists in
the United States and around the
world. A third-generation dentist,
Levin is one of the profession’s
most sought-after speakers, bringing his Total Ortho Success Seminars to thousands of orthodontists
and ortho professionals each year.
For more than two decades, Dr.
Levin and Levin Group have been
dedicated to improving the lives
of orthodontists. Levin Group may
be reached at (888) 973-0000 and
customerservice@levingroup.com.

OT At the PCSO
Don’t miss Dr. Roger Levin speaking
on “Achieve Total Ortho Success in A
Down Economy” from 8:30–10 a.m.
Friday, Oct. 23, during the PCSO.

critical to motivating parents (and
patients) to commit.
4. Answer questions and inspire confidence. Questions from parents
and patients are inevitable. It is
at this stage that trust is built with
the practice. The orthodontist
should be perceived by patients
and parents as knowledgeable
and enthusiastic. Enthusiasm

spreads to patients, which will
create confidence. The more confidence patients have, the more
trust they develop for the practice.
5. Finalize with the treatment/financial coordinator. Once questions
have been answered, it is time for
the orthodontic treatment coordinator or financial coordinator
to handle financial matters. The
clinician’s time should be limited
to treatment issues.

Conclusion
Why should patients and parents
come to your office? By making
an effective case presentation to
patients, the practice has the oppor-

tunity to add sufficient value and
gain case acceptance before the
patient visits (or decides to visit)
other offices.
When patients develop a sense
of trust in your ortho practice, their
shopping ends at your office!
Ortho Tribune readers are entitled
to receive a 20 percent courtesy on
Dr. Roger Levin’s next Total Ortho
Success Seminar being held Jan. 28
and 29 in Las Vegas. To receive this
courtesy, call (888) 973-0000 and
mention “Ortho Tribune” or e-mail
customerservice@levingroup.com
with “Ortho Tribune Courtesy” in the
subject line. OT
AD

[10] =>

[11] =>

Ortho Tribune | October 2009

Industry Clinical 11

Analyzing the modus operandi of
the TRAINER System Appliances
By German Ramirez-Yañez, DDS, MDSc, PhD

Part 2 of three

s suggested by the name, the
appliances of the TRAINER
System™ just train or exercise
the muscles at the craniomandibular system (CMS) to physiologically
load the bones, stimulating growth
and development in the structure
composing the CMS. Through
development of the maxilla, the
mandible and the dental arches,
as well as by re-educating tongue
posture, the teeth tend to position
better and align correctly.
The effects produced by the trainers on the maxilla and mandible
have been demonstrated through
scientific studies (Usumez et al.
2004; Ramirez-Yañez et al. 2007), as
well as through clinical cases successfully treated with these appliances and reported in the literature
(Ramirez-Yañez GO and Faria P.
2008; Kanao et al. 2009).
Currently, there is ongoing
research with the TRAINER System Appliances focusing on understanding their effect on the muscular activity of the masticatory and
facial muscles, as well as further
investigation of the positive effect
the appliances can have in mouthbreathing patients and on some
altered oral functions, such as swallowing.
In the following sections, the
modus operandi of the TRAINER
System Appliances are explained,
considering separately their effect
on the three dimensions of the
mouth: sagittal, transverse and vertical. Scientific literature supporting
the physiological concepts involved
in the effects produced by the trainers is presented to further support the concept that the TRAINER
System Appliances (including the
MYOBRACE®) are a viable alternative in treating malocclusion.

Sagittal growth and
development (antero-posterior)

The effect produced by the TRAINER System Appliances is in part
similar to those functional appliances designed to stimulate mandibular growth and development
by bringing the mandible forward
into an edge-to-edge position (bionator, monoblock, twin-block, etc).
By placing the mandible in such a
position, the muscles protruding the
mandible are stretched (masseter,
medial pterigoid and lateral pterigoid muscles).
The TRAINER Appliances are
recommended to be worn one to
two hours during the day and 10 to
12 hours at night while sleeping. It
was explained by Van der Linden
and colleagues (Van der Linden,

Frans & Proffit 2004) that all action
maintained for more than six continuous hours produces an effect on
the CMS.
The trainers maintain the mandible in a forward position for 10 to
12 hours during the night, keeping
the muscles protruding the mandible stretched.
This makes the blood vessels in
the muscle decrease their diameter,
which hinders sufficient blood flow,
therefore decreasing the gas and
substance exchange in the muscle

through the blood. This situation
produces muscular tiredness due
to an accumulation of lactic acid in
the muscle.
A similar physiological process
occurs in our body when people initiate an exercise routine at the gym,
and muscles that had not been used
for a certain period are activated.
This is the reason a patient wearing any of the trainers complains of
muscular soreness on the face and
mouth during the first couple weeks
of treatment.

When the appliance is taken out
of the mouth, the muscles protruding the mandible fall into hyper-contractibility (involuntary and repeated contractions of the muscles),
which moves the mandible forward and backward. This explains
why at the beginning of treatment
(about three to four weeks), patients
report that in the morning when
they remove the TRAINER (or
MYOBRACE) from the mouth, they
g OT page 12
AD

[12] =>

Industry Clinical

f OT page 11

cannot maintain the teeth in maximum contact (maximum intercuspation) and cannot maintain the
mandible in a relaxed position. The
muscles protruding the mandible
are still performing contractions.
ADS

This muscular hyper-contractibility produces higher blood flow
in the muscles protruding the mandible, and thus the excess of lactic
acid accumulated during the period
the trainer was in the mouth is
removed from the muscles. This
increase in blood flow brings to

Ortho Tribune | October 2009
the muscles more undifferentiated
cells, which have the ability of differentiating into myoblasts that can
produce new muscular fibers in
those muscles.
One of the muscles playing an
important role in stimulating mandibular growth and development
when these kind of functional appliances are used is the lateral pterigoid muscle. This muscle inserts on
the mandibular condyle and is in
charge of moving the mandibular
condyle forward, together with the
articular capsule and the interarticular disc at the temporo-mandibular
joint, when the mandible protrudes
or performs lateral excursions.
As previously explained, there
are small movements of the condyle within the glenoid fossa at the
temporo-mandibular joint that are
interpreted by the patient as discomfort in the morning. It is noth-

Fig. 3: Patient is 8 years old.
After treatment with a TRAINER
Appliance (T4K) for more than 16
months (two bottom photos), the
mandible is positioned forward and
the inclination of the maxillary
incisor teeth improved.
ing more than the movement of the
mandibular condyle, produced by
the hyper-contractibility of the lateral pterigoid muscle raising after
the appliance is removed from the
mouth.
These forward and backward
movements of the mandibular condyle within the glenoid fossa stretch
the retro-discal pad (also known as
Zenckel’s zone) where the blood
vessels release nutrients and growth
factors that reach the mandibular
condyle, stimulating mandibular
growth and development through
endochondral ossification.
This was reported by Prof.
Alexandre Petrovic, who showed
through his studies (Petrovic et al.,
1991; Stutzmann and Petrovic 1990)
how these FMO appliances maintain
the mandible over a certain period
of time in an edge-to-edge position and how mandibular growth
is stimulated by this action. (It is

[13] =>

Ortho Tribune | October 2009 Industry Clinical & Products 13
EasyFit Jumper
FORESTADENT introduces a fixed
functional orthodontic appliance for
the protrusive movement of the mandible with its new EasyFit™ Jumper.
This modified Herbst appliance is
attached in the maxilla within the
molar area (between teeth #5 and #7)
and in the mandibular within the premolar area (teeth #3 and #5), similar
to the well-known mandibular protrusion hinge by Prof. Dr. Herbst.
The EasyFit Jumper is not attached
to bands or splints but placed directly
on the archwire of the multibracket
appliance. It is fixed in position using
special nuts with integrated rectangular tubes that are simply slipped onto
the archwire to be fitted, adjusted and
clamped using pliers.

The majority of Class II appliances
have to be disassembled several times
due to the use of spacers, but this is
not necessary with the Easy-Fit Jump-

er, which operates without spacers.
Instead, the thread construction in the
guide tube ensures smooth adjustment
of mandibular advancement.
The key supplied is simply inserted into the hole of the sleeve on the
guide tube and turned in the required
direction until the planned protrusion
is reached. There is no longer the need
for time-consuming laboratory procedures or several appointments for individual adjustments of the appliance. All
working stages can now be performed
directly at chairside in one appointment. The appliance can also be easily
reactivated intraorally.
The dorsal angulation bar of the
Class II device automatically produces a
horizontal movement, which is parallel

to the occlusal plane. Applied forces can
therefore be channeled to a favorable
direction on the square archwire and
multibracket appliance.
The intelligent design of the EasyFit Jumper also enables left-handed or
right-handed activation without having to alter the position of the patient.
Furthermore, the unique construction
eliminates the risk of accidental aspiration of loose parts.
Forestadent USA
2315 Weldon Parkway
St. Louis, Mo. 63146
Phone: (800) 721-4940 or (314) 878-5985
Fax: (314) 878-7604
E-mail: info@forestadentusa.com
www.forestadentusa.com
AD

important to remember the mandibular condylar cartilage, as all
cartilages, does not contain blood
vessels and receives its nutrients
and growth factors through its surrounding structures.)
This repetitive stimulation every
night, maintaining the mandible in
an edge-to-edge position, induces
new muscular fiber formation in the
muscles protruding the mandible
and improves the activity in those
muscles.
This allows the mandible to be
kept in a forward position without
muscular tiredness due to lactic
acid accumulation. In other words,
the mandible is now in a forward
position held by the muscles.
On the other hand, this muscular
hyper-contractibility, occurring in
the muscles protruding the mandible the moment the appliance is
removed from the mouth, stimulates
endochondral ossification, which
leads to more mandibular development. These effects together bring
the mandible forward through an
increase in the performance of the
muscles protruding the mandible
and endochondral ossification.
This explains the significant clinical results presented in Figure 3,
and those reported in the literature
where a significant improvement in
the relationship between the maxilla and the mandible was observed
in patients Class II, division 1 and 2
when treatment was performed
with the TRAINER System Appliances (Quadrelli, et al. 2002; Usumez et al. 2004; Ramirez-Yañez and
Faria 2008). OT
Look for Part 3 of this article in
the November issue of Ortho Tribune. References will appear at the
end of Part 3.

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

[14] =>

Industry & Products

Ortho Tribune | October 2009

Financial relief for the holidays
Get them what they want, give them what they need.
By Tamara Hobbs
Creative Director, Yourtown Direct

• You don’t have to choose! You can
have BOTH this holiday season!
• Get a FREE Wii Game System
(“or a $250 gift card to the store of
your choice”).

n order to reach out and meet the
needs of your potential patients
during the upcoming holiday
season, we suggest meeting them
where they are — which is getting ready to deal with the expense
of gift giving and having to make
wise financial decisions to make
every dollar stretch in this tough
economy.
So let’s get outside the box and
help them find relief. With our
innovative approach to the difficult
task of marketing during the holidays, we have developed a win-win
program for the orthodontist and
patient alike.
Here’s how it works: Utilizing
Yourtown Direct’s postcard mailing
program for as low as 45 cents a
piece, you can reach your targeted market with a holiday message
unlike any other.
Instead of a coupon-style discount that usually ranges from
$300–$1,000 per new start, give
them a gift card that will help ease
the burden of their holiday shopping.
Taking into consideration that a
typical discount simply means not
charging as much for your time,
this new approach will require you
to decide to do business differently.

And in this economy, deciding to do
business differently is key to your
practice’s financial stability and
growth.
You have to decide how much
you can afford to invest in each new
start (be as generous as possible),
then select a company with mass
appeal, such as Target. After the
contract has been signed and the
treatment process has begun, purchase a gift card as your gift to each
start to help ease holiday shopping.
This display of goodwill and
understanding will cause word-ofmouth advertising to spread. Not
only will your new patients not

have to pick between getting what
they want versus what they need
(braces!), but instead of orthodontics being seen as an expense, you
will be seen as a solution to holiday
gift-giving problems.
Headlines to consider:
• We’ll make you both smile this
holiday season with a $500 gift
card to Target.
• Get a $300 gift card to Target. Get
them what they want — give them
what they need.
• Ease the financial holiday burden with a $300 (or fill in your
amount) gift card from Target (or
store of your choice).

Using YTD’s postcard mailing
program, we will work with you to
pick an item that has cross-market
appeal based on the demographics of your mailing list, along with
images that promote a holiday tradition you’d like those people to see.
The possibilities are endless.
So don’t let the tough economy
and holiday season make you feel
like going underground with your
marketing efforts. It’s not Groundhog’s Day, it’s the greatest season of
all, and you can take this opportunity to really reach out and connect
with perspective new patients, ease
their holiday burden and, yes, build
your practice.
Give us a call or go online to our
Holiday Ortho Sample Gallery and
see what we can do for you.
And to kick off the holiday spirit,
we’re giving gifts too: You get your
choice of 1,000 business cards or
appointment reminder cards, 1,000
4-by-6 handout cards or even a
fresh new logo design.
Go to YourtownDirect.com or
YourOrthoPostcards.com, or give us
a call at (858) 780-2899, and we’ll
get the holiday gift giving started. OT

Opal Seal

Contra-Angle Hand Driver

Opal® Seal is a revolutionary 38
percent filled primer that releases
and recharges fluoride throughout
the orthodontic treatment. Filled with
nano and glass ionomer particles,
Opal Seal offers strong, long-lasting
coverage and excellent mechanical retention.
Opal Seal contains a drying agent to chase moisture and draw fluoride-containing resin into etched enamel for enhanced bonds and recharging fluoride uptake.
The unique tip employs a spiral canal to deliver resin in a thin, uniform layer.
Opal Seal’s non-yellowing formulation cures translucent and is detectable
under a UV black light to facilitate removal and re-application.

DENTAURUM USA announces a new Contra-Angle Hand Driver for its marketleading tomas® system. This new driver is specially designed to provide much
greater access, stability and efficiency during the placement of TADs in hard-toreach areas such as the palate or the posterior mandible and maxilla.
The pre-molar region of the palate is quickly becoming the No. 1 preferred area
for all TAD placements in the maxilla because of the easy access to the entire maxilla from one central location and due to the absence of roots that are to be avoided.
In hard-to-reach areas, it is common to see rocking and movement during placement of TADs, and this can be a key factor in widening the insertion path and
causing higher failure rates. By using the Contra-Angle Hand Driver, you are able
to maintain constant and stable pressure on the TAD with one finger, while turning the knob slowly and consistently with the other hand.
Increase your success rates and efficiency with TADs with the tomas ContraAngle Hand Driver. The driver has been designed to accept any latch-head attachment, so it can be used with other TAD systems on the market, if needed. Activation and use of this Contra-Angle Hand Driver is very easy — simply turn the knob
at the bottom of the handle.
Mention this product announcement and receive a $100 discount off your
purchase of this driver, or you can
get the driver completely free of
charge with the purchase of only
25 tomas pins.
Call (800) 523-3946 for more
information or to order this product.

Opal Orthodontics
(888) 863-5883
www.opalorthodontics.com

Dentaurum USA
10 Pheasant Run
Newtown, Pa. 18940
E-mail: sales@dentaurum-us.com
www.tomasforum.com

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