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Orthodontic practice US 11-12.2013 Vol4 No6 Tạp chí Chỉnh hình răng miệng tháng 11-tháng 12/2013
For more information visit: www.carestreamdental.com or call 800.944.6365 Virtually everywhere CS OrthoTrac Cloud 9944-Ortho-Practice-cover-banner.indd 1 10/23/13 1:12 PM PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR! clinical articles • management advice • practice proles • technology reviews November/December 2013 – Vol 4 No 6 PROMOTING EXCELLENCE IN ORTHODONTICS BioDigital Orthodontics: part 6 Dr. Rohit C.L. Sachdeva The biology of orthodontic tooth movement: part 1 Dr. Michael S. Stosich Practice profile Dr. Jack Fisher Pride Institute “Best of Class” special awards tribute A golden opportunity for dentists: dental sleep medicine: part 2 Dr. Harold F. 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Precision Design Patented laser-etched pad for optimal bond strength and easy, comfortable debonding. © 2013 Ormco Corporation Practice Growth Proven practice marketing support, including consumer-focused Damon Doctor Locator, to drive more patients to your practice. On Both Arches *Clinical research and performance data available at ormco.com/damonclear January 15–18, 2014 | Phoenix, Arizona Register at damonforum.com Ormco-OrthoPrac-DamonClear-Oct2013.indd 1 9/17/13 2:18 PM November/December 2013 - Volume 4 Number 6 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com Tel: (480) 403-1505 MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Kay Harwell Fernández Email: kay@medmarkaz.com Tel: (386) 212-0413 EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com Tel: (727) 393-3394 DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com Tel: (480) 621-8955 NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 PRODUCTION MANAGER/CLIENT RELATIONS Adrienne Good Email: agood@medmarkaz.com Tel: (623) 340-4373 PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton Email: lauren@medmarkaz.com Tel: (480) 621-8955 MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.orthopracticeus.com SUBSCRIPTION RATES 1 year (6 issues) $99 3 years (18 issues) $239 © FMC 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher. This is the “punchline” to an old joke where a wife catches her husband in the middle of an encounter with another woman. While our experience may tell us otherwise, we are asked to believe things in orthodontics that just may not ring true. Whether it is the use of a cephalometric analysis that is based on one case and not only is in the literature but has become the “normal” for many other analyses, or a pronouncement of a new technique with magical brackets and wires, we must at long last — think! We cannot agree on where “centric relation” is; or if it is important; or if the mandible can be advanced without doing damage; or if articulators are useful; or whether or not self-ligating brackets are better than traditional; or if they are, whether they should be “passive,” “active,” or interactive.” Many orthodontists have become experts at the mechanical part of tooth movement. But even in this area, we do not agree! Light forces, small light wires, heavy stainless steel wires? University studies have shown that lower incisors will move no matter what is done. Extraction or non-extraction, upright teeth stay within certain limits; lower incisors must be at specific angles — we decide whether to increase canine width or not. Yet even though these studies show that nothing works, we are given guidelines to follow. What does all of this rambling mean? There are 28 reasons for relapse. Do not violate these areas, and relapse will be very unusual. We must pay attention to the role of muscles in orthodontic tooth movement. What happens when muscles are not relaxed? What is the physiologic meaning for using stainless steel wires, titanium wires, filling the slot, or not? Does a light-force, small-diameter titanium wire move teeth any faster than a medium-force, large-diameter round wire? No! If we use a pre-adjusted appliance, why do we continue to make wire adjustments and/or change bracket positions? There are dozens of questions that should be asked, and if you do ask them, there are answers. Our specialty must, in my opinion, pay attention to anatomy, periodontal physiology, and neuromuscular physiology. By this I do not mean placing patients on a machine to find out about muscles. I do mean we need to be experts in knowing how muscles and periodontal fibers are affected by what we do to move teeth and jaws. It is critically important to understand what is happening physiologically during and after tooth movement. At this time in orthodontics, I believe some common philosophies of treatment are incredibly theoretical and wrong! We need to ask lots of questions! Dr. Ron Roncone, DDS, MS Roncone Orthodontics, Vista, California Are you going to believe me or your own eyes? 1 Orthodontic practice Volume 4 Number 6 INTRODUCTION TABLE OF CONTENTS 2 Orthodontic practice Volume 4 Number 6 Orthodontic concepts BioDigital Orthodontics: Management of Class 1 non– extraction patient “Standard– Track”© – 9-month protocol: part 6 Dr. Rohit C.L. Sachdeva, and Drs. Takao Kubota and Kazuo Hayashi, discuss a treatment for Class I non- extraction patients 16 Special section Pride Institute “Best of Class” special award tribute 28 Practice profile 6 Dr. Jack Fisher: Changing smiles, changing lives This orthodontist employs both art and science to create great smiles. Corporate profile 10 Planmeca ® : innovative, upgradeable imaging technology This company delivers complete dental solutions based on integrated high-tech device and software options. ON THE COVER Cover photo courtesy of OraMetrix, Inc. Article begins on page 16. OrthoAccel Technologies, Inc. 12 With a focus on developing, manufacturing, and marketing innovative technologies, this firm helps clinicians enhance dental care and orthodontic treatment. Everywhere your practice needs to be Our CS OrthoTrac Cloud is a powerful practice management and imaging solution that makes data security simple and virtually worry-free. Access it any time, from any location using any computer or tablet device. • Greater exibility with offsite and HIPAA-compliant storage, always equipped with the latest software • The best of OrthoTrac software with the benets of a cloud environment • Ideal for single or multi-location practices with wireless Internet access via computer, tablet or iPad ® • Minimal upfront cost with simple monthly installments Call 800.944.6365 or explore it here carestreamdental.com/cscloud Virtually everywhere CS OrthoTrac Cloud © Carestream Health, Inc. 2013. OrthoTrac is a trademark of Carestream Health. iPad is a trademark of Apple, Inc., registered in the US and other countries. 9973 OR A D 1113 CS_Cloud_Ad_US_9x11.7.indd 1 10/18/13 3:30 PM 4 Orthodontic practice Volume 4 Number 6 Continuing education The biology of orthodontic tooth movement part 1: Biology of Bone 101 Dr. Michael S. Stosich outlines the basic premises and biology of bone related to orthodontics 38 A golden opportunity for dentists: dental sleep medicine: Part 2 Dr. Harold F. Menchel offers a wake- up call to clinicians to explore an evolving niche in dentistry 42 Orthodontic insights More than one way — an issue related to invisible aligners Drs. Donald J. Rinchuse, Ethan Drake, Janet Robison, and Dara L. Rinchuse offer insights on the various forms of tooth movement .46 Technology VELscope ® 50 Biology of bone 38 TABLE OF CONTENTS Practice management Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place .52 Hard-piped filtered water system vs. self-contained bottled water system John Bednar helps avert problems coming down the pipe 61 Product profile Dental technology gets a new look with Henry Schein’s augmented reality app 54 Abstracts The latest in orthodontic research from around the world Dr. Shalin R. Shah presents the latest literature, keeping you up-to-date on the most relevant research from around the world 56 Legal matters Employment Law 101 Dr. Ali Oromchian discusses basic laws every orthodontist needs to know 58 Book review Biomechanics in Orthodontics, 4th Edition Drs. Giorgio Fiorelli and Birte Melsen .60 Practice development Four social media channels that drive new patient acquisition and retention Diana P. Friedman offers advice on cultivating a dynamic web presence .62 Industry news .64 Materials & equipment 64 Practice Growth That Will Have You Grinning Ear to Ear! 800.645.5530 newdentsplygac.com New from DENTSPLY GAC, Bracket Ears are the fashionable way to grow your practice and build your brand. Each set of these high-quality earrings is made to the GAC standards of excellence, comes in a cool jewelers box and includes four interchangeable color bands. Help your patients embrace their new look before you begin treatment with new Bracket Ears. ® Part Art, Part Science, All Ears! What can you tell us about your background? I grew up in Mayfield, a very small town in western Kentucky. After my undergraduate studies, I attended the University of Louisville School of Dentistry and then went on to residency at the Medical College of Georgia where I received a certificate in orthodontics. Upon completion of my formal education, I returned home to begin a practice limited to orthodontics. Realizing very quickly that the small community could not support a full-time specialist, I acquired a private pilot’s license and started another practice in a larger community where I could practice 2 days a week with an oral surgeon. Owning my own plane allowed me to raise a family in my hometown while also allowing me to expand my professional career and see more complex cases. It also gave me the opportunity to treat many surgical cases together with the oral surgeon. I was able to scrub in on many cases, which I greatly enjoyed. After our two boys graduated from high school, we were able to liquidate the practices and relocate to Memphis, Tennessee. I took a position with a corporate dental group to treat their orthodontic patients. This experience turned out to be beneficial because I began to realize that corporate dentistry did not fit my personality or meet the standard of care I wanted to provide my patients. So, at the age of 58, I started over again. In 2006, I was able to develop a temporary skeletal anchorage system (TSAD). This has afforded me the opportunity to be involved with several residency programs. For the past 7 years, I have conducted a cadaver course for the insertion and use of TSADs. The company conducting this course is Elite Ortho. I am also currently practicing orthodontics in Cordova, Tennessee, 14 days per month, and I am a faculty member at three residency programs. After 30-plus years in this great profession, I still enjoy going into the office every day, and I truly consider it a blessing to be able to teach and to help people smile. Why did you decide to focus on orthodontics? My motto is, “Change a smile; change a life.” I enjoy orthodontics because it employs both art and science to create a great smile. I really feel that about 80% of what I do as an orthodontist is art. To be able to help patients achieve great smiles by altering their facial features, in conjunction with improving their oral form and function, is one of the most rewarding fields in healthcare. The demographics of most orthodontic practices are predominately teenagers. This age group is still early in its development, and most young people are very impressionable. We are privileged to be able to develop a relationship and spend time with them on a regular basis during the course of treatment. After the braces come off, which is a very exciting day in our office, we are then able to continue this relationship during the retention phase of treatment. This affords the orthodontist a distinct opportunity to be a positive influence for a significant amount of time in young people’s lives. How long have you been practicing, and what systems do you use? I have been practicing orthodontics for 30 years. I use a pre-adjusted fixed orthodontic appliance on more than 95% of my patients. Most of all our patients are treated with segmental mechanics initially and then are finished with continuous arch wires. Approximately 25% of our patients receive some type of a skeletal anchorage device. I do utilize DICOM imaging on approximately 80% of the cases. What training have you undertaken? I attended the University of Louisville School of Dentistry where I received a DMD. I furthered my education at the Medical College of Georgia where I received a certificate in orthodontics. Who has inspired you? I was inspired by a high school guidance counselor who asked me what I wanted to become. I responded by telling her that I wanted to become a dentist. When she laughed at me and told me that in her professional opinion, I would not be able to become a doctor, it drove and inspired me to prove her wrong. Her attitude toward my abilities, or lack thereof, has been a driving force for me for many years. I was also blessed to have parents that made sure I was surrounded by successful people during my formative years. What is the most satisfying aspect of your practice? I enjoy the ability to help young people with their self-confidence by improving their smiles. Professionally, what are you most proud of? Being invited to teach residents and other orthodontists techniques that they had not been directly exposed to previously. What do you think is unique about your practice? We have a therapeutic dog in our office that makes our patients and team members Dr. Jack Fisher 6 Orthodontic practice Volume 4 Number 6 PRACTICE PROFILE Changing smiles, changing lives PRACTICE PROFILE Volume 4 Number 6 Orthodontic practice 7 feel comfortable with their treatment and our working atmosphere. What has been your biggest challenge? Meeting my own expectations. What would you have become if you had not become a dentist? A machinist, or perhaps a mechanical engineer, or a commercial airline pilot. What is the future of orthodontics and dentistry? The future of the specialty of orthodontics is a big concern of mine. The fact that residents are finishing their residency with such a large amount of debt is a challenge. Can we really advise them to buy a million dollar practice with so much debt? Should we advise them to start a practice? This advice is difficult in most cases because of the market saturation. It leaves three options for the graduate: 1) to associate with an existing practice, 2) to take a job in the corporate dental atmosphere, or 3) to become employed by a pediatric dental group. The second option opens the door for a long discussion, depending on someone’s opinion of the business model for delivering dental services to the public. The more the corporate side of dentistry grows, the more it will keep the specialty side of dentistry in-house. The more these patients stay inside the corporate market, the fewer patients there will be for the private practice model to treat, whether it is for the private general practices or the private specialty practices. The market will become more limited for all private practices. Though there are fewer seats in first class, they are rarely empty. It does seem that there will always be a market for the high-end private practices, just a smaller version, which makes it difficult for these practices to thrive. The dental industry has been a relatively low-risk venture with good profit margins. The corporate world now knows this and can also hire the new graduates who are desperate to pay off debt. Also, pediatric specialists have a ready-made orthodontic practice and are often eager to hire recent graduates as well. It seems that because orthodontic practices are able to be owned and operated in most states without the owner being an orthodontist (i.e., corporate dentistry, general practitioners, pediatric dentists, and so on), that we are beginning to see the erosion of the first, and in my opinion, the greatest specialty in dentistry. Another challenge facing the orthodontic specialty is the traditional education model for residency programs. The traditional learning experience has usually consisted of a department chair and one or two full-time faculty members. Of these faculty members, one usually focuses on research and the other serves as a clinical director. The program then has orthodontists from the surrounding community who donate 1 or 2 days of their time per month to treat cases with the residents. This model has served the residency programs very well for many years. However, with the technological advances in recent years, the learning curve for many practitioners is difficult to maintain. Two examples include 3D-imaging technology and treatment modalities using skeletal anchorage devices. Many practitioners are either unable or unwilling to keep pace with their changing specialty. This is alarming to many residents who are paying hundreds of thousands of dollars for their education and find out, after the fact, that they weren’t fully equipped. Also, the use of aligners by general practitioners is growing rapidly, and this further eats away at the nature of the specialty. When we consider the shift to corporate dentistry, the debt load of newly graduated residents, the steep learning curve of the diagnostic tools and recent treatment modalities, the orthodontic specialty seems to be “dumbing down.” It seems this trend is in large part because residency programs are unable to keep up with the advances in the field. Many programs have also become seen as “cash cows” for financially strapped universities, and as a result, the gap between the standard of care delivered by clinicians who did not attend a residency and those who attended a 2- to 3-year program seems to be narrowing. I realize these comments could be offensive to some, and I do apologize if they are ill received. It is my opinion that we who choose to volunteer in residency programs have a responsibility to the future of the specialty, the residents we are teaching, and most of all, the patients we are treating to stay abreast of emerging diagnostic tools and treatment modalities. Otherwise, what will separate a recent graduate from an accredited orthodontic program and a GP who has taken a few weekend courses? What are your top tips for main- taining a successful practice? Focus on the details. The practice will not run itself, so the owner must focus on the business details, or there will be no business to focus on. There isn’t any one marketing strategy; it’s all the little things together that add up to something great. You have to do a lot of little things well. Neglect the personal relationships, and the practice will go away. Building relationships is the key to any success, whether in business or in life. 8 Orthodontic practice Volume 4 Number 6 PRACTICE PROFILE What advice would you give to budding orthodontists? Colleges, dental schools, and residency programs do not teach or emphasize, to any degree, the value in understanding personality types and understanding how to build solid relationships (at least I am not aware of any that do). Whether it is with a spouse, a child, a team member, a patient, or a referral source, to be successful in this era, it is vital to understand these principles. Any graduate from a CODA- approved program knows how to help patients improve their smiles. It is the rare graduate that understands the value or has been taught how to build relationships. My advice is to seek out a mentor who is trustworthy and possesses these skills. Then, learn and apply the wisdom offered by the mentor. Lastly, budding orthodontists need to understand that just because they graduated at the top of their class and attended a residency program, they are not entitled to anything. They still have to earn what they seek. Many budding orthodontists seem to have an entitlement attitude concerning what they want out of life, just because of their academic achievements. If they take a job position, they need to understand and accept that the position will pay only what the job is worth, not what they are worth. The market for the service they provide dictates to a large degree their earning potential. In their defense, I will say that I believe it is wrong for either a corporate office or private practice doctor to hire recent graduates and not pay them a significant percentage of what they earn for the practice. In this sense, I feel perhaps medicine has been a little more humanistic than we have been in dentistry. The recent graduates are not expendable and should be treated the way you would have wanted to be treated, if you were in their shoes graduating with such a significant debt load. Ten to 15 years ago, recent graduates could expect to start a de novo practice and to do well, or to find a senior doctor who valued their education and was looking for a partner or associate. Now, graduating residents are forced to work in a piecemeal fashion — a day per week here and a couple of days there — just to survive and to pay off student debt. We as a society of orthodontists must begin to address these issues in the very near future for the well-being and survival of our great profession. What are your hobbies, and what do you do in your spare time? Teaching and flying. OP Top Favorites In my opinion, I am a fairly boring person who is rarely wrong and never in doubt. I say this in jest, of course, but for those who do have an understanding of personality types, I have just revealed mine. I’m a true choleric or what’s known as a type D personality. Here is my list of top favorite things personally and in practice. • My relationship with God ranks first. • Family. I love investing time and money in family. • My friends. The relationships we develop with other orthodontists and peers have become invaluable. I love just hanging out with these friends, solving and debating the challenges life brings our way. I also love hanging around young adults in their 20s and 30s. • The use of DICOM imaging. We purchased a Midi Cone Beam, manufactured by Planmeca ® , over a year ago, and I would feel handicapped without the use of DICOM imaging. • Skeletal anchorage. The anchorage system we use is the Securus system. It is a system I developed in 2005, but I presently do not have any financial interest in either of these products. • The most valuable asset in our practice is our team. We spend 8 hours per day together. You have to have people around you whom you enjoy and work well with. They all have strengths and weaknesses, as do I, and I cannot imagine working without them. • The greatest asset that I have been blessed with is Debbie, my wife of 37 years. She is my best friend, and she continues to make me complete. . Fisher 6 Orthodontic practice Volume 4 Number 6 PRACTICE PROFILE Changing smiles, changing lives PRACTICE PROFILE Volume 4 Number 6 Orthodontic practice. on the details. The practice will not run itself, so the owner must focus on the business details, or there will be no business to focus on. There isn’t