clinical articles • management advice • practice profiles • technology reviews

November/December 2013 – Vol 4 No 6

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The biology of
orthodontic
tooth movement:
part 1
Dr. Michael S. Stosich

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A golden
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sleep medicine: Orthodontics: part 6

Virtually everywhere
part 2 Dr. Rohit C.L. Sachdeva
Dr. Harold F. Menchel

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Dr. Jack Fisher special awards tribute

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 INTRODUCTION
November/December 2013 - Volume 4 Number 6
Are you going to believe me or
EDITORIAL ADVISORS
Lisa Alvetro, DDS, MSD
Daniel Bills, DMD, MS
Robert E. Binder, DMD
your own eyes?
S. Jay Bowman, DMD, MSD
Stanley Braun, DDS, MME, FACD
Gary P. Brigham, DDS, MSD
George J. Cisneros, DMD, MMSc This is the “punchline” to an old joke where a wife catches her husband in the middle of
Jason B. Cope, DDS, PhD an encounter with another woman. While our experience may tell us otherwise, we are
Neil Counihan, BDS, CERT Orth
Eric R. Gheewalla, DMD, BS asked to believe things in orthodontics that just may not ring true. Whether it is the use of
Dan Grauer, DDS, Morth, MS
Mark G. Hans, DDS, MSD a cephalometric analysis that is based on one case and not only is in the literature but has
William (Bill) Harrell, Jr, DMD become the “normal” for many other analyses, or a pronouncement of a new technique
John L. Hayes, DMD, MBA
Paul Humber, BDS, LDS RCS, DipMCS with magical brackets and wires, we must at long last — think!
Laurence Jerrold, DDS, JD, ABO
Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD,
FAMS We cannot agree on where “centric relation” is; or if it is important; or if the mandible
Marc S. Lemchen, DDS
Edward Y. Lin, DDS, MS can be advanced without doing damage; or if articulators are useful; or whether or not
Thomas J. Marcel, DDS
Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, self-ligating brackets are better than traditional; or if they are, whether they should be
DOrth RCS “passive,” “active,” or interactive.” Many orthodontists have become experts at the
Mark W. McDonough, DMD
Randall C. Moles, DDS, MS mechanical part of tooth movement. But even in this area, we do not agree! Light forces,
Elliott M. Moskowitz, DDS, MSd, CDE
Atif Qureshi, BDS small light wires, heavy stainless steel wires? University studies have shown that lower
Rohit C.L. Sachdeva, BDS, M.dentSc incisors will move no matter what is done. Extraction or non-extraction, upright teeth stay
Gerald S. Samson, DDS
Margherita Santoro, DDS within certain limits; lower incisors must be at specific angles — we decide whether to
Shalin R. Shah, DMD (Abstract Editor)
Lou Shuman, DMD, CAGS
increase canine width or not. Yet even though these studies show that nothing works, we
Scott A. Soderquist, DDS, MS are given guidelines to follow.
Robert L. Vanarsdall, Jr, DDS
John Voudouris (Hon) DDS, DOrth, MScD
Neil M. Warshawsky, DDS, MS, PC
John White, DDS, MSD
What does all of this rambling mean? There are 28 reasons for relapse. Do not violate
Larry W. White, DDS, MSD, FACD these areas, and relapse will be very unusual. We must pay attention to the role of
CE QUALITY ASSURANCE ADVISORY BOARD muscles in orthodontic tooth movement. What happens when muscles are not relaxed?
Dr. Alexandra Day BDS, VT
Julian English BA (Hons), editorial director FMC What is the physiologic meaning for using stainless steel wires, titanium wires, filling the
Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government
for Wales slot, or not? Does a light-force, small-diameter titanium wire move teeth any faster than
Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private
Dentistry
a medium-force, large-diameter round wire? No! If we use a pre-adjusted appliance, why
Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of do we continue to make wire adjustments and/or change bracket positions?
Boots Dental, BUPA Dentalcover, Virgin
Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St
referral implant surgeon
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,

PUBLISHER | Lisa Moler and neuromuscular physiology. By this I do not mean placing patients on a machine to
Email: lmoler@medmarkaz.com Tel: (480) 403-1505
find out about muscles. I do mean we need to be experts in knowing how muscles and
MANAGING EDITOR | Mali Schantz-Feld
Email: mali@medmarkaz.com Tel: (727) 515-5118 periodontal fibers are affected by what we do to move teeth and jaws.
ASSISTANT EDITOR | Kay Harwell Fernández
Email: kay@medmarkaz.com Tel: (386) 212-0413
It is critically important to understand what is happening physiologically during and after
EDITORIAL ASSISTANT | Mandi Gross tooth movement.
Email: mandi@medmarkaz.com Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning

Email: michelle@medmarkaz.com Tel: (480) 621-8955 At this time in orthodontics, I believe some common philosophies of treatment are
NATIONAL SALES/MARKETING MANAGER incredibly theoretical and wrong! We need to ask lots of questions!
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
Dr. Ron Roncone, DDS, MS
MedMark, LLC Roncone Orthodontics, Vista, California
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

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author(s) and not necessarily the opinion of either Orthodontic Practice US or
the publisher.

1 Orthodontic practice Volume 4 Number 6

TABLE OF CONTENTS

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

Practice profile 6
Dr. Jack Fisher: Changing smiles, changing lives
This orthodontist employs both art and science to create great smiles.

Corporate profile 10 Special section

Pride Institute “Best of Class”
Planmeca®: innovative, upgradeable imaging technology
This company delivers complete dental solutions based on integrated high-tech special award tribute .............. 28
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.

2 Orthodontic practice Volume 4 Number 6

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© 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 AD 1113
TABLE OF CONTENTS
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
4 Orthodontic practice Volume 4 Number 6
38
Legal matters
Employment Law 101
Dr. Ali Oromchian discusses basic
laws every orthodontist needs to
Biology of bone
know.............................................58
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 Book review
vs. self-contained bottled water Biomechanics in Orthodontics,
system 4th Edition
John Bednar helps avert problems Drs. Giorgio Fiorelli and Birte Melsen .
coming down the pipe...................61 .....................................................60
Product profile Practice
Dental technology gets a new look
development
with Henry Schein’s augmented
Four social media channels that
reality app ...................................54
drive new patient acquisition and
retention
Abstracts Diana P. Friedman offers advice on
The latest in orthodontic research cultivating a dynamic web presence .
from around the world .....................................................62
Dr. Shalin R. Shah presents the latest
literature, keeping you up-to-date
Industry news ...........64
on the most relevant research from
around the world...........................56
Materials &
equipment .....................64
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PRACTICE PROFILE
Dr. Jack Fisher
Changing smiles, changing lives
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.
6 Orthodontic practice Volume 4 Number 6
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 Who has inspired you?
our office, we are then able to continue this I was inspired by a high school guidance
relationship during the retention phase of counselor who asked me what I wanted
treatment. This affords the orthodontist to become. I responded by telling her that
a distinct opportunity to be a positive I wanted to become a dentist. When she
influence for a significant amount of time in laughed at me and told me that in her
young people’s lives. professional opinion, I would not be able to
become a doctor, it drove and inspired me
How long have you been to prove her wrong. Her attitude toward my
practicing, and what systems do abilities, or lack thereof, has been a driving
you use? force for me for many years. I was also
I have been practicing orthodontics blessed to have parents that made sure
for 30 years. I use a pre-adjusted fixed I was surrounded by successful people
orthodontic appliance on more than 95% during my formative years.
of my patients. Most of all our patients are
treated with segmental mechanics initially What is the most satisfying aspect
and then are finished with continuous arch of your practice?
wires. Approximately 25% of our patients I enjoy the ability to help young people with
receive some type of a skeletal anchorage their self-confidence by improving their
device. I do utilize DICOM imaging on smiles.
approximately 80% of the cases.
Professionally, what are you most
What training have you proud of?
undertaken? Being invited to teach residents and other
I attended the University of Louisville School orthodontists techniques that they had not
of Dentistry where I received a DMD. I been directly exposed to previously.
furthered my education at the Medical
College of Georgia where I received a What do you think is unique about
certificate in orthodontics. your practice?
We have a therapeutic dog in our office that
makes our patients and team members

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
Volume 4 Number 6 Orthodontic practice 7
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
PRACTICE PROFILE
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.
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
8 Orthodontic practice Volume 4 Number 6
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.
CORPORATE PROFILE
Planmeca®: innovative, upgradeable imaging technology
Company history
Planmeca is the world’s largest privately
held dental imaging company and one of
the industry’s leading manufacturers of
panoramic and cephalometric X-rays. Over
the past four decades, it has expanded its
sales network in more than 100 countries
worldwide. Planmeca’s imaging units
offer superior image quality, reduced
radiation during routine procedures, easy
upgradeability, and advanced, user-friendly
imaging software. Planmeca has been a
leader in digital imaging and advanced
computer-integrated dental care concepts
for years and remains in the forefront of
technology as the field of dentistry evolves.
Since the company’s establishment,
Planmeca’s developers have worked
closely with dentists and leading universities
to anticipate future trends, using the data
to design an advanced line of high-tech
products. From the introduction of the
first microprocessor-controlled chair, to
the development of the ProMax™ line of
imaging units with SCARA (Selectively
Compliant Articulated Robotic Arm)
technology, Planmeca has always led the
way with new technology. The company’s
goal is to supply dental professionals with
the highest quality dental equipment that
is uniquely designed for today’s modern,
technologically advanced practice.
Patented SCARA technology
What truly sets Planmeca apart from the
competition is the company’s patented,
exclusive SCARA technology. This robotic
arm, which comes standard on all ProMax
units, enables free geometry based on
image formation and can produce any
movement pattern required. The precise,
free-flowing arm movements allow for
a wide variety of imaging programs not
possible with any other X-ray unit on the
market; this allows the dental professional
to take images based on diagnostic needs,
not machine limitations.
Anatomically accurate extraoral
bitewing program
Planmeca’s ProMax S3, 3D, and 3D
Mid imaging units offer an exclusive
extraoral bitewing program, possible
only with SCARA technology. This
innovative program consistently opens
interproximal contacts, eliminates patient
10 Orthodontic practice Volume 4 Number 6
positioning errors, and is more diagnostic
than other intraoral modalities. ProMax
extraoral bitewings are ideal for a number
of patients, from the elderly and those
requiring periodontal work to those with
claustrophobia, sensitive gag reflexes, or
those in pain. All of this comes in a true
bitewing program that enhances clinical
efficiency and takes less time and effort
than a conventional intraoral bitewing.
Upgradeable innovation
One of Planmeca’s greatest contributions
to dental imaging is its innovative,
upgradeable product platform — all based
on exclusive, patented SCARA technology.
Since it’s software-driven, SCARA
technology enables limitless possibilities
to upgrade existing equipment, allowing
the new dentist on a smaller budget to
grow while making only appropriate and
necessary equipment investments. For
example, Planmeca products can be
upgraded from a 2D panoramic X-ray to a
combination of pan/ceph capabilities, which
can be further upgraded to accommodate
3D imaging needs. Whether it is the
transformation of a film to a 3D unit, or the
addition of a cephalometric arm, Planmeca
offers solutions for every upgrade need.
This single piece of technology makes the
ProMax the most versatile all-in-one X-ray
unit available on the market.
Reduced radiation for safer
procedures
All Planmeca products are designed around
the ALARA radiation principle (As Low As
Reasonably Achievable). Through specially
designed programs, such as horizontal
and vertical segmenting, autofocus, and
pediatric pans, dental professionals are
able to provide their patients with excellent
care without compromising their safety.
Horizontal and vertical segmenting
options limit the exposure to diagnostic
areas of interest. By selecting these
options, patient dosage can be reduced by
up to 93%, which is highly advantageous
when follow-up images are needed.
Autofocus automatically positions the
focal layer using a low-dose scout image
of the patient’s central incisors, and uses
landmarks within the patient’s anatomy
to calculate placement. The result is a
fast, diagnostic pan every time, which
“The company’s goal is to
supply dental professionals
with the highest quality
dental equipment that is
uniquely designed for today’s
modern, technologically
advanced practice.”
drastically reduces retakes caused by false
positioning.
Pediatric programs further lower the
dose by automatically selecting the narrow
focal layer of young patients, adjusting
the collimator, and reducing the area of
exposure from the top and the sides.
This reduces the dosage area while still
providing full diagnostic information.
Digital Perfection™: the new
standard
Building on the well-established all-in-one
idea of integration, Planmeca introduced
the Digital Perfection concept in 2011.
Seamless integration of dental equipment
and software creates efficient diagnostic
tools, optimized workflow, and advanced
infection control methods that result in a
treatment environment where all equipment
shares an open interface.
The company works worldwide with
all aspects of the dental industry, including
dental schools, dentists, and dental team
members, as well as dealers, and uses
the latest technologies to create the best
products for dental offices and patients
alike. As a forerunner in digital imaging
technology, Planmeca delivers complete
dental solutions based on integrated high-
tech device and software options with
exquisite design. OP
For more information, visit
www.planmecausa.com
This information was provided by
Planmeca.
CORPORATE PROFILE

OrthoAccel® Technologies, Inc., developed AcceleDent® Aura, the first FDA-cleared clinical approach to safely accelerate orthodontic tooth movement by applying gentle SoftPulse
Technology® as a complement to existing orthodontic treatment

“How long will I have to wear braces?”
and “When do I get my braces off?” are
inevitably two of the most frequently asked
questions during orthodontic treatment
consultation and actual treatment. Patients
seek orthodontic treatment for a number
of reasons, often so that they may be able
to smile confidently at a special life event,
such as a graduation or a wedding, while
searching for new employment or working
toward a career promotion. Today,
advancements in technology allow patients
to achieve a beautiful smile in far less time
than ever before.
AcceleDent®, a new device from
OrthoAccel Technologies, Inc., offers
a noninvasive, innovative solution that
allows orthodontists and their patients to
dramatically accelerate treatment. Available
by prescription only, AcceleDent is a
FDA-cleared, Class II medical device that
exclusively uses SoftPulse Technology® to
accelerate tooth movement up to 50% with
just 20 minutes of daily use. This portable,
lightweight, and hands-free device delivers
gentle vibrations, or micropulses, to safely
accelerate tooth movement as guided by
orthodontists.
AcceleDent is offered worldwide
by leading orthodontists who view
accelerated treatment as a win-win
situation for themselves, their patients, and
their practices. With AcceleDent, patients
may spend less time in braces, allowing
orthodontists to potentially increase their
practice efficiency. Orthodontists and their
staff often hear comments and feedback
from their patients, including “I cut my
treatment time in half!” “I can hardly believe
it!” and “AcceleDent is my best friend on
adjustment day.”

12 Orthodontic practice Volume 4 Number 6

 CORPORATE PROFILE
AcceleDent’s history
Research has demonstrated that pulsating
forces increase the rate of bone remodeling
compared to static forces. AcceleDent “In addition to moving teeth at a faster rate than
uses the application of pulsating forces
to enhance orthodontics and moves expected, my AcceleDent patients report minimal
teeth faster through accelerated bone sensitivity after each adjustment compared to
remodeling. Rather than using only
constant pressure, the device applies very
other patients.” – Dr. Straty Righellis
light vibrations to the dentition.
AcceleDent is a removable device
and is comprised of an activator and
mouthpiece. The activator and connected
mouthpiece are used by patients to provide
a gentle vibration to the teeth – the activator
vibrates at a 25 grams force level and 30
Hz frequency for 20 minutes. The vibration
is transmitted from the activator through
the mouthpiece to patients’ teeth as they
lightly bite down on the mouthpiece.
This science has been applied in other
parts of the body to increase the rate of
fracture healing and bone density in long
bones. The science has been validated in
animals, and multiple U.S. clinical studies
have demonstrated that AcceleDent can
safely move teeth up to 50% faster.
AcceleDent has been on the market
in Europe and Australia since 2009. After
receiving FDA clearance as a Class II medi-
cal device, AcceleDent was launched in the
U.S. in 2012 and in Canada in early 2013.
In just over 1-1/2 years, AcceleDent is AcceleDent Aura’s SoftPulse Technology can help teeth move up to 50% faster
already available in over 1,000 orthodontic
practice locations across the U.S. and
Canada. In September 2013, the product’s
technology was issued a patent by the U.S.
Department of Commerce’s United States bracket adjustment and tightening on the for AcceleDent because of my results.”
Patent and Trademark Office, reinforcing day of their orthodontic appointments. Shortly after the U.S. product
OrthoAccel’s position as the industry’s launch, OrthoAccel Technologies, Inc.
leading supplier of an FDA-cleared device Clinical results formed a Key Opinion Leadership (KOL)
that accelerates orthodontic treatment. OrthoAccel® Technologies, Inc. has group comprised of a diverse group of
received positive feedback from leading world-class clinicians. Members present
Fast. Safe. Gentle. orthodontists and consumers who tout to their colleagues the scientific and
AcceleDent’s vibration is a reasonable AcceleDent for accelerating orthodontic clinical evidence behind AcceleDent’s
and safe approach for accelerating treatment while gently enhancing groundbreaking technology, in addition
tooth movement. In fact, the 25 grams movements directed by orthodontics. to their own personal experiences, which
of force applied to teeth with SoftPulse With AcceleDent, orthodontic treatment include patient case studies that clinically
Technology is at least 200 times less has been shortened significantly in some substantiate AcceleDent’s acceleration of
than during ordinary chewing (5000 g). In cases. Frederick Churbuck, the first U.S. orthodontic treatment.
addition to safely moving teeth at a rapid patient to complete orthodontic treatment “It’s important that we share the results
speed, AcceleDent’s gentle pulsing may using AcceleDent, was originally predicted of our case studies with our peers as it
help relieve the sensitivity and discomfort to undergo treatment for 18 months. demonstrates that AcceleDent is a quality
often associated with wearing braces. However, by using AcceleDent, Mr. medical device that lives up to its claims,”
Orthodontists and patients repeatedly Churbuck was elated to complete his case said Dr. Robert Miller, who is a member of
report that daily use of AcceleDent greatly in just 9 months. “My teeth are beautiful, the KOL group and is also a worldwide,
reduces the discomfort associated with and it only took 9 months,” said Churbuck board-certified orthodontic lecturer as well
orthodontic treatment. Patients have also after completing treatment. “It feels too as past president of the Virginia Association
reported that their 20-minute AcceleDent good to be true. I am in a place so far of Orthodontists. “Our evidence-based
routine helps relieve pain caused by beyond thrilled and am now an evangelist results are especially important since

Volume 4 Number 6 Orthodontic practice 13

CORPORATE PROFILE

AcceleDent is a leading medical device

that enhances and accelerates orthodontic
movements.”
Miller recently presented a case study Orthodontists and patients repeatedly report that daily
for a female patient who was in treatment use of AcceleDent greatly reduces the discomfort
to correct a Class II open bite and was
projected to wear braces for 24 to 30 associated with orthodontic treatment.
months. By using AcceleDent daily as
prescribed, she completed treatment in
10 months and did not have to undergo
surgery or extractions.
Dr. Straty Righellis, Diplomate of
the American Board of Orthodontics,
prescribed AcceleDent to a 49-year-
old female patient who then completed
treatment 6 months early. Dr. Righellis’
patient was projected to wear braces
for 18 months to eliminate spacing and
to correct a functional crossbite, but
completed treatment in just 12 months by
using AcceleDent as prescribed.
“I am recommending AcceleDent
because I have seen in my patients that
teeth move at a faster rate than I would AcceleDent Aura’s small, lightweight activator generates
normally expect,” said Dr. Righellis, who gentle micropulses and includes a USB interface which can be
plugged directly into a computer to view usage history via the
practices in Oakland, California. “In addition FastTrac Report. The mouthpiece, chosen specifically for each
to moving teeth at a faster rate than patient by an orthodontist, provides a comfortable fit and snaps
easily on and off the activator for transport and cleaning
expected, my AcceleDent patients report
minimal sensitivity after each adjustment
compared to other patients.”

AcceleDent® Aura aligns with

industry trends
The orthodontic industry is in a growth
phase driven by adults who are seeking
orthodontic treatment either for the first
time or to complement treatment received
in adolescence. According to the American
Association of Orthodontics, the number
of adult patients has increased 23% in the
past 20 years, with adults now comprising
more than one in five orthodontic patients.
These numbers are likely to continue rising
as health and esthetic consciousness is
at the forefront, and continues trending
upward.
Input from leading orthodontists and
patients led to introduction of OrthoAccel
Technologies’ newest device, AcceleDent
Aura. Launched in May 2013, AcceleDent
Aura houses a convenient USB port and
includes an extension cable and power
adapter. The USB port allows easy device
charging and also offers orthodontists
access to FastTrac, a patient usage

14 Orthodontic practice Volume 4 Number 6


report that allows doctors to monitor their
patients’ daily use to more accurately
manage treatment. AcceleDent Aura’s
sleek design is lightweight, accessible, and
compact, making it simple for patients to
use virtually anytime, anywhere.
Parents of teens are pleased with
AcceleDent Aura as it helps to alleviate
concerns of prolonged wearing of braces
and to help reduce pain and discomfort.
Faster treatment is also the preferred
choice for many students who may be
self-conscious about their appearance
in braces, or when participating in
extracurricular activities, such as athletics,
“We’re proud that AcceleDent has been rapidly
adopted by key influencers and mainstream orthodontic
practices.” – Mike Lowe, OrthoAccel Technologies CEO
Michael K. Lowe, CEO, OrthoAccel Technologies, Inc.
Volume 4 Number 6 Orthodontic practice 15
sports, cheerleading, acting, modeling,
and playing a musical instrument.
Jennifer Wammack of Houston,
Texas, is the mother of 13-year-old
aspiring actress, Hailey, who started using
AcceleDent with her braces in January
2013 and is on track to have them
removed in December 2013. “AcceleDent
was a no-brainer choice for us. I remember
wearing braces from middle school all the
way through my senior year of high school,
and I do not want Hailey or any of my
children to have to endure that discomfort
or any chance of teasing from classmates.
We’re happy with the results so far, and I’m
CORPORATE PROFILE
already committed to making sure my other
three children also use AcceleDent when
it’s time for their orthodontic treatment,”
said Ms. Wammack.
Commitment to enhance
orthodontic treatment
Mike Lowe, CEO of OrthoAccel
Technologies, Inc., reports the company
remains committed to supporting clinical
trials that drive innovations for enhancing
dental care and orthodontic treatment. An
Investigator Initiated Research Program
was recently launched by OrthoAccel
Technologies to support independent
research projects. The program awards
unrestricted grants to orthodontists, clinical
researchers, and basic scientists who are
interested in studying AcceleDent’s efficacy
in an academic or practice-based setting.
“We’re proud that AcceleDent has
been rapidly adopted by key influencers
and mainstream orthodontic practices.
To build upon that success, our
Investigator Initiated Research Program
will unveil additional product development
opportunities for OrthoAccel Technologies
as we strive to advance the area of
accelerated orthodontics,” said Lowe.
For more information or to schedule
an in-office presentation, please call 1-866-
866-4919 or visit acceledent.com. OP
About OrthoAccel Technologies, Inc.
AcceleDent was developed by OrthoAccel
Technologies, Inc., Houston, Texas, a
privately held company that focuses on
developing, manufacturing, and marketing
innovative technologies to enhance dental
care and orthodontic treatment. The first
AcceleDent was launched in 2009 and
has been recommended and prescribed
to thousands of patients by orthodontists
around the world. More information may be
found at acceledent.com and
acceledent.co.uk, or requested via
info@orthoaccel.com.
This information was provided by
OrthoAccel Technologies, Inc.
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

Introduction Table 1: Clinical Pathway Guidelines developed by Sachdeva for “Standard-Track” care Protocol B for both users of .018”
and .022” brackets systems
BioDigital Orthodontics is driven by a
culture of high performance organizing.1-4 Class I Non-Extraction “Standard-Track” © Protocol B CPG,
In a previous article,5 the ability to complete 9-Month Treatment (Sachdeva)
care of Class I patients requiring non-
extraction treatment in 6 months or less
• Initial consultation.
was discussed. This is only possible if • Diagnostic records.
the practice is geared towards providing • Take supplementary impressions for auxiliary appliances such as quad helix if
proactive and highly reliable care and if the needed.
patient, doctor, and care team are aligned • Diagnostic scan (OraScan or CBCT scan taken post bonding).
in terms of the treatment objectives. APPT I • Bond teeth.
The clinical pathway guideline for this (Week 0) • Place posterior molar turbos and check for height and balance.
Fast-Track approach to care was also • Perform IPR prn.
discussed. In certain clinical situations, it • Insert initial archwire.
- .016” preformed SE NiTi Af 35ºC or .017” x .025” SE NiTi Af 35ºC if minimal
may be difficult to implement a Fast-Track
crowding or torque control and deep bite correction needed.
approach, especially when the practice is - Place auxiliary appliances, eg., tipback springs, ART springs, etc.
new or not ready to change its culture to
that of a high performance organization.
The purpose of this article is to describe
an alternative clinical pathway guideline • Place auxiliary devices such as quad helix if needed.
• Remove posterior molar turbo.
enabled by SureSmile technology that APPT 2
• Perform IPR prn.
aids the clinician in providing timely care (Week 12)
• Therapeutic scan (OraScan/CBCT).
for Class I patients without losing quality • Replace molar turbos.
of outcome. This protocol is termed the
Standard-Track© 9-month protocol.

• Review progress against Virtual Diagnostic Simulation (VDS).

• Perform selective IPR prn.
APPT 3
• Check turbo for height/balance.
Rohit C.L. Sachdeva, BDS, M Dent Sc, is the (Week 20)
cofounder and Chief Clinical Officer at OraMetrix, • Insert SureSmile Precision Archwire (SSPA) (full expression).
SureSmile
Inc. He received his dental degree from the - Note: For .018” / .022” bracket, .017” x .025” SE NiTi Af 35ºC is used. Also, .019” x
University of Nairobi, Kenya in 1978. He earned his Therapeutic Phase
Certificate in Orthodontics and Masters in Dental .025” SE NiTi Af 35ºC may be used with the .022” bracket.
Science at the University of Connecticut in 1983. Dr. Sachdeva • Check archwire placement against bracket archwire image.
is a Diplomate of the American Board of Orthodontics and is
an active member of the American Association of Orthodontics.
He is a clinical professor at the University of Connecticut and
Temple University and the Hokkaido Health Sciences Center,
Japan. In the past he held faculty positions at the University
of Connecticut, Manitoba, and the Baylor College of Dentistry, APPT 4 • Review progress against Virtual Therapeutic Simulation (VTS)
Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of (Week 28) • Make adjustments if necessary.
the Japanese Society for Promotion of Science Award, and has
over 160 papers and abstracts to his credit.

Takao Kubota, DDS, PhD, is in private practice in Yours

Orthodontic Clinic in Yame City, Fukuoka, Japan, and is also
associate professor, Department of Orthodontics, at Kanagawa APPT 5 • Review progress against VTS.
Dental College, Yokosuka, Japan.
(Week 32) • Make adjustments if necessary.
Kazuo Hayashi, DDS, PhD, is associate professor, Division of
Orthodontics and Dentofacial Orthopedics, Department of Oral
Growth and Development, at the School of Dentistry, Health
Sciences University of Hokkaido, Japan.
APPT 6 • Debond.
Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.
blogspot.com. All doctors are invited to join the “Improving
(Week 36) • Take final records for outcome evaluation.
Orthodontic Care” discussion blog. Please contact
improveortho@gmail.com for access information.

16 Orthodontic practice Volume 4 Number 6

 ORTHODONTIC CONCEPTS
Patient III. “Standard-Track” Protocol B (9 months)

Figure 1: Patient III. A. “Standard-Track” presents with a Class I occlusion with moderate upper crowding and lower arch crowding with a crossbite tendency in the upper first molar and
bicuspid area. A non-extraction approach to treatment was chosen. B. Initial cephalometric and panorex radiographs

Figure 2: Patient III. Virtual Diagnostic Model (VDM) derived by scanning plaster model of patient using the OraScanner®
and is used for designing the initial treatment plan with Virtual Diagnostic Simulation (VDS)

Figure 3: Patient III. A. Simulation of correction of functional shift. Teeth in blue

demonstrate post simulation of functional shift. Note a transverse shift was
simulated. B. VDS superimposed on VDM. Note slight expansion planned in the
maxillary first bicuspid and cuspid area. C. Virtual Diagnostic simulation (VDS).
D. Planned recontouring of the mammelons on the upper incisors

Volume 4 Number 6 Orthodontic practice 17

ORTHODONTIC CONCEPTS

Figure 4: Patient III. Maxillary quad-helix appliance inserted 4 weeks from the time initial Figure 5: Patient III. Eight weeks post start of treatment. Upper 5-5 arch bonded with
records were taken .018” bracket system. Upper .016” CuNiTi Af 35°C engaged. Upper right first bicuspid not
engaged to minimize reactive intrusive displacement of the tooth. Bracket on upper left
second bicuspid debonded during archwire engagement

Figure 6: Patient III. Twelve weeks post start of treatment. Lower 5-5 arch bonded with Figure 7: Patient III. Sixteen weeks post start. Upper arch fully engaged. (Note upper right
.018” bracket system. Lower 6’s, banded. Lower .016” CuNiTi Af 35°C engaged first bicuspid engaged)

Figure 8: Patient III. Twenty weeks post start. Upper and lower 6-6 alignment being achieved. Upper right buccal
segment shows some intrusion despite the use of vertical check elastics

Figure 9: Patient III. A. Twenty-four weeks post start. Upper and lower 6-6 alignment substantially achieved. Upper right buccal segment open
bite substantially closed with the use of vertical elastics. Quad helix removed in upper arch. Upper and lower second molars bonded. Therapeutic
scan taken at this appointment with the OraScanner. B. Mid-treatment cephalometric and panorex radiograph

18 Orthodontic practice Volume 4 Number 6

 surezen.

© 2013 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix.
After comes before.
Dr. Scott Tyler
Birmingham, MI

December 2011 August 2012 May 2013

Initial intraoral Planned result Actual result (Final)

For our most recent detailed suresmile case studies,

please call 888.672.6387.

suresmile.com to be sure.
ORTHODONTIC CONCEPTS

Figure 11: Patient III. The VTM of the upper jaw shows the cant in the anterior occlusal
plane as a result of the intrusive reactive force felt in the right buccal segment as the
upper right second premolar was extruded

Figure 10: Patient III. Virtual Therapeutic Model (VTM)

Figure 13: Patient III. Virtual Therapeutic Simulation (VTS)

Figure 12: Patient III. SureSmile Virtual Prescription form completed with the Treatment Figure 14: Patient III. SureSmile Precision Archwire (SSPA) Design evaluated against the
Objectives. These are defined by “MACROS.” For this patient the following objectives were Virtual Therapeutic Model (VTM)
selected. Treat to the upper midline, lower archform, Class I occlusion, the upper and lower
first premolars as reference teeth, upper functional occlusal plane, correct cant of the upper
anterior occlusal plane

Figure 15: Patient III. SureSmile Precision Archwire (SSPA) upper and lower archwires Figure 16: Patient III. Progress 32 weeks from start of treatment and 8 weeks post-
SE 0.17” x 0.25“ CuNiTi inserted 28 weeks from start of treatment and 4 weeks post- therapeutic scan. Note: Up and down Class II elastics continued
therapeutic scan

20 Orthodontic practice Volume 4 Number 6

 ORTHODONTIC CONCEPTS
Figure 17: Patient III. A. “Standard –Track”. Debonded 9
months from start of treatment. B. Final cephalometric and
panorex X-rays. C. Virtual Final Models (VFM)

Patient IV. “Standard-Track” Protocol B (9 months)

Figure 18: Patient IV. A. “Standard-Track” presents with a Class I occlusion with minor upper and lower arch crowding with the upper midline shifted to the right of the lower midline. A non-
extraction approach to treatment was chosen. B. Initial cephalometric and panorex radiographs

Figure 19: Patient IV. Virtual Diagnostic Model (VDM) derived by scanning plaster model of patient
using the OraScanner and is used for designing the initial treatment plan with simulations

Volume 4 Number 6 Orthodontic practice 21

ORTHODONTIC CONCEPTS

Figure 20: Patient IV. A. Virtual Diagnostic Simulation (VDS) non-extraction, B. VDS superimposed on VDM

Figure 21: Patient IV. A. Twenty-four weeks post start of treatment. Upper and lower .018” bracket system was used. Only archwire used to this point for the upper and lower arch was
.016” CuNiTi Af 35°C. From the start of treatment the patient was seen every month. The therapeutic scan was taken at this visit with the OraScanner. B. Mid-treatment panorex radiograph

Figure 22: Patient IV. Virtual Therapeutic Model (VTM)

Figure 23: Patient IV. SureSmile Virtual Prescription form completed with the Treatment Objectives. These are
defined by “MACROS.” For this patient the following objectives were selected. Treat to the upper midline, lower
archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal
plane. It was recognized that the patient would be treated with minimal overbite since she refused to have any
IPR in order to retract the lower incisors to establish a better overjet-overbite relationship

22 Orthodontic practice Volume 4 Number 6

ORTHODONTIC CONCEPTS

Figure 24: Patient IV. Virtual Therapeutic Simulation (VTS)

Figure 25: Patient IV. SureSmile Precision Archwire (SSPA) Design evaluated against the Virtual Therapeutic Model (VTM)

Figure 26: Patient IV. Eight weeks post SSPA insertion and 32 weeks from the start of treatment. The upper and lower SSPA used were
SE 0.17” x 0.25” CuNiTi

24 Orthodontic practice Volume 4 Number 6

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ORTHODONTIC CONCEPTS
Figure 27: Patient IV. A. “Standard –Track.” Debonded 9
months from start. B. Final cephalometric and panorex
radiographs. C. Virtual Final Models (VFM)
Conclusions
Both the “Fast-Track” protocol (discussed
previously)1 and the “Standard-Track”
protocol discussed currently using
SureSmile offer substantial efficiencies
in treating patients without any loss of
quality.6-10 It should be noted that the
SureSmile Therapeutic Phase for both
protocols are similar.
However, the “Fast-Track” protocol
References
1. Sachdeva R. BioDigital orthodontics-5. Management
of Class 1 non–extraction patient with “Fast–Track”©–
6-month protocol. Orthodontic Practice US. 2013;5.
2. Sachdeva R. BioDigital orthodontics: Designing
customized therapeutics and managing patient
treatment with SureSmile technology: part 2.
Orthodontic Practice US. 2013;4(2):18-26.
3. Sachdeva R. BioDigital orthodontics: Diagnopeutics
with SureSmile technology: part 3. Orthodontic Practice
US. 2013;4(3):22-30.
4. Sachdeva R. BioDigital orthodontics: Outcome
evaluation with SureSmile technology: part 4.
Orthodontic Practice US. 2013;4(5).
26 Orthodontic practice Volume 4 Number 6
developed by Sachdeva is distinctly faster
than the “Standard-Track” protocol.
Patient and practice characteristics play
a significant role in determining the path
chosen by the doctor.
Future articles will systematically
discuss the management of the additional
spectrum of patients treated in the
orthodontic practice.
5. Sachdeva R. BioDigital orthodontics: Planning
care with SureSmile Technology: part 1. Orthodontic
Practice US. 2013;4(1):18-23.
6. Alford TJ, Roberts WE, Hartsfield Jr JK, Eckert GJ,
Snyder RJ. Clinical outcomes for patients finished with
the SureSmile™ method compared with conventional
fixed orthodontic therapy. The Angle Orthodontist.
2011;81(3):383-88.
7. Saxe AK, Louie LJ, Mah J. Efficiency and
effectiveness of SureSmile. World J Orthod.
2010;11(1):16.
8. Sachdeva R, Aranha S, Egan ME, Gross
HT, Sachdeva NS, Currier GF, et al. Treatment
time: SureSmile vs conventional. Orthodontics.
2012;13(1):72.
Acknowledgments
It is with the deepest sense of gratitude that
the authors thank Dr. Sharan Aranha for her
unconditional and enthusiastic support in
the preparation of this manuscript. Without
her efforts, it would be impossible to write
and prepare this paper in a timely fashion.
OP
9. Groth C. Compare the quality of occlusal finish
between SureSmile and conventional. Thesis at
University of Michigan; 2012.
10. Rangwala T. Treatment outcome assessment of
SureSmile compared to conventional orthodontic
treatment using the American Board of Orthodontics
grading system. Thesis at Albert Einstein College of
Medicine, Department of Dentistry-Orthodontics Bronx,
New York; 2012.
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Volume 4 Number 6 Orthodontic practice X

 Special Awards tribute
from MedMark, llc
and Pride Institute

boc2013.indd 1 10/22/2013 6:01:49 PM

 Letter from the Publisher
Dear Readers:

As publisher of three dental specialty magazines, I have spoken with many dentists and
seen many dental products over the years. That is why I am thrilled to have the opportunity
to spotlight Pride Institute’s ”Best of Class” Technology Award winners on behalf of
Orthodontic Practice US, Implant Practice US, and Endodontic Practice US. The evolution of
products with a meaningful impact on dentistry is vital to patient care and practice progress.
These products and services have undergone scrutiny by Pride Institute’s knowledgeable
panel of judges who invested a year of their time and effort to explore the attributes that
made them stand out from the competition.

From fledgling products to those that have already achieved name recognition, the winners
represent an amazing array of categories from clinical to business applications. Since panelists
who receive compensation from dental companies are prevented from voting in that company’s
category, the result is an unbiased look at the products and their practical applications
to dentistry, providing the dental professional with a product perspective untainted by
manufacturer intervention.

Pride Institute’s ”Best of Class” Technology awards debuted in 2009, and through print and
digital media coverage have grown to impact approximately 150,000 dentists. At the ”Tech Expo”
at the American Dental Association’s Annual Awards Session, held October 31 – November 3 in
New Orleans, attendees will be able to interact face-to-face with the companies and participate
in technology-centered education provided by members of the panel and esteemed consultants
of Pride Institute.

The Pride ”Best of Class” Awards were created and are organized by Dr. Lou Shuman, President
of Pride Institute, who works tirelessly to maintain the rigorous standards of the selection
process and its communication process through all its multimedia partners. The panel’s
unrelenting pursuit to select technologies that provide continuous improvement for the dental
community has resulted in a huge following, which continues to grow each year, culminating
in the ADA Pride Tech Expo at the ADA Annual Session. Attendees have the opportunity to
experience all the winners in one location for a hands-on experience, as well as are provided
CERP presentations by all the expert panel members themselves.

This year’s winners are:

3Shape TRIOS® Isolite Systems Isodry®

ActionRun® Clinical Reactivation® Kerr SonicFill™

Align Technology SmartTrack™ Lexicomp® Online™ for Dentistry featuring: VisualDX® Oral

DEXIS® Imaging Suite and DEXIS go® Liptak Dental DDS Rescue™

Doxa Ceramir® Crown and Bridge Orascoptic XV1

Gendex GXDP-700™ SRT™ Technology SciCan STATIM G4

Glidewell Laboratories BruxZir® Shaded Sesame Communications Sesame 24-7

Interactive Diagnostic Imaging Tru-Align® Ultradent VALO®

Henry Schein Dental Viive™ LED Dental VELscope® Vx

i-CAT® FLX Cone Beam 3D

Enjoy this tribute to some very special products and services. We at MedMark hope that the
insights you gain from reading these pages and the benefits that you reap from implementing
the products will raise your practices to new levels of clinical excellence and business success.

Thank you, and again, congratulations to the ”Best of Class” Technology Award winners for 2013!

Best regards,

Lisa Moler
Publisher MedMark, llc

boc2013.indd 2 10/22/2013 6:01:51 PM

 Letter from the founder of Pride
“Best of Class” Technology Awards

Dear Readers:

The excitement and enthusiasm surrounding Pride Institute’s

2013 ”Best of Class” Technology Awards continue to invigorate
the winning companies long after they are announced. This
initiative culminates in the honorees’ participation in the ”Tech
Expo” at the American Dental Association’s Annual Session —
where attendees have a chance to interact and gain insight into
the dynamic and technology-centric products and services that are
impacting the contemporary dental practice.

The ”Best of Class” Awards have attained a reputation of the highest

integrity due to its rigorous and unbiased selection process and its
distinguished panel of technology experts. The panel searches for
companies that show initiative, and commit time, resources, and
expertise in developing new technologies or improving existing ones.
Their characteristics differentiate them in a compelling way, thus
creating significant value for the clinician.

I am very proud of the integrity of our unbiased and not-for-profit

process. The thoughtful and many times heated debate, which is
the hallmark of the panel’s decision-making process, takes place
with absolute honesty and openness. Panel members must divulge
all paid relationships with manufacturers, and as a result, are not
allowed to vote in that specific category. Also, we are not tied down to
have to choose a winner for every technology category in dentistry. If
there is no clear differentiator in a category, there is no winner.

The mission is to provide the dental community the benefit of having

the opportunity to discover what our dental technology experts
would choose to have in their own practices. As you read about
these companies, know that they can provide a significant benefit in
achieving the ultimate goal of the ”Best of Class” award process —
selecting the technologies that allow us to provide the best possible
care to our patients.

Sincerely,

Dr. Lou Shuman

THE DISTINGUISHED PANEL President of Pride Institute

Lou Shuman, DMD, CAGS

President of Pride Institute, Best of Class founder

John Flucke, DDS

Writer, speaker, and Technology Editor for Dental Products Report

Marty Jablow, DMD

Writer, speaker, technology consultant, and columnist for Dr. Bicuspid

Paul Feuerstein, DMD

Writer, speaker, and Technology Editor for Dental Economics

Parag Kachalia, DDS

Vice-Chair of Preclinical Education, Research and Technology, University of
Pacific School of Dentistry

Larry Emmott, DDS

Writer, speaker, and Technology Editor for dentalcompare.com

Titus Schleyer, DMD, PhD

Associate Professor and Director, Center for Dental Informatics at the
University of Pittsburgh, School of Dental Medicine

boc2013.indd 3 10/22/2013 6:01:52 PM

 DEXIS® IMAGING SUITE AND DEXIS GO® i-CAT® FLX COMPLETE 3D TREATMENT SOLUTION

DEXIS® Imaging Suite is the latest software program

in a long, dynamic history of bringing the best possible
imaging solutions to general dentists and specialists
alike. This innovative program has been rewritten on
a next-generation code platform combining the image
management capabilities of the award-winning DEXIS® 9
with a solid base
for growth and
exciting tools
and applications.
One such
application is the
new companion
iPad app,
DEXIS go® that
provides a sleek,
engaging new
way for dental i-CAT® FLX is the complete 3D Treatment Solution. It
professionals to optimizes clinical control over scan size, resolution,
communicate with patients using an iPad®. It is designed modality, and dose to help deliver optimum patient care,
to provide a great visual patient experience around image assist clinicians to quickly diagnose complex problems
presentation in support of clinical findings and treatment with less radiation, and aid in developing treatment plans
recommendations. Like DEXIS Imaging Suite, DEXIS go more easily and accurately. Features include QuickScan+
functions as an imaging hub, displaying all radiographic for a full-dentition 3D scan at a lower dose than a 2D
and photographic images within a patient’s record. DEXIS panoramic*; Visual iQuity™ technology for i-CAT’s clearest
users will find a comfortable familiarity with its simplicity images*; SmartScan STUDIO’s touchscreen for easy
and quad environment now infused with a modern iPad- selection of the appropriate scan size and resolution for
style flair and elegance. each patient’s need; Tx STUDIO™ planning software with
integrated tools for implant, surgical, and orthodontic
applications; and i-PAN 2D panoramics.

*Data on file

ISODRY® DENTAL ISOLATION SYSTEM

The Isodry® dental isolation system is a proven, easy-to- BRUXZIR® SHADED RESTORATIONS
use alternative to traditional forms of dental isolation,
such as the rubber dam or manual suction and retraction. BruxZir® Shaded restorations are made of monolithic
The system aids in dental procedures by improving zirconia with no porcelain overlay. Exhibiting class-
patient management and leading durability with up to 1465 MPa of flexural
giving dental professionals strength and high fracture toughness, they can be used in
unprecedented control almost any clinical situation, but are ideal for demanding
of the oral environment: situations like bruxers, implant restorations, and areas
keeping the patient’s mouth with limited occlusal space. Because BruxZir zirconia is a
open, improving visibility, monolithic material, it can be milled to a feather edge, for
controlling suction and oral a more natural and hygienic emergence profile. BruxZir
humidity, and minimizing Shaded restorations
sources of contamination. display translucency
and color similar to
The key to Isodry’s natural dentition,
effectiveness are the Isolite making them a more
Mouthpieces that work with esthetic alternative
the system. Morphologically to PFMs with metal occlusals/linguals or full-cast gold
correct Isolite Mouthpieces restorations. The BruxZir Shaded formulation offers
are available in five sizes and complete color penetration all the way through the
are designed to fit patients from pediatric to large adult. restorations, ensuring greater shade consistency and
preventing any shade change after occlusal adjustment.
The wide range of mouthpieces means that it is now For the second consecutive year, The Pride Institute
much easier to have effective isolation for every patient recognizes BruxZir restorations as ”Best of Class.”
of every size. Isolite Mouthpieces also provide an
added measure of safety during the dental procedure BruxZir Shaded restorations are available nationwide at
— protecting the patient from foreign body aspiration an Authorized™ BruxZir Laboratory near you.
and shielding the tongue and cheek from injury by the
handpiece or other dental instruments. For more information:
www.bruxzir.com
For more information:
www.isolitesystems.com

boc2013.indd 4 10/22/2013 6:01:54 PM

 VALO® AND VALO CORDLESS
Ultradent created VALO in 2009 to address the many
problems left unsolved by other curing lights on the
market. Since its introduction, VALO has proven to be
the most powerful light on the market, thanks to its
multiwavelength light-emitting diode (LED) and optimally
collimated beam capable of polymerizing any dental
material, including porcelain and underlying resins. The
ergonomic design of VALO’s wand-style body and large
footprint of the curing head provides unprecedented
access to the oral cavity where other curing lights simply
cannot reach.
Precision milled
from a solid bar of
high-grade, aircraft
aluminum, VALO’s
unique unibody
construction
ensures
unsurpassed
durability. The
award-winning
line of VALO curing
lights now includes
the original VALO,
VALO Cordless, VALO Ortho, and VALO Ortho Cordless.
Each one offers a unique combination of features that
allows dental professionals to consistently deliver the
right power in the right place.
For more information:
www.ultradent.com
Call 1-800-552-5512
VELSCOPE® VX SYSTEM
Distributed by DenMat, Velscope® Vx is the industry’s
leading adjunctive screening device used to discover
oral mucosal abnormalities. When
used in combination with standard
examination procedures, Velscope
Vx facilitates the early discovery and
visualization of abnormal tissue,
including oral cancer. A Velscope
Vx examination is easy, painless to
the patient, takes just one or two
minutes to administer, and does not
require additional rinses or stains.
The portable Velscope Vx handpiece
emits a safe blue light, which excites
fluorophores from the surface tissue
to the membrane where premalignant
changes typically begin. The Velscope’s
proprietary filter makes fluorescence
visualization possible by blocking
reflected blue light, and by enhancing
the contrast between normal and abnormal tissue. The
Velscope Vx system includes the handpiece, a charging
station, and sanitary covers for the handpiece and lens.
A digital camera accessory is also available to capture
images of abnormal tissue.
boc2013.indd 5
SESAME 24-7 CLOUD-BASED ONLINE PATIENT
ENGAGEMENT MANAGEMENT SYSTEM
Sesame 24-7 is a cloud-based online patient engagement
management system that helps dental and orthodontic
practices accelerate new patient acquisition, build patient
loyalty, and transform the patient experience. Sesame
24-7 is an end-to-end system, which provides state-of-
the-art web design that optimizes viewing across any
device, Search Engine Optimization (SEO), social network
management, online sweepstakes and contests, and
Search Engine Marketing (SEM) services. It also includes
Dental Sesame, a robust patient engagement portal that
helps practices maintain a loyal patient community that
shows up for appointments, pays their bills on time,
and refers friends to the practice. Sesame 24-7 delivers
everything a dental practice needs to leverage the
Internet to expand growth and profitability.
GENDEX GXDP-700™ SRT™ TECHNOLOGY
SRT image optimization
technology delivers 3D scans
with higher clarity and detail
around scatter-generating
material. By using SRT
Technology, clinicians are able to
reduce artifacts caused by metal
or radiopaque objects such as
restorations, endodontic filling
materials, and implant posts.
When a scan is prescribed near a
known area of scatter generating
material, the user only needs to
select the SRT button from the
GXDP-700 touchscreen interface
to utilize this new optimization
technology. From endodontic to
restorative and the post-surgical
assessment of implant sites, SRT offers a significant
improvement to image quality.
Gendex’s design philosophy focuses on delivering award-
winning innovations with clinicians and patients in mind,
and the addition of the SRT to the GXDP-700 platform
aligns with that goal. The company’s strong history in
continuing innovation, along with a deep dedication
to deliver products that exceed the needs of dental
professionals, have earned Gendex recognition as a global
leader.
For more information:
www.gendex.com
10/22/2013 6:01:56 PM
boc2013.indd 6 10/22/2013 6:01:57 PM
 HENRY SCHEIN’S VIIVE™
Henry Schein’s Viive (pronounced
”Vive”) is a clean and elegant new
practice management system
designed for the Apple Mac®. The
system takes full advantage of
the Mac’s simplicity and esthetics,
allowing dentists to use the same
robust features and tools they have
come to love in the Mac . Because a
group of dentists who are also Mac enthusiasts actually
designed Viive, the system has a unique patient-centric
workflow that helps dentists work the way they want to
work using the tools they’re most comfortable using.
Right from startup, Viive focuses on the patient with
a patient screen that gives team members fast and
easy access to nearly every feature, function, and task
associated with that patient. It boasts a design that
makes most of these accessible with just a single click.
Viive also includes integration with a variety of advanced
services from trusted partners — including leading digital
imaging solutions—to expand the capabilities of your
modern digital practice.
For more information:
www.viive.com
Call 855-Mac-Viive for a personal demo of Viive.
3SHAPE TRIOS® COLOR NEXT-GENERATION INTRAORAL
IMPRESSION SOLUTION
3Shape TRIOS® Color is a next-generation intraoral
impression solution that is fast, accurate, and easy to
use. TRIOS® Color is built on 3Shape’s Ultrafast Optical
Sectioning™ technology, and its features include high
accuracy capture in color, spray-and-powder-free
scanning, clinical scan validation, intuitive Smart-Touch
user interface and
more. TRIOS® is
optimized for a wide
range of indications.
Scanning is easy with
3Shape TRIOS® Color.
There is no need to hold the scanner at a specific angle
or distance, and dentists or assistants can even rest
the scanner on the teeth for support as they scan. The
system contains a broad array of smart tools that lets
dentists edit their scans and easily rescan specific areas.
The built-in Communicate™ software lets dentists and
labs interact and exchange case information, 3D designs,
2D treatment previews, and comments. As an integral
part of every TRIOS® system, 3Shape offers yearly
software upgrades to keep the system ever-strong with
new features and enhanced performance.
For more information:
www.3shapedental.com/trios
Call 1-908-867-0144
boc2013.indd 7
STATIM G4
SciCan is proud to unveil the
newest STATIM family member,
the G4 series. The STATIM G4
is the same renowned and
trusted autoclave it has been for
over 20 years, but now boasts
a new contemporary look and
connectivity that is the first of its kind. The G4 technology
will change the way you interact by providing a direct
channel of communication through the Internet to you,
or anyone you desire. Still powered by SciCan’s signature
steam technology to provide sterilization and dryness at
speeds faster than conventional chambered autoclaves,
the STATIM has been drastically upgraded with a level of
interactivity never seen before.
• Statim 2000 G4 cycles times: 6 minutes unwrapped
– 14 minutes wrapped
• Statim 5000 G4 cycle times: 9 minutes unwrapped
– 17.5 minutes wrapped
• A large 3.5” high-resolution touchscreen offers
a vivid display of messages and current cycle
information all with extraordinary clarity
• SciCan’s STATIM G4 Technology offers a platform
with endless possibilities. The product expansion and
modes of communication will provide visibility from
every facet, from usability to troubleshooting
• Uses fresh steam distilled water with every cycle
• Dri-Tec drying system for fast dry loads
For more information:
www.scicanusa.com
Call 1-800-572-1211
DOXA CERAMIR® TECHNOLOGY
Ceramir is a revolutionary technology used to create a
new class of unique materials called Nanostructurally
Integrating Bioceramics (NIB). This Ceramir technology,
which holds more than 100 patents, is the result of more
than 25 years of extensive bioceramic research by Doxa.
Ceramir Crown & Bridge permanent cement is the first
product utilizing
NIB technology,
creating a resilient,
more natural,
biocompatible
dental luting cement
that integrates
with natural tooth
structure, is stable in the mouth, and exhibits tooth-like
physical and mechanical properties. It is a self-sealing
material that results in an alkaline seal for permanent
acid resistance. Ceramir Crown & Bridge is indicated for
PFM, zirconia, gold, metal and lithium disilicate full-
coverage crowns and bridges, as well as gold inlays and
onlays, and metal pre-fab or cast metal posts. Ceramir
is incredibly easy to use because it eliminates the need
for bonding agents, conditioners, special cleaners, and
primers. It also cleans up extremely easily, and the
patients are thrilled because of no pain during placement,
or post-op sensitivity. It’s a new way to think about
cementation!
10/22/2013 6:01:59 PM
 SMARTTRACK™ ALIGNER MATERIAL

Align Technology recently introduced SmartTrack – a new

highly elastic aligner material that has been shown to
improve control of tooth movements with Invisalign®.

A study of 1,015 patients shows statistically significant

improvement in the control of tooth movements such
as rotation and extrusion (p<0.001). Percent of patients
on track with treatment is also significantly higher at 5
months follow-up (p<0.001)*

SmartTrack features:

• More constant force over the two wear aligner wear

to improve tracking

SONICFILL™

SonicFill is the only easy to use, sonic-activated,

Single-Fill™ dental posterior composite system for
restorations that require no liner or additional capping
layer. Proprietary sonic activation liquefies a highly-filled
posterior composite, allowing it to flow into the cavity for
effortless placement and superior adaptation. Along with
low shrinkage stress and a high depth of cure, SonicFill
lets you reliably place posterior cavities up to 5 mm in • Higher elasticity to improve tracking
a single increment. It’s that fast, easy, and effective —
greatly reducing procedure time. And with outstanding
strength and Kerr’s patented 0.4 micron filler technology,
restorations will last and look great.

XV1 FROM ORASCOPTIC

The new XV1

from Orascoptic • More precise aligner fit to improve control of tooth
is the first and movement and finishing
only loupe with a
built-in headlight.
Traditional light
systems employ
an electrical cable
that connects
the headlight to
a battery pack
that is typically
worn on a belt
or in a pocket.
These cables
are notorious for ”The clinical results with SmartTrack have been excellent
breaking after getting caught on chairs, drawers, and so far,” said Dr. Clark Colville, an orthodontist in Seguin,
doorknobs. By powering the headlight through circuitry Texas and a participant in the SmartTrack study. ”The fit
embedded in the loupe frame itself, the XV1 eliminates around the teeth from aligner to aligner is better than
the need for a separate battery pack, and consequently with any group of patients I have treated with Invisalign
also eliminates the problematic cable. in my practice. Without a doubt, SmartTrack is the most
exciting change in Invisalign technology among the
The XV1 delivers a powerful, shadow-less illumination many that have been introduced in recent years.” Due to
in a compact, comfortable design. Innovative capacitive advantages in performance, SmartTrack material is now
touch controls make it easy to operate, even with the new standard Invisalign material for all Invisalign
instruments in hand. Choose from five stylish colors, and aligner products in North America and Europe, as well as
magnification powers between 2.5x and 4.8x. other International markets.

For more information:

www.orascoptic.com/xv1 for more product details.
Call 1-800-369-3698
to schedule a product demonstration.

boc2013.indd 8 10/22/2013 6:02:01 PM

 LEXICOMP® ONLINE FOR DENTISTRY: COMPUTER TRU-ALIGN®, THE LASER-ALIGNING RECTANGULAR
ASSISTED DECISION SUPPORT FOR DRUG INTERACTIONS COLLIMATION SYSTEM FROM IDI
AND LESION DIAGNOSIS

Lexicomp Online for Dentistry provides industry-leading

reference information and screening tools to help
answer prescribing, diagnosis, and treatment questions.
Dental professionals can help enhance patient safety by
accessing dental-specific pharmacology information on
over 8,000 prescription drugs, OTCs, and natural products,
plus decision support tools like
VisualDx® Oral lesion diagnosis
and an unsurpassed drug
interactions screener.

VisualDx® Oral is the new lesion

identification tool designed to
help dentists quickly develop
a differential diagnosis and Tru-Align®, the laser-aligning rectangular collimation
reduce diagnostic error. system from IDI, lowers dental X-ray scatter radiation by
Available only through Lexicomp Online for Dentistry, as much as 60-70%, allaying patient fears and ensuring
dental professionals can have access to both VisualDx the safest and most beneficial dental office visit. Tru-
Oral’s specialist-level information and the top-rated Align® technology, while reducing radiation exposure,
dental-specific pharmacology information provided also significantly reduces the need for X-ray retakes from
by Lexicomp – saving time in research and helping to the patented laser
enhance treatment safety. In addition to lesion diagnosis, alignment system.
Lexicomp Online for Dentistry is the only product that Tru-Align® can be
provides instant access to up-to-date, dental-specific used with film, digital
pharmacology information and important clinical tools, sensors, or phosphor
such as drug interaction analysis and dental medication plate (PSP) systems.
alerts. Lexicomp Online for Dentistry, enhanced with the
revolutionary lesion diagnosis tool VisualDx Oral, will truly Oral health
change how you practice dentistry, help save time in your professionals are
office and help enhance treatment safety. ”bound” by the
ALARA principle
when it comes to
taking X-rays. ALARA
stands for ”As Low
As Reasonably Achievable.” In other words, dentists
are committed to minimizing radiation exposure. Tru-
Align®provides dentistry with a solution for complying
ACTIONRUN’S CLINICAL REACTIVATOR® with the ALARA principle and protecting their patients
and staff from unnecessary dental radiation, in
Dormant patients need more than a generic reason to compliance with the most current FDA, ADA, and NCRP
return. ActionRun’s Clinical Reactivator® service gives guidelines.
each GP’s patients clinically personalized reasons to
come back. Many of these clinical reasons are tailored for
specialties’ referrals including orthodontics, endodontics,
and implants. Instead of
simple, generic automated
email or text solutions
commonly offered by
others, ActionRun is
uniquely able to analyze
each patient’s clinical
record and compel dormant
patients to return with Congratulations
clinical reasons specific to each patient - even without
a treatment plan. Clinical Reactivator® is completely
to all of the
autonomous and requires no involvement from staff. 2013 Winners
Because it is cloud-based, there is no hardware or
software to buy or maintain. By effectively reactivating
GP’s dormant patients, ActionRun increases referrals
to specialists and improves those patients’ health
while boosting production for both GPs and specialists.
Because it works so consistently well, ActionRun uniquely
offers a performance guarantee based on production
from reactivated patients. Clinical Reactivator® is part of a
complete line of HIPPA-compliant patient communication
solutions offered by ActionRun.

boc2013.indd 9 10/22/2013 6:02:02 PM

 Leading the industry in
targeting the niche specialties of dentistry

Contact Us
15720 North Greenway Hayden-Loop, Suite #9
Scottsdale, AZ 85260
Phone: 866-579-9496 Fax: 480-629-4002
Visit online: www.medmarkaz.com

boc2013.indd 10 10/22/2013 6:02:03 PM

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
T he various influences of bone
physiology underlying the phenomenon
of orthodontic tooth movement need
to be examined thoroughly for a true
understanding of how we, as orthodontists,
are capable of exerting orthodontic and
orthopedic effects on the dentofacial
complex.
Long thought of as a static structure
of the body used mainly to support and
protect, bone has been shown to be a very
dynamic system in constant modeling and
remodeling to optimize its strength and
mass. For such an optimization process to
exist, sensor and feedback mechanisms
must be present to sense changes in the
state of the environment (loading forces)
and send signals to an effector that can
begin the process of optimizing bone.
Macroscopic anatomy of bone
The structure of bone is best examined by
first looking at the anatomy of a standard
long bone such as the femur. The two ends
Michael S. Stosich, DMD, MS, MS, has
performed orthodontic and craniofacial
reconstruction work throughout the world,
but his first priority is his patients at iDentity
Orthodontics in the Chicagoland area. With
educational credentials and training twice that required
of an orthodontist, Dr. Stosich has published and
lectured throughout the U.S. and abroad. His sincere
interest and dedication toward the study of stem cell
tissue engineering, combined with a rare creativity
toward scientific discovery, paved the way for Dr. Stosich
to serve as lead scientist in a variety of studies. This
yielded numerous publications that lead to important
advancements in craniofacial cases. His achievements
were also awarded by the National Institutes of Health,
which endowed grants toward future study. Dr. Stosich
is also faculty at the University of Chicago Medicine.
Dr. Stosich believes in giving back to the communities
he serves and focuses on charitable giving where it
can do the most good by treating underserved and
unprivileged children through his involvement in the
Smiles Change Lives foundation, Smiles for Service,
and his work on the Chicago craniofacial team. Dr.
Stosich is also involved in local community programs
linking orthodontics to philanthropy.
38 Orthodontic practice Volume 4 Number 6
Educational aims and objectives
This article aims to discuss how the structure of bone affects the orthodontic
process.
Expected outcomes
Correctly answering the questions on page 41, worth 2 hours of CE, will
demonstrate the reader can:
• Identify the macroscopic anatomy of bone.
• Identify the microscopic anatomy of bone.
• Recognize molecular pathways for orthodontic bone remodeling.
• Recognize the three steps in the bone remodeling process.
of the bone, epiphyses, form joints with
other bones and are covered with a layer
of hyaline, or articular, cartilage. Between
the two ends of the bone lies the diaphysis,
or shaft of the bone. It contains many
holes called nutrient foramina through
which nerves and blood vessels enter into
the bone. Enclosing the bone is a layer of
tough, vascular covering of fibrous tissue
called the periosteum. The periosteum
is firmly attached to the bulk bone, and
its fibers are continuous with the various
tendons and ligaments connected to the
bone. The periosteum is made of two main
layers, the fibrous layer and osteogenic
layer. The fibrous layer is made of dense
connective tissue while the osteogenic
layer contains osteoprogenitor cells that
play important roles in the formation and
repair of bone tissue1.
Mineralized bone is composed of
two main types. Cortical (or compact)
bone is tissue that is very tightly packed
resulting in a substance that is solid,
strong, and resistant to bending. Cortical
bone composes the walls of the diaphysis
and also forms a thin wall around the
epiphyses. The epiphyses, however,
are mainly composed of cancellous, or
spongy, bone. Spongy bone is composed
of numerous branching bony plates called
trabeculae. The trabeculae are arranged so
that irregular interconnecting spaces occur
between them, thus reducing the overall
weight of the bone while also providing
the needed strength. The spongy bone is
densest in areas of the epiphyses, subjected
to the largest forces of compression. In
the larger bones, the diaphysis contains a
hollow tube down the center of the cortical
bone called the medullary cavity. This area
is lined with a thin membrane, called the
endosteum, and filled with a specialized
type of connective tissue called marrow,
which is also continuous into the spongy
bone of the epiphyses1.
Microscopic anatomy of bone
Despite being seemingly static and inert,
bone is a very dynamic tissue containing
many active cells and processes at all
times. Bone tissue itself is composed of
bone tissue cells (osteocytes, osteoblasts,
and osteoclasts) surrounded by insoluble
extracellular matrix proteins. The protein
matrix consists of both mineralized matrix
to provide stiffness and strength, and
collagen to provide flexible reinforcement
for the mineral components.
In cortical bone, bone matrix is
deposited in thin layers called lamellae.
The lamellae are arranged in concentric
circles around tiny longitudinal tubes called
Haversian canals. The Haversian canals
contain mostly capillaries and nerves
surrounded by loose connective tissue.
Evenly spaced and trapped within the
lamellae are osteocytes, also arranged
in concentric patterns. The osteocytes
themselves are located in pockets of
fluid called lacunae. The osteocytes and
lamellae together form a cylindrical-shaped
unit called an osteon, which is the main
structural unit of cortical bone (Figure 1).
Each osteon is on the order of 200-250 μm
in diameter1.
Bone cells receive nutrients via
blood vessels running through the
 CONTINUING EDUCATION
Figure 1: A. Microscopic anatomy of bone shows the osteon as the main structural unit of Figure 2: Front view of the craniofacial skeleton
bone. The osteocytes are buried in the bone matrix and send processes outward that are used without the supporting dentition
to communicate with other osteocytes as well as bone lining cells2. B. Exploded view of an
osteocyte showing the many cell processes that extend to neighboring cells.

Haversian canals. The Haversian canals
run longitudinally through bone tissue
and are interconnected by transverse
communicating canals called Volkmann’s
canals. These canals contain larger blood
vessels by which vessels in the Haversian
canals communicate with the surface of the
bone and medullary cavity. The Haversian
and Volkmann canals are on the order 10
μm in diameter.1
Spongy bone is also composed of
osteocytes in bone matrix. However,
the bone cells are not arranged around
Haversian canals. Instead, the cells are
found within the trabeculae.1
Bone cells include the osteoblasts,
osteoclasts, osteocytes, and bone lining
cells. Osteoblasts are cuboidal-like cells
that originate from mesenchymal stem
cells; they are involved in bone formation
by forming osteoid that they later mineralize
by releasing alkaline phosphatase.
Osteoclasts are multinucleated giant cells
that originate from hematopoietic stem
cells; they are involved in bone resorption.
Bone lining cells are located on the
periosteal surface and are osteoprogenitor
cells that can differentiate into osteoblasts.
Lastly, osteocytes are embedded in bone
matrix and located in lacunae. Each
osteocyte contains numerous cytoplasmic
processes that extend outward and pass
through fluid-filled tubes of bone called
canaliculi, which are on the order of 100 nm
in diameter. These cellular processes are
attached to the membranes of neighboring
cells by gap junctions and connect all
osteocytes in the bone matrix as well as the
bone lining cells at the periosteal surface,
which are very important in cell signaling.
Due to these processes, osteocytes are
thought to be the main sensor cells of bone
to mechanical forces.2
Molecular pathways for bone
remodeling in orthodontics
Remodeling of bone can be broken into
three steps, each step involving many
different cell types coming from different
cell lineages. Something must first sense
the mechanical force (shear stress) and
signal osteoblasts, and osteoclasts to
the remodeling area. The osteoclasts
and osteoblasts must then migrate to
the remodeling area via some sort of
chemotactic signal. Finally, when the cells
reach the damaged zone, they must begin
the remodeling process.3
Osteocytes as sensor cells
Fluid flow could occur at three different
levels of the bone porosity. The Haversian
and Volkmann canals that contain blood
vessels and nerves are the first possibility
but, being on the order of 10 μm, are too
large to have an effective shear stress.
The lacunar and canalicular network that
contains the osteocytes is the second
possibility. Being on the order of 0.1 μm,
these networks correspond with the
primary porosity scale associated with the
relaxation of the excess pore pressure due
to mechanical loading. The third possibility
would be the movement of fluid through
the collagen-hydroxyapatite matrix of the
bone, which is on the order of 20-60 nm.
Experiments have shown this to be unlikely
because the crystals bind tightly to water
and heavily restrict flow.4,5
By modeling the canalicular spaces
as cell processes surrounded by a protein/
carbohydrate matrix called glycocalyx,
levels of shear stress from physiological
levels of loading have been estimated
between 8-30 dynes/cm.2,4 Even though
exact values have not been measured in
vivo, new techniques have been developed
to show that increased flow through the
lacunar and canalicular space does occur
as a result of mechanical loading.6
Because of their location within the
fluid-filled lacunae of bone, osteocytes
have been proposed as the mechanical
sensors that sense the fluid flow caused by
mechanical loading and produce signals
initiating bone remodeling and modeling.
The processes can, therefore, sense the
shear stress created by fluid flow, which
can set off intracellular pathways. The
processes of the osteocytes are used to
communicate with other osteocytes of the
bone as well as bone lining cells located
on the bone surface. The osteocytes
can, therefore, also send signals to other
osteocytes as well as osteogenic bone
lining cells about their mechanical state.7
How the fluid flow and shear stresses
are sensed by the osteocytes is currently
believed to be along two distinct pathways.
Cytoskeletal changes with integrins being
the mechanotransducer is one possibility.
The activation of G-proteins that then
trigger intracellular pathways is a second.
Integrins are transmembrane, het-
erodimer receptor proteins located on
almost every cell in the body. They are of
extreme importance in cell adhesion and
bind to extracellular proteins containing the
RGD sequence. Integrins have the unique
property of being able to bind extracellular
proteins and being attached directly to the
intracellular actin cytoskeleton via binding
proteins. Because of this unique property,

Volume 4 Number 6 Orthodontic practice 39

CONTINUING EDUCATION
Figure 3: Lateral view of the craniofacial skeleton without
the supporting dentition
integrins are thought to be able to function
as mechanotransducers by transmitting
mechanical signals from the extracellular
matrix to the cytoskeleton.8
Cyclic adenosine monophosphate
(cAMP) is another second messenger that
has been shown to increase in response
to mechanical forces.9 Unlike the PKA
pathway, cAMP production can be inhibited
by use of indomethacin, suggesting a
prostaglandin dependent pathway.9,10 The
production of cAMP has been shown to
inhibit ERK activation, and therefore, cAMP
may play a negative regulatory function.10
Another important pathway stimulated
by both G-proteins and integrins is
production of nitric oxide (NO). Increases
in intracellular Ca2+ activate nitric
oxide synthase (NOS), particularly the
isoform eNOS.11 The NO produced may
also stimulate the production of more
prostaglandins or may be a paracrine
factor for osteoblasts.8
Signaling osteoblasts
Since the sensor-cell osteocytes are
unable to directly make bone themselves,
a paracrine factor must be released to
stimulate bone formation, either by direct
activation of osteoblasts or differentiation,
and activation of bone lining cells. The
intracellular pathways described above
References
1. Hole JW Jr, Koos KA. Human Anatomy; 2nd ed.; Wm. C.
Brown Publishers; Dubuque, Iowa; 1994; pp. 86-7, 122-8.
2. Smit TH, Burger EH, Huyghe JM. A case for strain-
induced fluid flow as a regulator of BMU-coupling and
osteonal alignment. J Bone Mineral Res. 2002;17(11):2021-
2029.
3. Tami AE, Nasser P, Verborgt O, Schaffler MB, Knothe
Tate ML. The role of interstitial fluid flow in the remodeling
response to fatigue loading; J Bone Mineral Res.
2002;17(11):2030-2037.
4. Weinbaum S, Cowin SC, Zeng Y. A model for the
excitation of osteocytes by mechanical loading-induced
bone fluid shear stresses. J Biomechanics. 1994;27(3):339-
360.
5. Burger EH, Klein-Nulend J. Mechanotransduction in bone
– role of the lacuno-canlicular network. FASEB Journal.
1999;13(Suppl.),S101-S112.
40 Orthodontic practice Volume 4 Number 6
Figure 4: A. CBCT image of the frontal aspect of the cranofacial skeleton including the dentition B. CBCT image from the
upper perspective of the cranofacial skeleton including the dentition C. Reconstructed 2D panorex including dentition
produce two possible paracrine factors,
NO and prostaglandins (PGE2). Insulin-
like growth factor (IGF) in the form IGF-1
has also shown to be a possible paracrine
factor for the bone forming cells.12 It is also
possible that PGE2 is an upstream regulator
of IGF-1; inhibition of prostaglandin release
using indomethacin has significantly
inhibited IGF-1 (Chow, 2000).
Recent work has shown that PGE2 may
also act on the osteocytes as well. Jiang
and Cheng13 demonstrated that PGE2 has
a stimulatory effect on the formation of gap
junctions among osteocytes in a parallel
plate flow chamber model. They proposed
that PGE2 stimulates the synthesis of
connexin 43 (Cx43); the connexin involved
in gap junctions between osteocytes, and
formation of more functional gap junctions.
By this method, greater numbers of
signaling molecules can pass between
osteocytes to increase the efficiency of cell
signaling and ultimately bone remodeling.
After the signal is received from the
osteocytes, the osteoblasts begin the
production of new bone. This process
generally occurs about 72 hours after the
mechanical stimulation and is evidenced
by increases in osteocalcin (OCN) and
collagen at the bone-forming surface,14
along with a measurable increase in
mineral apposition rate8. The process has
6. Mak AFT, L. Qin L, Hung LK, Cheng CW, Tin CF. A
histomorphometric observation of flows in cortical bone
under dynamic loading. Microvascular Res, 2000;59:290-
300.
7. Pead MJ, Suswillo R, Skerry TM, Vedi S, Lanyon LE.
Increased 3H-uridine levels in osteocytes following a single
short period of dynamic bone loading in vivo. Calcified
Tissue International. 1988;43(2):92-96.
8. Bloomfield SA. Cellular and molecular mechanisms for
the bone response to mechanical loading. International J
Sport Nutrition Exercise Metabolism. 2001;11(S128-S136).
9. Reich KM, Gay CV, Frangos JA. Fluid shear stress as a
mediator of osteoblast cyclic adenosine monophosphate
production. J Cell Physiol. 1990;143:100-104.
10. Wadhwa S, Choudhary S, Voznesensky M, Epstein M,
Raisz R, Pilbeam C. Fluid flow induces COX-2 expression
in MC3T3-E1 osteoblasts via a PKA signaling pathway.
Biochemical Biophysical Res Comm. 2002;297:46-51.
been described on both the periosteal and
endosteal sides of cortical bone as well as
in trabecular bone.8
Endocrine factors such as parathyroid
hormone (PTH) also appear to function as a
signaling factor for osteoblasts. Instead of
directly stimulating the osteoblasts to form
bone, PTH seems to play a permissive
role in the anabolic response of bone to
mechanical loading and may play a key
role in sensitizing the threshold of bone
formation. Turner, et al.,15 hypothesize that
PTH gives bone cells “memory” that allow
them habituation to certain magnitudes
of mechanical forces. Supporting this
hypothesis is the fact that each bone in
the body seems to have its own threshold
for remodeling, with one example being
long bones exhibiting different sensitivities
to mechanical loading than craniofacial
bones.
Concluding remarks
In this article, I have attempted to outline
the basic premises and biology of bone
as it relates to orthodontics in order to
further delve into fundamental questions in
orthodontics and dentofacial orthopedics.
In the next issue, clinical questions will be
posed and answered on the biology of
tooth movement. OP
11. McAllister TN, Frangos JA. Steady and transient fluid
shear stress stimulate NO release in osteoblasts through
distinct biochemical pathways. J Bone Mineral Res.
1999;14(6):930-936.
12. Lean JM, Mackay AG, Chow JWM, Chambers TJ.
Osteocytic expression of mRNA for c-fos and IGF-1: an
immediate early gene response to an osteogenic stimulus.
Amer J Physiology. 1996;270(6):E937-E945.
13. Jiang JX, Cheng B. Mechanical stimulation of gap
junctions in bone osteocytes is mediated by prostaglandin
E2. Cell Commun and Adhes. 2001;8(4-6):283-288.
14. Chow JWM. Role of nitric oxide and prostaglandins in
the bone formation response to mechanical loading. Exerc
Sport Sci Rev. 2000;28(4):185-188.
15. Turner CH, Owan I, Jacob DS, McClintock R, Peacock
M. Effects of nitric oxide synthase inhibitors on bone
formation in rats.” Bone. 1997;21:487-490.
 CE CREDITS
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The biology of orthodontic tooth movement part 1: Biology of Bone 101

1. Long thought of as a static structure of b. lacunae the body.

the body used mainly to support and protect, c. lamellae a. Indomethacins
bone has been shown to be a very dynamic d. mesenchymal layers b. Integrins
system in constant modeling and remodeling to c. Prostaglandins
optimize its ____. 5. The Haversian canals contain mostly d. Adenosines
a. strength ______surrounded by loose connective tissue.
b. mass a. trabeculae 9. Since the sensor-cell osteocytes are unable
c. epiphysis b. capillaries to directly make bone themselves, _____must
d. both a and b c. nerves be released to stimulate bone formation,
d. both b and c either by direct activation of osteoblasts or
2. Enclosing the bone is a layer of tough, differentiation, and activation of bone lining
vascular covering of fibrous tissue called the 6. The osteocytes and lamellae together form cells.
_____. a cylindrical-shaped unit called a(n) ____, which a. a paracrine factor
a. periosteum is the main structural unit of cortical bone. b. nitric oxide synthase
b. Haversian canals a. osteon c. prostaglandin
c. lamellae b. osteoblast d. indomethacin
d. Volkmann canals c. osteocyte
d. collagen-hydroxyapatite matrix 10. Endocrine factors such as ______also
3. _______ (or compact) bone is tissue that appear to function as a signaling factor for
is very tightly packed, resulting in a substance 7. _____ are multinucleated giant cells that osteoblasts.
that is solid, strong, and resistant to bending. originate from hematopoietic stem cells; they a. G-proteins
a. Spongy are involved in bone resorption. b. oxide synthase
b. Cortical a. Osteoblasts c. parathyroid hormone (PTH)
c. Endosseous b. Osteoclasts d. osteocalcin (OCN)
d. Cancellous c. Integrins
d. Actins
4. In cortical bone, bone matrix is deposited in
thin layers called ______. 8. ______ are transmembrane, heterodimer
a. trabeculae receptor proteins located on almost every cell in

Volume 4 Number 6 Orthodontic practice 41

CONTINUING EDUCATION
A golden opportunity for dentists: dental
sleep medicine
Part 2: implementing sleep dentistry into your practice
Dr. Harold F. Menchel offers a wake-up call to clinicians to explore an evolving niche in dentistry
In last issue’s article, a general overview
was presented on sleep dentistry. Part
2 will emphasize the practical aspects
in implementing sleep dentistry in your
practice. Discussed will be:
• Your role coordinating treatment with
the sleep physician
• A flowchart for OSA patients with dental
appliances
• Discussion of specific sleep appliances
and criteria for selection
• Standard of care for examination and
informed consent.
Sleep dentistry can be introduced into
your practice in two ways:
1. As a supplement to your traditional
practice
2. Growing your practice with an emphasis
on sleep dentistry.
Choice 1 does not involve a significant
financial or time commitment. In this case,
you will be acting more as a technician for
the sleep physician. You should consult
with the sleep physician as to his/her
preference for dental appliances as they
may adjust them in the sleep lab.
Choice 2 is more involved as will be
discussed later in the article.
Table 1 will describe the basic flow of
patients in your practice.
It may be difficult in many instances
to get a follow-up split study due to
lack of insurance coverage and patient
compliance.
There are dozens of dental sleep
Harold Menchel, DMD is a dentist in
Coral Springs, Florida, who limits his
practice to TMD, orofacial pain, and sleep
disordered breathing. Dr. Menchel teaches
undergraduate and graduate education in
TMD and orofacial pain at Nova Southeastern School
of Dental Medicine in Fort Lauderdale, Florida. He is the
director of orofacial pain at Larkin Teaching Hospital in
Miami, and lectures both nationally and internationally.
He is a fellow of the American Academy of Orofacial
Pain, a Diplomate of the American Board of Orofacial
Pain, and a member of the American Academy of Dental
Sleep Medicine.
42 Orthodontic practice Volume 4 Number 6
Educational aims and objectives
This article aims to discuss some treatment methods for sleep
disorders.
Expected outcomes
Correctly answering the questions on page 44, worth 2 hours of CE, will
demonstrate the reader can:
• Recognize some different types of sleep appliances and advantages
and disadvantages.
• Identify some devices that can help with the process.
• Realize the need for interaction with a sleep physician and knowledge
of state laws regarding the dentist’s role in sleep disorder treatment.
• Realize the various aspects of informed consent on sleep appliances.
appliances on the market, all of which or autoimmune diseases such as
claim certain advantages. All dental sleep scleroderma. Dental sleep appliances
appliances do the same thing. They all are contraindicated in these instances.
advance the mandible to open the airway. • At this time, Medicare only allows
In general the following guidelines may be reimbursement for Herbst and TAP
useful: appliances.
• No single type of sleep appliance There are devices that can aid you
will be appropriate for every patient. in taking protrusive bite records, e.g.,
Depending on whether the patient has George Gauge®, TAP gauge®, that are
a full dentition, partially edentulous, or inexpensive and simple to use. A pulse
edentulous on one arch, different ones oximeter may be helpful as a screening
may be chosen. device that you should consider adding to
• The choice of materials is important your practice.1 (Review the limitations of
also. The softer laminates are more PO as mentioned in Part 1. TMD issues,
comfortable for the patient than jaw lesions, and gross dental disease
hard acrylic, but not as durable and should be screened with a panoramic film.)
adjustable if dental restorations change TMD is not necessarily a contraindication
the tooth configuration. for dental sleep appliances, but these
• Some appliances allow full mouth patients have to be relatively pain free
opening while others restrict it. Some prior to treatment. In many instances, the
sleep dentists assert that opening will mandibular advancement appliance can be
tend to close the airway. therapeutic.
• Tongue space is a strong consideration Basic sleep dentistry courses are
for many patients. The appliance should available to familiarize you with the more
minimally constrict the tongue. popular sleep appliances (e.g., TAP,
• The more adjustable the appliance Somnodent, Herbst, Kleerway, OASYS).
is and the ease of adjustment for the There are even dental appliances available
dentist, sleep physician, and patient are for partially edentulous patients. Patient
also important. Some dentists will allow selection will be presented as well as how
the patient to adjust the appliance while to take a protrusive bite record.
others do not. If this is the depth that you prefer
• There are patients with significant to take sleep dentistry in your practice,
limited openings and mandibular range it is important that you have a good
of motion, due to arthritis, post radiation relationship with a sleep physician to help
fibrosis of the muscles of mastication, you in titrating and evaluating the benefit

of the dental appliance. If you want to
make sleep dentistry a significant part of
your practice, it is necessary to have an in-
depth understanding of sleep anatomy and
physiology, diagnosis, and management.
You may consider prescribing your own
home sleep studies for this as a screening
method.3 Contact the AASM and AADSM
for information on this. This can involve a
significant investment in time and money.
This is not discussed in this article.
Dentists who make this choice need
to have more advanced instrumentation,
and, more importantly, may take the initial
responsibility for titration and follow-up of
their patients. Dental practice acts may vary
greatly depending on the state you reside
in, and it is imperative that you familiarize
yourself with your state laws. Every state
requires that only physicians diagnose
sleep disorders, and that a physician reads
the sleep study.
Informed consent for dental
appliances
• All patients should be made aware that
CPAP is still the gold standard for treating
OSA, especially severe conditions, and
that the dental appliance may not be as
effective.4
• There have also been reports of dental
sleep appliances causing permanent
bite changes by advancing the
Volume 4 Number 6 Orthodontic practice 43
mandible, and creating posterior open
bites due to lateral pterygoid shortening
and condylar and eminence remodeling.
Patients need to be informed of this
possibility.5
• Any dental appliance can promote
decay and periodontal inflammation if
dental hygiene is neglected.
• Sore teeth or minor tooth movement
may occur with the dental appliance.
• Rarely, the patient may develop jaw and
or muscle pain.
Conclusions
Adding sleep dentistry to your practice can
be of great benefit to both you and your
patients. Sleep physicians should be made
aware that dentists are significant referrers.
This is also a good motivation for your staff
to learn a new and interesting facet in the
practice of dentistry. There is no downside
in introducing sleep dentistry into your
practice. It can be done with minimal time
and financial investment to you and grow
as part of your practice as you decide.
It is important to establish a good
relationship with the sleep physicians in
your community, and to let them know
that you are available to make appliances
for their patients as needed. Taking a good
basic sleep course is essential. You must
understand the physiology of sleep and
pathophysiology of OSA, how to read a
CONTINUING EDUCATION
Table 1: This table is
a recommended flow
chart to be followed.
It is important to note
that a sleep physician
has already examined
the patient and a dental
appliance prescribed. It
may be difficult in many
instances to get a follow-
up split study due to lack
of insurance coverage
and patient compliance.
PSG, how to do basic screening, and
how to make, insert, and monitor dental
appliances.
Sleep dentistry is a wonderful new
opportunity and should be strongly
considered by all dentists.
Acknowledgements
I would like to thank Drs. Barry Glassman,
Don Malizia, and Steven Bender for their
assistance with this article. It is greatly
appreciated. OP
References
1. Netzer N, Eliasson AH, Netzer C, Kristo DA.
Overnight pulse oximetry for sleep-disordered
breathing in adults: a review. Chest. 2001;120(2):625-
633.
2. de Almeida FR, Bittencourt LR, de Almeida CI,
Tsuiki S, Lowe AA, Tufik S. Effects of mandibular
posture on obstructive sleep apnea severity and the
temporomandibular joint in patients fitted with an oral
appliance. Sleep. 2002;25(5):507–513.
3. Gagnadoux F, Pelletier-Fleury N, Philippe C,
Rakotonanahary D, Fleury B. Home unattended
vs hospital telemonitored polysomnography in
suspected obstructive sleep apnea syndrome: a
randomized crossover trial. Chest. 2002;121(3):753-
758.
4. Ferguson KA, Ono T, Lowe AA, Keenan SP,
Fleetham JA. A randomized crossover study of
an oral appliance vs nasal-continuous positive
airway pressure in the treatment of mild-moderate
obstructive sleep apnea. Chest. 1996;109(5):1269–
1275.
5. Martínez-Gomis J, Willaert E, Nogues L, Pascual
M, Somoza M, Monasterio C. Five years of sleep
apnea treatment with a mandibular advancement
device. Side effects and technical complications.
Angle Orthod. 2010;80(1):30-36.
CE CREDITS

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dentistry or AGD endorsement
12/1/2012 to 11/30/2016
Provider ID# 325231

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free AGD REGISTRATION NUMBER
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Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The
CE provider, however, does not independently verify the content or materials. Any opinions expressed in
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professional.

Please allow 28 days for the issue of the certificates to be posted.

A golden opportunity for dentists: dental sleep medicine: part 2

1. All dental sleep appliances do the same c. the mandible 8. All patients should be made aware that
thing. They all advance the mandible ______. d. the protrusive bite _____is still the gold standard for treating OSA,
a. to open the airway and that the dental appliance may not be as
b. to create biting force 5. There are patients with significant limited effective.
c. to stop tooth decay openings and mandibular range of motion, a. TAP
d. to decrease tongue space due to _____. Dental sleep appliances are b. Herbst
contraindicated in these instances. c. CPAP
2. No single type of sleep appliance will be a. arthritis d. Kleerway
appropriate for every patient. Depending on b. post radiation fibrosis of the muscles of
whether the patient has ______ different ones mastication 9. Any dental appliance can promote _______
may be chosen. c. autoimmune diseases such as scleroderma if dental hygiene is neglected.
a. a full dentition d. all of the above a. malocclusion
b. partially edentulous b. decay
c. edentulous on one arch 6. All patients fitted with sleep appliances c. periodontal inflammation
d. all of the above should have a ______as part of a TMD d. both b and c
screening.
3. The softer laminates are more comfortable a. TAP appliance 10. You must understand the physiology of
for the patient than hard acrylic, but b. cephalogram sleep and pathophysiology of OSA, how to read
_____if dental restorations change the tooth c. panoramic film a PSG, how to do basic screening, and how to
configuration. d. EKG ______dental appliances.
a. not as durable a. make
b. not as adjustable 7. ____ requires that only physicians diagnose b. insert
c. not as constricting sleep disorders, and that a physician reads the c. monitor
d. both a and b sleep study. d. all of the above
a. No state
4. The appliance should minimally constrict b. Every state
_____. c. Some states
a. the edentulous arch d. The sleep association
b. the tongue

44 Orthodontic practice Volume 4 Number 6

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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

H ooke’s Law for springs (and in

orthodontics, springs act like beams)
simply states, “The extension of (a spring),
so the force.” Hooke’s Law applies to
stainless steel wires (linear curve) and not
for nickel-titanium wires (nonlinear curve)
or rubber materials. For systems that obey
Hooke’s Law, the extension produced
is directly proportional to the load in an Figure 1A Figure 1B
exponential manner. That is, the elongation Figures 1A-1B: Appliance No. 3 (from Table 1), Modified Hawley spring aligner
of a bar is directly proportional to the
tensile force and the length of the bar, and
inversely proportional to the cross-sectional
area and the modulus of elasticity.
Figures 1-3 represent various labial
and lingual wire configurations for Hawley-
type removable appliances that can be
used for minor tooth movement (Table 1).
Two of the Hawley-type spring aligners
pictured in these photos (Figures 1A-1B
and 2A-2B) utilize stainless steel wire, with Figure 2A Figure 2B
one having a double-helical loop (Figures Figures 2A-2B: Appliance No. 4 (from Table 1), Modified Hawley spring aligner with double-loop (helix) labial and lingual
wires
2A-2B), which would increase the force
range as compared to the appliance in
(Figures 1A-1B). Figure 3 represents an made in a “spring aligner” fashion versus approach to resolve minor to moderate
Inman Spring Aligner™, which utilizes push- traditional Hawley), wire components of crowding, there are certainly many ways
and-pull NiTi coils that alter the force and five Hawley-type appliances (Appliance No. other than the use of vacuum-formed
range (increase) of the appliance. Table 1 5 - Inman) when stretched 1/2 to 2 mm. thermoplastic aligners. Nonetheless, the
represents forces (grams) of the labial, and Different wire configurations and types results of Invisalign® (Align Technologies
labial and lingual (when the appliance is of wires can affect the force of various Inc.) treatments have generally been
modified Hawley-type appliances as the good1,2 (Figures 4A-4C), but there have also
data in Table 1 illustrates. Note that the been some mixed reviews.3-8 For sure, the
forces for Appliance No. 4 and Appliance resolution of minor crowding can involve
Donald J. Rinchuse, DMD, MS, MDS, PhD,
is Professor and Graduate Orthodontic No. 5 are somewhat comparable. the use of a host of different appliances,
Program Director at Seton Hill University However, Appliance No. 4 is a Hawley-type such as Hawley spring aligners, Inman
Center for Orthodontics in Greensburg, spring aligner but with labial and lingual aligner, clear braces, and so forth. And,
Pennsylvania.
stainless steel 0.30-inch double-loop it is possible to use more than one type
Ethan Drake, DMD, MS, is a former (helix) wire components, while Appliance of appliance, one following the other, for
orthodontic resident Seton Hill University No. 5 is an Inman Spring Aligner utilizing particular cases.
Center for Orthodontics, presently in private
orthodontic practice in Chambersburg, NiTi coils. Certainly, the force and range There is also the possibility that
Pennsylvania. of each appliance must be ascertained some cases that are treatment planned
when deciding on a treatment approach. for orthodontics are best resolved with
Janet Robison, PhD, DMD, MDS, is Assistant Professor
of Orthodontics, University of Pittsburgh, Pennsylvania. Forces for invisible aligners are not so cosmetic dentistry (Figures 5A and 5B),
easily obtained for a number of reasons; and vice versa. The advantage of cosmetic
Dara L. Rinchuse, DMD, is Clinical Faculty, one reason is the practicality of actually dentistry over orthodontics in certain
Seton Hill University Center for Orthodontics
in Greensburg, Pennsylvania and in private utilizing/placing a “gauging” system for situations is that cosmetic dentistry can
orthodontic practice in Belle Vernon, measurements. alter the size, shape, and color of teeth
Pennsylvania. In deciding on an appliance and/or (Figures 5A and 5B), which is clearly

46 Orthodontic practice Volume 4 Number 6


Figure 3: Appliance No. 5 (from Table 1), Inman spring
aligner push-and-pull NiTi coils
Figure 4B: Use of clear vacuum-formed aligner for
orthodontic treatment
Figure 5A: Pre-treatment
Figures 5A-5B: Case treated with cosmetic dentistry> 4 maxillary incisor veneers.
not possible with orthodontic treatment.
For middle-aged and older adults, a
recommendation of cosmetic dentistry
may be a prudent choice. Patients in
this age range typically have worn teeth
and possibly “dark triangular gingival
spaces” due to tooth recession, which
can be addressed with dental cosmetic
and restorative treatments, i.e., veneers
or crowns. In addition, the stability of the
results with cosmetic dentistry (orthodontic
relapse) is better since the pre-restored
teeth are in a somewhat stable position. Of
course, there are cases that require both
orthodontics and cosmetic dentistry.
When a patient has no rotated or
angulated teeth, a Hawley spring aligner
may be the appliance of choice. Removable
appliances with finger springs can also be
used (Figures 6A-6C). For other patients,
the choice may be clear brackets (Figure
7), and, it makes sense in certain situations
to start with clear fixed appliances for 4-6
weeks, and then finish with either vacuum-
formed clear aligners or a spring aligner
Volume 4 Number 6 Orthodontic practice 47
Figure 4A1
Figures 4A1-4A2: Pre-treatment photos
Figure 4C1
Figures 4C1-4C2: Final results of treatment with vacuum-formed aligner
Figure 5B: Post-treatment
(Figures 8A-8E). For patients where the
decision is to start with fixed appliances
for 4-6 weeks, several wire changes can
be made in this time frame. One of the
advantages of starting with “braces” and
then finishing with a removable appliance(s)
is that leveling/aligning/uprighting can be
achieved prior to the use of removable
appliances. The other advantage is that
the teeth are typically “loose” and easier
to move after using “braces” — and at
the time the vacuum-formed aligner(s) (or
spring) is (are) placed.
The modern paradigm for correction
of minor to moderate crowding should
not be limited to one treatment technique,
i.e., vacuum-formed aligners. Just as there
are various types of malocclusions and
types of crowding, so should there be
different treatment approaches, including
orthodontic and non-orthodontic. As
previously mentioned, there are times
when a concomitant orthodontic approach
makes sense, and fixed appliances can be
initially used followed by vacuum-formed
ORTHODONTIC INSIGHTS
Figure 4A2
Figure 4C2
aligner(s).
There are some caveats for treating
patients with minor crowding. Although the
amount of tooth movement may be minor,
these types of cases should be viewed
as difficult from a patient satisfaction
perspective. There may actually be more
complaints from this group of patients than
those coming from patients/families with
severe and handicapping malocclusion,
because even when severe cases do
not finish ideally, the patients/families are
typically very satisfied considering where
they “came from.” On the other hand,
if a case is not “that bad” to start, the
expectations for a perfect result are higher.
Another consideration is that patients/
families expect that a “perfect finish” will
stay that way forever. Be reminded, many
of these minor tooth movement cases (now
typically referred to as “Invisalign” cases)
are individuals who had had braces before
(and usually full braces), and their teeth
have relapse. So this may be a situation
where the orthodontist has a lifetime
commitment to these patients.
The future of vacuum-formed
thermoplastic aligners will inevitably lead
to the use of “shape memory polymers.”
This technology would be somewhat
comparable to the advance in orthodontic
wire technology going from stainless steel
to nickel-titanium. With shape memory
technology, it will be possible to fabricate
one aligner (“shape memory”) for each
ORTHODONTIC INSIGHT

Figure 6A1 Figure 6A2

Figures 6A1–6A2, 6B, 6C1–6C2: Case with anterior crossbite (6A1–6A2) where a removable Hawley appliance with a
finger spring was utilized (6B) to correct the anterior crossbite (6C1–6C2)
Figure 6B

Figure 7: Clear, fixed

appliances used to
mitigate mild to moderate
crowding.

Figure 6C1 Figure 6C2

Table 1: Labial and lingual wire components of Hawley type appliances stretched 1/2, 1, 1-1/2, and 2 mm. Force of stretched labial and lingual wires obtained in grams.

APPLIANCE 1/2 mm stretch** 1 mm stretch 1-1/2 mm stretch 2 mm stretch

No. 1 Traditional Hawley

-Labial wire* 100g 250g 400g No measurement

-Lingual wire No lingual wire No lingual wire No lingual wire No lingual wire

No. 2 Hawley with double-loop

labial bow
80g 120g 150g 250g
-Labial wire

No lingual wire No lingual wire No lingual wire No lingual wire

-Lingual wire

No. 3 Hawley spring

-Labial wire 100g 250g 400g No measurement

-Lingual wire 91g 249g 390g 475g

No. 4 Hawley spring with double

loop
80g 120g 150g 250g
-Labial wire

60g 80g 120g 250g

-Lingual wire

No. 5 Inman spring aligner

-Labial wire 55g 150g 240g No measurement

-Lingual wire 80g 130g 150g 190g

*Maxillary Removable Hawley Type Appliances No. 1, No. 2, No. 3, No. 4 (Labial bow wire size: 0.30 inches)
** Stretch force obtained by the use of Halden AB Strain Gauge; Sweden (Jonard Ind. Corp., Bronx NY 104630)

48 Orthodontic practice Volume 4 Number 6


Figure 8A1
Figures 8A1-8A2: Case with moderate mandibular anterior crowding (post orthodontic treated case that relapsed)
Figure 8B1 Figure 8B2
Figures 8B1-8B2: Case was started with mandibular clear, fixed appliances for 6 weeks
Figure 8D1
Figures 8D1-8D2: Case now with mandibular spring aligner
Figure 8E1
Figures 8E1-8E2: Final result
patient that will be capable of being
deformed (by light or heat, etc.) as it being
placed over a crowded arch and then have
the ability to slowly return to its original
shape once activated again. The activation
could be by means of light, heat, or other
sources. The single shape memory aligner
is fabricated after a “tooth setup” of the
patient’s crooked teeth/arch is made into
an ideal tooth position. In addition, laser
scans can be done directly in the mouth
without the need for traditional impressions
to produce 3D images of the teeth that
can be seamlessly integrated to produce
computer models.6,9 OP
Volume 4 Number 6 Orthodontic practice 49
Figure 8A2
Figure 8C1
Figures 8C1-8C2: Treatment result after the use of clear, fixed appliances.
Figure 8D2
Figure 8E2
References
1. Boyd RL. Complex orthodontic treatment using a
new protocol for Invisalign appliance. J Clin Orthod.
2007;41(9):525-547.
2. Miller KB, McGorray SP, Womack R, Quintero JC,
Perelmuter M, Gibson J, Dolan TA, Wheeler TT. A
comparison of treatment impacts between Invisalign
aligner and fixed appliance therapy during the first
week of treatment. Am J Orthod Dentofacial Orthop.
2007;131(3):302.
3. Lagravere MO, Flores-Mir C. The treatment effects
of Invisalign orthodontic aligners: A systematic review.
J Am Dent Assoc. 2005;136:1724-­1729.
4. Djeu G, Shelton C, Maganzini A. Outcome
assessment of Invisalign and traditional orthodontic
treatment compared with the American Board of
Orthodontics objective grading system. Am J Orthod
ORTHODONTIC INSIGHTS
Figure 8C2
Dentofacial Orthop.2005;128(3):292-­298.
5. Kuncio D, Maganzini A, Shelton C, Freeman K.
Invisalign and traditional orthodontic treatment
postretention outcomes compared using the
American Board of Orthodontics objective grading
system. Angle Orthod. 2007;77(5):864-­869.
6. Ackerman JL, Proffit WR. What price progress? Am
J Orthod Dentofacial Orthop. 2002;121(3):243.
7. Rinchuse DJ, Rinchuse DJ. Orthodontics
and the general practitioner. J Am Dent Assoc.
2002;133:1160-­1164.
8. Miller RJ, Duong TT, Derakhshan M. Lower incisor
extraction treatment with Invisalign system. J Clin
Orthod. 2002;36(2):95-­102.
9. Keim RG. Intraoral scanners have arrived. J Clin
Orthod. 2013;47(6):341-­342.
TECHNOLOGY

T he VELscope Vx is LED Dental Inc.’s

latest model release of the VELscope
system. The VELscope Vx is the most
powerful FDA- and Health Canada-
approved tool to screen for oral cancer,
a growing health-care issue around the
world. It is used by dentists to detect early
stage oral cancer and pre-cancer, as well
as other oral abnormalities such as viral,
fungal, and bacterial infections that might
otherwise go unseen. The technology is the
first to offer both cordless convenience and
an optional digital camera and customized
bracket that make it easy for dentists to
photo-document suspicious lesions.

The VELscope Vx is:

• cordless
• compact
• affordable – even for multiple operatories.
The VELscope’s distinctive blue- The VELscope Vx is
spectrum light causes the soft tissues of
the mouth to naturally fluoresce. Healthy
the most powerful
tissues fluoresce in distinctive patterns FDA- and Health
— patterns that are visibly disrupted by
trauma or disease. Using the VELscope,
Canada-approved
a wide variety of oral abnormalities can be tool to screen for oral
discovered — often before they’re visible to
the unassisted eye. Discovering soft tissue
cancer, a growing
abnormalities is particularly important in health-care issue
the fight against oral cancer. Because the
VELscope Vx assists in early detection,
around the world.
cancer can be caught before it has time to
spread, potentially saving lives through less
invasive, more effective treatment.
Used on a regular basis, the VELscope
Vx helps dental professionals find a wide
variety of soft-tissue abnormalities, allowing
practices to aspire to an advanced level of
patient care. The VELscope Vx is:
• completely safe
• simple to use
• no unpleasant rinses or stains
• entire exam in about 2 minutes.
Occasionally, the VELscope system
plays a crucial role in saving lives. OP

This information was provided by LED

Dental Inc.
50 Orthodontic practice Volume 4 Number 6
 AUTHOR GUIDELINES
Orthodontic Practice US is a peer-reviewed,
bimonthly publication containing articles by leading
authors from around the world. Orthodontic
Practice US is designed to be read by specialists
in Orthodontics, Periodontics, Oral Surgery, and
Prosthodontics.
Submitting articles
Orthodontic Practice US requires original,
unpublished article submissions on orthodontic
topics, multidisciplinary dentistry, clinical cases,
practice management, technology, clinical updates,
literature reviews, and continuing education.
Typically, clinical articles and case studies
range between 1,500 and 3,000 words. Authors
can include up to 15 illustrations. Manuscripts
should be double-spaced, and all pages should be
numbered. Orthodontic Practice US reserves the
right to edit articles for clarity and style as well as
for the limitations of space available.
Articles are classified as either clinical,
continuing education, technology, or research
reports. Clinical articles and continuing education
articles typically include case presentations,
technique reports, or literature reviews on a clinical
topic. Research reports state the problem and the
objective, describe the materials and methods (so
they can be duplicated and their validity judged),
report the results accurately and concisely, provide
discussion of the findings, and offer conclusions
that can be drawn from the research. Under a
separate heading, research reports provide a
statement of the research’s clinical implications
and relevance to orthodontic dentistry. Clinical
and continuing education articles include an
abstract of up to 250 words. Continuing education
articles also include three to four educational aims
and objectives, a short “expected outcomes”
paragraph, and a 10-question, multiple-choice quiz
with the correct answers indicated. Questions and
answers should be in the order of appearance in
the text, and verbatim. Product trade names cited
in the text must be accompanied by a generic term
and include the manufacturer, city, and country in
parentheses.
Additional items to include:
• Include full name, academic degrees, and
institutional affiliations and locations
• If presented as part of a meeting, please state
the name, date, and location of the meeting
• Sources of support in the form of grants,
equipment, products, or drugs must be
disclosed
• Full contact details for the corresponding author
must be included
• Short author bio
• Author headshot
Volume 4 Number 6 Orthodontic practice 51
Pictures/images
Illustrations should be clearly identified, numbered
in sequential order, and accompanied by a
caption. Digital images must be high resolution,
300 dpi minimum, and at least 90 mm wide. We
can accept digital images in all image formats
(preferring .tif or jpeg).
Tables
Ensure that each table is cited in the text. Number
tables consecutively and provide a brief title and
caption (if appropriate) for each.
References
References must appear in the text as numbered
superscripts (not footnotes) and should be listed at
the end of the article in their order of appearance in
the text. The majority of references should be less
than 10 years old. Provide inclusive page numbers,
volume and issue numbers, date of publication,
and all authors’ names. References should be
submitted in American Medical Association style.
For example:
Journals:
(Print)
Greenwall L. Combining bleaching techniques.
Aesthetic & Implant Dentistry. 2000;1(1):92-96.
(Online)
Author(s). Article title. Journal Name.
Year;vol(issue#):inclusive pages. URL. Accessed
[date].
Or in the case of a Book:
Greenwall L. Bleaching techniques in Restorative
Dentistry: An Illustrated Guide. London: Martin
Dunitz; 2001.
Website:
Author or name of organization if no author is
listed. Title or name of the organization if no title is
provided. Name of website. URL. Accessed Month
Day, Year. Example of Date: Accessed June 12,
2011.
Author’s name:
(Single) (Multiple)
Doe JF Doe JF, Roe JP
Permissions
Written permission must be obtained by the author
for material that has been published in copyrighted
material; this includes tables, figures, pictures,
and quoted text that exceeds 150 words. Signed
release forms are required for photographs of
identifiable persons.
Disclosure of financial interest
Authors must disclose any financial interest they
(or family members) have in products mentioned
in their articles. They must also disclose any
developmental or research relationships with
companies that manufacture products by signing
a “Conflict of Interest Declaration” form after their
article is accepted. Any commercial or financial
interest will be acknowledged in the article.
Manuscript Review
All clinical and continuing education manuscripts
are peer reviewed and accepted, accepted with
modification, or rejected at the discretion of the
editorial review board. Authors are responsible
for meeting review board requirements for final
approval and publication of manuscripts.
Proofing
Page proofs will be supplied to authors for
corrections and/or final sign off. Changes should
be limited to those that are essential for correctness
and clarity.
Articles should be submitted to:
Mali Schantz-Feld, managing editor
mali@medmarkaz.com
Reprints/Extra issues
If reprints or additional issues are desired, they
must be ordered from the publisher when the page
proofs are reviewed by the authors. The publisher
does not stock reprints; however, back issues can
be purchased.
Checklist for article submissions:
3 A copy of the manuscript and figures/
captions, including all pictures (low res)
necessary for reviewers
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separate references, figure legends, and
tables
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outcomes paragraph
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American Medical Association style
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3 Mandatory submission form, signed by all
authors
Please contact managing editor Mali Schantz-
Feld with any questions via email:
Mali@medmarkaz.com
PRACTICE MANAGEMENT
Growing the money tree
William H. Black, Jr. discusses the financial advantages of having a good plan in place
Y our practice is established. You
have a good reputation and a good
management team in place. Gone are the
days of building the practice and putting all
profit back toward growth. That’s the good
part! But success creates other questions
and concerns.
When clients first come to us they
typically have the same refrain: “I am
paying salaries, sick pay, vacation pay,
major medical, matching Social Security
and Medicare, paying into unemployment
and Workman’s Comp. I have to pay a
lot of money in income taxes…How do I
keep more of what I make? No one has any
solutions for me!”
What I’ve found clients really mean is
they want an idea that is not “outside the
box,” that won’t increase their audit profile,
an idea that won’t get them in trouble with
Internal Revenue. The simple answer is
to consider a custom-designed qualified
plan! In other words, consider a form of a
pension plan (known as “qualified” because
the contribution qualifies for an income tax
deduction).
Think about it this way: there is
not a company on the New York Stock
Exchange, a union, or government agency
that doesn’t have a pension plan. So using
the rules that are on the books to create a
custom-designed plan for the closely held
professional practice may be the answer.
Consider the benefits:
• Contributions are income tax deductible
William H. Black, Jr. has been in the pension
administration business for 34 years. The
firm Pension Services, Inc. administers both
defined contribution and defined benefit
plans, employs an ERISA attorney, an Enrolled
Actuary, and complete clerical staff. Mr. Black is qualified
to give continuing education to CPAs in 47 different
states. He has spoken nationally and internationally on
retirement plans, has been quoted in USA Today, written
articles for several industry journals and has appeared
on many financial radio shows discussing the topic of
retirement and financial matters. He may be contacted
at bill@pensionsite.org.
52 Orthodontic practice Volume 4 Number 6
• Plan assets grow tax deferred
• Plan assets are protected from
judgment creditor claims1
• Plan assets are eligible for tax-free
rollover to one’s IRA account
• Qualified plans receive up-front approval
from Internal Revenue in the form of a
Favorable Determination Letter
Let me clear up a few myths
straightaway. These plans are not about
retirement; they are about the tax benefits
and asset accumulation features, i.e.,
your money tree. Who’s worried about
retirement? It’s the employees putting $25
a week into their 401(k) plan. More power
to those employees, but we, as business
owners, are past that. Look at a plan as a
way to pay yourself on a tax-favored basis!
Here is how to look at the merits.
Assume a 39% federal income tax rate and
assume a 6% state income tax rate. So, for
brevity, we will assume an overall tax rate of
45%. Since there is no requirement to have
a plan, what does it look like without one?
For every $10,000 in taxable income, what
does it look like with a plan or without one?
(We use $10,000 in this analysis because
it is scalable. Want to know what $50,000
would do? Multiply by 5. $75,000? Multiply
by 7.5, etc.)
Here is where it gets interesting. On
one hand you have $10,000 working for
Without a Plan
Taxable Income $10,000
Tax at 45% $4,500
After-tax Balance $5,500
Comments on graph:
• No tax on the “with a plan” column as the contribution is income tax deductible.
• After-tax balance is as of the present day. In the future, monies coming out of an IRA or qualified plan are subject to
ordinary income taxes.
• The chart does not take into account asset protection benefits.
• This is scalable. Considering a $50,000 contribution? The values are five times as much, etc.
you; on the other, you have $5,500. The
tax benefits alone give you 81% more
(10,000 ÷ 5,500) right out of the gate.
Now, consider the plan’s assets grow tax
deferred while the non-plan grows taxably.
Add it all together, and you can see the
benefits growing with every passing year!
Many believe, initially, that the plan
will cause all employees to come in, with
contributions for all, and any employee is
entitled to take his/her contribution out
immediately. While plans like that do exist,
they are not well designed or well thought
out.
ERISA, the Employee Retirement
Income Security Act of 1974, gives us 39
years of instruction on how to design a
plan. In other words, these plans are black
and white, really no gray area.
Now the question becomes how to
design a plan to benefit the rainmaker?
That is the easy part!
Many different options exist, hence
the need for customization. Many “cookie
cutter” plans are out there, a one-size-fits-
all approach. These are commonly referred
to as “bundled” plans. While those plan
designs have their place, they cannot be all
things to all people. What to do? Start with
a checklist of basic questions. What is the
annual budget for the contribution? How is
the business set up, as a Corporation either
With a Plan
$10,000
$0
$10,000
 PRACTICE MANAGEMENT
When clients first come to
us they typically have the
same refrain: “I am paying
salaries, sick pay, vacation
pay, major medical, matching
Social Security and Medicare,
paying into unemployment
and Workman’s Comp. I
have to pay a lot of money
in income taxes…How do I
keep more of what I make?”

S or C, as an LLC, LLP, PA, Partnership, or
Sole Proprietor? How many employees?
Are there existing plans in place now? How
is the ownership structured, all in the hands
of one person, or two or more?
With the above, and an employee
census, i.e., employee names, dates of
birth and dates of hire, job titles and annual
business decision on what is right for your about the proper application of the laws
situation. OP to their situation.
This discussion is not intended as tax
advice. The determination of how the
tax laws affect a taxpayer is dependent
on the taxpayer’s particular situation. A
taxpayer may be affected by exceptions References

salaries, a projection can be created that
will show, in black and white, what the
benefits and detriments are. Look at it in
conjunction with your CPA and make a
to the general rules and by other
laws not discussed here. Taxpayers
are encouraged to seek help from a
competent tax professional for advice
1. Patterson v. Schumate (http://
financial-dictionary.thefreedictionary.com/
Patterson+v.+Shumate)

Volume 4 Number 6 Orthodontic practice 53

PRODUCT PROFILE

Dental technology gets a new look with

Henry Schein’s augmented reality app

S ome technologies have become so

routine to our daily lives that it’s hard
to believe they didn’t exist 20 years ago.
Online banking first launched in 1994.
Amazon opened its virtual doors in 1995.
Text messaging became mainstream in
2001. Smartphones gained momentum
and exploded in popularity with the
introduction of the first Apple iPhone® in
2007. In just two decades, inventions that
seemed impossibly futuristic have become
practical, widely used tools.
One of the newest technologies
still in its infancy, but already making a
major impact, is augmented reality. Henry
Schein has long been an innovator and
early adopter of cutting-edge technology,
and once again, they lead the way and
are embracing this exciting development.
Henry Schein Dental’s first interactive
Equipment and Technology Catalog using
augmented reality technology was released
in October, and it literally changes the
way doctors and their teams view dental
products and services.

What is augmented reality?

Augmented reality projects a virtual layer
of interactive features on top of an actual
physical environment, when viewed on the
screen of a mobile phone or tablet.
Henry Schein’s catalog and other
brochures give readers another world
of options — a digital world — that is
interconnected to the printed page they
are reading. Viewing the page through
their device’s camera, they can launch
interactive product descriptions and
specifications, training videos, current
promotional offers, and one-click buttons
that connect them quickly to a sales
representative. It’s all done just by hovering
over an augmented reality enhanced page
with an iPad®, iPhone® or Android™ device
loaded with the Henry Schein Xtra app.
Augmented reality can be difficult
to explain in words, and its benefits
can’t be grasped fully unless you see the
technology yourself. You will be amazed at
how powerful and applicable it can be to
your dental practice.
Test drive Henry Schein’s aug-
mented reality app — It’s quite a
ride
If you have a mobile device, you can try
augmented reality right now by scanning
the page right next to this article.
Just go to the Apple App Store
or Google Play and download the free
augmented reality mobile app called Henry
Schein Xtra. Next, open the Henry Schein
Xtra app and hover over the page with
your device, being sure the entire page
is displayed on your screen. Your device
will “scan” the page to find the augmented
reality features, and then watch the ad
come to life with an on-screen button that
launches a video.
As you’ll see, augmented reality puts
you in control of your browsing experience
because you engage with items that matter
most to you in an informative new way. Plus
augmented reality gives Henry Schein the
opportunity to constantly update materials
with new information, promotions, videos,
and more so you always have the latest
news at your fingertips.
Thanks to this new innovation, Henry
Schein’s printed catalogs and brochures
can remain a doctor’s go-to resource for
what’s new in dental technology today,
tomorrow and months from now.
Search for Henry Schein Xtra in the
Apple App Store or Google Play to give
augmented reality a try today. OP
This information was provided by Henry
Schein Dental.
Download the Watch the Video
Henry Schein Xtra App

54 Orthodontic practice Volume 4 Number 6

 Customized Practice Solutions Scan this page with the
Henry Schein Xtra App for
for ORTHODONTISTS an interactive experience!

Scan this page w

Henry Schein Xt
an interactive exp

From the Front Office to the

Treatment Room and every touch-
Office Design & Consultation
point in between, Henry Schein has Service, Repair & Installation
the solutions you need to connect
all of your practice technologies
to maximize the digital workflow
resulting in greater efficiencies.

With your success in mind, let us

help you determine which products
and technologies will enhance
patient care within your practice.
Our specialists have the experience
and knowledge to assist and guide
you in all of your equipment and Imaging Solutions
technology choices.

Computer Solutions & Support

Operatory Equipment
Practice Management

Contact your Henry Schein Sales Consultant

1-800-645-6594 prompt #1 to ask about equipment and technology
www.henryscheindental.com to advance patient care in your practice.
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

Pulp vitality and histologic changes in

human dental pulp after the application
of moderate and severe intrusive
orthodontic forces
Han G, Hu M, Zhang Y, Jiang H. American
Journal of Orthodontics and Dentofacial
Orthopedics (2013) 144:518-22.

Abstract
Aims: Orthodontic forces produce a
series of changes in dental pulp. However,
no one has attempted to investigate the
incidence of pulp necrosis after orthodontic
therapy in the clinic. In this study, we aimed
to investigate pulp vitality and histologic
changes after the application of moderate
and severe intrusive forces.
Materials and Methods: Twenty-seven
adolescent patients were assigned to one
of three groups: the control group of three
subjects; the moderate-force group, with 12
subjects who received a 50-g force to the
first premolars bilaterally; and the severe-
force group, with 12 subjects who received
a 300-g force. The forces were applied for
1, 4, 8, or 12 weeks. An electric pulp tester
was used to test for vitality, and teeth that
did not respond to the electric pulp tester
were subsequently tested thermally with a
stick of heated gutta percha.
Results: The teeth with a negative
response to the electric pulp tester still
responded to the thermal test. We found
odontoblast disruption, vacuolization,
and moderate vascular congestion in
both force groups, but no necrosis was
observed. Pulp stones were formed only in
the severe-force group. Conclusions: Dental pulp still has vitality Abstract
after intrusive treatment with different Aims: Bonded retainers are used in
forces. These data provide new insights orthodontics to maintain treatment result.
into the effects of intrusive orthodontic Retention wires are prone to biofilm
forces. formation and cause gingival recession,
bleeding on probing, and increased
Shalin Raj Shah, DMD, MS, received his Biofilm formation on stainless steel and pocket depths near bonded retainers. In
Certificate of Orthodontics and Masters of
Science in Oral Biology from the University
gold wires for bonded retainers in vitro this study, we compare in vitro and in vivo
of Pennsylvania and is a Diplomate of the and in vivo, and their susceptibility to oral biofilm formation on different wires used for
American Board of Orthodontics. He is antimicrobials bonded retainers and the susceptibility of
also a graduate of the University of Pennsylvania
College of Arts and Sciences and School of Dental
Jongsma MA, Pelser FDH, van der Mei in vitro biofilms to oral antimicrobials.
Medicine. Currently, Dr. Shah is Clinical Associate of H, Atema-Smit J, van de Belt-Gritter B, Materials and Methods: Orthodontic
Orthodontics at the University of Pennsylvania and is Busscher HJ, Ren Y. Clin Oral Investig wires were exposed to saliva, and in vitro
in private practice (Center for Orthodontic Excellence)
in Princeton Junction, New Jersey, and Philadelphia,
(2013) 17:1209-18. biofilm formation was evaluated using plate
Pennsylvania. counting and live/dead staining, together

56 Orthodontic practice Volume 4 Number 6


with effects of exposure to toothpaste
slurry alone or followed by antimicrobial
mouth rinse application. Wires were also
placed intraorally for 72 hours in human
volunteers, and undisturbed biofilm
formation was compared by plate counting
and live/dead staining, as well as by
denaturing gradient gel electrophoresis for
compositional differences in biofilms.
Results: Single-strand wires attracted
only slightly less biofilm in vitro than multi-
strand wires. Biofilms on stainless steel
single-strand wires, however, were much
more susceptible to antimicrobials from
toothpaste slurries and mouth rinses
than on single-strand gold wires and
biofilms on multi-strand wires. Also, in
vivo significantly less biofilm was found on
single-strand than on multi-strand wires.
Microbial composition of biofilms was more
dependent on the volunteer involved than
on wire type.
Conclusions: Biofilms on single-strand
stainless steel wires attract less biofilm
in vitro and are more susceptible to
antimicrobials than on multi-strand wires.
Also in vivo, single-strand wires attract less
biofilm than multi-strand ones.
Clinical Significance: Use of single-
strand wires is preferred over multi-strand
wires, not because they attract less biofilm,
but because biofilms on single-strand wires
are not protected against antimicrobials as
in crevices and niches as on multi-strand
wires.
Development of labial gingival recessions
in orthodontically treated patients
Renkema AM, Fudalej PS, Renkema
A, Kiekens R, Katsaros C. American
Journal of Orthodontics and Dentofacial
Orthopedics (2013) 143:206-12.
Abstract
Aims: Our aim was to assess the prevalence
of gingival recessions in patients before,
immediately after, and 2 and 5 years after
orthodontic treatment.
Materials and Methods: Labial gingival
recessions in all teeth were scored (yes or
no) by two raters on initial, end-of-treatment,
and post-treatment (2 and 5 years) plaster
models of 302 orthodontic patients (38.7%
male; 61.3% female) selected from a post-
treatment archive. Their mean ages were
13.6 years (SD, 3.6; range, 9.5-32.7 years)
at the initial assessment, 16.2 years (SD,
3.5; range, 11.7-35.1 years) at the end
Volume 4 Number 6 Orthodontic practice 57
of treatment, 18.6 years (SD, 3.6; range,
13.7-37.2 years) at 2 years post treatment,
and 21.6 (SD, 3.5; range, 16.6-40.2 years)
at 5 years post treatment. A recession
was noted (scored “yes”) if the labial
cementoenamel junction was exposed.
All patients had a fixed retainer bonded to
either the mandibular canines only (Type I)
or all six mandibular front teeth (Type II).
Results: There was a continuous increase
in gingival recessions after treatment from
7% at end of treatment to 20% at 2 years
post treatment, and to 38% at 5 years post
treatment. Patients less than 16 years of
age at the end of treatment were less likely
to develop recessions than patients more
than 16 years at the end of treatment (P
= 0.013). The prevalence of recessions
was not associated with sex (P = 0.462)
or extraction treatment (P = 0.32). The
type of fixed retainer did not influence
the development of recessions in the
mandibular front region (P = 0.231).
Conclusions: The prevalence of gingival
recessions steadily increases after
orthodontic treatment. The recessions are
more prevalent in older than in younger
patients. No variable, except for age at the
end of treatment, seems to be associated
with the development of gingival recessions.
Evaluation of optimal length and insertion
torque for miniscrews
Suzuki M, Deguchi T, Watanabe H,
Seiryu M, Iikubo M, Sasano T, Fujiyama
K, Takano-Yamamoto T. American
Journal of Orthodontics and Dentofacial
Orthopedics (2013) 144:251-9.
Abstract
Aims: The purpose of this article was to
test the theory that short miniscrews will
decrease the possibility of damaging the
root, but the failure rate will increase.
Materials and Methods: One hundred
eighty-six miniscrews (diameter, 1.3 × 5
mm, n = 63; 6 mm, n = 62; 7 mm, n = 61)
were placed in 105 consecutive patients.
Multi-slice computed tomography and
cone beam computed tomography scans
were taken before and after miniscrew
placement. Insertion torque was measured
at miniscrew placement.
Results: The success rate of the
miniscrews in the maxilla (93.4%) was
higher than that in the mandible (70.3%).
A significantly lower success rate with 5
mm miniscrews was observed compared
ABSTRACTS
with 6 mm and 7 mm miniscrews in the
mandible. Miniscrews placed in less than
approximately 3.8 mm of bone and those
within 1.4 mm of the root had significantly
higher failure rates. Miniscrews placed with
insertion torque greater than 10 N-cm had
a tendency for a lower success rate.
Conclusions: The optimum lengths
of miniscrews of a diameter of 1.3 mm
are 5 mm in the maxilla and 6 mm in the
mandible. They should be placed at a
distance from the root with insertion torque
less than 10 N-cm for safe orthodontic
anchorage without failure.
Effect of piezopuncture on tooth
movement and bone remodeling in dogs
Kim Y-S, Kim S-J, Yoon H-J, Lee PJ,
Moon W, Park Y-G. American Journal
of Orthodontics and Dentofacial
Orthopedics (2013) 144:23-31.
Abstract
Aims: The aim of the study was to elucidate
whether a newly developed, minimally
invasive procedure, piezopuncture, would
be a logical modification for accelerating
tooth movement in the maxilla and the
mandible.
Materials and Methods: Ten beagle dogs
were divided into two groups. Traditional
orthodontic tooth movement was performed
in the control group. In the experimental
group, a piezotome was used to make
cortical punctures penetrating the gingiva
around the moving tooth. Measurements
were made in weeks 1 through 6. Tooth
movement and bone apposition rates
from the histomorphometric analyses were
evaluated by independent t tests.
Results: The cumulative tooth movement
distance was greater in the piezopuncture
group than in the control group: 3.26-fold
in the maxilla and 2.45-fold in the mandible.
Piezopuncture significantly accelerated
the tooth movements at all observation
times, and the acceleration was greatest
during the first 2 weeks for the maxilla
and the second week for the mandible.
Anabolic activity was also increased by
piezopuncture: 2.55-fold in the maxilla and
2.35-fold in the mandible.
Conclusions: Based on the different
effects of piezopuncture on the maxilla and
the mandible, the results of a clinical trial
of piezopuncture with optimized protocols
might give orthodontists a therapeutic
benefit for reducing treatment duration. OP
LEGAL MATTERS
Employment Law 101
Dr. Ali Oromchian discusses basic laws every orthodontist needs to know
O ne of the most dreaded aspects
of business for any entrepreneur,
especially the dental entrepreneur, is
employee management. Employees are
vital to any successful business, and
particularly in an orthodontic office where
personal relationships and communication
ensure loyal and happy patients. However,
in our litigious society, orthodontists need
to take extra care to guarantee that they
are compliant with all applicable federal,
state, and local employment laws.
This article will discuss the most
common traps including overtime pay,
lunch, and other breaks, last paychecks
for terminated employees, HIPPA, and
employment handbooks.
Overtime pay
The United States Department of Labor
oversees compliance with laws for
overtime pay for employees at the national
level. Overtime pay is regulated by the
Fair Labor Standards Act (FLSA), which
prescribes standards for minimum wage
and overtime pay for both private and
public employment. The FLSA requires
employers to pay employees at least the
federal minimum wage plus overtime pay
of one and a half times the regular rate
of pay for their work. Unless specifically
exempted, employers must pay overtime
pay to employees for hours worked in
excess of 40 hours in a workweek. There
is no limit in the FLSA to the amount of
overtime hours an employee can work.
Importantly, the overtime requirement may
not be waived by agreement between
Ali Oromchian, JD, LL.M, is the founding attorney
of the Dental & Medical Counsel, PC law firm and is
renowned for his expertise in legal matters pertaining
to dentists. Mr. Oromchian has served as a key opinion
leader and legal authority in the dental industry with
dental CPAs, consultants, banks, insurance brokers,
and dental supplies and equipment companies. He
serves as a legal consultant for numerous dental
practice management firms who rely on his expertise
for their client’s businesses. He is also recognized as
an exceptional speaker and educator who simplifies
complex legal topics and has lectured extensively
throughout the United States.
58 Orthodontic practice Volume 4 Number 6
the employer and employee, and any
announcement by an employer that no
overtime work will be permitted or that
overtime work will not be paid for unless
authorized in advance does not impair an
employee’s right to compensation for the
overtime worked.
Some states, such as California,
have overtime laws. In cases where an
employee is subject to both the state and
federal overtime laws, the employee is
entitled to overtime according to the higher
standard (i.e., the standard that will provide
the higher overtime pay).
Some typical pitfalls that occur include
(a) paying a fixed sum for a varying amount
of overtime; (b) creating a fixed salary for
an employee for a regular work week that
the federal or state overtime laws; and (c)
trying to convince the employee to waive
overtime.
Lunch and break laws
Federal law does not require meal or other
breaks from work. Meal breaks are not
compensable, but other breaks, typically
short breaks lasting 5 to 20 minutes, are
compensable under federal law. If an
employer decides to offer a short break of
some sort, then it is included in the sum of
hours worked during the workweek, and it
is considered when determining overtime
pay.
Many states have their own lunch/
break requirements, which must be
adhered to strictly; however if the state
does not have specific laws pertaining to
lunch/breaks then the federal law applies.
One frequent violation in orthodontic
offices occurs when the employees are
interrupted and required to work at any
point in their lunch break. This can be
as simple as answering phone calls or
checking insurance coverage.
Last paycheck
Under federal law, employers are not
required to give former employees their final
paycheck immediately upon termination
of employment. However, some states
require immediate payment. One such
state is California, where discharged
employees or employees who quit are
due their final paycheck upon termination
of employment. There are significant
penalties, which accrue as soon the final
paycheck is not paid. Additionally, it is
illegal in many states to withhold a final
paycheck to persuade an employee to
return uniforms, laptops, pay back money,
or return any other item.
HIPAA
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
legislates certain privacy protections that
apply to health care providers, including
orthodontists. The law is designed to help
patients keep as much of their personal
information private as possible. The law
protects from unauthorized disclosure
of any personally identifiable health
information (protected health information,
or PHI) that pertains to a consumer of
health care services. Health information
is personally identifiable if it relates to an
individual specifically and includes the
following:
• Health care claims or health care
encounter information, such as
documentation of doctor’s visits and
notes made by physicians and other
provider staff;
• Health care payment and remittance
advice;
• Referral certifications and authorization.
Covered entities, including
orthodontists, must adopt written PHI
privacy procedures; designate a privacy
officer, require their business associates
to sign agreements respecting the
confidentiality of PHI; train all of their
employees in privacy rule requirements;
give patients written notice of the covered
entities’ privacy practices and access
to their medical records; give patients a
chance to request modifications to the
records; give patients a chance to request
restrictions on the use or disclosure of
their information; give patients a chance to
request an accounting of any use to which
the PHI has been put, and give patients a
chance to request alternative methods of
communicating information. They must

also establish a process for patients to
use in filing complaints and for dealing
with complaints. Under HIPAA, patient
authorization is not necessary if a disclosure
is made for purposes of treatment,
securing payment, or in accordance with
the operations of a health care provider.
However, if PHI is to be disclosed for
any other purpose, the patient’s written
authorization is necessary.
Employee handbooks
Employee handbooks are a useful tool
for communication between an employer
and employee about many aspects of
the employer-employee relationship. An
employee handbook should describe
the legal obligations of an employer and
the employee’s rights. An employee
handbook should include a section with
Volume 4 Number 6 Orthodontic practice 59
anti-discrimination policies and sections
explaining compensation to the employee,
the employer’s policies regarding work
hours and schedules, standards of
conduct, safety and security, employee
benefits, and leaves policies.
The absence of an employee
handbook, or a poorly drafted one, puts
you at a disadvantage when defending a
claim brought against you by a current or
former employee. At the very least, your
employment manual should define who is
covered by the handbook, review existing
policies and practices, draft consistent,
understandable and legally permissible
employment policies, review the handbook
with management prior to implementation
to obtain feedback, and submit the draft
handbook to experienced labor law
counsel for review.
LEGAL MATTERS
...in our
litigious society,
orthodontists need
to take extra care
to guarantee that
they are compliant
with all applicable
federal, state, and
local employment
laws.
Solutions
Employee management and legal
compliance is usually the weakest link
within any orthodontic practice because
the owner-dentist had to manually manage
records, and ensure proper time keeping
and performance reviews. HR for Health
is a SAAS-based employee management
system that ensures legal compliance with
federal and state documents, performance
improvements through metrics, increases
employee satisfaction, and provides
insights into your employees that allow you
to turn their weaknesses into strenghts.
The risks are high and the
responsiblities important, but with powerful
strategic tools such as HR for Health, all
orthodontic offices can be compliant with
complicated employment laws. OP
BOOK REVIEW

Biomechanics in Orthodontics, 4th Edition

Drs. Giorgio Fiorelli and Birte Melsen

W hen I interviewed Drs. Melsen

and Fiorelli 17 years ago upon
the publication of the 1st edition of
Biomechanics in Orthodontics, I asked
them what they intended as an encore to
their epoch-making publication that used
a CD-ROM with computer hypertexts and
multimedia resources. They promised to
make periodic upgrades to the material,
and have they ever with this 4th edition.
Without doubt, Biomechanics in
Orthodontics has been the quintessential
reference for orthodontists regarding
the mechanics of tooth movement for
many years. But this new edition, which
is completely cloud-based, brings a
new dimension to orthodontic learning.
The information is no longer dependent
upon any particular operating system or
computer. Rather now, users can access it
with any computer or tablet, which makes
it universal in application.
The same subjects are covered as
in previous editions, but there are more
clinical examples with vastly improved
This new edition, which
photographic and image quality. Also,
improvements in techniques, such as
is completely cloud-based, brings a
TADs, bracket-free fixed orthodontics, and
lingual orthodontics, are now included.
new dimension to orthodontic learning.
Another new feature illustrated nicely
in anchorage preservation is Triad® Gel
The information is no longer dependent
posterior occlusal additions that lock in
the reactive parts of the dentition during
upon any particular operating system or
space closures. The accompanying
videos are superbly done and do much to
computer. Rather now, users can access it
illustrate many of the concepts presented.
Extensive and up-to-date bibliographies
with any computer or tablet, which makes
add an important component and afford
readers with a rich resource for references.
it universal in application.
The authors have made every effort to
afford this information to the orthodontic
public, e.g., reduced prices for those who
purchased the 3rd edition, 1-month rentals
of the entire book, and 1-month free trials
for a single chapter. Those wishing to Biomechanics Summer School, which 1,000 pages, 3,000 photos and illustrations
purchase or request a free chapter can lasts 5 weeks in Tuscany, Italy.
visit the website at http://www.ortho- No other single source for orthodontic Review by Larry White, DDS, MSD
biomechanics.com/en/. The authors also biomechanics exceeds what Drs. Melsen For more information on this book, visit
encourage readers to visit their Facebook and Fiorelli have collected and presented http://www.ortho-biomechanics.com/en OP
page 
https://www.facebook.com/ in this 4th edition of Biomechanics in
OrthodonticBiomechanicsSummerSchool. Orthodontics, and in my opinion, any
Biomechanics in Orthodontics is the professional library will be incomplete
reference for their International Orthodontic without this publication.

60 Orthodontic practice Volume 4 Number 6


Hard-piped filtered water system vs. self-contained
bottled water system
John Bednar helps avert problems coming down the pipe
I f your office currently has a hard-piped
filtered water system, and you are strictly
practicing orthodontics, now is a good
time to consider if and when you should
change to a self-contained bottled water
system. A hard-piped filtered water system
is a system that has a copper water line
connected to a water filter that is usually
located within the equipment room. The
copper water line is typically installed under
the concrete floor and either runs towards
the front of the office, and then branch lines
run to each treatment room, or individual
lines run from the equipment room to each
treatment room.
There are a few issues in having the
hard-piped filtered water system. One issue
is where the hard-piped filtered copper
water line terminates within the treatment
area. It usually requires a 3/8” compression
fitting to be installed on the line so that
the DCI water handpiece hose can be
connected. The point of this connection
often fails, and if an equipment control
panel is not being utilized, then the water
is constantly running. If the failure occurs
after hours, then the doctor and staff arrive
the following morning to find that the office
has flooded. Another issue that is standard
practice is that building departments and/
or city inspectors are requiring that a
backflow preventer be installed on every
line where a handpiece or another piece
of equipment is connected. So, a backflow
preventer is beginning to be a requirement
in the individual treatment areas, in addition
to  within the equipment room or wherever
the main water source enters the suite. A
backflow preventer will cost anywhere from
$800 to $1,000 and will require annual
testing.
John Bednar currently serves as the construction
project manager at OrthoSynetics and has been with
the company since 2002. Mr. Bednar works with the
entire project team from the initial space-planning,
concept through the architectural and engineering
phase, ultimately working with and overseeing the
construction of the office until the office is open. He also
helps in expansions and remodels and assists in facility
management. John has over 17 years of experience in
the construction of orthodontic and pediatric dental
facilities.
Volume 4 Number 6 Orthodontic practice 61
If your office did not to have to meet
these requirements at the time it was built,
then you can expect for these requirements
to be imposed on you some time in the
near future as more local jurisdictions are
starting to perform inspections to check
on items such as these. Keep in mind that
after the backflow preventer installation is
complete, it then must be tested on an
annual basis by a company that is certified
to do so. The reason for this requirement
is to prevent any contaminated water from
backing up and finding its way back into
the city’s main domestic water supply. If
your office currently has this hard-piped
filtered water system, then you may want
to make sure you have an equipment
control panel or another way to shut off
this water line when you leave for the day
or for an extended period of time. The
equipment control panel has switches and/
or buttons to control the turning on and off
of the hard-piped filtered water system, the
vacuum pump, and the air compressor.
This equipment control panel should be
conveniently located so that staff can easily
turn the filtered water, air compressor,
and vacuum pump on upon arrival and
then turn if off before leaving for the day.
Turning the filtered water off at the end of
the day will prevent the office from flooding
if a failure should occur since the only water
that will leak from the system will be the
minimal amount of water still within the line.
As an alternative, you could install a
self-contained bottled water system. This
system comes with different-sized bottles
depending on your needs. The cost of
these bottles ranges between $200 and
$400 per bottle. The bottle can mount
inside a cabinet if rear delivery is used or
inside a chairside mobile or stationary cart.
The bottle can also attach directly to the
chair or to the pivot arm if an over-the-
patient delivery is desired. The bottle is
pressurized directly off of the air line. The
3/8” compression fitting installed on the
air line may possibly need to be replaced
with a double 3/8” compression fitting
depending on the exact system to be used.
Since an orthodontist uses very little water,
filling the bottles with domestic water has
PRACTICE MANAGEMENT
become more of the norm, although an
independent countertop filtering system
can be utilized to fill the bottles without
the worries of backflow prevention. The
old hard-piped filtered water line in the
treatment areas would simply be capped
since it would no longer be in use, and the
same would apply within the equipment
room or wherever the main water source
may be.
When you consider updating your
hard-piped water system, it is important
to evaluate the cost of the modifications
that need to be made and implemented in
an effort to prevent failure, as well as the
cost of the inspections to meet your city’s
building requirements. While doing so, you
should also evaluate the potential costs for
a self-contained water system considering
the versatility, and if such system meets
your needs. It is important to address this
issue as we are coming across more cities
and jurisdictions that are changing their
requirements. You will also be making
an effort to protect yourself against the
potential of a flooded office. Please keep
in mind that different cities and jurisdictions
will have different building requirements,
and it is important to educate yourself
on these, as well as surround yourself
with people who understand the issues
and requirements associated with such
projects. OP
PRACTICE DEVELOPMENT

Four social media channels that drive new patient

acquisition and retention
Diana P. Friedman offers advice on cultivating a dynamic web presence

Facebook, Twitter, and other online sites

have become not just wildly popular but
significant parts of their users’ daily lives
— for instance, the average Facebook user
spends 55 minutes a day there!
For many consumers — including
your current and prospective patients —
these channels have also become a go-to
resource for buying decisions. In fact, 74%
of consumers rely on online resources to
guide purchase decisions, while consumers
are 71% more likely to make a purchase
based on online referrals.
By cultivating a comprehensive,
active, and well-branded online presence,
your practice can make the most of these
opportunities to acquire new patients and
strengthen loyalty with current ones. Here
are four online social media channels on
which to focus.

Facebook
Facebook is one of the most business-
friendly social media sites. Businesses can
create branded, customized Facebook
pages and effectively drive traffic to their
page using multiple inexpensive marketing
tactics, including a broad spectrum of
practice patient-directed communications
as well as search engine-targeted ads. The
practice can leverage its Facebook channel
to post a wide variety of multimedia content
to engage and educate visitors. Don’t
forget Facebook’s Page Insights analytics
feature, which allows you to measure your
page’s reach, engagement, and other key
performance data.
Diana P. Friedman, MA, MBA, is president and chief
executive officer of Sesame Communications. She
has a 20-year success track record in leading dental
innovation and marketing. Throughout her career,
she served as a recognized practice management
consultant, author, and speaker. She holds an MA in
Sociology and an MBA from Arizona State University.
Why it’s worth your time
Your existing and prospective patients are
there…Over one billion users…that’s nearly
one-sixth of the world’s population! But
more to the point, a staggering 93% of all
U.S. adult Internet users are on Facebook.
…And they’re engaged — We already
know Facebook users spend a lot of time
there. They participate, too: More than 2.7
billion “Likes” and comments occur on
Facebook each day.
YouTube
YouTube, the popular video-sharing site,
allows you to easily upload videos up to
15 minutes long. These can be shared
with your YouTube community as well as
leveraged in other practice web channels
such as posted on social media pages and
embedded in your website.
Why it’s worth your time
Your existing and prospective patients are
there — YouTube stats show that 6-plus
billion videos are watched every day, and
that 1-plus billion unique users visit the site
each month. This is the perfect place to
feature patient testimonials. Testimonials
— especially in video format — act as very
strong influencers: 90% of consumers trust
peer recommendations. This channel can
also be leveraged effectively to educate the
community through short presentations
by the orthodontist as well as provide an
effective introduction to the practice.
It’s great for SEO — Did you know
YouTube is technically the world’s second-
largest search engine? And according to
Forrester research, videos are 50 times
more likely to rank on the first page of
search engines.
Google+
Google+, Google’s foray into social
networking, shares many features with
sites like Facebook. Google+ is business-
friendly: It allows you to create brand-
focused pages for your practice, “circle”
other users (their version of “friending”
someone), share videos, pictures, and
status updates, and much more.

62 Orthodontic practice Volume 4 Number 6


These very important online channels can
help your orthodontic practice accelerate
new patient acquisition. The best thing you
can do for your practice is to get started.
Why it’s worth your time
Your existing and prospective patients are
there — Google+ has exploded in the last
year: It now has more than 500 million
users, and recently passed Twitter to
become the world’s second-largest social
network. Google+ has moved beyond
a niche network and is now essential for
any practice trying to attract patients
through social media. Most importantly,
as an orthodontic practice you serve a
local community, and Google+ is all about
targeting that local audience.
Twitter
Twitter is an interactive stream of
messages — each message is limited
to 140 characters. These messages
(“tweets”) post on your Twitter page, and
automatically stream to users who “follow”
you. With Twitter, it takes just seconds to
create a tweet that reaches thousands of
potential patients.
Why it’s worth your time
Your existing and prospective patients are
there — Twitter has 200-plus million active
members. Twitter is widely regarded as a
powerful marketing tool that can be used to
share quick and focused updates, connect
Volume 4 Number 6 Orthodontic practice 63
with patients, learn from customers’ past
experiences, and connect with professional
peers.
And they’re using it to inform potential
buying decisions — 42% of all active
Twitter users learn about products and
services via Twitter, and 88% follow
brands or companies.
Final thoughts
These very important online channels can
help your orthodontic practice accelerate
new patient acquisition. The best thing you
can do for your practice is to get started. If
you haven’t already, start by setting up a
Facebook Business page — Facebook is
so popular that not having a page in 2013
looks nearly as bad as not having an up-
to-date practice website. Next, evaluate
how you can fold these other channels into
your online marketing mix and strategy.
Once your practice gets started with these
channels, it’s important to keep them
updated, fresh, and relevant. It’s worth your
time to consider getting some help from a
proven online dental marketing company
— just make sure they are focused on
orthodontics and have a track record of
success in helping practices grow through
these channels. OP
PRACTICE DEVELOPMENT
References
1. Leonard, H. This is what an average user does
on Facebook. Business Insider. http://www.
businessinsider.com/what-does-an-average-
facebook-user-do-2013-3. Published March 6,
2013. Accessed November 5, 2013.
2. Nelson, A. 20 stats about how social
media influences purchasing decisions.
Salesforce marketing cloud. http://www.
salesforcemarketingcloud.com/blog/2012/11/20-
stats-about-how-social-media-influences-
purchasing-decisions/. Published Nov. 21, 2012.
Accessed November 5, 2013.
3. Teen and Young Adult Internet Use. Pew
Research Center. http://www.pewresearch.org/
millennials/teen-internet-use-graphic/. Published
February, 2010. Accessed November 5, 2013.
4. Kern, E. Facebook is collecting your data —
500 terabytes a day. Gigaom. http://gigaom.
com/2012/08/22/facebook-is-collecting-your-
data-500-terabytes-a-day/. Published August 22,
2012. Accessed November 5, 2013.
5. YouTube. Press room. http://www.youtube.
com/yt/press/. Accessed November 5, 2013.
6. Qualman, E. 39 Social Media Statistics to Start
2012. Socialnomics. http://www.socialnomics.
net/2012/01/04/39-social-media-statistics-to-
start-2012. Published January 2012. Accessed
November 5, 2013.
7. Christensen. A. 12 valuable tips for SEO
beginners. Search Engine Watch. http://
searchenginewatch.com/article/2234885/12-
Valuable-Tips-for-Video-SEO-Beginners.
Published January 9, 2013. Accessed November
5, 2013.
8. Watkins, T. Suddenly, Google Plus is
outpacing Twitter to become the world’s second
largest social network. Business Insider. http://
www.businessinsider.com/google-plus-is-
outpacing-twitter-2013-5. Published May 1,
2013. Accessed November 5, 2013.
9. Wickre, K. Celebrating #Twitter7. Blogs.
https://blog.twitter.com/2013/celebrating-
twitter7. Published March 21, 2013. Accessed
November 5, 2013.
10. Baer, J. 7 surprising statistics about Twitter
in America. Convince&Convert. http://www.
convinceandconvert.com/twitter/7-surprising-
statistics-about-twitter-in-america/. Accessed
November 5, 2013.
11. Baer, J. 7 surprising statistics about Twitter
in America. Convince&Convert. http://www.
convinceandconvert.com/twitter/7-surprising-
statistics-about-twitter-in-america/. Accessed
November 5, 2013.
INDUSTRY NEWS

Carestream Dental’s CS 8100 digital panoramic imaging system

receives 2013 International Medical Design Excellence Award
Carestream Dental announced its CS 8100 digital panoramic imaging system has been selected as the Bronze Winner in the Dental
Instruments, Equipment, and Supplies category of the 2013 Medical Design Excellence Awards (MDEA) competition. Presented by UBM
Canon and Medical Device and Diagnostic Industry (MD+DI) magazine, the MDEA program recognizes the achievements of medical
device manufacturers, their suppliers, and the many people behind the scenes (engineers, scientists, designers, and clinicians) in the areas
of product innovation, design and engineering achievement, end-user benefit, and cost-effectiveness in manufacturing and healthcare
delivery.
The CS 8100 digital panoramic imaging system offers the latest imaging technology to obtain highly detailed and optimally contrasted
panoramic images. The CS 8100 also comes with exclusive 2D+ technology that enables practitioners to create slices at regular intervals
along the jaw to focus on one area of interest and visualize more details than standard 2D images reveal. It’s a cost-effective solution that
overcomes some of the limitations of standard panoramic imaging such as structure overlap.
The patient-centric design and transparent patient support features of the CS 8100 also help practitioners obtain high-quality images
effortlessly. Integrated handgrips help patients remain stationary, while the face-to-face positioning aids with patient alignment. Images are
captured in as little as 10 seconds, reducing the period of exposure while also minimizing the risk of patient movement and need for retakes.
The CS 8100’s open design accommodates patients of all shapes and sizes, including those in wheelchairs.
For more information about the CS 8100, call 800-944-6365 or visit www.carestreamdental.com/CS8100.

6th Annual Ethics and Legal Aspects of Dentistry Conference

The 6th Annual Ethics and Legal Aspects of Dentistry Conference sponsored by the American College of Legal Medicine will be held Friday
and Saturday, February 28 – March 1, 2014, at the Westin Galleria in Dallas, Texas. Dentists attending the conference will be able to learn
more about legal issues in dentistry and understand the government’s role and the role of dental education, describe ethical, moral, and
diagnostic issues as they relate to the dental practice; evaluate risk management considerations; and identify issues relating to patient care,
access to care and dental healthcare coverage, electronic record keeping, licensure issues, the current landscape for malpractice, and
more. For further information and registration, visit the ACLM website at www.aclm.org or contact Wendy Weiser at wendy@wjw.com or
Dr. Bruce Seidberg at bseidbergddsjd@me.com.

MATERIALS & EQUIPMENT

OrthoEssentials

OrthoEssentials, of Mount Holly, New Jersey is now an authorized distributor for Select
Defense Enamel Surface Sealant. It comes in two convenient sizes and will provide an
86% reduction in enamel demineralization around orthodontic brackets. This product also
contains Selenium which will greatly reduce plaque buildup around orthodontic brackets.
Select Defense is the only surface sealant on the market with Selenium. For more
information, email info@orthoessentials.net or call 866-517-3257 or 215-396-3803.

64 Orthodontic practice Volume 4 Number 6

PLANMECA ProMax® S3 Pan/Ceph

• Face-to-face patient positioning

• Pediatric mode
reduces radiation by 35%
• Advanced imaging programs
include improved interproximal
pan program for better spacing and
root positioning for TAD placement
• Patented SCARA technology allows
unlimited movement to
accommodate complex and
unique jaw shapes
• Integrates with Dolphin, Ortho II,
and other ortho imaging programs
• Upgradable to 3D at any time
• Mac OS compatible and
DICOM compliant

For a free in-office

consultation, please call
1-855-245-2908
or visit us on the web at
www.planmecausa.com

PLANMECA’s ProMax has won Townie

PLANMECA
Choice Awards for its pan/ceph model
2006-2012
ProMax® S3
 ORTHOPHOS XG 3D
The right solution for
your diagnostic needs.

Implantologists
will appreciate the
seamless clinical
workflow from initial
Endodontists diagnostics, to treatment
will enjoy instantly planning, to ordering
viewable 3D volumetric surgical guides and final
images for revealing implant placement.
and measuring canal
Orthodontists shapes, depths
will benefit from high- and anatomies.
quality pan and ceph
images for optimized
therapy planning.
The advantages of 2D & 3D in one comprehensive unit
General Practitioners ORTHOPHOS XG 3D is a hybrid system that provides clinical
will achieve greater workflow advantages, along with the lowest possible effective
diagnostic accuracy dose for the patient. Its 3D function provides diagnostic accuracy
for routine cases. when you need it most: for implants, surgical procedures and
volumetric imaging of the jaws, sinuses and other dental anatomy.

For standard 2D images, it offers the most comprehensive selection

ORTHOPHOS XG 3D of pan and ceph programs to meet virtually all needs, from standard
panoramic programs for adults and children, to extraoral bitewing,
sinus, TMJ options and many more.

Automatic patient positioning

The new Auto-Positioner measures the exact tilt of the patient’s
occlusal plane and automatically adjusts the height for an optimal
panoramic image within the sharp layer, thereby preventing incorrect
positioning and reducing re-takes.

For more information, visit www.Sirona3D.com

or call Sirona at: 800.659.5977

www.facebook.com/Sirona3D