Blog - The Ortho Cosmos

Phase I Treatment with Aligners

August 11, 2017 by Sean Holliday Leave a Comment

Interceptive Aligner Therapy

Why would an orthodontist or an orthodontic patient consider treatment with clear aligners in the mixed dentition? My thoughts center around the same premise why adults and teens are offered aligner therapy: for a more comfortable patient experience. While the orthodontic world is full of appliances used for Phase I treatment, aligner therapy is finding a place in this age. Invisalign is already in the process of tailoring their product to function more seamlessly for interceptive treatment, but the extended refinement period on approved cases has opened the doors for most practices to start offering this option.

Considerations

For any of you considering integrating aligners into a Phase I treatment plan, you should take into account a few factors that will make your experience, as well as the patients, the most positive it can be. First being the purpose and objectives of your Phase I treatment. Since patients are often in the early mixed dentition, the treatment should be focused on the limited goals. Ordering several sets of additional aligners can easily prolong treatment when managing erupting teeth. Keep the goals and limits very clear to avoid getting sucked into multiple and excessive refinements.

Anterior crossbite — Six months of Phase I treatment with aligners to correct an anterior crossbite.

Clinical Crowns

Second, the clinical crowns in the mixed dentition are short, so beware. Short clinical crowns in aligner treatment can spell fit and retention issues, if not managed properly. To address this challenge, add many more of attachments for retention. I add attachments on the primary molars and try to avoid the primary canines since their loosening can cause issues with fit.

Phase I attachments — Retention attachments for a Phase I case.

Tooth Eruption

Third, beware of erupting teeth. We have had a few patients where we scanned and by the time the aligners came, they wouldn’t fit! Whenever possible, I have been more selective with cases that are in a less transient mixed dentition where the four incisors have erupted and you have several months before any more primary teeth erupt. Remember that eruption tabs are quite specific and more designed for late mixed dentition cases. When incisors have not erupted, or even first premolars, I find I was chasing the case until I could scan again and again. Therefore, be selective in timing of cases. Also be creative using pontics where eruption tabs are not available. The advantage of the developing and erupting dentition, is that once space is opened, teeth will erupt into place and commonly drift into pontic spaces or eruption tabs. These are advantages in an aligner system, compared to the obstruction brackets bonded on exfoliating primary teeth.

Phase I Features

There are also some additional features in the pipeline that are well suited for early treatment. These include pending features such as a Phase I aligner product, an expansion appliance in the works, and the MFA appliance that will facilitate Class II correction.

Despite some potential challenges, and many young patients requesting colors for treatment, proper case selection in Phase I aligner cases can lead to success. Aligners for young patients can offer another great option that was not available before. Knowing these potential challenges and proper preparation for these treatment plans can offer the same advantages teens and adults experience while in the early mixed dentition.

Rejecting Facemask Fundamentalism

August 9, 2017 by Scott Frey 2 Comments

Facemask Fundamentalism

It has been well established that the early correction of anterior crossbites is beneficial for jaw development¹ so certainly interceptive treatment to resolve crossbites is advisable. However, there seems to be significant confusion in the orthodontic community about what exactly people are achieving with certain treatment modalities.

I continue to be astonished by the persistent dogma that reverse-pull facemasks “protract the maxilla” because a comprehensive and unbiased examination of scientific evidence reveals this to be little more than wishful thinking.

There is zero evidence of any anterior displacement relative to controls of actual skeletal structures, such as the zygoma, pyriform aperture, etc. with facemask therapy.^2,3,4 The sutural strains produced (with or without any expansion protocol) with a facemask are several hundred fold lower than the frost thresholds required for any orthopedic effect based on finite element analysis.⁵ Why a dentoalveolar landmark like A-point, which is known to remodel significantly in response to both retraction and protraction of the dentition, has served as the basis for assess the “skeletal response” in so many papers makes very little sense.
The counterclockwise rotation of the maxillary occlusal plane is a hallmark of dental movement and not an orthopedic effect. The data on Bone Anchored Maxillary Protraction (with infrazygomatic plates) resoundingly confirmed Ricketts proposal that the center of resistance for the maxillary bone (not the maxillary dentition) is at the pterygoid plates. Thus, true orthopedic traction of the maxilla will exhibit a clockwise rotation and not the counterclockwise rotation that we try to mitigate during facemask therapy.⁶
Although palatal TADs due to their easy and predictability of placement have been proposed as an alternative means of bone-anchorage, their addition does not improve the effects on the maxilla. In fact, the palatal TADs actually seem to reduce the effects of maxillary traction on A point, backward rotation of the mandible, and any positive dental “side effects” in the maxillary arch.⁷ Anchoring the dentition to TADs is a strategy that is better suited for hyperdivergent class 3 patients where vertical side effects may be less desirable, but it does not translate into an improved effect on maxillary hypoplasia.

The bottom line is that the clinical effectiveness of a facemask is entirely due to dentoalveolar changes and an improvement in sagittal position of mandible. There is no effect on mid-face, and if that were required then a surgical procedure or bone anchored maxillary protraction should be explored as an option for that patient (though better long term data on BAMP is still needed).

Facemasks are certainly more cost effective to use than many alternatives; however, the same basic outcome that you are prescribing with a facemask can be achieved just as effectively using appliances that facilitate better compliance and are less traumatic to patients.

References:

Tollaro I, Baccetti T, Franchi L. Craniofacial changes induced by early functional treatment of Class III malocclusion. AJODO 1996;109(3):310–8.
Pangrazio-Kulbersh V, Berger J, Kersten G. Effects of protraction mechanics on the midface. AJODO 1998;114(5):484–91.
Arman A. Evaluation of maxillary protraction and fixed appliance therapy in Class III patients. Eur J Orthod 2006;28(4):383–92.
Masucci C, Franchi L, Defraia E, Mucedero M, Cozza P, Baccetti T. Stability of rapid maxillary expansion and facemask therapy: A long-term controlled study. AJODO 2011;140(4):493–500.
Holberg C, Mahaini L, Rudzki I. Analysis of Sutural Strain in Maxillary Protraction Therapy. Angle Orthod 2007;77(4):586–94.
Nguyen, Tung, et al. “Three-dimensional assessment of maxillary changes associated with bone anchored maxillary protraction.” American Journal of Orthodontics and Dentofacial Orthopedics 140.6 (2011): 790-798.
Ngan, Peter, et al. “Comparison of two maxillary protraction protocols: tooth-borne versus bone-anchored protraction facemask treatment.” Progress in orthodontics 16.1 (2015): 26.

The Only Formula For Success

August 8, 2017 by Donna Galante 1 Comment

Thomas J. Watson, founder of IBM, once said,” Would you like me to give you the formula for success? It’s quite simple, really. Double your rate of failure. You are thinking of failures as the enemy of success. But it isn’t all that. You can be discouraged by failure – or you can learn from it. So go ahead and make mistakes. Make all you can. Because, remember, that is where you will find success.”

Many of us see successful people in our profession, but also in other fields such as law, finance, music, medicine, art, computers, technology, and more. You get the idea…there are certainly loads of people who are apparently successful and they appear to have gotten there with little effort or no effort at all.

Am I the only one who feels this way?

I bet not. You know who I am talking about. They usually are orthodontists who seem to have a booming practice, no shortage of new patients, all their patients gladly accept all treatment and best of all either pay in full or put $2000 down. Oh and yes, these offices seem to also have no employee problems and minimal money spent on marketing.
Can you think of a practice like that?

Well, if it is your practice, congratulations. If it not your practice (and it certainly is not mine), keep reading, because I am going to share with you some strategies that I have learned to help me when it seems like nothing is going right.

I used to think that some people are just plain lucky. They open a practice or buy a practice in an area without competition, without corporate offices and with a booming economy. In fact I have been known to say, “If it wasn’t for bad luck, I would have no luck at all!”

Let’s talk reality for a moment.

Yes, sometimes we attempt to do something to improve our bottom-line at our practice. We spend the time and money and guess what, we get ZERO in return. Not one new patient, not one phone call not one single dollar in our bank account.

Worse than that, we hire a new employee that we “feel” will be the one to encourage patients to get the needed treatment we have proposed. They are doing the follow-up, making the calls, presenting amazing payment plans and yet, still patients are leaving your office without making an appointment to get their treatment.

Frustrating, I know. Even worse, it can make you feel like you are ineffective, unproductive or just plain stupid for making this hire to begin with!

I’ve been there more often I would like to admit. Even more humbling, is the fact that I try not to make the same mistake twice, but seem to find new ways to fail in different areas.

What I have learned about failure, mistakes and “bad luck” I will share with you to offer encouragement and the opportunity to look at failures as being one step closer to the success you are looking to achieve.

Here are my strategies for handling failures and setbacks. I hope they will help you too!

1. Do not take them personally.

The blame game is one we as professionals excel at. We will often take the responsibility for a bad decision and then fear making any further progress towards our goals. The motivational speaker, Les Brown is quoted as saying, “ The good times we put into our pocket. The bad times we put into our heart.”

Hanging on to failures or regrets puts fear into your heart and prevents you from taking the necessary action to move forward again.

2. Take a realistic and objective look at the situation.

We are human beings and emotions can get in the way of being objective when it comes to a situation that we anticipated turning out to be more successful. We may know of the story behind Thomas Edison’s invention of the incandescent light bulb, which took him years of experimentation and thousands and thousands of attempts. He looked at his various attempts as one step closer to success never as a failure.

When we find ourselves with a disappointing result, step back and evaluate the situation and see if there is a way to make changes right away that could produce your desired result. Often we are ready to toss out our project without further study or even giving it enough time to actually work.

3. Be on the lookout for new opportunities

Many times when I was faced with a setback or even multiple setbacks, after I stopped licking my wounds, I would sit down and begin the process of looking at new or different opportunities to gain the success I was seeking.

Searching for new opportunities may require you to pick up a book, go to a seminar, join a mastermind group, hire a consultant or just carve out some time to let your brain focus on a solution.

<em>Norman Vincent Peale stated: “ Positive thinking is how you think about a problem. Enthusiasm is how you feel about a problem. The two together determine what you do about a problem.”

By staying positive and enthusiastic despite your setbacks, new opportunities will present themselves to you. It is up to you to take action towards those new goals which brings me to the last strategy

4. Take Action

The final step is to not let fear of failure stand in your way of moving closer to achieving your goals. Fear is paralyzing when you allow it to control your actions and movement forward. After practicing for 31 years now, I have my wounds; some are very deep and have not fully healed. However, I do not let fear stand in the way of moving forward as I continually look for opportunity to grow and improve both professionally and personally.

How am I able to do this?

One tip is to make sure you surround yourself with supportive people who encourage you, listen to you and help you push past those barriers of fear and anxiety. These key people could be spouses, other colleagues, friends, significant others, other family members or even your employees.

Forums, such as this one, are invaluable for providing the support and information you need to weather through the inevitable storms of practice and life.

John Maxwell, one of my very favorite authors, is quoted as saying;” The quality that distinguishes a successful person from an unsuccessful one is the capacity to manage disappointment and loss.”

In summary, failure, loss and disappointment are a part of all of our lives; use these 4 strategies above to overcome the paralyzing effects of failure to help you achieve the success and achievement you have desired.

Try This Today

August 4, 2017 by Donna Galante Leave a Comment

I recently had an amazing experience while renting a car from Enterprise. An energetic, passionate young woman helped me with my rental and I was so impressed with her customer service skills, that I actually offered her a job in California working for us in our Orthodontic practice.

I honestly, did not expect her to take it (I was in Ohio renting the car and Cincinnati is her home town.) But what did happen helped me remember how important it is to recognize people in our everyday interactions.

Unfortunately in today’s world, we tend to remember all the negative outcomes or negative experiences. With review sites that promote negative reviews such as YELP, there is now more and more focus on what is “wrong” with a service provider or product than focusing on what is right.

Maybe I am naïve, but I believe most people get up each day and want to have a great day and help their customers, clients and patients. Of course, some people give up sooner, or just do not have the energy or focus to sustain a customer” centric attitude all day.

My proposal today, is to try to make a change in the collective atmosphere that focuses on all the “bad” and start handing out praises to people we encounter all day long.

Try it starting today.

I have to admit, at first it takes some effort, but once you get going, you will love the rewards. People will smile more, you will smile more, you will get better service and even some special perks and best of you will be making the world a better place, a “millimeter” at a time of course!

Back to my Enterprise story. I told her how impressed I was with her customer service skills and ability to make me feel like I was the only customer in that day getting a car. She actually teared up a bit and said to me that was the nicest thing anyone had said to her all day and in fact she had been having a “bad” day (although she did not show it).

She thanked me profusely, blushed at my job offer, but declined and I thought I saw her gleefully skip (like a schoolgirl) back into the Enterprise Rental store as I pulled out of the parking lot. Remember folks, “its all about millimeters.”

Try this today and please share your stories….

Best Practices for Invisalign Concierge Patients

August 2, 2017 by Scott Frey 2 Comments

Invisalign’s Concierge Program

In early 2017 Invisalign began rolling out a new program to better engage with patients who are interested in enhancing their bite and smile with clear aligners, using “smile concierges” to help guide patients to orthodontic practices offering a high level of care with Invisalign. As with anything new, there has been a fairly steep learning curve both for Invisalign and the orthodontists being connected with these potential patients.

I had an opportunity to briefly speak with the head of Invisalign’s concierge program over lunch yesterday, and I wanted to share some important updates that have happened recently and discuss best practices in handling patients coming through the Invisalign concierge system.

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Using TAD’s with Aligners

July 31, 2017 by Sean Holliday 10 Comments

In orthodontic treatment, we are fortunate to have several different resources to address a variety of malocclusion. Since the 1980’s TAD’s (temporary anchor devices) were introduced as a tool in orthodontics. They allow us to use an anchorage system that widens the scope of treatment plans.

Similar to many other tools in orthodontics, TAD’s are primarily used with fixed appliances to facilitate different corrections. Direct or indirect anchorage setups can be combined with braces. In an aligner practice, the use of TAD’s also becomes an option and can serve to increase the ability of the orthodontist to setup patient care for success. Consider we can use the force systems and the strengths of a TAD, to enhance aligner therapy.

There are many options for integrating TAD’s with aligner systems. I am not an expert with them, but I want to share my experience in using this orthodontic tool to better serve patients. I have found TAD’s help broaden the range of applicability in complex, aligner treatment.

Molar Intrusion

TAD’s can be placed and supported by elastics or chain to intrude posterior teeth in combination with an aligner system. Usually buccal and lingual TAD’s with elastics will support the intrusion. If lingual TAD’s are considered, add a significant amount of expansion to counteract the lingual component in the intrusion.

Molar intrusion 2 — To intrude lingual cusps, buttons were tied to palatal TAD’s.

Pontics and TAD’s

The use of aligners allows for custom pontics to be placed in edentulous regions. This allows for the pontic and the aligners to be seamlessly integrated with a TAD supported, pontic crown. The temporary crowns can be used as an anchorage system to facilitate mesial or distal movement where insufficient posterior support is present.

Anchorage — In order to move canines into a Class I position, TAD supported pontics were integrated into aligner therapy.

Segmental Treatment

Sometimes, the use of limited, fixed appliances are best suited for significant root movements or tooth translation. Segmental mechanics with a TAD supported appliance allows for challenging movements in localized areas. A TAD supported pontic with bracket segments can be used along side aligner therapy.

TAD’s and Power Arms

In some cases, tools available in the Invisalign system can be combined with TAD’s to broaden the range of movements. Power arms can be used to support significant mesial movements and root control in an otherwise challenging aligner force system.

Mesialization — Due to a missing premolar, a custom power arm was designed to move the left side mesially into a Class II molar, Class I canine position.

These are but a few examples of the integration of TAD’s into aligner therapy. These tools offer many creative options when we allow our imagination to develop treatment plans for our patients.

Culture Shifts in Orthodontics

July 26, 2017 by Sean Holliday Leave a Comment

The delivery of orthodontic treatment has remained the same for many decades. With the digital influence in orthodontics, and the changes from patient expectations in care, our specialty is undergoing perhaps one of the largest culture shifts ever.

The primary shift in culture is the change from a doctor centric practice, to a patient centered culture. Ultimately, as the consumer’s values have changed, those who succeed will learn to adapt. This is where adapting the orthodontic journey becomes so important.

With the influence of new technologies comes increasing costs to deliver orthodontic care. This has made the entry into private practice much more difficult to achieve, and has contributed to the corporatization of orthodontics. With higher costs, the challenges of a single doctor practice increase. The growth of group practices and corporate service organizations will continue to shift the model of the orthodontic care.

Technology is also democratizing the access to care, and new delivery methods have opened the opportunity to deliver orthodontic products direct to the consumer. Sure, doctors are contracted to oversee the treatment, but the model now shifts to a business model called Mechanical Turk. Where the excess supply of orthodontic and dental practitioners accept legal responsibility and low reimbursement to deliver volume outcomes for corporate goals. When there is no direct link between the practitioner and the patient, the culture of care changes. As more outlets for this model are developed, the commoditization of straight teeth develops.

Direct to consumer delivery of care will continue to grow. Doctor delivery will also evolve and we should accept the fact that patients have different priorities and expectations of orthodontic care. Many will continue to expect the traditional delivery of care with better experience and convenience. While others value a lower cost and self driven solution.

The shift in culture out there is many ways out of our control. What is not out of our control is what we do about it. Improving your team culture and the practice culture will help us attract those who are interested in what we offer. Offering a unique and patient centered experience will drive continued growth. Some developments in culture and technology are inevitable, but we should continue to focus on the areas we can improve and control.

It’s All About the Journey

July 25, 2017 by Scott Frey Leave a Comment

The Journey is What Matters

Evaluating the quality of your practice model based solely on patient starts and treatment finishes overlooks the most substantial portion of the care you provide, the patient’s journey. The time spent with our patients throughout is the most impactful portion of the treatment process, yet it often receives the least amount of attention. How your patients’ feel about your brand and what they tell their friends, as well as their desire to do so, is the result of all their interactions with your practice, so delighting patients at every step of the way should be your mission.

An integral part of designing exceptional patient experiences is also considering the appliances and treatment approaches that are used to achieve similar goals. Yet, all too often I hear dismissive statements like “all appliances can deliver the same outcome” and decisions being made on the basis of the doctor’s comfort level with a particular treatment. Experience driven treatment is not appliance drive treatment. It is simply the recognition that appliances should be selected in order to provide the best possible experience for the patient.

To develop a better understand how our decisions impact the patient’s journey, it is helpful to map out the patient’s (and parents’) entire treatment experience and examine what they thinking and feeling throughout the process. This should be based on a real information about their behavior, thoughts, and feelings throughout their journey, paying attention to key “stress points” like an initial phone call, initial appliance placement, repair appointments, etc. A very basic example of what a various treatment journeys might look like for different appliance choices is show below:

On one end of the spectrum you see a treatment approach where the patient’s experience has been exceptional across the board; while on the other end, we see a fairly generic brand experience where uncomfortable, outdated appliances are used, creating a substantial decline in the patient’s experience during the treatment phase. The cumulative differences between the two experiences represent a huge missed opportunity to drive word-of-mouth referrals and better patient motivation.

Ironically, most orthodontists are completely unaware of any problems in their approach because their patients are all on similar treatment arcs and there is little outside perspective. Both the doctor and the patients have simply accepted things as the way things are, and the only way to break the cycle is by actually performing a critical examination of patients’ treatment journeys using qualitative and quantitative measures.

By visualizing their journey in this fashion, the focus can now be on engineering an optimal customer experience that drives value and practice growth. Unnecessary pain points can be identified and eliminated, and investments made to create more positive movements in the patient’s journey. Treatment goals are extremely important, but the patient experience is just as important so it should not be overlooked.

Are You Inspiring or Discouraging?

July 24, 2017 by Donna Galante Leave a Comment

One of my favorite books is See You At The Top, by the famous Zig Ziglar

A classic book on leadership and becoming the best you can be, this book was one of the first I read in my quest to become a better leader. This book is truly inspirational and motivational. When I heard about Zig’s death, it reminded me of the time that I found out Jim Rohn had passed away. It made me stop and think about his contribution to so many peoples’ lives. I had the opportunity to meet Mr. Rohn in the mid 90’s and have been a student of his work ever since.

I mention these 2 great men, because they built their lives on inspiring and motivating people. By studying leaders such as Jim Rohn and Zig Ziglar, you too can not only become motivated and inspired, but also share your inspiration with your employees, patients, family and friends.

Wouldn’t the world be a better place if more people were inspiring versus discouraging?

As we enter the second half of 2107, for many of us, it has been one of ups and downs. Maybe your practice numbers are not where you wanted them to be. You might be having challenges at home with a teen or spouse. Maybe you had some health issues this year or even lost a loved one. Your finances are less then ideal and you haven’t had a real vacation in a long time.

All these scenarios can make you become quite discouraged. It is a human response to events in our lives that are not going the way we had planned. In this article, I hope to bring some inspiration into your life and if I am successful, promise me to pay it forward and inspire those around you.

Going back to Zig Ziglar, there are a few lessons that we all can learn from this great man. When you read and study his writings and teachings, there are several key strategies that he followed in his life to become successful and an inspiration to many.

First, you need to start believing in yourself.

Zig talks and writes about how he grew up poor and had a “poor man” mindset when he started to sell cookware. I remember listening to an audio of a talk he gave and said he was a great salesman during this time….he was good at selling his car, his furniture ….( not the cookware!)

He started to realize that when he changed his mindset and the way he thought about himself and his abilities, he became one of the top sales people in his company.

Second, be constantly learning.

I read that Zig would read 3 hours a day. While that may be extreme and unreachable for most of us, maybe committing to 15 minutes a day to start and gradually working up to 1 hour a day. You will be amazed how much you can learn, simply by picking up a book, journal, magazine or newspaper. Personally, I have a goal to read 1 non-fiction book a month. You can do this easily by turning off the TV or budgeting the time in your day to read for 15 minutes. Try it and be inspired.

Third, find a mentor.

There are many people that have mentored me over the years and I continue to have mentors in my life. These are the people who are going to help you see your potential and give you the courage and push we all need to move past our perceived barriers to success. You can be inspired and motivated to make the necessary changes in your practice or personal life, but having a mentor to help you gets you where you can and should be sooner.

An finally, hang out with inspiring people.

Have you ever hung out with people who are depressed, always seeing the worse in the situation or constantly have discouraging advice? Of course , we all have! How do you feel after an hour or even less around these people? I call it getting “slimed” because that is how they can make you feel.

You can control the situation by removing yourself from those people and their circle of influence and getting yourself around more like minded, upbeat, positive and inspiring people. When you are around those types of people, you can’t avoid being lifted up and feeling positive and hopeful about your future. Your job is to continue to feel motivated and positive and bring that inspiration back to your office and home.

These are just a few of the strategies I learned from Zig Ziglar. I encourage you to check out his books and get your hands on audio or video of his presentations. He was an inspiring, motivating, kind, funny, loving and a generous man.

Take inventory of yourself. Are you inspiring or discouraging.

If you answered mostly discouraging, it is not too late to change your mindset and attitude. Start by picking up a book from Zig Ziglar and you will learn how to become an inspiring person. Best of all, you will learn how to inspire those around you.

It can be one of the best gifts you give to your family, patients, friends and even strangers!

The Opportunities in Failure

July 20, 2017 by Sean Holliday 2 Comments

Learning From Failure

Failure is not something we like to consider. But oftentimes, experiencing failure is one of the ways we grow and become better. Making mistakes often means you are trying, and learning from failure is a key factor. We all will experience failure at some point in our lives. It becomes critical to avoid repeating those failures and accept that not all failures are bad. We should properly learn from such difficulty. Even a genius like Einstein, made many mistakes.

The opportunity in failure is not commonly acknowledged since failure is regarded as always being bad. Certainly there is bad failure, but there is failure that is sometimes unavoidable, and at times a good thing. Developing a process to detect the failure and properly learning from it is not easy.

We should avoid jumping straight into finding blame, and build a learning culture in our practices. Blame prevents failure from being reported, and this is a basic step for your team to learn. A learning culture also offers the opportunity for your team members to take risks. No risk, no reward. In a blame culture, as opposed to a learning culture, team members will avoid experimenting, developing and implementing change. Because change is risky, and can lead to failure, it is often avoided. Change continues to happen all around us, so we must accept failure is bound to happen if we plan to embrace change, adapt and grow.

When considering strategies for learning from failure, Amy Edmondson suggests a spectrum of failures that start with blameworthy failures and progresses to praiseworthy failures. This allows us to see that not all failures are equal:

Let’s consider acknowledging failure and finding its causes. Once we avoid denial and embrace a process of learning from failure, we can stop living behind excuses and work to make our future better.

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