CLINICAL ®

ImpressionsPUBLISHED BY ORMCO CORPORATION • VOL. 6, NO. 2, 1997

Dr. Turley Interviews Dr. Nanda Page 2

Dr. Scott Takes a New Tack to Close Spaces Page 6

Mr. McMahan on Managed Care Page 12

Ms. Brunner on the Upbeat Office Page 13

Dr. Clark on Marketing Plan Implementation Page 16

Dr. Nanda Biomechanics Dr. Patrick Turley Interviews Dr. Ravi Nanda

r. Turley: Ravi, biomechanics in improve them. The specialty is moving orthodontics has taken a backseat for away from technique-oriented approaches years, but recently, more and more that treat, for example, all Class II, orthodontists are paying attention to division 1 patients with wire “X” and it. Where do you think we are headed extraction cases with wire “Y.” Now we in this area? want to know the “guts” of a wire, loop or a spring, such as magnitude, moments, Dr. Nanda: Yes, Pat, I have noticed a keen constancy, direction of force, as well as interest in biomechanics by the ortho- side effects and methods to prevent and dontic specialty in recent years. We are reduce them. more and more curious about how our D appliances work and what we can do to I have always said that we orthodontists

Dr. Patrick K. Turley received his D.D.S. Dr. Ravindra Nanda currently serves as degree from UCLA and his M.S.D. degree and professor and head of the Department of certificates in both orthodontics and pediatric Orthodontics, University of Connecticut. dentistry from the University of Washington. He received his orthodontic training first at He currently serves at UCLA as professor Lucknow University, India, then from the and chairman of the Section of Orthodontics University of Nijmegen, The Netherlands, and director of the postgraduate program and the University of Connecticut. He also in orthodontics, as well as the combined received a Ph.D. from the University of orthodontic/pediatric dentistry postgraduate Nijmegen. Dr. Nanda has done extensive program. Dr. Turley is president of the Pacific research, most recently concentrating on Coast Society of Orthodontists. His interests clinical orthodontic trials and the application have focused on the areas of early treat- of biomechanics in a busy orthodontic ment (especially Class III malocclusion), practice. He has authored and coauthored treatment of traumatic injuries in children three orthodontic books and more than and the use of endosseous implants as 100 scientific and clinical articles in major orthodontic anchors. journals. 2 “Simple, sound principles of biomechanics often spend half our time treating can be applied to any technique.” patients’ problems and the other half correcting the problems we create, often due to inadequate mechanics. Such examples include loss of anchorage and faulty root inclination of incisors and posteriors. If we apply sound A mechanics, side effects can be minimized, treatment time shortened, and chair time A B C saved, not to mention the benefits of peace of mind.

Since Edward Angle invented the edge- wise appliance, there have been few, if B any, revolutionary advances in mechano- therapy. Most of our progress has been D E F made through improvements in and Third-order side effects from space closure. variations on bracket design and the A – Vertical forces acting on the molar clinical application of new wire alloys. secondary to unequal moments used for Yet, 100 years later, we are still vexed by Group A space closure; the beta moment the same problems as our forefathers. is greater than the alpha moment. An Anchorage control, predictable and extrusive force occurs at the bracket. precise results, stability and compliance C B – The equivalent force system at the are still confounding difficulties in center of resistance of the molar; the orthodontics. Many clinicians have extrusive force at the bracket results in offered solutions by making refinements a moment rotating the molar in a crown lingual direction. C – The predicted tooth in the appliance itself. The tremendous movement from this force. D – The vertical Clinical examples of moments of a force. number of bracket prescriptions and forces acting on the canine secondary to A – A mesial force at the molar bracket orthodontic techniques advocated by unequal moments used for Group A space creates a moment tending to rotate the the leaders in this field are evidence of closure. E – The "equivalent force system" tooth "mesial-in." B – An expansion force our focus on the appliance. Perhaps the at the center of resistance of the canine; on a molar creates a moment tipping the problems are not in the appliance, but the intrusive force at the bracket results crown bucally. C – An intrusive force at the in our analysis of its use. Incorporating in a moment rotating the canine in a crown molar bracket creates a moment tipping biomechanical concepts into everyday buccal direction. F – The predicted tooth the crown bucally. patient care may be where we are headed movement from this force. and the source of the next generation of clinical advances. high-school level geometry. The more force, its moments or its side effects. Dr. Turley: A lot of clinicians find bio- exotic analysis, such as finite element So the first order of business for all ortho- mechanics difficult and too theoretical. analysis, are used more in the engineering dontists should be to take a step back and Why? of appliances than in clinical practice. try to understand from the standpoint of This is changing fast. biomechanics what is working and what Dr. Nanda: This has had a lot to do with is not working and how to fix it. us – educators, researchers and orthodon- One should remember that biomechanics tists active in the area of biomechanics. is not a technique. It is applicable to all With an understanding of biomechanics, We did not describe principles and the orthodontic techniques – any wire, we’ll find that simple loops, cantilevers appliances in a user-friendly way. The spring or loop which delivers a force and a small bend at the right place in terminology associated with learning when ligated into the brackets. So a the wire are all that is necessary to im- biomechanics probably has limited the basic understanding of biomechanics is prove our favorite technique. Simple, clinician’s understanding. Sometimes essential for all orthodontists in order to sound principles of biomechanics can be simple ideas seem complex because of understand what forces we are applying applied to any technique. the language and terms used. Another and what sequelae to expect. We would problem is the quantitative nature of not expect our internist to prescribe a Dr. Turley: Why isn’t biomechanics the field: the mathematics used to drug without telling us the dosage, the a bigger part of all orthodontists’ demonstrate the concepts often seems to frequency and the duration of intake. training? intimidate the learner. But for the most In orthodontics, we apply a force on part, the mathematics is simply based on teeth with only a minimal idea of that continued on following page 3 Illustrations from Biomechanics in Clinical Orthodontics courtesy of W.B. Saunders Company Dr. Nanda continued from preceding page

Dr. Nanda: A good question, Pat. Our tooth movements. A given wire may look Dr. Nanda: Orthodontists should care basic problem in this area has been a the same from the standpoint of its shape about specifics of forces and moments. huge gap between the classroom and in the mouth, but a different placement of Orthodontics is little different, let’s say, clinical practice. The students are taught a bend or loop would deliver a completely from driving a car and knowing the all the details of forces, moments and different type of tooth movement. mechanics of an automobile. In our couples, but in the clinic, there is little specialty, we deliver the forces, so it application of biomechanics. Many Dr. Turley: What are the advantages becomes imperative that we must know clinical approaches follow specific wire of using biomechanically oriented what we are doing. sequences or are taught as if there are appliances? “magical” properties incorporated into the I concede that 60 to 70 percent of the bracket. The student becomes more con- Dr. Nanda: The #1 advantage is that you adolescent patients in our practices cerned with the technical aspects of care can go from point A to point B in a probably do not need specialized mech- and forgets about how the appliance is straight line. Let’s take a look at an anics. The problem comes with patients working. There is good news, however. example. In extraction patients with who have complex problems such as Orthodontic departments are spending biomechanically oriented space closure, open bites, deep overbites, midline more time in educating their students you can retract all six anterior teeth into discrepancies, asymmetric molar about biomechanics, and several schools the extraction site with minimal anchor- occlusion, moderate to severe crowding, are moving away form technique-based age loss, excellent root alignment of the critical anchorage, crossbites, etc. A approaches to orthodontics. posterior teeth and ideal axial inclinations simple straight wire and chain elastics are of the incisors. On top of that, you only not going to solve these problems. These I must add that we at the University of have to activate the appliance once patients need a comprehensive treatment Connecticut have contributed signifi- during treatment. The maximum force plan with a mechanics plan to achieve cantly by providing educators in various you need for space closure ranges from results. Use of biomechanically oriented programs who can link biomechanics to 300 to 350 grams, and you lose only 25 appliances in these patients will help clinical practice. Out of our 100+ gradu- to 30 grams of force with each millimeter achieve tooth movement compatible with ates in the last 25 years, 20 are in full-time of tooth movement. Compare this with soft tissues, facial bones and jaw function. teaching, 20 are in part-time teaching, and sliding mechanics: There you have Let’s face it. No one has perfect results four are department heads. unknown force values, continual elastic every time. We love to show off our changes, uneven forces due to fast successes, but it’s when we come up short Dr. Turley: What are some examples of drop-off in force, force reactivation each that we lose sleep. When problems arise, biomechanically oriented appliances? time – I can go on and on. for instance, when our tried-and-true approaches are failing, we must develop Dr. Nanda: The best example is the Applying the principles of mechanics to alternatives. Understanding biomechanics intrusion arch. Although the name implies appliance design and selection increases and applying these principles aid our that it only intrudes, it can simultaneously creativity and innovation in solving our problem solving. correct Class II molar relationships, patients’ problems. How many times have especially in adolescents. The same wire we faced the perplexing problem of one Dr. Turley: What are some examples with a simple variation can close anterior of our patients not responding well to of commonly held beliefs in clinical spaces, flare incisors, correct occlusal treatment? When we are dependent on orthodontics that make little sense planes or, if ligated upside down, extrude “cookbook” techniques, these problems from a biomechanical perspective? anterior teeth. On top of that, you know may never be solved. With careful analysis how much force you are using, what from a biomechanical perspective, unique Dr. Nanda: Simple examples would be moments you are generating and what solutions may be found. the use of straight wires, step-ups and measures you have to use if you do not step-downs or reverse curve of Spee wires like the side effects. And this appliance In a nutshell, biomechanics allows you to to correct deep bites. You often hear can be used with any treatment approach. design an appliance that will give you a orthodontists say that they have intruded Actually, all appliances are biomechan- predictable tooth response without guess- the incisors to correct the deep bite. ically oriented; we just do not look at work. Actually, all these wires correct the deep them that way. bite by extruding the posterior teeth Dr. Turley: Why should an orthodontist and/or flaring the incisors. These As several chapters in our book care about the specifics of forces and approaches may result in bite opening, Biomechanics in Clinical Orthodontics moments if a particular technique is but predictable intrusive tooth movement reveal, only three to four types of wire clinically successful from an empirical may or may not occur. Unless you use designs accomplish almost all types of perspective? specific intrusive mechanics, it is difficult “With an understanding of biomechanics, simple loops, cantilevers and a small bend at the right place in the wire are to achieve intrusion. all that is necessary to improve an A straight wire or a flat wire placed in a crowded arch or one with a deep curve of orthodontist’s favorite technique.” Spee will invariably level the teeth by the process of extrusion and flaring. This has serious implications for a patient with a long face, a large interlabial gap and gummy smile. The straight wire will align teeth very well, but it will increase vertical dimension problems. This brings me back A B C to your earlier question as to what is Movement “clinically successful.” A Sequence of canine movement during retraction with sliding mechanics. Another example is the description ortho- A – The normal component of force (N) dontists use for incisor torque. A hundred and the frictional resistance to movement (f). years ago, torque was described in B – The bracket tips until the diagonally degrees. Now, we have been to the moon opposite corners of the bracket contact the and are moving on to the next millenni- wire. C – The wire deflects produce a couple um, and we still describe incisor root to upright the tooth. movement in degrees. Degrees is not the B way to describe force magnitude. A twist in a rectangular wire can deliver signifi- cant stress at the apex, but we still use it A without any idea of magnitude of force and moments.

Finally, all techniques are limited by Newton’s laws of motion, perhaps the C most important being that for every action T-loop positioned off center for Group A there is an equal and opposite reaction. space closure. A – The force system for This means for every distal force, there Group A space closure, with greater beta B must be a “balancing” mesial force, or moment than alpha moment. Note that there vice versa. Many times tooth movements are vertical forces in conjunction with a are described without regard for the moment difference. B – The length of the reactive forces. Distalization of molars beta "arm" is shorter (by about 2 mm) than with intraoral anchorage may often the length of the alpha "arm." The activation Clinical examples of couples. A – Engaging a produce a reactive mesial movement of of the spring is 4 mm. C – The fully inserted wire in an angulated bracket. B – Engaging a spring for Group A space closure. rectangular (edgewise) wire in a bracket slot. the anchorage teeth. In other words, there are no free lunches; the laws of physics apply to all our techniques. Drs. Bantleon, Burstone, Dermant, emphasis of various chapters has been to Dr. Turley: In the book you recently Gianelly, Graber, Kuhlberg, Kusy, correct specific problems, rather than to edited, Biomechanics in Clinical Lindauer, Melsen, Mulligan, Ram Nanda, describe a malocclusion on the basis of Orthodontics, Class II treatment Pancherz, Pearson, Shroff and Siatkowski the molar occlusion. receives a lot of attention. Why? have all contributed excellent chapters to this book. The emphasis of the book is on Dr. Turley: Can these principles be Dr. Nanda: We had a symposium in Class II, division 1 treatment as it relates applied to Class III treatment? Connecticut in 1993 on the correction of to biomechanics. However, the principles Class II malocclusions and another in described in the book are applicable to Dr. Nanda: Yes, Pat, you can apply the 1995 on biomechanics. I invited speakers every aspect of clinical orthodontics. very same principles. As you and I have from the two symposiums to contribute We have deep bite, anchorage problems, been active in improving methodologies chapters for this book. Leaders in the field extraction and nonextraction mechanics, to correct skeletal Class III in grow- of biomechanics and orthodontics such as etc., in all types of malocclusions. Overall, continued on page 23 5 Illustrations from Biomechanics in Clinical Orthodontics courtesy of W.B. Saunders Company The Orthodontic Application System – Still More Ammun

by Michael W. Scott, D.D.S., M.S.D. the missing teeth are ultimately replaced Longview, Texas by a removable partial denture, a fixed bridge or an implant. In other cases, it is n a previous issue of Clinical Impressions, best to close the spaces by orthodontically I stated the list of my personal practice moving the teeth. goals. That list of goals has remained one of the foundations of my practice for years The latter situation will be the focus of and consists of: this article: • Producing consistent, predictable, • A patient presents with missing high-quality orthodontic results maxillary permanent lateral incisors. • Practicing with great efficiency • The primary lateral incisors are either • Starting all the cases I care to start missing or will be extracted due to root • Making a reasonable profit resorption or other considerations. • Having fun • After all factors are considered, a decision is made to close the spaces It is with the first two goals in mind that by moving the permanent cuspids, I would like to present an orthodontic bicuspids and molars mesially. problem that, at least for me, poses a • The cuspids will be cosmetically bonded treatment planning dilemma virtually after orthodontic treatment. every time it is encountered. The numerous factors involved in the An eight-year-old patient is referred to diagnosis and treatment planning are not your office by her general dentist. The the subject of this article. How one arrived patient’s dentist is concerned that the at the decision to close the spaces is maxillary permanent lateral incisors have immaterial to this paper. not erupted and wants your evaluation. You take a panoramic radiograph and When tooth movement is the elected I discover that the laterals are congenitally procedure, there are several ways to missing. In addition, the primary lateral approach it. I will describe a method incisors show significant root resorption, that I feel greatly increases my ability to even though there are no succeeding achieve the goals of consistency, pre- permanent teeth. As you begin your dictability, quality and efficiency. My expe- explanation to the parents that “the rience has been that mesial movement of patient is missing her maxillary lateral the cuspids, bicuspids and molars can be incisors,” before the word missing is a very time-consuming, unpredictable and completely off your lips, the question is inefficient process. A solution to this posed by the parents, “What are you problem came and bit me on my backside going to do, Doctor ?” several years ago when, by chance, one of my facemask patients was seated next The answer to the question, of course, to a patient with missing maxillary lateral depends on myriad factors. In some cases, incisors. (You know where this is going,

Dr. Scott earned his D.D.S. from the University of Tennessee School of Dentistry in 1982 and his M.S.D. in Orthodontics from Baylor College of Dentistry in 1984. He has lectured in both the United States and abroad on the Orthos Appliance System, early treatment and facemask therapy. He is a board-certified orthodontist with a private orthodontic practice in Longview, Texas. 6 on of an Orthopedic Force unition for Your Operatory!

Case Presentation: Patient S.A., female, 7 years, 6 months of age, congenitally missing upper laterals.

Figures 1-6. Pretreatment photographs and panoramic radiograph. Phase 1 treat- ment initiated in May 1989 and completed in May 1990.

Figure 1. Figure 2. Figure 3.

Figure 4. Figure 5. Figure 6.

don’t you?) To make a long story short, Clinical Case Presentation shown in Figure 6. A summary of signifi- I began to use the A.D. Protraction Patient S.A. The patient presented to my cant findings from diagnostic records Facemask™ in many cases where the treat- office in March 1989. At that time she revealed: ment plan called for closing spaces. was 7 years, 6 months of age. Summer • Balanced facial appearance in both was referred by her pediatric dentist for frontal and profile views. The orthodontic application of orthopedic the evaluation and treatment of missing • End-on Class II molar relationship. force systems is not a new idea. One maxillary lateral incisors. Her mother was • Overjet of 4 mm. example is the use of headgear to distalize also concerned about a large diastema • Missing maxillary permanent lateral maxillary molars. I can think of much between Summer’s maxillary central incisors. better ways to accomplish that, i.e., incisors. Pretreatment facial and intraoral • Mild mandibular crowding. Lokar™ Molar Distalizers, but that is what photographs are seen in Figures 1-5. The • Maxillary and mandibular mid- is often proposed. pretreatment panoramic radiograph is continued on following page 7 Dr. Scott continued from preceding page

lines were coincidental. move the maxillary posterior teeth • Skeletal Class I. ANB = 3°, • Skeletal Class II. ANB = 6°, mesially as time passed. NA - APo = 4°. NA - APo = 9°. • Space excess in the maxillary arch of • Maxillary midline diastema. Phase 1 treatment was initiated in May 10 mm. • Roots of the maxillary primary lateral 1989 and completed in May 1990. incisors were resorbing. Summer was then seen every four months The panoramic radiograph taken January to monitor the integrity of her lingual 1994 is seen in Figure 13. The principle concern was the long- arch. The lingual arch was removed in term management of the missing lateral July 1991, upon the eruption of the The Phase 2 treatment plan was as incisors. Summer and her mother were mandibular cuspids. follows: both very hesitant about placing implants • Band/bond the maxillary arch. or bridgework in her mouth. Secondary Facial and intraoral photos taken in • Bond the maxillary cuspid brackets in a concerns were the crowding of the October 1991 are seen in Figures 7-11. position slightly more distal than mandibular anterior teeth and the maxil- A progress panoramic radiograph taken at normal to help rotate the teeth into lary midline diastema. the same time is shown in Figure 12. Note more favorable positions for future cosmetic bonding. • Bond the maxillary cuspid brackets upside down (Figure 14) to produce “The use of the facemask more favorable lingual root torque, because these teeth would ultimately helped to close a 10 mm space be made to resemble laterals. • On an .016 S.S. upper archwire, use excess in the maxillary arch sliding hooks distal to the cuspids and begin elastic traction from the sliding that would have otherwise hooks to a facemask (Figure 15). • Once the cuspids are forward, position the hooks distal to the 2nd bicuspids posed significant mechanical and slide both the 1st and 2nd bicus- pids mesially at one time (Figure 16). challenges.” • The .016 S.S. archwire would be constructed with omega loops and be tied back to the 1st molars. The diagnostic data, along with the the favorable eruption pathway of the • Band/bond mandibular arch soon after concerns of the patient and parent, led to maxillary cuspids. Evaluation of the facemask started. the decision to close the lateral incisor panoramic radiograph led to the decision • Class III elastics if needed. spaces over the course of time. A phase of to have the maxillary right and left • Cosmetic bonding of the maxillary early treatment would be undertaken to primary laterals, cuspids and 1st molars cuspids posttreatment. address the mandibular crowding and (upper B’s, C’s, and D’s ) removed. the maxillary midline diastema. Phase 1 Summer was then seen every six months Cuspid brackets as opposed to lateral treatment consisted of the following: for observation. brackets were used on the cuspids simply • Maxillary 2 x 2 to close the diastema because of the better fit. and align the central incisors In January 1994, progress records were cosmetically. obtained and Phase 2 treatment was ad- Summer was instructed to wear her face- • Lip bumper to relieve the mild vised. A summary of significant findings mask 12 hours per day. Ormco Ram (1/4 mandibular crowding. included: inch, 6 oz.) or Impala (3/16 inch, 6 oz.) • Mandibular lingual arch after lip • Age: 12 years, 4 months. elastics were used for traction, one on bumper. • Missing maxillary lateral incisors each side. The facemask was adapted to • Selective extraction of primary teeth (no divine intervention occurred). the patient exactly as it would be used in over time. • End-on Class II molar relationship. maxillary protraction. (Please refer to my • Bonded lingual retainer for upper • Overjet of 3 mm. articles in Clinical Impressions, Vol. 2, No. 1-1 posttreatment. • Maxillary 1st bicuspids rotated 1, 1993, and Vol. 2, No. 4, 1993.) The •The skeletal Class II and overjet were not mesially 45°. only exception is the direction of pull of addressed in Phase 1. No headgear • Maxillary and mandibular midlines the elastics. Instead of pulling downward 8 was used because of the decision to coincidental. continued on page 11 Figures 7-12. Photographs and progress panoramic radiograph taken in October 1991. Evaluation led to the decision to remove upper B's, C's and D's, after which patient was seen every 6 months for observation.

Figure 7. Figure 8. Figure 9.

Figure 10. Figure 11. Figure 12.

Figure 13. Panoramic radio- Figures 14-16. Phase 2 treatment plan included: graph taken in January 1994.

Figure 14. Maxillary cuspid brackets bonded Figure 15. Sliding hooks distal to cuspids Figure 13. upside down to produce more favorable used for elastic traction to facemask. lingual root torque. Note that the "dot" (usually positioned distally and gingivally) is positioned mesially and occlusally.

Figure 16 (right). After cuspids were moved forward, hooks were placed distal to 2nd bicuspids to slide both 1st and 2nd bicus- pids mesially at one time. Figures 17-19. Intraoral progress photographs taken in May 1996, 20 months into Phase 2 treatment.

Figure 17. Figure 18. Figure 19. Figures 20-22. Posttreatment photographs taken in November 1996 prior to cosmetic bonding.

Figure 20. Figure 21. Figure 22. Figures 23-27. Final photographs taken in January 1997 after cosmetic bonding.

Figure 23. Figure 24.

Figure 25. Figure 26. Figure 27. Dr. Scott continued from page 8

at a 45° angle, as in maxillary protraction, bonding. Final facial and intraoral pho- high-quality orthodontic care to a the direction of pull should follow the tographs taken after cosmetic bonding are 12-year-old patient by providing her with plane of occlusion. shown in Figures 23-27. the ability to go through life with an occlusion composed of all natural denti- Once the maxillary cuspids and bicuspids Conclusion tion. The use of the facemask helped to were forward, the maxillary 1st molars As can be seen in the previous clinical close a 10 mm space excess in the maxil- had to be moved. This was accomplished example, the use of the A.D. Protraction lary arch that would have otherwise posed by wearing Class III elastics (Ormco Ram) Facemask as an orthodontic force delivery significant mechanical challenges. This from an .016 x .025 S.S. mandibular arch- system can be a valuable tool in specific was also accomplished very efficiently in wire to an .016 S.S. maxillary archwire situations such as the one described. In that the facemask was only worn for five without omega loops. The maxillary 2nd considering how the use of this force months. This efficiency of mechanics molars were not banded and followed very system has impacted my practice goals, resulted in the case being more profitable. nicely. I have reached several conclusions. The Only 19 appointments were needed to results that can be expected from the use complete treatment. Progress intraoral photographs taken 20 of this force system are predictable and months into treatment are shown in consistent. The quality of the final result As you consider the treatment and results Figures 17-19. Note the buttons placed achieved in Summer’s case was greatly achieved in this case, I hope you will on the lingual of the upper 2nd bicuspids. improved by the fact that she was spared agree that the orthodontic application of These were used along with power chain the need for major posttreatment restora- orthopedic force systems truly adds more to maintain rotational control of the bicus- tive work. I feel that I delivered extremely ammunition to your operatory! pids as they were moved mesially. Profile Protraction Facemask has a more Treatment proceeded well with the excep- The A.D. Protraction flattened forehead rest, a flatter and tion of six missed or canceled appoint- Facemask – broader chin cup and less curvature in ments over the course of treatment. Three the vertical bar profile. Some orthodon- of the missed appointments occurred in Designed with tists prefer the new design for their the first year of treatment and accounted Patient Compliance non-Asian patients as well. Both types for 25 weeks of excess time between are available as a complete package visits. That might not be that critical in in Mind containing a choice of blue or lavender ™ today’s world of 35°C Copper Ni-Ti masks, three chin and three forehead The A.D. (Adjustable Dynamic) archwires. However, when you are in the replacement pads and a hex key for ® Protraction Facemask™ provides dynam- 1994 world of braided D-Rect , it makes adjustments. Order information is pro- ic movement in the forehead rest while a huge difference! The other three missed vided on page H of the Center Section. appointments accounted for nine weeks of allowing the chin cup to slide vertically excess time between visits. along the main frame. This means maxi- mum patient comfort while sleeping, Summer’s treatment summary is as talking or any time the jaw is moving. follows: Since the movement of the softly padded chin cup and forehead rest involves • Total treatment time = 29 months. much less sliding contact with tissue, • Total number of visits to complete irritation is reduced and comfort is treatment = 19. improved. Increased patient compliance • Total time wearing facemask = equates to more efficient orthopedic and 5 months. orthodontic therapy. • Total time wearing Class III elastics = 4 months. The A.D. Protraction Facemask is fully adjustable, so one size fits all patients. Due to the explosion in archwire technol- The horizontal arm for elastic hookup ogy, the archwire sequence I used is not can also be positioned inside or outside relevant. It is amazing how much has the vertical bar to modify forces and changed in less than three years. Intraoral vectors. In addition to the standard photographs taken posttreatment are facemask design, a modification is now shown in Figures 20-22. These photo- available for the Asian patient. The Asian graphs were taken prior to cosmetic 11 Perspective on Dental Managed Care Plans The Solution: “Don’t sign up!”

by Wayne McMahan dental managed care plans and gave some was eventually passed by an overwhelm- Montgomery, Alabama advice to his audience. Dr. Zatts said, ing majority of both the House and Senate “The way for dentists to respond to bad and signed into law by then Governor couple of years ago, managed care plans is simply not to sign Jim Folsom, Jr. Dr. Marvin Zatts, a dental up for them.” When I had a chance to consultant for The respond, I observed that Dr. Zatts’ “don’t BCBSA’s next step was to file suit in Prudential Insurance sign up” proclamation was one of the best Federal District Court seeking to have Company, and I made arguments I had heard in defense of the the APCL overturned. The BCBSA separate presentations to Alabama Patient Choice Law (APCL). challenge to the APCL was assigned to the Middle Atlantic Society Federal District Judge Seybourn Lynne. of Orthodontists in In essence, the APCL allows individuals Due in part to some serious health AWilmington, Delaware. Later in the day, in managed care plans to seek care from problems that Judge Lynne experienced Dr. Zatts and I served on the same panel. any provider they choose, even if the shortly after the lawsuit was filed, the At one point during the panel discussion, provider is not under contract with the Birmingham Federal Judge did not Dr. Zatts abruptly stopped defending all patient’s health plan. If the noncontract issue his ruling in the case until January provider’s fees are higher than the contract of last year. The decision was in favor allowance, then the patient, not the plan, of BCBSA. is required to pay the difference. The contract payment allowance can be Although the defendants (seeking to assigned by the patient to the noncontract uphold the APCL) in the suit immediately provider. determined that Judge Lynne’s order would be appealed to the Eleventh How does Dr. Zatts’ “don’t sign up” advice Circuit, the formal filing of the appeal substantiate the need for the APCL? proved to be a legal marathon. It now Obviously, dentists have the option of not appears that a three-judge panel of the signing up for managed care plans that Eleventh Circuit will hear oral arguments they feel are, in Dr. Zatts’ words, “bad regarding the APCL in either spring plans.” But what about the patient who is or early summer of this year. In addition an employee of company XYZ? Rarely are to the briefs already submitted to the employees allowed any input into the Eleventh Circuit by the attorneys selection of their company’s health plans. representing the defendants, both the So what is the employee’s option if the American and New Jersey dental associa- company plan is a bad one? Without a tions have submitted written arguments law like the APCL, there is obviously no supporting the defendants’ position. option. The dentist may elect to eschew “bad plans,” but the employee must The case before the Eleventh Circuit Wayne McMahan has been the executive acquiesce to the employer’s decision or involves a number of complex legal director of the Alabama Dental Association for the past 17 years. Prior to his current pay for care out of his or her own pocket. issues. In essence, however, the court will position, he worked for eight years as the review two facets of Judge Lynne’s earlier executive secretary to a former governor and When the APCL legislation was being decision: first, that ERISA (self-insured) lieutenant governor of the state of Alabama. considered in 1994, lobbyists for Blue plans are preempted or exempt from Mr. McMahan is also currently serving as the Cross and Blue Shield of Alabama complying with the APCL and, second, president of the American Society of Constituent Dental Executives. He resides (BCBSA) told legislators that the passage that the APCL is not applicable to any in Montgomery, Alabama, with his wife and of the APCL would result in the demise of BCBSA plans. two children. managed care in Alabama. Legislators did 12 not buy BCBSA’s arguments, and the bill continued on page 22 Just Say It! Creating the Upbeat Office

by Barbara Brunner, M.A. Each staff member represents you and Orange, California your practice in each and every inter- action with a patient. With patient ustin Hoffman, Robert De Niro, Meryl service being so inextricably tied to the Streep, Susan Sarandon, Harrison Ford, perception of your clinical care, it seems James Earl Jones. Actors and actresses curiously uncharacteristic of you (who renowned for creating signature roles. fusses over tooth movement measured in But no director ever sent any of them fractions of millimeters) to leave critical before a camera with only inspiration and communications to happenstance. One an abstract concept of how they were to alternative is scripting. develop their dialogue. They got a script. Make Sure We’re All Reading Choirs sing from hymnals. Orchestras from the Same Sheet of Music play from scores. Presidents speak from Scripts are working documents, not meant notes. They plan. They practice. to have everyone marching in lockstep, but flexible models that provide key They practice. They practice. They prac- words and, more importantly, key tice. philosophies about how to deliver specific messages or answer critical questions. Yet every day doctors send unseasoned Like mission statements, much of the staff members to represent them and their value in developing scripts is the discus- D offices before the moms and dads, the sion that goes into them. Such discussion youngsters and the teens of the world encourages buy-in from your staff. It also with only the most vague idea about how helps them internalize your philosophies to translate their vision of quality patient by getting a clear understanding of the care into day-to-day conversations and importance of key phrasings. With scripts, instructions. “We’re a patient-oriented you and your staff will weave your office, Mary Ann. You’ll find that we do individual brands of humor (“Retainers whatever it takes to make sure that our are pajamas for your teeth”) and your patients are happy to come here and are chairside charm (“So, Christy [age 12], satisfied with their smiles when they continued on following page leave.” Some staff members are naturals, keen at transforming such abstract ideas into dialogue, picking up specific wording Ms. Brunner is manager of Ormco’s Practice from you and other talented staffers. They Development Seminar Series. She holds are the peak performers. Others, at best, a master's degree in organizational simply muddle by. communication and management from Ohio University. With 20 years’ experience in communication and marketing, Ms. Brunner You usually find out about the worst has led two companies in transitioning muddlings inadvertently, perhaps when to a culture where increased involvement you overhear a particularly jarring verbal in decision making at all levels resulted in blunder, when repeated misunderstand- overachievement of stringent goals. With Ormco, Ms. Brunner has been instrumental ings occur or when your best referring in translating skill requirements of doctors dentist relates an appalling comment one and staff members into educational policy of your staff members made to a mutual and practice. patient. 13 Just Say It! continued from page 13

did you come with your husband today?”) habits of phrasing early in life. We may missing a lot of areas between the brackets with proven patient relations techniques. wish to espouse important values of and your gums.” With: “David, you’re When they become second nature, you being patient-centered, partnership- doing a great job wearing your elastics. can just say it and know that the wording oriented, caring and positive in our It means you might get your braces off you’ve shaped will support and clarify the outlook. Our language can often still sooner. Won’t that be super? Being a message you purposely mean to deliver. connote myopia, condescension, control World Class Elastics Wearer, I know you and even cynicism. Communication can handle brushing with braces – getting when handling persistent noncompliance between the brackets and the gums. Let’s issues should certainly be progressive, have Jenny give you some tips on becom- with greater brevity and more directness ing a World Class Tooth Brusher, too.” “Restating as discussion continues. First, however, let’s look at ways we can inject consistency Jenny then follows up the discussion with: problems in between our philosophies and our “You know, David, if you’ve got elastics language before the conversation needs down pat, you've done the really hard terms of to escalate. part. Now you can focus on a couple of tricky areas that your toothbrush seems to challenges and No Buts About It miss. Easy stuff for the Master of Elastics.” Ever been given a compliment only to have it taken away in the same breath? Compare: “Jenny, you’ve really impressed opportunities “Hey, Doc, nice job, but that space me with having picked up so many essen- between these two back teeth always tial chairside assisting skills in the short with a solution collects food.” What message did you time you’ve been here, but I’d like to see hear? Certainly not the compliment. more detail in your treatment cards.” approach With: “Jenny, you’ve really impressed me A staff member is doing a particularly with having picked up so many essential encourages good job in one area. We’d like the chairside assisting skills in the short time approach modified for a particular aspect you’ve been here. Way to go! You know of the job, so we say something like this: what I’d like your next challenge to be? partnership “Cindy, I like the way you’re giving the Detail with treatment cards. Let me get tour, but I wish you’d give more emphasis Marcy to review with you what’s expected in care.” to the sterilization area.” What does the and why, so that by this time next week, staff member hear? Certainly not the you’ll have mastered that as well.” Not compliment. She hears nothing except only have we built on Jenny’s successes to what is said after the but. challenge her to the next level, we’ve also Your Relationship is Showing made our language more specific, making There are at least two aspects to every Why do we sandwich a but between a our expectations clear with a goal and a communication: the content and the compliment and a criticism? Who knows? time frame. relationship. The relationship between (Maybe we picked up the idea from people colors every aspect of the content. Blanchard’s One Minute Manager.) It’s a Note: If you have a persistent performance It’s why a good friend can say something skill. We learned it. We can unlearn it. issue, keep the message clean. Mixing rude and you chalk it up to a bad day. If you truly want to compliment an messages about substandard performance It’s why a person whom you distrust can individual, do so without the but. If the with a compliment is misleading and give you a compliment and you wonder compliment is a well deserved one about unfair to your staff. what they want. We often convey how important accomplishments and the we feel about someone through how we constructive criticism is a trifling thing, Patient Focus Starts with You shape the content. you end up sounding picky. If someone When you deliver a message from the is doing a good job in one area except perspective of listeners (e.g., McDonald’s Every interaction should have the same for certain aspects, build on successes to slogan, “You deserve a break today.”), objective: to have the patient clearly change behavior in another way. you help yourself see things from their understand the content and have the vantage point. You will more likely, then, relationship aspect continuously be Compare: “David, you’re doing a great job deliver the message with a patient- saying, “You’re worthwhile. We care.” wearing your elastics. That means you centered or staff-centered focus, reinforc- While most of us have these inten- might get your braces off sooner, but your ing the emphasis on meeting their needs. 14 tions, we have often picked up our brushing hasn’t been very good. You’re Introductory patient letters and Scripts: Ten Easy Steps to Power Talk brochures, for example, are peppered with bands back on after lunch. Is there some 1. Brainstorm to identify every situation we, our, I and my staff and I (e.g.,“We are way we can help him remember – maybe where communications are critical pleased to have the opportunity to explain by packing these Ormco Z-pak elastics (e.g., recurring patient “compliance” the benefits of orthodontics,” or “We in his lunch box? Or maybe he could discussions, your most unpopular appreciate the trust you have shown by wear his elastics on his little finger while policies, situations in which you selecting us to help with your orthodontic he’s eating? Think either of these ideas know you tend to preach rather than needs.”). Anytime you can replace these could help? Or maybe you have another partner). pronouns with you, do so (e.g.,“Your suggestion?” Now the discussion is 2. Prioritize the top three. initial visit is a time for us to get to know oriented away from the problem and 3. Brainstorm all the ideas you already you and what you want to accomplish,” toward the challenge of finding possible use (not judging them at this point). or “Your decision to take advantage solutions, focused on behavior rather 4. Develop one or two scripts for each of the benefits of orthodontics is an than attitude and on shared ownership of situation. investment in your child’s future.”). the challenge. 5. Check your phrasing against the do’s The you perspective helps focus on the and don’ts listed here, using other patient’s needs and can often keep you What’s in It for Me? techniques you know work well. from spouting platitudes. Work the Translating features into benefits. It’s a 6. Rephrase where appropriate. you perspective into your case presenta- primary tenet of every case presentation 7. Role play using the script, putting the tion verbiage. It’s a good way to differenti- and marketing course given. If the patient expressions into your own manner of ate yourself. And it’s a theme that works is still asking “So what?” after you’ve speaking, adding humor. with staff, too. bragged about some aspect of your 8. Incorporate one script every three to practice, you may still be focusing on a four weeks. Note: Want to try an interesting exercise? feature, assuming that your patients can 9. Share results and alter where Have everyone refrain from using the translate features into benefits on necessary. words I or we for ten minutes at your their own. Don’t leave this to chance. 10. Choose the next three priorities and next staff meeting. It provides insight repeat the process. into the paradigm within which we all Feature: “We use the most advanced wire operate. technology available.” Just Say It! is a course offered through Pose Problems as Challenges Benefit: “Because we use the most Ormco’s 1997 Practice Development to Focus on Solutions advanced wire technology on the market Seminar Series that Ms. Brunner will Problems point out what’s wrong. today, appointment times can often be conduct in Minneapolis, Minnesota, Challenges position issues in terms of scheduled eight to ten weeks apart rather June 20, 1997, and Vancouver, British what can be done. Restating problems in than monthly as we did only a couple of Columbia, August 29, 1997. For more terms of challenges and opportunities years ago. This means less time away from information about this course, contact with a solution approach encourages school for Kristin and from work for you. your local Ormco representative or an partnership in care. And then there’s the comfort. These new Ormco customer service representative wires move with so little force to do the at (800) 854-1741, Ext. 7001. Compare: “Mrs. Jacobs, I’ve got a problem same job as traditional stainless steel wires with David’s poor elastic wear. He’s not that Kristin should be quite comfortable progressing as quickly as he should, and throughout treatment.” Tact is the Language of I know he’s going to be frustrated Strength if we can’t take his braces off when we How You Get Started Almost every time we open our mouths originally planned. He just needs to Psychologists tell us that it takes 21 days to speak, we are attempting to influence understand how critical wearing his to develop a new skill. If changing your another human being. These language elastics is to his progress.” Here the team’s language is something you skills are centered around tact. Tact is the doctor owns the problem, is focused consider worthwhile, work in increments. language of strength. Exhibiting tact on attitude (understand) rather than Choose one script or one general requires that you continually monitor behavior and has expended considerable language change on which to work. what you are about to say, given your breath without yet being directed toward Concentrate on that change for three listener’s perspective and your relationship a solution. With: “Mrs. Jacobs, we’ve got weeks or until you feel comfortable with that listener. It’s the art of making a a challenge to help David improve his with it, then move on to another change. point without making an enemy. As Zig elastic wear so he’ll be able to get his Make a game of it. Every time someone Ziglar aptly puts it, “It’s difficult to offend braces off when planned. David men- works creatively to eliminate an unneces- people and influence them at the tioned that he forgets to put his rubber sary but, ante up $1 for pizza. same time.” 15 Developing and Implemen

by Jerry R. Clark, D.D.S., M.S. or those influencing conditions can be Greensboro, North Carolina analyzed by using statistical research to provide the doctor a much better grasp n the previous article*, we discussed the of why people might choose his or her importance of getting all your practice’s practice. This involves: systems in place prior to initiating the • Practice Analysis development of a marketing plan. This • Geographic Analysis process is essential to providing such a • Competitive Environment Evaluation wonderful experience for your patients that they will want to tell everyone they From this analysis, conclusions are drawn know about your practice. Only after all and strategies developed to maximize the the appropriate systems have been estab- effectiveness of the plan and to allow the lished is it time to aggressively market the plan to be implemented in a cost effective practice, to develop a strategy to increase manner. We will illustrate this process by the number of individuals who will developing an actual plan compiled for a demand your service. The plan, which practice by Orthodontic Management will be outlined, is similar to the sophisti- Group to show how the information cated marketing plans used by major gathered is used to mold and develop the corporations like McDonald’s. You, too, plan. To be effective, accurate statistical can attract more customers just like they data must be obtained and appropriate do and do it in a manner consistent with market research must be performed. The I the highest levels of ethics and profession- eventual marketing plan will be no better alism. There are three basic steps in than the research information obtained, developing the actual marketing plan: so take the time to do your research care- • Positioning fully; otherwise, you are probably wasting Positioning (differentiation) involves the your time. analysis of the determining factors, or as they are called in the marketing field, Practice Analysis “influencing conditions,” which cause Evaluate the practice by thoroughly ana- consumers to choose one product or lyzing all aspects of the practice and service over another. benchmarking the practice at one point in • Development time. These include the following: Development of the marketing plan involves using those influencing condi- Statistical Analysis – Involves the tions to develop goals and strategies to tracking of meaningful information about reach and attract patients through the the practice over a period of time so use of specific internal and external trends can be determined and under- marketing efforts. stood. See Figure 1 for an actual statistical • Implementation analysis of a practice. Implementation of the plan involves the • New-Patient Growth – The number of Dr. Jerry R. Clark is a board-certified ortho- establishment of a marketing calendar new patients is growing nicely and indi- dontist with a practice in Greensboro, North and a budget for the marketing efforts. cates a positive trend. Carolina. He is also CEO of Orthodontic Management Group, Inc. (800-621-4664), Staff members and the doctor are assigned • Seasonality – The practice reaches its a consulting firm specializing in increasing specific responsibilities to make sure the peak season during June, July and August. the profitability and productivity of ortho- marketing strategies are carried out as People usually are not interested in spend- dontic practices. Services include develop- planned. ing money on orthodontics in December. ment of strategic business plans, budgeting • Start Rate – There is a dramatic rise in and marketing plan implementation, doctor and staff training, tracking services, practice Positioning (Differentiation) patients getting ready to start treatment. valuation, partner location services and The decision of a consumer to choose This is an extremely favorable trend. practice transition facilitation. one product or service over another is a 16 complicated issue. However, that process Conclusions: Continue to increase the *See article by Dr. Jerry Clark, “Developing an Effective Marketing Plan for Your Practice,” Clinical Impressions, Vol. 6, No. 1, 1997 enting the Marketing Plan

number of new patients by implementing a strong marketing plan. Do not concen- Statistical Analysis trate on external marketing during the 1992 1993 summer months or December. Investigate New Diagnostic New Diagnostic the new-patient exam and recall proce- Patients Records Patients Records dures and discuss any improvements January 28 16 24 15 which can be made. February 29 15 26 21 March 27 19 27 18 Procedural – Based on the statistical April 27 18 20 18 information, many procedures which are May 23 17 21 20 already in place seem to be working well. June 32 24 27 23 However, some improvements can be July 31 17 47 29 made. August 28 13 34 31 September 27 18 24 10 Conclusions: To improve current new- October 20 20 31 30 patient procedures: November 22 11 34 20 • Make the new-patient “experience” December 21 7 18 14 more comprehensive and informative (minimum 30-minute exposure). TOTAL 315 195 333 249 • Ask the new patient his or her primary Start Rate 62% 75% concern and focus on it. • Inform new patients of sterilization Figure 1 procedures. • Give a thorough office tour before the new-patient exam. fessional; projects warm, caring attitude. orthodontics is expensive. However, it is • Office atmosphere – Excellent and the responsibility of the practice to To improve the consultation: professional, yet light, friendly, warm make sure that treatment is affordable • Shorten consultation and make it more and caring. and will be made so through flexible relevant to the patient. financial arrangements. Flexible • Begin the consultation by addressing the External arrangements should be provided only patient’s concerns. • Correspondence – Excellent; all to those individuals who have demon- • Use visuals – photographs, models, brochures, letters and correspondence strated financial responsibility in the imaging. are professional in appearance and past, i.e., good credit rating. If the rating • Provide the patient with a vision of comprehensive, yet brief; everything is is good, provide sufficient options for completed treatment. coordinated and is highlighted by an payment to facilitate treatment accep- attractive, professional, distinctive logo. tance. Image – What image does the practice • Positive outside perceptions – Very • Doctor is often out of office – Doctor present to potential patients? What is their positive, good treatment, competent, needs to inform staff of exact plans, and perception of the office, doctor and staff friendly staff, patients seen on time, staff conveys to patients that the doctor members? How does the community view a fun place for patients to be treated. is out of the office for legitimate reasons. the practice? These are all assessed and • Negative outside perceptions – Too Example – “Doctor is attending a evaluated. expensive, doctor is often out of the office, continuing education seminar. He is doctor is perceived to be too tough on constantly going to programs to allow Internal patients and parents for noncompliance. him to keep abreast of all the latest • Physical facility – Has been completely developments in orthodontics.” remodeled and redecorated; grounds, Conclusions: Concentrate on changing the • Doctor is too tough on patients and parents parking lot and signage are very good. outside perceptions of the practice from for noncompliance – In the future, the • Staff appearance – Excellent, profession- negative to positive. Address each issue in doctor will only give positive feedback al; uniforms project an unspoken unity a strategic manner. and leave it to the staff to discuss among staff members. • Too expensive – Convey to patients at compliance issues. The staff will • Doctor’s appearance – Excellent, pro- the new-patient appointment that Continued on following page 17 Dr. Clark continued from page 17

discuss hygiene and noncompliance Current Referral Status with patients/parents and keep the doctor out of the “fray.” If treatment is No. of No. of No. of being extended due to noncompliance, Doctor referrals Doctor referrals Doctor referrals the treatment coordinator will discuss, Anderson 4 Herbin 1 North 1 well in advance, the potential for Best 2 Hewitt 2 Orr 1 increased charges or early appliance Blair 4 Hicks 3 Owens 17 removal before treatment completion. Blaylock 1 Hill 4 Parker 1 Boles 6 Jolly 4 Rabb 1 Current Referral Status – See Figure 2 Campbell 1 Jones 1 Redding 1 for an example of patient referrals to a Capps 1 Kiser 1 Riley 3 practice. From this information, important Cecil 15 Kramer 1 Sharp 2 conclusions can be drawn that will guide Chandler 2 Lee 2 Smith 1 you in the formulation of the strategy for Church 19 Lewis 2 Snead 1 marketing to referring doctors. Costello 3 Lind 1 Taylor 1 No. patients Percent Douglas 1 Lockhart 1 Watkins 1 referred of total Earl 1 Lowry 1 White 1 into practice referrals Fowler 4 McNair 6 Wilson 8 Doctor referrals 174 47 Fox 1 Meyer 1 Zales 19 Friend/family referrals 128 35 Garrett 11 Mobley 1 Fr/Fam 128 Previous orthodontist 15 4 Harper 2 Moss 1 PrevOr 15 Other 53 14 Henson 1 Noble 3 Other 53 Total 370 100

Figure 2 One hundred thirty referrals came from 16 doctors while the other 35 doctors referred only 44 patients. Seventy-five percent of the doctor referrals came from approxi- Financial Policy and Options mately 30 percent of the doctors. In an effort to help you in budgeting the financial portion of your Conclusions: The referring doctors should orthodontic investment, we have organized several payment options: be divided into two tiers. • Tier 1: The 16 doctors providing the • Option 1 – Ten percent off total fee for cash payment at the start of treatment largest percentage of referrals. The prac- • Option 2 – Seven percent off total fee for full payment within 90 days from the start of tice should also choose five doctors not treatment, divided into three equal payments in the current Tier 1 level and concen- • Option 3 – Twelve equal monthly payments with no down payment for full treatment; six trate on bringing them into Tier 1 over equal monthly payments with no down payment for Phase 1 and partial treatment the next year. Market this group • Option 4 – Twenty-five percent down and 18 months to pay for full treatment; 25 percent aggressively. down and 12 months to pay for Phase 1 treatment • Tier 2: The doctors who only occasion- • Option 5 – Ortho-Line financing with zero down and long-term payment of a minimum of ally refer to the practice. Should receive 3 percent of the balance only minimal marketing efforts at little or no expense to the practice. NOTE: As in any financial arrangement, credit history may influence final arrangements. Extension of payments beyond 18 months may be Current Patient Base – possible with the addition of a small bookkeeping fee. It is our goal to • Adults, 33 percent maintain excellent financial relationships with our patients. The #1 • Children, 67 percent reason for unhappy patients is unclear or unkempt financial arrange- Practice should concentrate on fulfilling ments. the wants and needs of both patient bases.

Figure 3 Adult • Needs: orthodontic treatment, affordable treatment. 18 • Wants: constant information on what is happening to them; communication on Current Marketing Plan – Figure 4 progress toward completion; encourage- illustrates a marketing plan previously Previous ment; “don’t waste my time;” want to used by a practice. know you care. Marketing Plan Conclusions: Many marketing approaches Current Patients – Children Children are currently being directed toward • Give away pencils with practice • Needs: orthodontic treatment. patients and referring doctors. Ensure name and telephone number • Wants: to have fun; “How much they are organized in a fashion to produce • Water bottles with practice name longer?” (information); encouragement maximum productively and cost effective- and number (compliance). ness. Omit some of the more expensive • Give away tooth-shaped erasers things such as T-shirts, water bottles and • Sugarless gum Conclusions: Provide ongoing information tooth erasers. Give away only coupons • T-shirts and encouragement about treatment and that can be obtained at no expense to • Gift certificates treatment progress that does not back the practice. A thorough and complete • Video games in the office the doctor into a corner of promising the analysis of the practice is the most • Occasional contests exact time treatment will be completed. essential step in determining the final • Cupcake on patient’s birthday Make sure children have fun every time marketing plan. When diagnosing a case, • Skating party they come in for an appointment. your treatment can be no better than the • Gift the day braces are removed quality of the diagnostic records and the Current Patients – Adults Fees and Financial Arrangements – research performed in devising a treat- • Gift the day braces are removed Fees must be fair for both the patient and ment plan. Similarly, your marketing plan • Special adult day in practice the doctor. The entire patient experience will be no better than the initial research (only adults scheduled) must be one of excellence, not just the to devise that plan. • Christmas party treatment being performed. After all, aren’t the beds at Ritz-Carlton the same as Geographic Analysis Outside Office the beds at Days Inn? The difference in The type of information shown in Figure • Visit patients in the hospital what these two companies charge for a 5 can be obtained from various informa- • Annual advertising in school night’s stay has nothing to do with why tion services such as your local chamber yearbooks you are staying there (the bed) but every- of commerce or a state department • Sponsor softball team thing to do with the experience (customer involved with census information. This • Speaking engagements service and quality of the facility). will provide valuable information on how Referring Doctors to target the age groups. • Luncheon meetings Conclusions: Establish your fee structure • Golf tournament according to the experience, not just the Conclusions: The natural demographics • Thanksgiving letter treatment. Financial arrangements must and economics indicate the population • Gifts at Christmas be made affordable for patients to accept will not be growing. To increase the • Conferences to discuss difficult treatment. Several specific payment number of younger patients, the practice multidisciplinary cases options should be presented to allow the should provide information and education patient to choose the most suitable. An continued on page 21 Figure 4 example of financial options can be found in Figure 3. The Demographic Analysis – County Population % by Age doctor must also determine the prac- Age Current Year 2000 Change tice’s discount policy. 0-4 6.29% 5.36% down For remainder of the ‘90s, all age cells under Are any individuals 5-9 7.01% 5.98% down 30 will be decreasing while the 30-40 age offered treatment at 10-14 6.55% 5.82% down group will be increasing as a percentage reduced fees? Clergy? 15-19 6.80% 5.99% down of the population. Physicians? Dentists? 20-24 7.18% 6.22% down Staff? This policy 25-29 6.82% 6.56% down Economic Analysis: must be established 30-34 7.12% 7.41% up According to the chamber of commerce, and discounts given 35-39 7.90% 8.14% up there are no plans for any major business only to those predeter- moves either in or out of the area. mined to be eligible. Figure 5 Competitive Environment Future There are currently 11 practicing orthodontists. Marketing Plan The top four competitors are listed below along with their positive and negative perceptions in the marketplace. Estimated Cost Competitors Adolescent Patients 1. Dr. Galackowitz Birthday cards $350 2. Dr. J Contests 160 3. Dr. Jeckell Skating party 1,200 4. Dr. Livingston Adult Patients Positives Negatives Birthday cards 100 Dr. Galackowitz Christmas party 250 Great doctor Not flexible with payment plans Contests 160 Great staff Parents Excellent sterilization/high tech Cookies 40 Lots of community involvement Carnations 80 Good marketing/patient parties Thanksgiving treats 0 Nice office Luncheon 1,500 Dr. J Christmas gifts 1,000 Nice practice Long waits for appts., up to 20 mins. Referring Doctors Good technically Serious/stale atmosphere, not a lot of fun Treats – cookies, fruit, Dr. Jeckell pizza, candy, apples, etc. 500 Throws things and yells Golf outing 1,000 Not very friendly, rude Cruise on private boat 2,000* Lots of staff turnover Birthday cards 50 Dr. Livingston Appreciation luncheon 1,600 Lots of staff turnover Referring Staff No consistent pricing Treat same as above 500 Figure 6 Your Staff Trip to AAO 4,800* Trip to dental society meeting 2,000 Trip to district Demographic Breakdown orthodontic society meeting 3,000* of Dental Community Birthday lunches 360 Barbeque dinner 200 Age <35 35-44 45-54 55-64 65+ Total Appreciation dinner 360 GP 22 46 21 33 9 131 Community (%) 17 35 16 25 7 Special Olympics Ortho 24 3 3 1 13 participation 0 (%) 15 31 23 23 8 Christmas gifts to families 100 Figure 7 TOTAL $21,310

*$12,000 was budgeted; therefore, asterisked items were eliminated

Figure 8 20 Dr. Clark continued from page 19

regarding the benefits of Phase 1 treat- orthodontists are lacking. Address all the restorative cases, periodontal considera- ment. To take advantage of the increase in negatives of the other practices and make tions, surgery and esthetics. the older age cells, the practice should them your positives. In this case that continue to aggressively market to adult involves: Development patients, especially parents of children • Flexible payment plans. Now, and only now, a plan can be devel- already in treatment. • Zero waiting time. oped to effectively market the practice. • Fun atmosphere. This is analogous to the orthodontist’s treat- Competitive Environment • Friendly environment. ment plan. At this point, it is imperative Evaluation • Consistent pricing; explain value of to establish the goals and strategies to be This is one of the most interesting aspects orthodontics. used in your marketing plan. However, in the development of a good marketing Also, since age plays an important role if the practice analysis has been done plan and the third and final method of in referral patterns (you are generally well, this portion is easily accomplished positioning your practice. Gather and referred to by dentists within ten years of because the entire marketing plan, both compile information on all competitive your own age), it is important to know the external and internal, has already been practices. Talk to staff members, patients breakdown of referring doctors by age. devised for you. It consists of the conclu- and former patients, parents and dentists. Figure 7 presents such a breakdown. sions that were reached through the study Use surveys to obtain the impression or of each area of practice analysis. Your perception people have of your competi- Conclusions: Gear the marketing plan to research makes it very clear exactly what tors’ practices. This data is then compiled doctors in the 35-44 age segment. They needs to be done; now it is merely a as is shown in Figure 6. (The names have the more mature practices and the function of prioritizing and implementing have been changed to protect the doctors’ greatest number of child patients. Educate those findings. privacy.) In all cases, fees were compara- them concerning Phase 1 treatment. ble and perceived to be “high.” Also market older dentists but concentrate Implementation on adult treatment and the benefits of Now it’s time to put all your research, Conclusions: Provide services the other preprosthetic orthodontics in complex continued on following page

Marketing Calendar Adult Referring Referring Month Adolescent Parents Patients Doctors Staffs Community Your Staff Jan Birthday cards Birthday cards Birthday cards Birthday lunches throughout year throughout year throughout year all year Feb Groundhog contest Valentine cookies Contest Mar Easter egg contest Contest Bowling lunch Apr Best mom contest Appreciation lunch May Smile contest Mother’s Day Contest carnations Jun Olympic contest Contest Participate in # of USA gold medals Special Olympics Jul Trivia contest Contest Aug Trivia contest Contest Golf outing Barbeque at doctor’s house for staff & family Sep Back to school Attend district skating party ortho meeting Oct Candy corn contest Contest Nov Christmas contest Thanksgiving Contest Thanksgiving Deliver treats Collect gifts Appreciation treat letter for Christmas night Dec Christmas contest Christmas party Christmas gift Collect gifts Secret Santa gift for Christmas exchange

Figure 9 Dr. Clark Mr. McMahan continued from page 21 continued from page 12

analysis and planning into action. The Develop a Schedule The largest dental managed care plan in doctor should already have refurbished Establish a grid (Figure 9) with the months Alabama is operated by BCBSA in the the practice facility so it is attractive and of the year in the left column and the form of a PPO. Statewide, approximately clean. The staff should now be thoroughly seven major groups marketed across the 50 percent of all practicing dentists are trained in the technical aspects of their top of the page. Now complete the agreed- contract providers for BCBSA. A review job, as well as all aspects of quality cus- upon marketing ideas and space them of the BCBSA directory of “Preferred tomer service. Practice systems should all strategically during the year to keep the Dentists” reveals that participation in be in place so everything runs smoothly. flow of new patients as level as possible. BCBSA’s dental PPO is not uniform The four steps to implementing a market- Build up the weak months and keep the throughout the state nor is there wide- ing plan are: strong months strong. The calendar allows spread specialty participation except for 1. Decide what you want to do you to space out your efforts so all market- oral surgeons. 2. Determine cost ing energy is not expended at one or two 3. Develop schedule times during the year. Now your calendar For example, nearly 70 percent of the 4. Delegate responsibility should be in place and ready for the last practicing dentists in Birmingham are Let’s look at these one at a time: step in implementation. listed as contract providers, while only two of 35 general dentists in Decatur are Decide Delegate Responsibility participants. You know what you’ve done in the past. Just like major corporations, every practice What has been successful? What has should have a director of marketing to Orthodontists are one of the specialty not? Use a brainstorming session to coordinate the marketing efforts, keep groups that have basically elected not to record on a flip chart any idea to market projects on schedule and hold people become contract providers for the BCBSA the practice to adolescent patients and accountable for their marketing responsi- PPO. Most of the dental plans offered or their parents, adult patients, referring bilities. Analyze the entire marketing administered by BCBSA do not include doctors and their staff, the community schedule and have people volunteer for any orthodontic benefits. and to your own staff. Then go back the portions of the marketing plan for and eliminate duplications and ideas which they would like to be responsible. The failure of most of the BCBSA plans to that are inappropriate, impractical, Everyone should share in this aspect of the adequately address orthodontic coverage complicated or expensive. Narrow down practice in order to learn to appreciate the is epitomized in a communication to some the suggestions to specific ideas that importance of continually building the of BCBSA’s insureds: all staff members feel good about and name and reputation of the practice in the to which they can willingly pledge their community. It is everyone’s responsibility to “Although Orthodontists and Periodontists involvement. The plan requires every- help market the practice. are listed in the directory, they are covered one’s commitment and enthusiasm only for routine Standard Option dental to make it work. Figure 8 provides an Conclusion services. example. The implementation of an organized marketing plan, with the commitment of “We hope you will find that your Preferred Determine Cost (Budget) the doctor and total involvement of the dental benefits are convenient and easy on Now that you know exactly what you staff, can have a dramatic impact on the your wallet.” would like to do, it’s time to see if it’s growth of the practice, even a mature one. affordable. A budget for practice A well-conceived, properly orchestrated Well, to paraphrase Dr. Zatts, perhaps promotion must be established that approach to marketing the practice will there is a solution for orthodontists who will keep costs within the parameters of allow it to grow beyond your wildest wish to become contract providers for the income of the practice. Don’t just dreams. It is not unusual for practices with BCBSA. They need to shift their focus throw money into a plan. Designate a which Orthodontic Management Group from traditional orthodontics to setting specific amount of money you plan to has worked to grow 20 to 50 percent the up “prophy parlors.” Dr. Zatts was correct spend and make the plan fit that target first year the plan is implemented. in saying that dentists have options amount. Look carefully at all the pro- regarding managed care plans. However, posed marketing ideas and estimate As you can see, marketing does not only if laws like the APCL are upheld a specific cost for each one. The costs necessarily mean advertising. Marketing by the courts and subsequently passed involved in the example marketing a practice to increase patient flow can be either by the Congress or state legisla- plan we are developing are also listed done in an ethical, professional manner tures will patients enjoy a basic right in Figure 8. consistent with quality orthodontic care. to which they should be entitled – the As a matter of fact, advertising is the least right to determine who will provide 22 cost effective way to market your practice. their dental care. Dr. Nanda continued from page 5 Biomechanics in Clinical Orthodontics ing patients, we are both well aware that development of new orthodontic wires. Edited by Ravindra Nanda, B.D.S., M.D.S., biomechanics is extremely helpful In recent years, wires such as nickel Ph.D., professor and head, Department of in achieving predictable results. For titanium and TMA® have allowed delivery Orthodontics, School of Dental Medicine, example, I designed a reverse headgear of lower and longer activating forces. University of Connecticut Health Center bow to be used with a facemask to In the future, I see more precalibrated deliver force to the maxilla to achieve orthodontic springs, wires and loops Twenty-four authorities present beautifully a predictable response. This replaces which will deliver predictable orthodontic illustrated coverage of biomechanical prin- conventionally used elastics which cannot tooth movement. ciples in the first and only book to describe be biomechanically applied due to lip how these principles can be successfully opening. We all know that elastics with Dr. Turley: Where is the field of bio- applied to clinical orthodontics. Practical protraction headgear often increase the mechanics going in the 21st century? clinical guidance includes: vertical dimension of the face due to the • A simplified approach to biomechanics extrusion of the teeth and cause the Dr. Nanda: I feel market pressures will that makes its principles and their mandible to swing downward and back- make it imperative for all orthodontists to practical application easier to under- ward, giving us an illusion that we have understand the wires they put into the stand and employ. achieved forward displacement of the mouth. The future of biomechanics is • Descriptions of orthodontic treatment maxilla. very bright, especially in the area of planning and biomechanics that help you orthodontic materials and development apply specific mechanisms to specific Dr. Turley: What about the “bio” in of new appliances. Even in this age of problems. biomechanics? Do biomechanically managed care, HMOs and increased • Advances in the use, selection and prop- oriented appliances give a more opti- practice efficiencies, I am confident the erties of orthodontic wires that can mal biologic response for tooth move- specialty will keep the quality of results improve the quality of tooth movement. ment than other types of appliances? always in the foreground. • Coverage of nonextraction treatment modalities that enables you to achieve Dr. Nanda: Pat, “bio” is a big part of Dr. Turley: Ravi, the last question, who predictable results with headgears, Herbst biomechanics. Indeed, biomechanics are/were your mentors in this field? appliances, memory alloy springs, etc. teaches us to use force values which • Over 575 superb line drawings and deliver tooth movement in the shortest Dr. Nanda: I have been lucky to be clinical illustrations (100 in full color) possible time with the least amount of associated with leaders in the field of that clarify important information and nonreversible damage to the tissues. It orthodontics. My brothers, Ram and techniques. also allows the use of appliances which Surender, come to the forefront as my have low deflection rates, are active for mentors. Both have contributed tremen- This book a long time and need small force values dously to the specialty as researchers, brings together per millimeter of tooth movement. educators and prolific writers. In the late leading ‘60s, I had the fortune of having Frans clinicians, Unfortunately, our understanding of van der Linden as my teacher, and for researchers mechanics is presently well ahead of a period, Allan Brodie, who was on and authors our understanding of the biology of sabbatical in Nijmegen, Holland. My last in clinical orthodontics. The physics of our appli- 25 years have been at the University of orthodontics ance design is comparatively simple Connecticut, and I have had the fortune who have relative to the biological response of the of being associated with Charlie Burstone, made significant tissues. But I think our knowledge of who is unquestionably the leader in the contributions to the biology of tooth movement (at the field of biomechanics. Needless to say, the area of biomechanics. The concepts patient level) has been limited by our I also have had the opportunity to be a and appliance design can be applied to inability to precisely apply mechanical teacher and mentor of excellent ortho- any technique and are easily adaptable. principles to treatment. dontic graduates who are now leaders in This addition to your library affords you our field in their own right. the counsel of widely recognized experts Dr. Turley: Can biomechanics be in biomechanics, presented in a format applied to innovations by manufactur- Dr. Turley: Thank you. that makes it simple to understand and ers for improving our appliances? apply. Order information for Biomechanics Dr. Nanda: I want to thank you, Pat, and in Clinical Orthodontics is provided on Dr. Nanda: Orthodontic manufacturers at the same time, I want to congratulate page H of the Center Section. play a major role in the field of biome- you for your excellent contributions to chanics from the design of brackets to the our specialty.