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clinical impressions®clinical & practice management orthodontic resourceVOLUME 19 NUMBER 01 FEBRUARY 2013A New Era inDigitalOrthodonticsDr. Jeff Kozlowski — Page 4also in this issueCase Review:Skeletal Open Bite Treated Without Surgery— Drs. Rafael García Espejo and Juana Mª Ruiz RodríguezLower Cuspid Rotational Control MadeEfficient with Accurate Bracket Base Design— Dr. Straty RighellisTapping into a Promising Market:Targeting the Adult Whitespace— Ms. Debby HartmanOnline Edition | ormco.com/ci

Your Practice. Our Priority.Technology todifferentiate your practice......because being standardis never your style.Insignia is an all-inclusive orthodontic solutionthat combines your treatment goals and smiledesign with software and customized appliances,resulting in efficient, precise smile outcomesoften in less time. And now Insignia offers theworld’s most expansive menu of treatmentoptions including Insignia Clearguide ExpressAligners, Damon ® Clear , Damon Q , Inspire ICE and completely customized self-ligating andtraditional twin appliances.Multiple Appliance OptionsA wide variety of applianceoptions ranging from aligners toaesthetic and metal appliancesmeet your clinical needs andincrease patient acceptance.Increased Clinical EfficiencyCustomized brackets andeasy-to-use placement methodsreduce mid-treatment adjustmentsand deliver precise, predictablefinishes in less time.User-Friendly SoftwareApprover software can be used toapply a higher level of finite designinto your patient’s treatment anddisplay the virtual end-result.Learn Moreormco.com/insigniaNo Investment NeededNo start-up, licensing or inventory costs. Cases are manufacturedper patient and shipped in inventory-conscious packaging.Twins Digital Auxiliaries Practice Development EducationSelf Ligation Aligners Tubes/Bands Archwires Lab ProductsTwins Digital Auxiliaries Practice Development EducationSelf Ligation Aligners Tubes/Bands Archwires Lab Productsormco.com© 2013 Ormco Corporation

TABLE OF CONTENTSclinical impressions ® | vol. 19 | no. 01 | february 2013PAGE 4PAGE 19PAGE 27PAGE 32A New Era in Digital Orthodontics— Dr. Jeffrey T. KozlowskiNew London, ConnecticutCase Review:Skeletal Open Bite Treated Without Surgery— Drs. Rafael García Espejo and Juana Mª Ruiz RodríguezCordoba, SpainLower Cuspid Rotational Control MadeEfficient with Accurate Bracket Base Design— Dr. Straty RighellisOakland, CaliforniaTapping into a Promising Market:Targeting the Adult Whitespace— Ms. Debby HartmanDirector of Marketing CommunicationsOrmco CorporationSubscribe to CI onlineThis edition and future issues ofClinical Impressions will onlybe available online. To access newand archived articles, registertoday at www.ormco.com/ci.Article SubmissionsIf you’re interested in having anarticle considered for publicationin Clinical Impressions, e-mailus at ci@ormco.com. Someonefrom the editorial staff willcontact you about taking theprocess further, providingwriting and editorial supportas needed. We look forward topartnering with you to continuethe important tradition of thisclinician-driven publication.From the PresidentDear Colleagues –Welcome to the latest edition of Clinical Impressions featuring some of the profession’s mostadvanced orthodontic appliance systems—systems that Ormco has engineered to help differentiateyou and your practice.In his article, Dr. Jeff Kozlowski discusses his extensive clinical evaluation of Insignia , ourcomprehensive digital treatment solution that combines 3D diagnostic technology and interactivetreatment planning with customized appliances. According to Jeff, Insignia has elevated his standard of care with lesseffort and more precision than with his previous treatment modality.It is important to note that Insignia would not be a reality today without the vision and determination of Dr. Craig Andreiko,Ormco Director of Advanced Projects. After three decades of intensive development, Craig has now seen his passion tocreate the first true straight-wire appliance system come to fruition. Ahead of its time when originally conceived, Insignianow represents a natural evolution in appliance choice.Also in this issue, Drs. Espejo and Rodriguez present a detailed review of a particularly challenging Class III open bite casethat they treated without surgery using Damon ® Q . As if you are in the clinic with them, Rafa and Juana explain theirprotocols and the rationale behind their impressive treatment plan.For doctors treating with an active self-ligating appliance, I invite you to review Dr. Straty Righellis’s success with Prodigy SL ,particularly as it relates to lower cuspid rotational control that precludes wire bends and repositioning brackets. As Ms. DebbyHartman explains in her article, leading-edge products that result in fast, comfortable, aesthetic treatment can translate intoincreased patient starts because of their appeal to what is still a vast untapped market—adult patients.I would like to thank the esteemed doctors who have contributed their valuable time and clinical expertise to this edition.And to all of our customers and readers of this journal, thank you for your continued support.Sincerely yours,Vicente ReynalPresident, Ormco Corporation

A New Era inDigitalOrthodonticsJeffrey T. Kozlowski, DDSJeffrey T. Kozlowski, DDSNew London, CTDr. Kozlowski obtained his DDSdegree in 1996 and a certificate inorthodontics at State University ofNew York at Buffalo in 1998. Hispractice, Kozlowski Orthodontics,has locations in New London and EastLyme, Connecticut. He has lecturedextensively all over the world,including for the AAO and its variousconstituent societies and universitiesand study clubs as well as annually atthe US Damon Forum and EuropeanDamon Symposium. His topicsinclude efficiency and excellencein orthodontics, early treatmentand facial esthetics. He hasalso been published in severalorthodontic journals, includingSeminars in Orthodontics and theJournal of Clinical Orthodontics.A fitness advocate, he has completedfive Ironman Triathlons, more than adozen Half-Ironman Triathlons andnumerous marathons and endurancecycling events, including the gruelingMt. Washington Bicycle Hill Climbseven times. He and his wife, Amy,a pediatric dentist, have two children:Amelia and Jake.A true straight-wire appliance would necessitatepatient-specific appliances based on anindividual’s anatomy. Now, with advances incomputer software and digital scanning andfabrication, that idea is a reality and a practicalconsideration for your practice. CustomizedInsignia is the first true straight-wire appliance.It involves two components: customizedappliances—brackets, wires and placementgauges—and 3D real-time virtual treatmentplanning software. The 3D software enablesclinicians to design the patient’s final occlusionon-screen before initiating treatment, thenprescribes the fabrication of patient-specificappliances to achieve the planned result. Thisconcept is quite different from how clinicianscustomarily practice orthodontics. Traditionally,we choose appliances with specific torque valuesto have certain effects, then react to thoseeffects by repositioning brackets and makingwire bends to guide the teeth into the desiredpositions. With Insignia, we begin with the endin sight and drive directly towards the desiredend result.Over 20 years in development, customizedInsignia appliances offer the only comprehensivepatient-specific solution available. Thetreatment planning process begins withaccurate PVS impressions. New clinicalmethods and materials make this procedurequick and easy. From the impressions, thepretreatment malocclusion (T1) is digitizedinto a precise mathematical model of thepatient’s skeletal and dental anatomy and theproposed setup (T2) designed (Figure1a-b).See Dr. Craig Andreiko’s discussion. The setupis loaded to the Insignia web portal where,based on clinical experience, functional andesthetic preferences and intimate knowledgeaFigure 1a-b. T1 and T2 with bracketsbFigure 2. The Insignia Approver softwaregives clinicians unprecedented flexibilityand control in designing case outcomes.4 vol. 19 | no. 01 | february 2013 ormco.com/ci

of the patient’s specific orthodontic needs, theclinician can easily customize it using the InsigniaApprover software (Figure 2). The included softwareoffers clinicians unprecedented control indetermining accurate tooth position and in theirability to make changes directly to the 3D modelswithout relying on an operator’s interpretationof instructions.Insignia does not determine treatment mechanicsnor prescribe tooth movements and it allows cliniciansto use the mechanics and adjuncts of theirchoice. As doctors modify the desired final outcomein the Approver software, they can view in “realtime” how the changes affect the opposing occlusion.Once the clinician finalizes the ideal setup,the Insignia software engineers the customizedbrackets, wires and precision bonding placementgauges to the exact prescription required to deliverthe designed end result accurately and efficiently.My experience with Insignia is with both thecustomized passive self-ligating appliance(Insignia custom SL) and Insignia using stockDamon ® System appliances. The Insignia softwarecan be used to fabricate patient-specific conventionaltwin brackets and aligners as well. You canalso use Insignia software with stock appliances(Orthos ® , Inspire ICE and, as I mentioned, Damon).The difference between customized Insignia andInsignia using stock brackets is the third-ordercustomization (torque) that is engineered into thecustomized brackets. This difference saves considerabletreatment time and effort over using a “bestfit torque” stock appliance. Having treated withboth customized Insignia SL and Insignia usingstock Damon brackets, I can attest to thesuperior value of the customized appliances.The Clinical EvaluationMy initial experience with customized InsigniaSL began in 2007 when I conducted an extensiveclinical evaluation by treating 41 patients to completion.The only limitations on the selection criteriawere that patients have no missing or impactedteeth, no pending restorative needs, and must notexhibit poor oral hygiene. The criteria were limitedin these ways simply because it wouldn’t havebeen feasible for me to coordinate the ancillaryprocedures from across the country. At the time,I was in the process of opening my new office inConnecticut and the clinical evaluation was to beconducted at Ormco in California—nearly 3000miles away. For operator consistency, I playedthe roles of doctor and assistant, performing thediagnoses, treatment planning, initial bondings andwire changes, providing all mechanics for 100%of treatment. Full records were taken of eachpatient, including PVS impressions and iCAT ® scans(Imaging Sciences, International, Hatfield, PA)for diagnostics and treatment planning using the3D Construction of the Pre- and Posttreatment Occlusion and DentitionCraig Andreiko, DDS, MS | Director of Advanced Projects, Ormco CorporationCustomized appliance design is only as good as its underlying foundation. The medullary trough of the mandibularbone at approximately the level of the center of resistance is the most stable foundation for the nonsurgicalconstruction of occlusions and dependable soft-tissue outcomes. PVS impressions provide the information thatdescribes the shape and size of the cortical limits of the mandibular bone. When digitized via high-resolutionCT scanning, impressions form a precise model of the patient’s anatomy and serve as the scaffold upon whichthe patient’s pretreatment occlusion (Figure 3) and, with tooth segmentation and landmarking, the dentition areconstructed (T1). Dental models contain between 800,000 and one million digital data points in each arch; individualteeth are composed of more than 40,000 data points each. Suchdetail creates occlusions of unprecedented precision. Based on theanatomical mapping, clinician preferences and related mathematicalcalculations, the Insignia software designs the proposed setup(T2). Even though the software identifies the skeletal arch formand designs the proposed final outcome, the clinician can, withinanatomical limits, change virtually any aspect of the treatmentplanning and appliance design.Figure 3. The digital model of each patient’s lower occlusion showsthe shape and size of the cortical limits of the mandibular bone.

A New Era in Digital OrthodonticsInsignia interactive Approver software. Based onmy previous experience with Damon System appliances,I estimated that treatment time for the 41patients would average 17.5 months.While I wouldn’t recommend selecting this manypatients to begin treating with customized InsigniaSL for the first time, I am convinced that the bestway to learn Insignia is to submit cases regularly.Regular case submission allows the clinician torelate what is designed in the digital environmentto the clinical experience and final results. Thispositive feedback loop of learning will help theclinician design each successive Insignia case witha higher level of understanding and accuracy andhence be more successful with its application. Myexperience has been that clinicians who regularlysubmit Insignia cases are more successful withit than those who start only a few cases and waitto see how they work out. My skills improvedsubstantially through the first 10 to 20 cases, andlike using any other new appliance, it takes a bit oftime to learn the nuances. I also strongly recommenddoctors initially select easier cases, and thenadd more challenging cases when they becomefamiliar with the software and clinical protocols.In late February, 2008, in a one-chair operatoryat Ormco’s Insignia manufacturing facility inGlendora, California, I bonded all 41 patients overa five-day period. This intensive week of bondingproved to be my first insight into the potentialefficiencies of Insignia’s direct view/indirect bondingprocess. After just the first few patients mybonding technique using the placement gaugessignificantly improved and during the balance ofthe week, the bonding appointments averagedless than one hour, including preparing the teeth,bonding the brackets, placing bite turbos, engagingthe wires, attaching the elastics and reviewingthe patient instructions. And all without the helpof a clinical assistant!We all know the importance of placing bracketscorrectly, but few of us can consistently and quicklyplace each bracket precisely where it needs to be.With Insignia, you design the final occlusion andthe customized appliances will be fabricatedwith custom torques, custom bases (in-out) andcustom wires. You specify your bracket positioningpreference (e.g., center of the tooth, more gingivalor more incisal) so that the custom appliances aredesigned to your specifications; thus, it is possiblefor your Insignia SL appliances to clinically matchthe placement of your direct-bonded appliances.To transfer the Approver-designed appliances tothe mouth, Insignia provides customized placementgauges that place the brackets in the rightspot without need for adjustment (Figure 4). Theprecision built into the brackets is matched by theaccuracy of the placement gauges that offer thebenefit of a direct viewwith the precision ofplanned indirect bonding.The major challenge inconducting this clinicalevaluation was logistics.Managing treatmentfrom so far away was Figure 4. Insignia customized placementgauges offer the benefit of direct viewa daunting experiencebonding, putting the brackets in theat first; however, the right place without adjustment.process reinforced theimportance of good clinical decision making and itsimpact on clinical efficiency. Gone was the luxuryof shortening patients’ appointment intervals toaccommodate case management alternativeswhen we need to make clinical decisions basedon how a patient responds. It was thus incumbentupon me to create mechanical systems that wouldwithstand the eight- to ten-week appointmentcycle of my West Coast trips.At six months, the first patient finished treatmentand by December 2009, after just 21 months, the41st patient had his appliances removed. To determinethe value of customized Insignia SL for myown practice, I initially compared the results of thisevaluation with my previous seven years of experiencetreating patients with direct-bonded DamonSystem appliances. This comparison helped meevaluate customized Insignia SL with what I usedto do in my office—direct bonding. These 41customized Insignia cases treated in an averagetime of 12.5 months —a full five months (28%)shorter than my estimateof 17.5 months (Figure 5).I based the estimates onmy previous seven yearsFigure 5.Breakdown of 41 Cases inClinical EvaluationClass I – 19 Cases» 5 were Class I, div 2Class II, div 1 – 11 CasesClass II, div 2 – 5 CasesClass III – 6 Cases» 3 were Class I with Class III tendency» 3 were full Class III6 vol. 19 | no. 01 | february 2013 ormco.com/ci

of experience with the Damon System appliancebut before I had had any experience with Insignia.In my opinion, this difference alone attests to theefficiency of customized Insignia SL treatment.Another value indicator was the number of repositionedbrackets needed to finish the customizedInsignia SL cases, which was 50% less thanmy cases with direct-bonded stock DamonSystem appliances.After completing the evaluation, I compared theresults with comparable patients I later treatedwith Insignia using stock Damon appliances. Thissecond comparison assisted me in placing a valueon the patient-specific customized torques ofthe customized Insignia SL appliance. The 41customized Insignia SL cases in the evaluationfinished in 22% shorter treatment time (at 12.5months) than the next consecutive 41 cases usingInsignia with stock Damon brackets that I treatedin my private practice (16.1 months). The averagenumber of appointments for the 41 Insignia stockDamon cases was 10.2 versus 8 appointmentsfor the 41 customized Insignia SL cases.In terms of quality, a subjective evaluation I grantyou, I feel that my customized Insignia SL casesfinish with quality that equals or exceeds mydirect-bonded Damon System cases or myInsignia cases using stock Damon brackets yet inless time and with significantly less effort. I havefelt confident enough with the customized Insigniacase results to have shown them in presentationsaround the world and have been so pleased withthe results that I now treat 70% of my cases withcustomized Insignia SL appliances. I still treat 30%of my patients with direct-bonded stock Damonappliances, primarily those who start treatmentin late mixed dentition, but for all those cases forwhich customized Insignia SL applies, it is now myappliance of choice.This article highlights a few of the patients I treatedin the clinical evaluation, demonstrating the qualityof the results and efficiency of treatment.CASE 1: MARY Y.Importance of Case Management. Value of Custom Torques. Planning Contacts.Treatment SummaryImproved macro-, mini- and microesthetics, including lower facial height improvement andcorrection of Class III facial appearance. Treated in 10 months; 6 treatment visits. No repositions.No wire adjustments.If any patient stands out in demonstrating the benefits of customized Insignia SL combined witheffective case management, it’s Mary Y. While I’ve shown the pre- and posttreatment records ofMary’s case in presentations, I’m frequently asked to show and explain the entire course of treatmentso I’m taking this opportunity to do so.CASE 1: PRETREATMENTCASE STUDYclinical impressions ® vol. 19 | no. 01 | february 2013 7

A New Era in Digital OrthodonticsMary presented with a mild Class III malocclusion, reverse overjet of the upper anteriors, a deep bitewith a low mandibular plane angle, maxillary crowding and mandibular spacing (Case 1: Pretreatment).The macroesthetic 1 goals were to improve Mary’s Class III facial appearance by creating positive overjetand increase her lower facial height by extruding posterior teeth and rotating the mandible downwardand backward. The treatment plan was to bond all teeth with customized Insignia SL appliances, placebite turbos on the lower incisors to help create positive overjet, and use posterior vertical elastics witha Class III vector to erupt the posterior teeth to the new vertical dimension, thereby increasing herlower facial height.CASE 1: PRETREATMENT1The expressions “macroesthetic (facial),miniesthetic (smile), and microesthetic(teeth)” are terms that Dr. David Sarver(Vestavia Hills, AL) coined to providecommon nomenclature for diagnosticanalysis.Bonding: I positioned the customized appliances (both arches) with the customized bonding placementgauges, bonded bite turbos (LL1-2) with Flowtain composite, shade A1 (Reliance Orthodontic Products,Itasca, IL) and a Mini-Mold kit (Ortho Arch, Schaumburg, IL) and engaged customized .014 Cu Ni-Ti wires6-6. The bite turbos were polished to a CL III ramp design to assist maxillary anterior teeth in developingideal axial inclination towards positive overjet. With posterior occlusion now open approximately 4 mm, Istarted early, light elastics (Parrot 5/16”, 2 oz.) to extrude posterior teeth in a Class I direction.CASE 1: BONDING7 Weeks/1st Visit: In my practice, first return visits after bonding are scheduled at 10 weeks, but managingcases from 3000 miles away dictated they be at 7 weeks. At Mary’s first return visit, the effects ofwell-planned mechanical systems were already evident. Her posterior teeth were in Class I occlusion andthe overjet had corrected from -2 mm to +1 mm. I placed custom .018 Cu Ni-Ti wires back to the 7s andswitched the Class III elastics to an anterior box configuration (U/L 2-2, Parrot) to assist in creating positiveoverbite and to enhance her smile arc.8 vol. 19 | no. 01 | february 2013 ormco.com/ci

CASE 1: 7 WEEKS/1ST VISIT CASE 1: 17 WEEKS/3RD VISIT CASE 1: 27 WEEKS/4TH VISIT17 Weeks/3rd Visit: I engaged custom .014 x .025 Cu Ni-Ti archwires, initiated anterior space closure withpower chain (U/L 3-3) and engaged steel tie-backs U 6-3, bilaterally. For the next 10 weeks, she engaged CLIII “V” elastics 12 hours daily to ensure that the posterior occlusion remained locked in Class I.27 Weeks/4th Visit: I engaged custom .018 x .025 Cu Ni-Ti archwires. While all the mandibular dentalspacing had closed, some maxillary dental spacing remained. Close inspection of my original setup using theclipping function in the Approver software yielded the reason.clinical impressions ® vol. 19 | no. 01 | february 2013 9

A New Era in Digital OrthodonticsBecause of heavy contacts between the prominentlingual marginal ridges of Mary’s upper incisorsand the incisal edges of her lower incisors(Figures 6a-b), her upper incisors remained anteriorto the planned setup position. Clinical evaluationled me to address the issue with a few simplemeasures: first, gentle equilibration of theprominent lingual marginal ridges on her upperincisors. Second, due to the shape of her lowerincisors and the presence of small black triangles,I performed mild lower IPR for both functionaland esthetic improvement and replaced thepower chain under the wire (L3-3) to assistanterior space closure.There are two important messages here.1) Ensuring the accuracy of the digital casesetup as it relates to treatment progress is vital.You will see clinically what you approve in thesoftware so employing a few key protocols eachtime you review a case will ensure that yourcases will treat out as planned. 2) While Insigniaprovides digitally-assisted treatment planningand customized appliances, clinicians neverrelinquish their ability to manage cases as theyprogress. I say this because I’ve heard doctorsvoice the concern that once they’ve approveda setup, they don’t feel that they will be able tomake adjustments to the original plan and thattheir years of skill development would seldombe required. While it is true that computer-aided3D treatment planning is inordinately valuableand is certainly how most of us will be treatingpatients in the future, there are always clinicalmechanics, occlusal function and biology in thehuman masticatory system at play. Sometimesunforeseen mechanical issues arise during thecourse of treatment on which clinical decisionsneed to be made. All of these decisions requireuniversity-level orthodontic training and ouryears of professional experience and cliniciansare always in control of their cases.34 Weeks/5th Visit: I engaged the customized.019 x .025 TMA archwires with crimped posts.Since all anterior space was closed, I “figure-8”lace-tied steel ligatures (U/L 6-6) under theaFigure 6a-b. The clipping function in the Approver softwareindicated excessive lingual contacts between the upper andlower incisors for Case 1 (a). Ideal intercisal contacts (b).wires and placed tiebacks to close small spacesbetween the 6s and 7s. Some minor anteriorincisal manicuring enhanced the microestheticgoals and transitioning to bilateral posterior triangleelastics (Bear ¼”, 4.5 oz.) ensured properseating of the posterior occlusion prior to treatmentcompletion.10 Months/6th Visit: I debonded Mary’s appliances,placed fixed lingual retainers and took impressionsfor fabricating clear retainers to ensurestability posttreatment (Case 1: Final Records).The accuracy of customized Insignia SL’s computer-designedappliances and wires combinedwith the precision bonding process helped providethis result, which required no repositionedbrackets and no wire adjustments. Thoroughevaluation of her post-treatment records showsa marked improvement in her macroesthetic facialaspects. The serial cephalometric tracing fromMary’s iCat scans (Case 1: Cephalometric Tracings)shows that her lower facial height increaseddue to the planned supereruption of the maxillaryposterior teeth and downward and backward rotationof the mandible. Miniesthetic changes includeimprovement of her anterior dental esthetics andsmile arc. Microesthetic improvements resultedfrom careful and appropriate tooth reshaping thatput the finishing touches on what I consider to bean excellent case result. Equally important to myview of the success of treatment is the fact thatMary loves her new smile.b10 vol. 19 | no. 01 | february 2013 ormco.com/ci

CASE 1: 10 MONTHS/6TH VISIT - FINAL RECORDS AND INITIAL INSIGNIA SETUPCASE 1: CEPHALOMETRIC TRACINGSINITIAL FINAL OVERLAYclinical impressions ® vol. 19 | no. 01 | february 2013 11

A New Era in Digital OrthodonticsThe Effect of Custom Torque Values: Improved EfficiencyGiven the facial contours of the porcelain crowns onMary’s lower first molars and my design of Mary’sT2 occlusion, the Insignia software calculated nearlyzero-degree torque molar brackets to manage herfinal posterior occlusion accurately (Figure 7). Otherthan in my residency, I can’t remember the last timeI chose zero-degree torque brackets to treat lowermolars. Using standard-torque stock Damon ® Q (DQ)brackets (even with Insignia treatment planning)would have taken considerable effort to finish hertreatment effectively, especially given the substantialdifference between the DQ first molar stockbracket torque (-28°) and the customized torquesInsignia prescribed for Mary’s first molars. Patientspecifictorque values are an excellent exampleof how customized Insignia SL appliances improvethe efficiency and effectiveness of treatment.With stock brackets, there are only two or threetorque options for the anteriors and usually only oneposterior torque option. Insignia offers an almostinfinite number of customized torque options. Bytreating with customized torque values, we canachieve high-quality results in shorter than averagetreatment times, with greater predictability, lesseffort and fewer wire adjustments.Custom Torque Valuesfor Molars: Case 1Tooth LR7 LR6 LL6 LL7Custom Torque 0.0° -0.2° -4.0° -0.8°The TorqueCompensation ModelCraig Andreiko, DDS, MSOne of the principles on which Insignia’scalculations are founded is called “torquecompensation.” In software, the 3Dmovements of the center of resistanceof the roots and the center of the archwireslot for each tooth are tracked. Thisallows for calculation of which way andhow far the tooth will move with respectto third-order constraints. Most cliniciansuse archwires that are undersized relativeto the slot, which for a .019 x .025archwire in a .022 lumen results in about+/-12° of wire play. By comparing T1and T2 positions and the results of thecalculations mentioned, customizedInsignia brackets are cut at an angle tocompensate for the loss of torque fromwire play so that the torque value assignedto the bracket will be expressedand the tooth will be driven all the wayto its desired final position.Stock DQ Torque -10° -28° -28° -10°Figure 7. Note the marked differences between the Case 1customized Insignia posterior torques and the standard torquefor the stock DQ bracket prescription.12 vol. 19 | no. 01 | february 2013ormco.com/ci

CASE 2: SUNNY S.Determining Accurate Bracket/Tooth Tip.Treatment SummaryFull correction of bilateral posterior crossbite.Treated in 12 months/1 week; 8 treatment visits.No repositions. One wire adjustment.Sunny presented for treatment with a Class Iocclusion and Class III tendency, the primary clinicalfinding being a bilateral posterior crossbite(Case 2: Pretreatment). The treatment plan wasto bond customized Insignia SL fixed appliances,using Optiband flat-plane bite turbos (Ormco) onhis lower molars and bilateral crossbite elasticsto address the crossbite. Treatment completedwith full correction of his bilateral posteriorcrossbite (Case 2: Final Records). Although hisCASE 2: PRETREATMENTCASE STUDYtreatment required no bracket repositioning, I did make one adjustment in thewire to tip his upper right central incisor. Note the distal root of the UR1 fromthe interim Panorex taken at 6 months (Figure 8). At first it appeared that thecustomized Insignia placement gauges had not yielded an accurately bondedbracket to the upper right central incisor, but after reviewing my Approvercase setup, it became apparent that I had built incorrect tip into the originalappliance (Figure 9a). Had I been more cognizant of the slight crown to incisaledge angle, I would have chosen to place a bit more mesial root tip in theupper right central incisor (Figure 9c-d). With this correction in the originalsetup, it’s possible that Sunny’s treatment would have finished as Mary’s hadwith no repositioned brackets and no wire adjustments.Figure 8. The interimPanorex for Case 2.abcFigure 9a-d. Tip difference between UR1 and UL1 (a-b). Original UR1 tip (c) versus Ideal tip (d).dclinical impressions ® vol. 19 | no. 01 | february 2013 13

A New Era in Digital OrthodonticsCASE 2: BONDING CASE 2: FINAL RECORDSThe challenge with any digital orthodontic treatmentplanning process is the initial disconnectbetween what we “visualize” on the computerand what we expect to see in the mouth.Insignia offers clinicians an important meansof increasing their understanding about howthe clinical decisions they make during thecourse of treatment affect tooth movementand occlusion because they can see the resultsin the simulated virtual environment beforeacting on those decisions. This feedback loopleads to better clinical decisions which leadto more effective treatment. Because I’vefrequently used Insignia to do such analysis,I believe that I have become a better orthodontistoverall, even when not using Insignia.14 vol. 19 | no. 01 | february 2013 ormco.com/ci

CASE 3. MELISSA H.Capitalizing on the Smile Arc 3 Function.Treatment SummaryCrowding and full CL II correction with early lightelastics. Treated in 11 months; 7 treatment visits.No repositions. Wire adjustment at one appointment.Melissa presented with a Class II malocclusionand significant crowding (Case 3: Pretreatment).The treatment plan called for full fixed customizedInsignia SL appliances, bite turbos and early, lightClass II elastics. With her crowding unraveled afterjust 6 months of treatment, Melissa’s malocclusionover corrected to a mild Class III. This phenomenonclearly demonstrates the power of early, light elasticswhen used in conjunction with disarticulation andDamon System mechanics with customized InsigniaSL brackets. By switching to light Class III elastics(nighttime only), she was solidly occluding in Class Iposition by the next visit and was ready for finishing.Figure10a-b. Original Case 3 setup for smile arc (a).Ideal smile arc (b). See Case 3 Final Records for thepleasing smile arc result.The Insignia smile arc function allows clinicians to design the curve of the upper anteriors to match thepatient’s lower lip contour with a click of the mouse. As Melissa’s treatment progressed, I felt that hersmile arc needed to be slightly deeper than I had planned. Repositioning the upper anterior brackets wouldhave been the preferred solution but the logistics of providing treatment from 3000 miles away made awire adjustment the favored protocol in this situation. You can see from her final records the pleasing result(Case 3: Final Records). After Melissa completed treatment, I analyzed her setup in the Approver softwareto determine how I might have planned her smile arc to create the most pleasing end result. Figure 10arepresents Melissa’s original setup. Had I set up her case with the smile arc shown in Figure 10b, no wireadjustment would have been necessary.abCASE STUDYCASE 3: PRETREATMENT3Sarver, D. Soft-tissue based diagnostic and treatment planning. Clinical Impressions, Vol. 14, No. 1, 2006: 21–26.clinical impressions ® vol. 19 | no. 01 | february 2013 15

A New Era in Digital OrthodonticsCASE 3: FINAL RECORDSConclusionHere are the primary things I have come tovalue over the past three years of working withcustomized Insignia SL:1. Computer-assisted diagnostics and treatmentplanning allows me to “begin with theend in SIGHT” and finish my cases with thesame high quality as stock Damon brackets,but faster and more easily. The fact that Iestimated 17.5 months for the patients inthe clinical evaluation and treated them inan average of 12.5 months was enoughevidence for me to begin treating most ofmy patients with customized Insignia SL.2. Insignia provides me with enhancedclinical efficiency. From the initial bondingappointment to the completion of treatment,having the custom appliances specificallyengineered to reflect the patient’s anatomydrives tooth movement directly to the desiredfinal occlusion, which means feweradjustments along the way. This efficiencyis based on a combination of: (1) creatingan ideal final occlusion in the Approver software;(2) quickly and accurately placing thebrackets the first time with the precisionplacement gauges; (3) managing progressivetreatment using the five custom-designedInsignia archwires; and (4) improved torquedelivery from the customized torquesdesigned into each bracket.3. Customized Insignia SL has helped mereduce treatment time by more than 20%(versus Insignia using stock Damon appliances)and bracket repositioning by 50%.4. Computerized orthodontics does not takethe orthodontist out of the treatment process.Just as today’s most technologicallyadvanced fighter jets require an experiencedpilot to manage its systems, the orthodontistmust still provide clinical oversight to manageeach case effectively. What I’ve realized isthat Insignia combined with my clinical expertiseyields better results than either of us canprovide alone.16 vol. 19 | no. 01 | february 2013 ormco.com/ci

Case 3: Cephalometric Tracings 4Profile (Auto)Nasion-Basion@CC (Auto)Nasion-Basion@Nasion (Auto)ANS-PNS@ANS (Auto)Corpus Left-Menton@Menton (Auto)INITIAL FINAL OVERLAYSummaryIn starting the customized Insignia SL clinicalevaluation, I drew upon my substantial clinicalexperience with Damon System techniques andmechanics to estimate the average treatment timeof 17.5 months for the 41 selected patients. Otherthan that, I had little idea about what to expect interms of the quality of the treatment outcomesor the clinical treatment efficiency I would experience.In the end, I was “blown away” by theresults I was able to achieve by combining myclinical expertise with Insignia Advanced SmileDesign Approver software and fully customizedappliances. The average treatment time for these41 patients was a mere 12.5 months—nearly30% shorter than my initial estimate. Along withthe substantial decrease in treatment time came acorresponding reduction in the number of clinicalvisits and the results were achieved through muchless overall effort.However, the most important thing I learned fromthis evaluation is that Insignia’s patient-specificappliances gave me the vehicle to achieve resultsthat are better than I have ever produced for 41consecutively treated patients at any time in myorthodontic career. In my opinion, the contributionthat this appliance system makes in elevatingmy standard of care speaks volumes in supportof the benefits of customized Insignia SL for thepracticing orthodontist.4Orbit Oral/Maxillofacial Imaging and Diagnostic Services, Newport Beach, CAclinical impressions ® vol. 19 | no. 01 | february 2013 17

Your Practice. Our Priority.ProvenPractice GrowthLooking to drive more patients to your practice?Over 50 million consumers have been exposed to theDamon ® System through Fox News, Woman’s World,SHAPE, Pandora, HuffPost Teen and endorsement by“Soul Surfer” Bethany Hamilton.What does this mean to a Damon System practice?More patients to your practice via the Damon DoctorLocator on Ormco’s consumer website, damonbraces.com.Just look at the growth improvements over the last two years.• 190% increase in traffic to DamonBraces.com• 360% increase in Damon Doctor Locator searchesAsk Ormco how you can benefit from the Damon DoctorLocator and a wide range of customizable, turnkey practicemarketing support materials.Learn Moreormco.com/damonclearThe Damon System — proven clinical performanceand now proven marketing performance.Twins Digital Auxiliaries Practice Development EducationSelf Ligation Aligners Tubes/Bands Archwires Lab ProductsTwins Digital Auxiliaries Practice Development EducationSelf Ligation Aligners Tubes/Bands Archwires Lab Productsormco.com© 2013 Ormco Corporation

CASE REVIEW:Class III Skeletal Open Bite Treated Without SurgeryDr. Rafael García Espejo, Córdoba, SpainDr. Garcia Espejo holds a MS in Orthodontics and Dentofacial Orthopedics and a Medical Specialty in Stomatology fromthe University of Seville. He also holds a Ph.D. in Medicine and Surgery from the University of Córdoba where he servedas professor from 1985-2010. He is a visiting professor at seven universities and an Academician Member of the PierreFauchard Academy. He has published several scientific articles and has spoken internationally in more than 20 countries,including all of the European Damon Symposiums and many International Damon Forums. He is co-director with Dr. RamonPerera of the European Damon Master program that is offered for clinicians specializing in the Damon technique. Rafael andhis wife Ester have two children, Rafael and Ester, who are both in dental school and planning to become orthodontists.Dr. Juana Mª Ruiz Rodríguez, Córdoba, SpainDr. Rafael García Espejo • Dr. Juana Mª Ruiz RodríguezEditor’s Note: For the case, Drs. Espejo and Rodríguez employed passive self ligation (PSL) and high-tech archwires thatthey attribute to fostering the physiological transverse arch development critical to open bite treatment with elastics takinga secondary role. In their hands, this armamentaria generates extra space in the palatal vault, which allows the tongue toreposition itself away from the interocclusal space and fosters dentoalveolar remodeling that are central to bite closing.Important to the result—achieved in only 12 months—was precise bracket placement and the use of low-friction (purple)TMA that fine-tuned the intercuspation.Dr. Ruiz Rodríguez received her degree in dentistry from the University of Granada in 2003 where she obtained the PremioExtraordinario Fin de Carrera and the Tercer Premio Nacional Fin de Carrera de Educación Universitaria, national honorsawarded to the most outstanding graduates. She continued her training in orthodontics with a three-year apprenticeshipunder the tutelage of Dr. Espejo and has continued working in his private practice in Córdoba since then. Having employedthe Damon technique since 2003, she completed the Damon Master program in 2007 and has participated in several nationalDamon congresses. Juana obtained her Ph. D. in Stomatology from the University of Granada in 2012 and is an active memberof the Spanish Society of Orthodontics.CASE REVIEWPretreatment DiagnosisA 16-year-old male with a skeletal open bite, slight Class III molar and cuspid relationships, a low tongueposture, unfavorable swallowing habit and tongue thrust with rhizolysis affecting the root apices of theupper incisors (which was presumably a result of the prior conventional orthodontic treatment).INITIALclinical impressions ® vol. 19 | no. 01 | february 2013 19

CASE REVIEW: Class III Skeletal Open Bite Treated Without SurgeryPretreatment Diagnosis - continuedThe pretreatment rhizolysis could have been a consequence of the prior orthodontic treatment (roots are short).Facial/Soft Tissue/Macroesthetics 1Dolichofacial with a flat mid-face. Full lower lip,recessive upper lip and a slightly obtuse nasolabialangle. Symmetry between the nose and the chin.Smile/MiniestheticsAnterior open bite with 50% upper incisal display.No gingival display on smiling. Transversearch relatively well developed but with only thefirst premolars partially showing on smiling.Upper incisors slightly protrusive. Noticeabletongue thrust.Teeth/MicroestheticsMicrodontic lateral incisors. Gingival heights/contours symmetrical except for a slightlengthening at the lower cuspids. Healthy gumsexcept for a slight tendency for recession in thelower anteriors.Treatment Objectives and PlanEmploy Damon ® Q (DQ) and elastics beginningmid-treatment to achieve functional occlusionand enhanced smile and facial esthetics. Closethe open bite and achieve proper upper incisorinclination. Provide more volume to the mid-face.Balance the upper lip with the lower lip. The wiresequence for both arches progressed as follows:.014 Copper Ni-Ti 2 for 10 weeks; .014 x .025 CuNi-Ti for 10 weeks; .018 x .025 Cu Ni-Ti for 16weeks; .017 x .025 TMA (purple) for 16 weeks.Bracket torques: U 3-3: Standard; L 3-3 Low. Seethe Case Discussion for an explanation of thetorques used in this case.Treatment ProgressBONDINGIndirect-bonded 5-5 and banded 6s and 7s. Engaged.014 Damon ® Optimal Force Copper Ni-Ti ®archwires, but only to the 6s.BONDING20 vol. 19 | no. 01 | february 2013 ormco.com/ci

5 MONTHS/2ND VISIT 7 MONTHS/3RD VISIT5 MONTHS/2ND VISIT:By 5 months, the .014 and .014 x .025 Cu Ni-Ti archwires had been employed for 10 weeks each,then .018 x .025 Cu Ni-Ti archwires and crossbite triangular (right side) and box CL III tendency (leftside) light elastics were engaged.Interim PanoNote: There is no evolution in the initial rhizolysis7 MONTHS/3RD VISIT — Rebonding AppointmentTook an interim panograph and repositioned several brackets, maintaining the archwires and elastics,but in a standard triangle configuration, bilaterally.clinical impressions ® vol. 19 | no. 01 | february 2013 21

CASE REVIEW: Class III Skeletal Open Bite Treated Without Surgery10 MONTHS/5TH VISIT 11 MONTHS/6TH VISIT10 MONTHS/5TH VISITThe .017 x .025 low-friction (purple) TMA archwires had been engaged for 5 weeks with a changein the elastics configuration at 9 months (CL III tendency on the right side), then back to a triangleconfiguration, bilaterally at this juncture.11 MONTHS/6TH VISIT — Rotation Wedges EmployedThe TMA archwires had been engaged for 9 weeks at this juncture and the elastics were placed in adouble finishing configuration. The reduced widths of DQ brackets—while increasing the interbracketdistances that further reduce the already light forces that PSL applies—also reduce rotational controlin the upper incisors. This reduced control can sometimes warrant using rotation wedges (for smallrotations) or placing finishing wire bends (for more severe rotations).22 vol. 19 | no. 01 | february 2013 ormco.com/ci

12 MONTHS — Treatment Complete. 6 Treatment Appointments.The case was treated to a functional occlusion with the correction of the open bite and the molarand cuspid relationships while achieving excellent anterior and buccal segment crown inclinationand posterior intercuspation. The arch widened so that the premolars show on smiling and thereis greater incisor display. There is also greater volume in the mid face for pleasing symmetry.Maintained excellent tissue health and the final X-rays demonstrate that the rhizolysis was notexacerbated by treatment.12 MONTHS/FINAL VISITNote: There is noevolution in theinitial rhizolysisRetention: Damon Retention Splint(AOA) and lingual bars U2-2; L 3-3.clinical impressions ® vol. 19 | no. 01 | february 2013 23

CASE REVIEW: Class III Skeletal Open Bite Treated Without SurgeryCase DiscussionIn open bite cases such as this one, we canusually transition from the last Cu Ni-Ti wiresto TMA for finishing without first using stainlesssteel archwires if the position of the teeth andtheir inclinations, the transverse, gross A/P andopen bite issues have all been resolved. If so, theTMA wires can be directed toward the fine A/Pcorrections and perfecting the final intercuspation.In finishing open bite cases, we specifically use.017 x .025 cross-section wires because this wiredimension allows sufficient play in the bracketslot. Note: Engaging the second molars until finaldebonding fosters full control of the arch form.Normally, we use standard low-friction TMAwires to finish cases, but in cases such as thisone, where we placed finishing elastics with anA/P correction component, we prefer to employpurple TMA wires, which have a coefficientof friction close to that of stainless steel in orderto facilitate sliding and make the small (A/P)corrections possible.With passive self-ligation, the mechanism thatactually closes the bite is not the elastics (althoughthey no doubt facilitate bite closure), but thecapability of the appliance to obtain transverse developmentof the arch form. When first workingwith this PSL appliance to treat open bites, webegan to realize that after having engaged the.018 x .025 Cu Ni-Ti wires for a sufficient periodof time, the bite closed down without the useof a single elastic. At first, we were astonishedby this phenomenon but unable to explain it. Wenow believe that it is due to the physiologicaltransverse arch development that the final hightecharchwires in the PSL brackets produce. Theextra room this arch development generates inthe palatal vault allows the tongue to repositionitself away from the interocclusal space andfosters dentoalveolar remodeling that we attributeto being primarily responsible for the bite closing.Regardless of the incredible occlusal and estheticresults obtained, however, we see through superimpositionsthat the cephalometric values remainas severe as initially presented.We do not mean to imply that elastics do notfacilitate bite closing, but their use for this purposemust be considered secondary to and coordinatedwith the principal bite closing mechanism ofphysiological arch form development. Werecommend limiting the full-time use of anteriorelastics to early elastics using only very lightforces (no more than 2 oz.). Reducing theirFINALINITIALRegardless of the incredible occlusal and esthetic results obtained, the ceph tracings demonstrate that thecephalometric values remain as severe as initially presented, all of which demonstrates the enormous capacityfor dentoalveolar compensation that the Damon System engenders once the tongue leaves the interocclusalspace and repositions itself in the physiologically developed palatal vault.24 vol. 19 | no. 01 | february 2013 ormco.com/ci

Torque Selection—DQ BracketsHIGHSTANDARDLOWWhile most open bite casesnecessitate the use of low-torquebrackets for the upper anteriors,the Bolton discrepancy in this casesuggested the use of standardtorque brackets to compensate forthe reduced-size teeth with extratorque, thus better coordinatingthe arches.time to nighttime only when transitioningto heavier forces limits the risk of producinganterior teeth root resorption or a gummy smile.We would like to point out that even thoughthere was root resorption initially present in thepatient’s upper four incisors (probably a consequenceof the previous orthodontic treatmentwith traditional high-force mechanics), we completedthe case without worsening it, a directconsequence of working with PSL and lightforces during all phases of treatment, and, aswe already mentioned, without abusing theuse of potentially damaging anterior elastics.We tend towards the use of low-torque bracketsfor most open bite cases (both arches) since onlythe reduction of incisor crown proclination willfoster their closing. Since there was no crowdingin the lower arch of this case, we selected lowtorque for all of the lower arch anteriors, includingthe canines. Because there was a Bolton discrepancyin the upper arch (with the very small laterals),we decided to use standard torque bracketsthere, which allowed us to compensate for thesereduced-size teeth with a little extra torque, thusbetter coordinating the arches.“Although not pertinent to this case, when treating an openbite case with a significant cross bite or upper arch crowding,it is important to select the negative torque values availablewith SnapLink molar tubes for the upper molars (-18° for1st molars and -28° for 2nd molars), which afford bettercontrol of the curve of Wilson during transverse arch formdevelopment (the main mechanism in bite closing).”— Dr. Rafael García Espejo | Córdoba, Spain1The diagnostic terms Macro-, Mini- and Microesthetic are used courtesy of Dr. David Sarver, Westavia, AL, which areoutlined in his article, “Soft-tissue based diagnostics and treatment planning,” Clinical Impressions, Vol. 14, No. 1,2006: 21-28.2All Copper Ni-Ti archwires used in this case were Damon ® Optimal Force Copper Ni-Ti ® .clinical impressions ® vol. 19 | no. 01 | february 2013 25

Your Practice. Our Priority.NEW PerformanceEnhancements!Class II Correctionin Class I TimeIntroducing AdvanSync 2 Class II Molar-to-Molar, thenext generation in Herbst* therapy. Featuring all-newtechnological advancements that dramatically improveclinical performance and reliability, AdvanSync 2 helpsyou achieve both dental and skeletal correctionssimultaneously, advancing the mandible to a Class Iocclusion in as little as six months.Through AOA Lab, one of the world’s leading Herbstlaboratories, customize AdvanSync 2 to control initialactivation and accommodate a wide range of clinicalissues such as mixed dentition, tipped or rotatedmolars. Plus, select from a wide range of crowns,bands and framework options.With AdvanSync 2, synchronizing mandibular advancementwith 5-5 orthodontic appliances has neverbeen easier.*Herbst is a registered trademark of Dentaurum Inc.New enhancements include:• Electropolished rods with radiused corners forsmoother operation• Reinforced Spiralock threading for maximumscrew engagement• Relief hole at end cap to prevent food/debrisbuild-up• Upper and lower dual hole casing to enablecustomized activation for treatment versatilityAdvanSync 2Herbst ApplianceLearn Moreormco.com/advansync2Twins Digital Auxiliaries Practice Development EducationTwins Self Ligation Digital Aligners Auxiliaries Tubes/Bands Practice Development Archwires Education Lab ProductsSelf Ligation Aligners Tubes/Bands Archwires Lab Productsormco.com | aoalab.comormco.com | aoalab.com© 2013 Ormco Corporation© 2013 Ormco Corporation

Lower Article Cuspid Headline Goes HereRotational ControlMade Efficient withAccurateBracket Base DesignStraty Righellis, DDSOrthodontic appliance manufacturers carefully build torque, tip and rotational control into theirbracket prescriptions. If, however, the bracket pad is not contoured to provide an anatomical fit tothe labial surface of the tooth, the tooth will not move to the desired position. Bending archwiresto compensate for inaccurate bracket pad design wastes valuable chairtime. Making offsettingbends to counteract loss of control can often create additional undesirable tooth movements thatextend treatment.Straty Righellis, DDSOakland, CADr. Righellis graduated from UCLADental School and received hisorthodontic specialty certificationfrom the University of California,San Francisco. He maintains aprivate practice and serves asan associate clinical professorat the University of the Pacific,San Francisco. Dr. Righellisis a diplomate of the AmericanBoard of Orthodontics, is on theeditorial review board for theAmerican Journal of Orthodonticsand Dentofacial Orthopedicsand lectures domestically andinternationally on excellence inclinical orthodontics.Below are three questions I was continually asking myself before transitioningto Ormco’s active Prodigy SL appliance and which might help you focus on animportant clinical issue — cuspid rotational control.1: Does your current self-ligating bracket overrotate lower cuspids mesially?2: Do you feel you have to reposition brackets mesially too often to compensatefor lower cuspid rotations?3: Do you have to place step-in/step-out bends too often to resolve lowercuspid rotations?If you answered “yes” to any of thesequestions, you’re certainly not alone.Until recently, I had experienced the samefrustrations and have heard the samecomplaints from doctors who attend theseminars I conduct (Figure 1).Figure 1. Poor experience with a leading activeself-ligating appliance.My experience with the newly developedProdigy SL appliance, which I have beenemploying for 18 months since the bracketwas in its prototype form, demonstratesthat the design of this appliance resolvespretreatment rotations and precludesrotational issues from occurring. Whencomparing the mandibular cuspid fit of theProdigy SL appliance with the fit of theabFigure 1a-b. Lack of rotational control.cdFigure 1c-d. In/out bends to address lack of rotational control.clinical impressions ® vol. 19 | no. 01 | february 2013 27

Lower Cuspid Rotational Control Made Efficient with Accurate Bracket Base DesignFigure 2. Cuspid fit of the leading active sl bracket vs Prodigy SL.Figure 2a-c.Leading active sl cuspid bracket:Note poor bracket-to-cuspid fit.abcFigure 2d-f.defProdigy SL cuspid bracket:Note how the bracket anatomically conformsto the curvature of the cuspid.cuspid bracket of my former appliance (a leading competitiveappliance), I can easily see why I experienced rotational issues(Figure 2). On the other hand, the contour and tooth shape ofProdigy SL cuspid bracket pads assist in placing them at theheight of contour where they cradle the tooth snugly (Figure 3).Moreover, most active self-ligating appliances on the marketother than Prodigy SL utilize a flexible cobalt-chromium clip thatserves as the opening and closing mechanism. I have oftenexperienced considerable fatigue with this clip. The design ofthe Prodigy SL slide and its exacting fabrication with robust,superelastic Copper Nickel Titanium gives it significant resilienceto deliver constant forces without deforming. I haveexperienced no slide fatigue with Prodigy SL and no loss ofrotational control.Figure 3. The contour and tooth shape of the ProdigySL cuspid bracket pads assist in placing them at theheight of contour where they cradle the tooth snugly.Two Case Examples:Rotations from Another Active SL Bracket Resolved with Prodigy SLCases 1 and 2 are more examples of the types ofrotations I was experiencing with my former activeself-ligating appliance. As soon as the prototype ofProdigy SL became available, I rebonded these twocases and many others. Soon after rebonding thesecases, all the rotations resolved.CASE 1: PRETREATMENTIn Case 1, following 12 months of treatment withthe competitive bracket, the lower left lateral wasstill mesially rotated. Six weeks after rebonding withProdigy SL, the rotation had totally resolved.a28 vol. 19 | no. 01 | february 2013 ormco.com/ci

CASE 1: 12 MONTHS with another active SL bracket6 WEEKS rebonded with Prodigy SLbcCase 2 demonstrates a similar situation. After 14 months of treatment with the competitivebracket, the lower right lateral and canine were still mesially rotated. In only three weeks afterrebonding the case with Prodigy SL, the rotation had resolved and four months later, optimalalignment was achieved.CASE 2: PRETREATMENT14 MONTHS with another active SL bracketa3 WEEKS after rebonding with Prodigy SLbPOSTTREATMENT with Prodigy SLcdclinical impressions ® vol. 19 | no. 01 | february 2013 29

Lower Cuspid Rotational Control Made Efficient with Accurate Bracket Base DesignCASE 3:Incisor and Cuspid Control of Prodigy SLCase 3 demonstrates the incisor and cuspid control I consistently see with my Prodigy SL cases. Atbonding, a .014 Copper Ni-Ti wire was engaged to begin the leveling and aligning phase. Approximatelysix weeks later, with a .020 Cu Ni-Ti wire engaged, the right cuspid is being incorporated into the archand the incisor positions are being held. Four months later (5.5 months in treatment), with a .019 x .025Cu Ni-Ti wire engaged, the pretreatment rotations have resolved and the positions of the incisorsdemonstrate that the case is optimally aligned.CASE 3: PRETREATMENTBONDING: with Prodigy SL and a .014 Cu Ni-Ti wireab6 WEEKS in treatment: .020 square Cu Ni-Ti wire5.5 MONTHS in treatment: .019 x .025 Cu Ni-Ti wirecdConclusionProdigy SL is now my active appliance of choice, not only because of the rotational control but for itsmany other features. There’s a vertical slot for greater versatility in treating high cuspids and blocked outlaterals, optional bondable hooks, and a patented laser-etched pad with a rim to lock in the adhesive aswell as differential etching by tooth. An important benefit is that lower brackets open to the gingival sothere’s no wasted time closing slides to see the entirety of the occlusion.Changing appliances is an important decision for an orthodontist that no one considers lightly, but ifyou’re frustrated with your current active SL option or considering changing from your conventionalappliance to self-ligation, I recommend you consider Prodigy SL. You’ll be able to maintain your currenttreatment mechanics while gaining all the benefits of self ligation—which are considerable.30 vol. 19 | no. 01 | february 2013 ormco.com/ci

Your Practice. Our Priority.Intelligent Designfor MaximumRotational ControlThe patented design of Prodigy SL provides you withmaximum rotational control, proven bond reliabilityand consistent clinical performance. Plus, Prodigy SL’srobust SpinTek slide is constructed of Copper Ni-Ti ®for less wear and delivery of continuous force.That means more predictable results.Maximum ControlCopper Ni-Ti slide and patentedbridge design deliver more consistentclinical performance than Voudourisclip designs for greater rotationalcontrol and torque expression. *“The new slide mechanism works much better thanany other active system I have used. Due to theCopper Ni-Ti slide I have also found that there ismore control and teeth seem to line up quicker.~ Dr. Doug Knight”Precision FitAnatomically contoured pad fora better fit including tooth-shapedpad for cuspids.Learn Moreormco.com/prodigyEasy to OpenSpinTek slide design employsreciprocal forces during opening –for a net force of 0 kg even withcalculus build-up.* Internal testing data on fileTwins Digital Auxiliaries Practice Development EducationTwins Self Ligation Digital Aligners Auxiliaries Tubes/Bands Practice Development Archwires Education Lab ProductsSelf Ligation Aligners Tubes/Bands Archwires Lab Productsormco.com© 2013 Ormco Corporation

Tapping into a Promising Market:Targeting theWhitespaceAdultDebby HartmanDirector of MarketingCommunications andEditor-in-Chief ofClinical ImpressionsOrmco CorporationDebby Hartman brings morethan 19 years of marketingexperience to her positionas director of marketingcommunications at Ormcowhere she oversees Ormco’sgraphic design department,global brand development andcorporate communications.She is also the editor-in-chiefof the Clinical Impressionsjournal. Prior to joiningOrmco in 2004, Ms. Hartmanheld marketing managementpositions at Discus Dental,Lippincott Williams & Wilkins,TBC advertising agency andLegg Mason investmentfirm. She serves as vicepresident of the OrangeCounty chapter of Smile for aLifetime Foundation (S4L) andearned a bachelor’s degree inbusiness administration fromthe University of Delaware.Last year, the American Association of Orthodontists (AAO) kicked off its first-ever nationaladvertising campaign targeting adults. Why? According to Dr. Michael B. Rogers, president of AAO,there are many adults on the fence when it comes to receiving orthodontic treatment, making itincreasingly important for the AAO to educate the adult audience on the benefits of braces.Recent AAO statistics reported by The NewYork Times show that from 1994 to 2010, thenumber of Americans 18 years and older gettingbraces—or some type of teeth-straighteningtreatment—from an orthodontist has jumped58 percent, from 680,000 annually to 1.1 million.Furthermore, those same statistics show thatadults undergoing treatment account for 22percent of all orthodontic cases—that’s morethan one in every five patients.Another study commissioned by the AAOreports that one-third of American adultsare unhappy with their smile. Out of thoseadults, 36 percent believe they would havea better social life if they had better teeth.This sentiment is especially true among youngadults, as 48 percent of Americans ages 18-24have untagged a picture on Facebook becausethey didn’t like their smile.With such vast potential to treat the adultwhitespace, orthodontists can increase theirpractice revenue by better understanding thisuntapped market and effectively promotingthe latest treatment methods proven to deliverexceptional patient results. To help, I inviteyou to explore the following tips that offerinsight into the growing audience of adultorthodontic candidates.Start with MomMost doctors know the importance of targetingmothers—typically the key household decisionmaker. It is widely reported that women make orinfluence the majority of all purchasing decisions.But did you know that according to consultancyfirm Girl Power Marketing an astounding 80percent of healthcare decisions are made bywomen? Furthermore, thenextweb.com statesthat 64 percent of moms ask other momsfor advice before purchasing a new product.Therefore, doctors who market adult treatmentoptions to moms will have the best chanceto treat parents and their children. Educationis the best way to kick off your targeted adultmarketing efforts.32 vol. 19 | no. 01 | february 2013

Educate AdultsWhile many parents seek orthodontic treatmentfor their children, the majority of them may notrealize the benefits of straight teeth for themselves.In fact, there are approximately 23 millionU.S. adults who are interested in improving theirsmiles, but don’t seek treatment due to lackof education, according to a study from theMillennium Research Group. The same studyindicates that adults are more likely to seektreatment after reviewing educational materialsthat showcase the benefits of orthodontic treatment,as well as advancements in the treatmentexperience itself.With this in mind, it’s important to ensure thatyour practice website, lobby and consultationrooms resonate with the adult audience byfeaturing photographs of adults in treatmentand adult patient before-and-after photographs.Patient education brochures and consultationaids featuring adult patients are also effective andavailable via Ormco’s online practice marketinglibrary. Doctors may contact their Ormco salesrepresentative to access this online resourcelibrary of patient imagery, consultation tools,practice videos, webpage assets and more fordoctors offering the Damon ® System, Insignia ,Inspire ICE and Prodigy SL .In addition to implementing marketing materialsthat target adults throughout your office andpractice website, it’s important to provide potentialadult patients with information on treatmentthat addresses their key concerns. This includesadvanced solutions that are aesthetically pleasing,comfortable and fast.Showcase Advanced TechnologyMany adults are open to advanced treatmentsolutions that will create the best possible smile,despite marginal price increases. In fact, anOrmco study conducted by Boston ConsultingGroup indicates that patients would pay apremium for treatment that is faster, moreaesthetic and more comfortable.Another Ormcostudy conductedby the MillenniumResearch Groupfound that potentialadult patientsare only moderatelyprice sensitive inselecting a treatmentoption, citing very littledifference in preferencefor a treatment priced at$250 versus $300 per month.The bottom line? Adult patientsare willing to evaluate treatmentoptions based primarily on outcome andtotal treatment time—leading them to consideradvanced treatment options even despitemarginal increases in price.Ormco’s Insignia Advanced Smile Design isan all-inclusive digital solution that can also helpto differentiate your practice. Insignia combines3D smile design software with customizedappliances to help orthodontists deliver efficient,precise outcomes—often in less time and withfewer office visits. This is a huge advantage notonly for busy moms-on-the-go, but also imageconsciousadults who love customization—frombeauty products and makeup to tailored clothing.When speaking with prospective patients, besure to communicate how Insignia allows you toadd a level of precise detail and customizationthat provides the bestlong-term occlusionand smile in less time.Insignia also servesas a powerful consultationtool, allowingdoctors to presentprospective patientswith a 3D video morphof their final smilebefore starting treatment.Now patientscan be confidentDamon Clear patientsTo learn about the benefits of Insignia from a patients’ perspective,visit www.insigniasmile.com – Ormco’s consumer education websitewith an Insignia Doctor Locator.PretreatmentPosttreatmentTreatment Time - 10.5 months, 7 appointments ** Insignia case treated by Dr. Jeff Kozlowskiclinical impressions ® vol. 19 | no. 01 | february 2013 33

Traditional BracesDamon ClearTargeting the Adult WhitespaceInsignia ClearguideExpress aligner systemthey’re making the right decision to undergotreatment before bonding day.Aesthetics MatterPatient demand for aesthetic treatment continuesto grow. If you haven’t considered expandingservice offerings to include virtually invisiblebracket solutions, now is the time. For imageconsciousadults, Damon ® Clear provides adiscrete treatment experience with results thatgo beyond straight teeth — providing widersmiles with smoother cheek contours, betterfacial symmetry and improved profiles. Whenguiding adult prospects through Damon Clearfeatures, doctors and treatment coordinatorsshould stress how the brackets resist staining,are easy to keep clean and offer exceptionalcomfort without tightening. What’s more, DamonClear is a treatment option with Insignia, providingpatients with a customized, efficient and discretetreatment experience.For patients who require minor anterior toothmovements, consider showcasing the benefitsof Insignia Clearguide Express virtually invisiblealigners that won’t discolor over the wear period.Clearguide Express combines Ormco’s InsigniaAdvanced Smile Design software with AOALab’s custom aligner expertise. Thisaligner is an affordable option forpatients of all ages—especiallyadults—who are looking for analternative to braces to quicklytransform their smiles andboost confidence.What’s the best wayto showcase aestheticoptions to adults? Inaddition to including adultpatient photographs onyour practice website,office walls and educationmaterials, your patientsin treatment are evenmore convincing.Consider treatingyour office staffmembers andreferring dentalhygienists withyour clear bracesand/or alignersto proudly showofftheir discretetreatment to visitingparents in your office.The saying goes, “Apicture is worth a thousandwords.” That may be true,but a happy, smiling patientand corresponding referralis worth at least $5,000 inpractice revenue.Use the Power ofSocial MediaTo learn about the benefitsof Damon Clear from apatients’ perspective, visitwww.damonbraces.com –Ormco’s consumereducation website witha Damon Doctor Locator.Now that we’ve addressed theimportance of showcasing leadingorthodontic technology to potentialadult patients, let’s talk marketing. Relying solelyon a practice website may no longer be enoughto ensure a steady flow of new patients. With 62percent of adults worldwide using social media,according to thesocialskinny.com, one of thebest ways to reach and educate them is throughchannels such as Facebook, Twitter, YouTube andYelp. Facebook has more than 901 million users,and is an especially effective way to reach adultconsumers. In fact, one in three consumers saythey’re likely to purchase from a company theyfollow on Facebook, according toeMarketer.com.The benefits of social media aretwofold for doctors. First, activelymonitoring practice reviews andtracking social media conversationsabout orthodontics provides doctorswith a better understanding of patientconcerns and preferences. Second,engaging with current and prospectivepatients online helps to strengthenrelationships, build trust and achievethought leadership positioning.Make it easy for prospects to findyou. To increase search hits, alwaysinclude your practice’s name on yoursocial media platforms. Once socialprofiles are created, consider includingURLs to those profiles in all oformco.com/ci

your marketing collateral, such as business andappointment reminder cards, posters, t-shirtsand mailers. When you’re ready to post contentvia your social media profiles, make sure it’sinteresting and relevant to the adult audience,and engage with patients by encouraging themto comment, retweet or “Like” your posts. It’salso important to remember that social mediaisn’t just about pushing information out to potentialpatients, but fostering two-way engagementthat will build trust, educate and ultimately drivepatients through your door.Discuss Third-Party FinancingA recent research study conducted by theMillennium Research Group found that the costof treatment is the No. 1 barrier holding adultsback from seeking orthodontic care. If parents arealready investing in their child’s braces, they oftenwonder how they can afford it for themselves.Offering flexible financing options is a good wayto ease financial concerns. Orthodontists shouldinvestigate available third-party financing plansthat enable them to offer patients more affordablemonthly payments over longer periodsof time. This is especially helpful as treatmentcosts increase and treatment times decrease asa result of technologies such as self-ligation anddigital solutions. Offering financing options helpsincrease case acceptance and cash flow, whiledecreasing accounts receivables.Remember the “Why”A common question doctors often hear fromadults exploring orthodontic treatment is, “Whyshould I invest time and money in obtaining abetter smile? I’m too old.” But the fact is orthodonticshas come a long way from when adultswere kids, thanks to decades of research anddevelopment. A good way to mitigate thesequestions is to stress the positive long-termeffects orthodontic treatment can have on theirlives. Nearly one-third of Americans say the firstaspect of someone’s face they typically noticeis his or her teeth. Underscoring the point, arecent perception study from market researchconsultancy, Kelton, found that when looking atimages of other people, American adults perceivethose with straight teeth to be 45 percent morelikely than those with crooked teeth to get a jobwhen competing against someone with similarskill sets and experience. Furthermore, the samestudy found people with straight teeth were 58percent more likely to be successful, and wealthy.Most doctors know the importance of detailingthe oral health and self-confidence benefits ofa better smile, but it’s equally as important tostress how an improved smile can help potentialpatients increase their chances to excel in theworkplace and live more fruitful lifestyles.Remember, it’s never too late for your adultprospects to look their best.Ormco, AAO and YouThe eligible adult treatment populationrepresents a lucrative and largely untappedopportunity. Doctors who are motivated tounderstand what appeals to this particularmarket segment will see more patients in theirchairs and increase profitability. The emergingtrend of adults seeking orthodontic treatment isnot slowing down, and orthodontists have moresupport and resources to treat this patient populationthan ever before. By leveraging marketingassets and advanced treatment solutions fromOrmco, as well as materials from the AAO’srecent campaigns targeting the adult market,you will have a significant opportunity todemonstrate your dedication to improvingthe smiles of adults and make your practiceeven more successful.clinical impressions ®

Your Practice. Our Priority.TECHNOLOGY SYMPOSIUMSPassive Self Ligation • Digital Solutions • Class II CorrectionJune 7-8, Washington, D.C.Sept 6-7, Chicago, ILSept 20-21, Atlanta, GAOrmco’s 1½ day seminars incorporateinnovative technologies to provide anexceptional educational experience.Speakers:• Discuss diagnosis and treatment planning for functionalocclusion, smile arc and facial aesthetics• Incorporate the delivery of consistent phenomenal resultsvia precise finishing mechanics and aesthetic recontouring• Adopt advanced digital technology to speed treatmenttime, increase efficiency and deliver precise finishing• Discover how digital treatment with passive self-ligationcan clearly differentiate your practice for increasedpatient startsDr. Stuart Frost Dr. John Graham Dr. Jamie Reynolds Dr. Bill Dischinger• Learn how to successfully integrate Class II correctorswith treatment protocols for more efficient outcomesVisit ormco.com/education for more detailsOrmco is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying qualityproviders of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hoursby boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.This seminar provides 11 ADA continuing education credits. Acceptance of C.E. credits may differ among states.For more information about the products and techniques featured in this issueof Clinical Impressions, contact your local Ormco representative or office:United States and Canadawww.ormco.comCall: 800.854.1741 or 714.516.7400Latin AmericaOrmco América Latinawww.ormcoamericalatina.comOrmco de Méxicowww.ormco.com.mxCall: +52 (55) 5280 7851Asia and the Middle EastVisit www.ormco.com/index/Ormco-Companyfor your local Ormco DistributorAustralia and New Zealandwww.ormco.comAustralia – Call: 1800 023 603New Zealand – Call: 0800 446 140Europewww.ormcoeurope.comCall: 0031 334536161Austria, Belgium, France, Germany,Ireland, Italy, Luxemburg, Netherlands,Spain, Switzerland and United KingdomCall: 00800 3032 3032Portugal – Call: 800 286 349Israel – Call: 03 61 33 118Twins Digital Auxiliaries Practice Development Education© 2013 Self Ormco Ligation Corporation Aligners Featured articles Tubes/Bands may authored by Archwires clinicians who are Lab paid Products consultants and/or speakers for Ormco Corporation.Subscribe toClinical Impressions Online!This and future issues of Clinical Impressions willonly be available online. To access new and archivedarticles, register today at www.ormco.com/ci.Ormco Corporation1717 West Collins AvenueOrange, CA 92867