PITTS’ Issue 2

PROT OL

SAP™
™

Bracket Placement

H4 GO™ Aesthetic
Self-Ligating
Bracket System

Dr. David Herman’s

Meet
Building Blocks for
Sustainable Marketing Dr. Tom Pitts

e d u c a t i o n | c o m m u n i t y | c o l l a b o r a t i o n
Dear Doctor and Staff:

As I promised a few months ago, I am very pleased to offer you the 2nd issue of Pitts’ Protocol. Each and every year we
do our best to grow and improve as a company and this year has been an exceptional one for us. By working hand in
hand with Orthodontists, we have made great strides in broadening our product offerings and resources for you. In this
issue of the Protocol, Dr. Thomas Pitts, the Clinical Editorial Director, will introduce you to an “Active Early” approach
to Case Management and the second part of Smile Arc Protection for indirect bonding. Also in this issue, Dr. David
Herman of Four Corners Orthodontics has provided us an article about how he markets his H4 practice. So enjoy this
issue, as the next issue of the Protocol is already in the works and I am sure you will be eager to see it.

Ortho Classic have been designing and manufacturing orthodontic products in America for over 24 years and devel-
oped the technology that allows us to produce some of the highest quality and consistent brackets possible.
At Ortho Classic we are committed to consistent incremental improvements in our H4™ existing products and mean-
ingful innovation. This year alone, we have introduced H4 GO™, a wonderful aesthetic alternative that really performs,
the H4™ Buccal Tubes, and the Pitts’ Standard and Broad arch forms for our H4™ system. We will continue to adhere
to our “customer-first” philosophy, working tirelessly to provide superior products and services that consistently surpass
market expectations and excel on the world stage.

Please join us on our journey to the future, and accept our appreciation for your kindness and on-going support. Once
again, we at Ortho Classic would like to thank you for your continued loyalty and business.

Rolf Hagelganz
Ortho Classic President

© 2015 Ortho Classic. All rights reserved.

No portion can be reproduced without the expressed
written consent of Ortho Classic
PITTS’

PROT OL
TABLE OF CONTENTS

6 Dr. Tom Pitts

Find Dr. Pitts’ passion in orthodontics

8 Active Early
Active Early Principles by Drs. Tom Pitts and Duncan Brown

16 H4 GO™ Aesthetic Self-Ligating

Feature and benefits of the H4 Go™ Aesthetic Self-Ligating Bracket System

20 SAP™
Part 2 of Smile Arc Protection (SAP)

26 Dr. David Herman

Building blocks for sustainable marketing
Contributors

CONTRIBUTORS
Dr. Thomas Pitts D.D.S., M.Sc.D.

Dr. Pitts is a world renowned lecturer and clinician. He is highly recognized for
his continued teaching of orthodontic finishing and clinical excellence. Dr. Pitts
is an associate clinical professor at the University of the Pacific and founder of
the well-respected Pitts Progressive Study Club.

Dr. Pitts has been published in multiple journals and clinical publications. He
has been actively teaching the orthodontic community in a variety of settings
both nationally and internationally since 1986.

Dr. Duncan Brown B.Sc., D.D.S., D. Ortho

Dr. Duncan Brown is a highly regarded international speaker and educator in

passive ligation bracket systems. Dr. Brown teaches regularly at the University
of Alberta and University of Manitoba and is also a Kodak/Carestream Dental
speaker and consultant.

Dr. Brown has made large contributions to the orthodontic community from
creating effective hygiene programs for patients, to the G&H Pre-Torqued Arch-
wire series and much more!

Dr. David Herman D.D.S., M.S., M.P.H.

Dr. David Herman is credited with having one of the largest single office
practices in the United States. He is known for being years ahead of the curve—
foreseeing industry changes and adapting with success. Dr. Herman was one
of the pioneers in implementing same-day starts, passive self-ligation, staff-driv-
en management and adding dental and hygiene departments to an orthodon-
tic practice. Professionals from all over the United States come to observe Dr.
Herman’s staff-driven management concept and see the success of his mar-
keting campaign that brings in patients from more than two hours away.

Dr. Tomas Castellanos Arteaga D.D.S., M.Sc.D.

Dr. Tomas Castellanos is an international speaker and certified educator. Dr.

Castellanos has been the coordinator of research with important works, which
have developed new orthodontic and surgical techniques, that speed up the
treatment time and provide striking functional and aesthetic results. He has his
professional practice as an orthodontist in Colombia.

His progressive treatment planning and focus on facial aesthetics has created a
highly successful name for himself early in his career.

2015 Issue 2 // www.orthoclassic.com 4

5
About

Dr. T ho m a s P i t t s D.D.S., M.Sc.D.

WHAT IS YOUR PASSION IN ORTHODONTICS?

 My biggest passion is creating the highest and best smile

and facial esthetics possible for any given patient, without
compromising the functional occlusion.

  Many Orthodontists are challenged in controlling the

axial inclination of the anterior teeth, sometimes having to
accept proclined anteriors to avoid extractions. Working
with OC’s engineers, we have been able to develop a
bracket system with slot dimensions and tolerances that
go a long ways to improving the problem. When combined
with “Active Early” case management approaches, a world
of new opportunities are available.

  We will continue to develop both the appliance and

the concepts to make your lives in clinical practice easier,
and excellence in treatment results more predictable.

  In the next few months, Ortho Country, a working

practice as well as Ortho Classic’s educational and
research & development center in McMinnville, Oregon
will be up and running. This will allow us to run training
programs in a hands-on and intimate setting. I look
forward to seeing you there.

2015 Issue 2 // www.orthoclassic.com 6

 About
“Due to the quality manufacturing, tightened tolerances
and slot dimensions, I now have less bends in my wires for
detailing and finishing. Ortho Classic is really setting itself
apart from other manufacturing and supply companies, and
doing it with lower pricing.”
-Dr. Thomas Pitts

MEET THE
ORTHODONTIST
7 www.orthoclassic.com // 2 015 Issue 2
 PRINCIPLES *

“Perfection of means and

confusion of goals seems
to characterize our age”
- Albert Einstein
• The first of these is revolves around the core straight wire
principle that the wire plane parallel to the occlusal plane
is a requisite for excellent occlusions. It is not, and failure
to adjust bracket position to meet esthetic need can result
in esthetic decline3 in many patients. The contemporary
Introduction: I have been extremely fortunate to have Orthodontist needs expand his/her diagnostic and
traveled broadly in teaching orthodontics throughout my mechanical understandings beyond reliance on improved
career. One of the aspects that seems to create a great deal “straight wire” appliances to attain superior esthetic
of confusion among orthodontists around the world is the results. David Sarver has led the charge on the impact on
relationship between the means of using a “straight wire” esthetics of orthodontic treatment mechanics4 where the
appliance to align teeth and the contemporary clinical vertical position of the upper incisor is the prime diagnostic
goals of excellence in both esthetics and occlusion. criteria in developing superior esthetics in orthodontics,
and I agree with this concept.
Every orthodontist is familiar with the brilliant article by
Andrews1, which introduced the basis of “straight wire” • The second involves the misconception that
theory, which has dominated our profession for the last incremental increases in arch wires size is an effective
40 years. Building tip, torque, and in/out into the bracket means of controlling axial inclination. It is not, and failure
as a means of avoiding adverse “wagon wheel” effects of to appreciate how to control axial inclination results in
wire bending is the premise of every modern orthodontic frustration in many orthodontists when reliance on “the
appliance, and to this day, I use pre-adjusted appliances treatment built into the appliance” fails to deliver.
for this reason.
• The third limitation involves the lack of appreciation of
As with all great ideas, “Straight Wire” theory has some the pivotal role of case management in attaining superior
recognized limitations. Thomas Creekmore and Randy aesthetic and occlusal results. The best orthodontic
Kunik provided a good summary of these: inaccurate results are attained by the best case managers, regardless
bracket placement, variation in tooth structure and tooth of the appliances they use.
facial morphology, variations in the maxilla/mandible
skeletal relationships, tissue rebound, mechanically Today I would like to explore briefly the elements that are
deficiencies in the appliances2, and variable threshold of within the control of the Orthodontist; bracket position,
biological activation, to name a few. The combination appropriate use of pre-adjusted appliances, and arch form
of all these factors reduces the ability of the clinician to as they relate to esthetic outcomes.
rely strictly on the appliance to guarantee an excellent
occlusal result, with an even less likelihood of reaching
superior esthetic goals.

For me, there are three significant considerations of

straight wire theory as it applies to using a contemporary
PSL appliances in esthetics based treatment:

© 2015 OrthoEvolve, All Rights Reserved 8 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
Figure 1: Beautiful Smile Arc - The vertical Figure 2: SAP bracket placement - to Figure 3: SAP versus Traditional bracket
position of the upper anterior teeth relative protect the Smile Arc, and improve enamel placement: in situations with flat upper
to the upper posterior teeth determines display, brackets may be positioned in occlusal planes, or where more enamel
the Smile Arc. Importantly the Smile Arc a more gingival position on the upper display is required placing brackets with the
extends from first molar to first molar. anteriors than the upper posteriors. This wire plane parallel to the occlusal planes
approach may require a wire plane that is adversely impacts esthetics.
gingival to FA, and not parallel to the upper
occlusal plane.

Bracket Position as it effects Contemporary This approach to bracket placement has come to be
Esthetic Goals: called the “SAP”10 Smile Arc Protection approach. The
specifics of this approach have been published several
For many years, I have been teaching the “Top 10 times5 11 12, so rather than review those details again, I will
Esthetic Factors” that can be impacted by orthodontic cover the positive impact esthetics that SAP10 produces.
mechanics. These were recently published in a SIDO
article, so this article will deal more specifically with • ”Positive and negative” coronoplasty is very important.
bracket position, bracket selection, and arch form as it Patients today want beautiful faces, beautiful smiles, and
relates to these four factors; beautiful teeth. Teeth need to be “optimized” for shape
and contour. When done prior to bonding, esthetic re-
• Idealized inclination of the upper incisors and canines: contouring improves the ability to place brackets in the
Patients are more sensitive to adverse changes in axial appropriate location to maximize the smile arc, optimize
inclination than to changes in A/P position6 axial inclination, and control 1st and 2nd order changes
• Idealized smile arc: Idealized smile arcs are more in tipping mechanics. Prior to bonding, we encourage
attractive especially in women7 softening the cusp tips of the cuspids and first bicuspids,
• Incisal and Gingival display: Some gingival display, and normalizing facial irregularities, and optimize length/width
full enamel display is appropriate in a “posed” smile8 ratios of the upper anterior teeth. Other microesthetic
• Wide arch width, particularly in the molars: Smiles with aspects of contact point length, appropriate embrasure
small buccal corridors are more aesthetic, in both men spaces, and slenderizing for tooth size discrepancies are
and women9. accomplished after the anteriors are aligned. Centric
stop adjustments are made during the finishing stages
Placing anterior brackets in a more gingival position of treatment. All surfaces that have been adjusted are
improves enamel and gingival display by adjusting the smoothed with a white stone, and black rubber tips in a
vertical position of the upper incisors and cuspid high speed hand piece.
relative to the upper posteriors. (Figure 1, 2, 3).
Lower posterior brackets are placed in a more SAP Bracket Positioning:
gingival position to avoid the occlusion, and the lower
anterior bracket more incisally to intrude the lower • “SAP Bracket Position10” as a tool in gaining optimal
anteriors and optimize overbite (Figure 4,5). esthetics. Straight wire theory is based on occlusal results
but great occlusal results do not always provide great
esthetic results. Bracket position must be individualized
to patient esthetic need. In patients with “flat” occlusal
planes or those requiring increased enamel
display, the progression of the wire plane
created by bracket position must increase
to develop the smile arch by extrusion of
the upper incisors relative to the upper
bicuspids. In patients with normal occlusal
planes a more modest progression in the
wire plane is advisable to protect the smile

© 2015 OrthoEvolve, All Rights Reserved 9 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
arc as the upper arch broadens with treatment. Bracket Torque as it effects Contemporary
Orthodontists tend to focus on intrusion of the upper Esthetic Goals:
anterior teeth in deep bite cases with steep occlusal
planes, and excessive enamel display which can lead to • Realistic Expectations and Straight Wire Theory: In
esthetic decline. A modest progression in still advised in straight wire theory, control of first, second, and third
deep bite cases to avoid excessive reduction in smile arc order tooth movement is described as being achieved by
with reduction in overbite. It is important to remember incremental increases in arch wire size and placement of
that large bracket progressions in the upper arch must the bracket slot at FA. It is required to gain optimal torque
be compensated for by increased “overlevelling” of the expression relative to the occlusal plane using arch wires
lower arch to maintain optimal overbite through bracket that “fill up the slot”18. The recognition of the limitations
position. of “straight wire theory” has become relatively common,
with the conclusion that, ”we need to raise the need
for a re-evaluation of the theories of the straight-wire
appliance in orthodontics.”19

Few orthodontists fill the slot, so that the prescription

“built into” the bracket is seldom expressed. Actual torque
expression then is the result of many factors: bracket
design, wire/slot play (engagement angle) mode of ligation,
bracket deformation on loading, wire stiffness, magnitude
of wire torsion, corner radius, initial tooth position, bracket
position, and tooth anatomy20. The combination of
these effects makes creating torsion within the appliance
difficult when relying on incremental increases in wire
Figure 6: Impact of Head Position on Smile Arc - as the smile arc changes
size, without bending wire (Figure 7) using traditional
with head position, I use NHP (Natural Head Position) as the reference plane bracket positions. This is especially problematic in non-
for aesthetic based treatment. extraction, crowded cases where incisor flaring created
during the tipping phases of treatment is very difficult to
recover later.
• Head Position versus Frankfort Horizontal Plane in
Esthetics. The need to standardize the techniques used by “Today’s Orthodontist practices at the
orthodontists and anthropologists, to undertake diagnosis intersection of art and technology. The
and comparative studies of head anatomy generally
revolves around the Frankfort Horizontal reference plane. challenge of applying appropriate levels
This plane was selected in the outcome of deliberations of technology to an artistic end result is
at 2 craniometric conferences on disarticulated skulls, the art of case management.
held in Munich in 1877 and subsequently in Berlin in 1880,
and submitted for consideration to the 13th General The best case managers have a sound
Congress of the German Anthropological Society held understanding of the technology they
in Frankfort (or Frankfurt) in 1882. A more appropriate
apply on a daily basis”.
plane is clearly visible on a number of Leonardo da Vinci’s
proportional drawings13 as a “true horizontal reference Fortunately in the “SAP10” - Smile Arc Protection -
line” with the study postured in a Natural Head Position approach, with bracket placement guided by esthetic
(NHP) which has become a popular reference plane for requirements, benefits arise in the area of third order
esthetically driven treatment14. As NHP has been shown control.
to be reasonably reproducible, both in the short and long
term15 16 17, and smile arcs are highly dependent on the • SAP10 bracket positions are more effective in management
occlusal plane of the upper arch (Figure 6), I prefer using of axial inclination early in treatment. This is true during the
the natural head position for assessment. Patients should tipping phases of treatment. Early in treatment, incisor extrusion
be assessed while standing comfortably, engaged in creates a retroclining movement that helps control proclination
natural conversation, and generating unposed smiles. The as crowding unravels, when supported by ELSE (early light short
Orthodontist can then make a patient specific decision elastics) and proper disarticulation buttons. Case Management
regarding the bracket progression needed to generate is the key early in treatment, with needed torsion created by
optimal enamel display: larger progressions where more wire plane and disarticulation and supported by early elastics.
display is required, moderate progressions to protect the
existing smile arc.

© 2015 OrthoEvolve, All Rights Reserved 10 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
 Figure 7: Incremental increases in arch wire fail to provide lingual crown torsion when the slot is not filled.

Figure 8: SAP bracket positions decrease the angle of engagement, thereby improving control of axial inclina-
tion in dimensional wires.

Figure 9: Even with extreme SAP positions, it is unlikely to develop excessive torsion within the slot, with
common arch wire progressions.

Figure 10: “Flipping” the brackets, reduces the angle of engagement further, allowing torsional couple to be
developed in light dimensional wires.

Figure 11: Increased AW sizes in “flipped” brackets produce torsional couples within the slot to effectively
upright teeth.

© 2015 OrthoEvolve, All Rights Reserved 11 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
• Other key case management principles: ELSE, With North American patients seeking broader smiles
disarticulation, and AW progression are more effective. and fuller lips, treatment has trended towards avoiding
When using SAP9 bracket positions, improvements in bicuspid extractions to achieve that goal, frequently
esthetic and functional occlusions occur in the first few with the adverse side effect of proclined upper anteriors,
appointments. Patients notice these changes, and we which is difficult to recover, and not desirable esthetically.
encourage the use of “every patient/every appointment
photography” as a means of validating the mechanical Bracket inversion as a means controlling
setup and the progress of treatment. axial inclination:

• SAP10 bracket positions are more effective in Inverting brackets (“flipped”) as a means of creating
management of axial inclination during the torsional more lingual crown torsion has been a common case
phase of treatment. This attribute is a key contributor management practice for years, usually as applied to
to a case management philosophy that allows changes controlling single teeth. Earl Johnson21 provided a very
in both transverse and axial inclination far earlier in the nice summary of using this approach as it is applied to
treatment cycle that traditional straight wire treatment controlling axial inclination of upper lateral incisors. Some
would allow. There are other aspects to this “active early” companies advocate using “low torque” prescriptions as
approach which will be appearing in the next few months a means of uprighting proclined teeth, but the reality is
for those who are interested, but briefly: that the torque selections involved are frequently not
sufficiently negative to accomplish that task. Research
• SAP10 bracket placements reduces the angle of indicates that torsion of 20 to 25° between the bracket
engagement by reducing the torque designed into the slot and arch wires (19X25) are required to create the
Rx, which is advantageous in cases with proclined teeth, requisite forces22, and this is very close to that attained
crowded upper anteriors, or to recover proclination with “flipped” brackets placed at SAP positions, utilizing
occurring as a result of relief of crowding (Figure 8). By commonly used wire sequences (Figure 11).
applying active torsion within the appliance sooner, with
lighter forces, treatment has the potential to be both One of the strategies used in an “active early” approach
more efficient and more comfortable for the patient. is to invert (“flip”) groups of upper anterior brackets as
a means of creating lingual crown torsion earlier in the
The “10 tooth smile” is touted as treatment cycle. This technique dramatically reduces
“slop” within the bracket wire interface by lowering
representing an esthetic ideal. There the angle of engagement at the outset (Figure 10) and
are however many excellent students applies active lingual crown torsion with incremental
increases in arch wire size (Figure 11). One of the critical
of dental esthetics that prefer a “12 aspects of this approach is that in the inverted or “flipped”
tooth smile” esthetically, and I agree Rx, more lingual crown torsion must be applied to the
with them. central than the lateral incisor, due to root size, allowing
uprighting of the teeth with minimal adjustment to the
• Secure Force Application: Even with very large SAP10 wire in finishing. Again the H4 Rx provides appropriate
progressions, application of excessive torsion through torque when “flipped” (-12/-8) for uprighting proclined
incremental increases in wire size is unlikely using teeth, compensating for proclination created during
commonly employed AW sequences (Figure 9). unravelling of crowding, or counteracting the effects
of class III mechanics. (Figures 12 to 18)
I have been an advocate of the PSL bracket system for
the last 15 years of my career. I utilize Ortho Classic’s H4 It has been suggested that when applying “single tooth”
bracket exclusively, and have been very pleased with the activation by “flipping” individual brackets requires that
performance of the appliance. The familiar Rx (12/8/7) in the bracket be uprighted or the wire adjusted once an
the upper anteriors, solid gate, .026 depth slot, combined ideal inclination is achieved18, which is one of the reasons
with utilization of “Pitts Standard” and Pitts Broad” arch that I suggest “flipping” brackets in groups to activate the
forms has increased efficiency tremendously. appliance. In crowded cases it is desirable to “flip” the
upper cuspid bracket to avoid “paddling” of the cuspid
Choosing the right torque bracket or groups of with arch development, relief of anterior crowding, or to
brackets can minimize arch wire adjustments in finishing, compensate for the adverse effects of localized torsion in
but the development of “variable torque” appliances has the appliance. In this approach, with the four incisors and
complicated this relatively simple concept. Rather than cuspids “flipped”, all the anteriors have negative torque
picking a bracket torque from a constellation of variable (“flocked”), allowing uprighting of the anterior segment
torque Rx’s on a tooth by tooth basis, torque selection with an unbent wire.
has been simplified in the “active early” approach to
reduce the arch wire adjustments in finishing.

© 2015 OrthoEvolve, All Rights Reserved 12 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
Figure 12: Sample Case: Extra Oral Photographs.

Figure 13: Sample Case: Intra Oral Photographs

One of the reasons I have adopted the Ortho Classic’s

H4 bracket system is that combination of upright and
inverted H4 brackets provides a good variety of torques
to choose from, that are applicable in most situations Figure 12: Impact of Inverted Brackets - wide selection of torque values achiev-
able with “flipping” brackets in the H4 appliance. This can be utilized in most
(Figure 12), with a minimal inventory cost to the practice. cases to minimize wire bending while simplifying inventory considerations.

Arch Form as it effects Contemporary Esthetic

Goals: to be inadequate in terms of width in the posterior
sections, where transverse arch development provides
The “10 tooth smile” is touted as representing an esthetic significant advantages from an esthetic perspective.
ideal. There are however many excellent students of Wider arches posteriorly also provides the opportunity to
dental esthetics that prefer a “12 tooth smile” esthetically23, gain space and relieve crowding, which is very useful in
and I agree with them. Arch form is directly related to non-extraction cases.
the shape of the wire used, not to the bracket system an
orthodontist decides to use24. With this in mind, I do not Fortunately two companies now produce arch forms
use “standard arch blanks” but shape bendable arch wire that mimic this shape; Ortho Classic’s Pitts Standard and
to optimize posterior arch development for esthetics. Pitts Broad arch forms, and G&H Wires DYB V3 arch forms
Careful assessment at each appointment, with palpation both function well. Because research has shown that
of the buccal and lingual alveolar processes is required as much posterior arch development occurs in round
to ensure that the patient’s “biological availability”5 is not wires as occurs in dimensional arch wires21, both these
compromised. suites have round, square, and rectangular wires in the
same arch form. This feature facilitates an “active early”
I have always been challenged by arch forms that are approach to transverse arch development with a greater
too flat anteriorly, too broad through the cuspid and first degree of torsion control whether using familiar wire
bicuspid, and too narrow through the second bicuspid progressions or square wire progressions when using
and molars. I have found all commonly used arch forms Ortho Classic’s H4 appliance.

© 2015 OrthoEvolve, All Rights Reserved 13 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
 Figure 17: Improvement in axial inclination during the tipping phase of treatment
due to case management.

Figure 18: Inverted brackets on the up-

per anteriors engage a couple early in
treatment in light thermally activated di-
mensional wires. Notice the absence of a
Figure 14: SAP bracket placement, inverted upper anteriors, couple in the lower arch!
posterior bite turbos, ELSE (short class III through the bite elastics.
Notice the bracket progression increases as through out the
buccal segments and anteriors.

Where unadjusted nickel-titanium or beta-titanium

arches do not have optimized axial inclination, the
practitioner can use shapeable beta-titanium arch wires
or stiffer stainless steel to efficiently correct remaining
Figure 15: SAP bracket placement: bracket slot are positioned aberrant torque situations.
apical to FA to develop the smile arc.

Summary and the Role of Case Management:

I have always been a teacher. During my career I have

concentrated on the development of improved simplified
“case management” practices, combined with a sound
understanding of the impact of varying bracket position,
bracket torque and use of modern arch wires forms to
assist the orthodontist in creating an artistic end result.
Applying these principles will make case management
more efficient, and improve the quality of your end
results.

Today, I choose to activate the appliance as early as

possible, using the SAP10 bracket position to adjust vertical
position of the incisors, inverting groups of brackets to
activate the appliance, selecting arch wire progressions
that control axial inclination early in treatment, and using
arch forms that develop the posterior segments of the
arches sooner. We will be sharing more on the “active
early” approach in the coming months, so stay tuned!
Figure 16: Improvement in smile arc, gingival display during the
tipping phase of treatment Until next time……..
© 2015 OrthoEvolve, All Rights Reserved 14 Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles
 www.orthoevolve.com
© 2015 OrthoEvolve.
All rights reserved.

Author’s Comments

Dr. Tom Pitts Dr. Duncan Brown

“Our goal in teaching continues to be to improve esthetic and functional outcomes, while simpli-
fying treatment mechanics and improving predictability, and efficiency. Combining the “14 Keys of
Pitts Case Management”, an “Active early” approach to treatment, and superior OC H4 self-ligating
brackets with Pitt’s Broad Arch Forms has gone a long ways to achieving those ends.”

1. Andrews - The six keys to normal occlusion, American Journal of Orthodontic, 1972;62: 269-309
2. Creekmore TD, Kunik RL. Straight wire: the next generation. Am J Orthod Dentofacial Orthop. 1993 Jul;104(1):8-20.
3. Ackerman J, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile: Clin Orthod Res 1998;1:2-11.
4. Sarver D. The importance of incisor positioning in the aesthetic smile: the Smile Arc, Am J Orthod Dentofacial Orthop 2001;120:98-111
5. Pitts, T. Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46
6. Cao et al - Effect of incisor labiolingual inclination and anteroposterior position on smiling profile aesthetics, Angle Orthod 20;81; 121-129
7. Ker et al - Esthetics and smile characteristics from the layperson’s perspective, JADA, Vol 139; 1319-1327
8. Sarver - The importance of incisor positioning in the aesthetic smile: the smile arc, Am J Orthod Dentofacial Orthop 2001; 120:96-111
9. Martin AJ, Buschang PH, Boley JC, Taylor RW, McKinney TW. The impact of buccal corridors on smile attractiveness, Eur J Orthod
2007;29:530–537.
10. Term courtesy Duncan Brown
11. Pitts TR. Begin with the end in mind: bracket placement and early elastics protocols for smile arc protection, Clin Impressions 2009;17:1.
12. Pitts T. The secrets of excellent finishing, News Trends Orthod 2009;14.
13. Naini - The Frankfort Plane and Head positioning in Facial Aesthetic Analysis - The perpetuation of a myth, JAMA Facial Plastic Surgery
2013;15(5):333-334
14. Ramirez at al, Discrepancies in cephalometric measurements in relation to natural head position, Revists Mexicana de Ortodoncis,
Vol 1 No. 1, October- December 2013
15. Nouri st al - Three year Reproducibility of Natural Head Position: a longitudinal study, Journal of Dentistry Tehran University 2006 Vol 3, No 4
16. Pereira et al - Reproducibility of natural head position in children, Dental Press J Ortho, Vol 15 No 1, 2010
17. Peng et al - Fifteen year reproducibility of natural head posture, Am J Orthod Dentofacial Ortho, 1999, 116 (1): 82-55
18. Andrews - The six keys to normal occlusion, American Journal of Orthodontic, 1972;62: 269-309
19. Jimenez-Carlo et al - Are the Orthodontic Basis Wrong - Revisiting Two of the Keys of Normal Occlusion - ISBN: 978-953- 51-0143-7
20. Archambault et al - A comparison of torque expression…in metalic self-ligating brackets, Angle Orthod. 2010;80:884–889.
21. Earl Johnson -Selection of Torque in Straight Wire Appliances, Am J Orthod Dentofacial Orthop 2013;143:S161-7
22. Brauchi et al - Active and passive self ligation: a myth?, Angle Orthod. 2012;82:663–669
23. Martin - Goal Oriented Treatment, SIDO 2013: 4-11
24. Flemming et al - Comparison of maxillary arch dimensional changes with passive, active, and conventional brackets in the permanent
dentition, Am J Orthod Dentofacial Ortho 2013; 144:185-193

15
H4 GO™ Aesthetic Bracket

16
 H4 GO™ Aesthetic Bracket

H4 GO FEATURES & BENEFITS

TM

The H4 GO™ is a low-friction, light force orthodontic solution that delivers healthy tooth movement with
optimal control. The contours of the slide and smooth rounded edges increase patient comfort. The H4
GO™ has all the great features of the H4™ Self-Ligating Bracket in aesthetic!

Integrated Hooks
Available on 3’s, 4’s, and 5’s for no extra charge.

Smooth, Rounded Edges

For patient comfort.

Patent Pending Door

Slides into both open and closed positions. R
 ounded contours create hygienic
doors that repel plaque.

Large Under Tie-Wing Clearance

For easy ligation to support early elastics, ligatures, metal ligatures, and power
chain.

Fracture & Stain Resistant

Hybrid Resin™ material holds up to common patient abuse.

One Piece Base

Designed for optimum pad-to-t ooth fit and bond strength.

Slot is Passive
In initial stages. Full-sized wires will make 3-4 wall contact.

Better Sliding Mechanics

Smooth material provides less sliding f riction than stainless steel.

Treadlok ® Base
Patent pending base provides superior surface area for greater bond strength.

Compound Contour
Torque-in-base.

17 www.orthoclassic.com // 2 015 Issue 2

H4 GO™ Aesthetic Bracket

2015 Issue 2 // www.orthoclassic.com 18

 H4 GO™ Aesthetic Bracket

One Piece Base

One piece base/bracket design for optimum pad-to-tooth fit and bond strength.

Stronger Bond
Channels allow air to escape, creating a stronger and more conformed bond.

Deep Channels
Deep channels provide increased surface area for easier application and improved
stability.

Enhanced Anatomy Fit

Enhanced bicuspid base curvature creates superior pre-molar anatomy fit.

Compound Contour
Torque-in-base.

Treadlok ® Base
Tread pattern provides reinforced channels for multi-directional sheering protection.

Reduced Clean-Up
Improved Treadlok® guards minimize “flash” for easier adhesive clean-up.

TREADLOK® FEATURES & BENEFITS

Our patent pending Treadlok® base features the latest in bracket bonding
technology. The tread-like pattern creates a bond that holds up better to
sheering forces. By utilizing the Treadlok® pattern, our brackets adhere more
easily, and with a stronger bond, minimizing bond failures.

19 www.orthoclassic.com // 2 015 Issue 2

 ™

SMILE ARC PROTECTION™

IN INDIRECT BONDING
Drs. Tomás Castellanos and Thomas Pitts introduce placement
of brackets based on the effect upon the smile arc

Part 2 of 2 Continued from Pitts’ Protocol Issue 1

MAXI LLARY RIGH T M AX IL L ARY LEFT

2nd Bicuspid 1st Bicuspid Cuspid Lateral Central Central Lateral Cuspid 1st Bicuspid 2nd Bicuspid

Long axis of clinical crown Bracket Slots Remain Aligned

2nd Bicuspid 1st Bicuspid Cuspid Anterior Anterior Anterior Anterior Cuspid 1st Bicuspid 2nd Bicuspid

MAND I BUL A R RIG H T M AN D IBU L AR LEFT

© ORTHOEVOLVE 2015 // orthoevolve.com 20

 Smile Arc Protection™

or incisal edges, measured in mm, from

the second molar tube all the way to the
maxillary central incisor.

  This divergence is important as well,

considering that the difference in mm be-
tween the slot height of the central incisor
and the height in mm from the second
molar tube gives an idea of the amount
of overbite one will obtain at the end
of treatment. It also affects the occlusal
plane cant.

  The final overbite of any deep bite

or open bite also depends on elastics,
dis-articulation buttons, mini-screws, and
Image 1: Smile curve flattened after orthodon- Image 2: Consonant Smile-Arc, results of other auxiliary elements that potentiate
tic treatment. Brackets bonded with conven- bonding brackets with GPS-A (Guide Position the expression of the bracket’s torque.
tional heights. (Patient treated by Dr. Tomas Smile-Arc) Tom-Tom (Patient treated by Dr. Of course, mini-screws can also help
Castellanos - MBT brackets) Tomas Castellanos - H4 brackets). enhance the maxillary incisor position by
intruding the mandibular incisors when
The present article introduces a new hand, individuals with shorter faces, flatter needed.
table to guide vertical placement TMJ eminences, and anterior teeth with
of brackets, based on the smile arc shorter clinical crowns, less overbite is   The transition point between the anteri-
effect — therefore, the table is named necessary to disocclude posterior teeth in or and posterior dental segments addi-
eccentric movements4. tionally establishes the track of the smile
Guide Position Smile-Arc (GPS-A)
arc, and therefore, the positioning for
(Images 1 & 2).
  Also when considering the incisal–smile the whole dental arch should be planned
arc relationship, clinicians must extrude taking this point as a clue.
Table suggested for vertical the upper incisors in flat smile cases or
placement of brackets maintain the incisal smile arc when it is   When the maxillary incisors are further
esthetically adequate. extruded to enhance the smile curve
Rationale and enamel display, a deeper bite can be
  The table presented (Figures 3 and 4)   For a functionally adequate occlusion produced by increasing the overbite. To
is based upon a great number of clinical and esthetic smile curvature, a divergence avoid this effect, the table introduces a
studies and measurements taken on plas- must be kept between the occluso-gingi- compensation in the position of the slot
ter casts and digital models from patients val position of the slot with occlusal cusps of mandibular canine-to-canine brackets.
treated by the team of Drs. Tom Pitts and
Tomás Castellanos. Its versatility and effi-
cacy will be the subject of other articles
presenting cases successfully treated MBT™ Versatile Appliance Bracket Placement Guide
applying this table.
7 6 5 4 3 2 1 High
  The table facilitates the vertical place-
ment of brackets in positions that result in 2.0 4.0 5.0 5.5 6.0 5.5 6.0 + 1.0 mm
adequate smile curves, as well as mutually 2.0 3.5 4.5 5.0 5.5 5.0 5.5 + 0.5 mm
protected occlusions.
2.0 3.0 4.0 4.5 5.0 4.5 5.0 Average
  It takes into account occlusal morphol- 2.0 2.5 3.5 4.0 4.5 4.0 4.5 - 0.5 mm
ogy, such as the angle of the articular
eminence that is more vertical in dolicho- 2.0 2.0 3.0 3.5 4.0 3.5 4.0 - 1.0 mm
cephalic subjects than in mesocephalic or 7 6 5 4 3 2 1 Low
brachycephalic patients. In dolicocephalic
patients as compared to brachycephalic,
3.5 3.5 4.5 5.0 5.5 5.0 5.0 + 1.0 mm
the molar cusps are higher, and fossae 3.0 3.0 4.0 4.5 5.0 4.5 4.5 + 0.5 mm
are deeper; anterior teeth clinical crowns
2.5 2.5 3.5 4.0 4.5 4.0 4.0 Average
are longer in a cervico-incisal direction.
All these characteristics indicate that 2.0 2.0 3.0 3.5 4.0 3.5 3.5 - 0.5 mm
more overbite is necessary to disocclude 2.0 2.0 2.5 3.0 3.5 3.0 3.0 - 1.0 mm
posterior teeth in eccentric movements
in dolicocephalic subjects. On the other Figure 2: MBT™ Versatile+ Appliance Bracket placement guide. MBT™ is a registered trademark of
3M Unitek. Table is used as reference and does not imply any affiliation with or endorsement by them.

21 orthoevolve.com // © ORTHOEVOLVE 2015

Smile Arc Protection™

Figures 3 and 4: Tables GPS-A lower and upper

Instructions to Use the Table
GUIDE TO POSITION SMILE-ARC GUIDE TO POSITION SMILE-ARC
(Figures 3 and 4)
  Previous to using the table, some TOM X TOM - LOWER TOM X TOM - UPPER
patients require a recontouring to provide GPS-A 7 6 5 4 3 2 1 GPS-A 7 6 5 4 3 2 1
basic ideal morphology to each tooth.
11 mm 4,5 4,5 5,5 6,0 6,0 5,0 5,0 12 mm 2,5 4,0 5,0 5,5 6,0 6,0 7,0
This ameloplastic procedure is based in
the study of plaster models and removes 10 mm 4,0 4,0 5,0 5,5 5,5 5,0 5,0 11 mm 2,5 3,5 4,5 5,0 5,5 5,5 6,5

only the necessary minimum dental 9 mm 3,5 3,5 4,5 5,0 5,0 4,5 4,5 10 mm 2,0 3,0 4,0 4,5 5,0 5,0 5,5
enamel.
8 mm 3,0 3,0 4,0 4,5 4,5 4,0 4,0 9 mm 2,0 2,5 3,5 4,0 4,5 4,5 5,0

  The ameloplasty includes pronounced TOM x TOM is a table that studied and designed by Dr. Tomas Castellanos, based in “Smile Arc Protection”
- Dr. Tom Pitts - All rights reserved
marginal ridges on the lingual surfaces, of
incisors’ angles and incisal ridges, as well
as irregular vestibular surfaces. Irregular
vestibular surfaces prevent an optimum
placement of brackets, which control
rotations and torque1.

  In most cases, canines require re-con-

touring to improve their role in the smile
arc. This process does not interfere with
their functional role of canine disocclu-
sion.

  Gingival margins are very important for

anterior esthetics. Sometimes clinicians
need to perform initial gingivoplasties with
laser, electro-surgery, or any other similar
technique.

  It is important to provide the right

morphology, but clinicians should not Figure 5: Accurate measurement for each tooth with digital gauge (Mitutoyo™ Super-Caliper
re-contour all hard and soft tissues, since Solar-Powered Series 500 — Digital Caliper at www.amazon.com)
leaving small discrepancies until the end
of treatment allows for final detailing
when the teeth have the best possible
TOM X TOM - UPPER TOM X TOM - UPPER
position.
  When teeth have fractures or abnormal GPS-A 7 6 5 4 3 2 1 GPS-A 7 6 5 4 3 2 1
wear, the teeth should be reconstruct-
12 mm 2,5 4,0 5,0 5,5 6,0 6,0 7,0 12 mm 2,5 4,0 5,0 5,5 6,0 6,0 7,0
ed prior to bracket bonding, in order to
assure the ideal dental anatomy. Clinicians 11 mm 2,5 3,5 4,5 5,0 5,5 5,5 6,5 11 mm 2,5 3,5 4,5 5,0 5,5 5,5 6,5
should communicate this to the patient,
since future restorations may be neces- 10 mm 2,0 3,0 4,0 4,5 5,0 5,0 5,5 10 mm 2,0 3,0 4,0 4,5 5,0 5,0 5,5
sary.
9 mm 2,0 2,5 3,5 4,0 4,5 4,5 5,0 9 mm 2,0 2,5 3,5 4,0 4,5 4,5 5,0

  If the maxillary molars present high

and pronounced mesopalatal cusps, they
should receive recontouring to avoid
interferences or early contacts. The same
applies to the lingual cusps of the premo-
lars.

  After obtaining the ideal dental mor-

phology, the heights for bracket bond-
ing in the maxillary arch are selected as
follows:
  1. Measure the length of the maxillary
canine crown, from the cusp tip to the
gingival margin (after reconstruction, Figure 6: The second step is to find the maxillary canine crown length and then the positions of
recontouring, or gingivoplasty). the other maxillary teeth

  2. Find this measurement in the col-

© ORTHOEVOLVE 2015 // orthoevolve.com 22

umns of the table GPS-A (Guide Position
Smile-Arc upper), and choose the adja- Smile Arc Protection™
cent number in the row. (Figure 6). The
number in this file indicates the position
TOM X TOM - LOWER TOM X TOM - LOWER
for each bracket.
GPS-A 7 6 5 4 3 2 1 GPS-A 7 6 5 4 3 2 1
  3. Select in a similar way the height
11 mm 4,5 4,5 5,5 6,0 6,0 5,0 5,0 11 mm 4,5 4,5 5,5 6,0 6,0 5,0 5,0
to bond brackets for mandibular teeth:
a) measure the length of the crown of 10 mm 4,0 4,0 5,0 5,5 5,5 5,0 5,0 10 mm 4,0 4,0 5,0 5,5 5,5 5,0 5,0
the mandibular canine, from cusp tip
to gingival margin (after reconstruction, 9 mm 3,5 3,5 4,5 5,0 5,0 4,5 4,5 9 mm 3,5 3,5 4,5 5,0 5,0 4,5 4,5
recontouring, and gingivoplasty); b) find
8 mm 3,0 3,0 4,0 4,5 4,5 4,0 4,0 8 mm 3,0 3,0 4,0 4,5 4,5 4,0 4,0
this number in the column of the table
GPS-A (Guide Position Smile-Arc lower),
and choose the number in the adjacent
row. This number indicates the position
for bonding each bracket in the mandibu-
lar area (Figure 7).

In general, this
technique
allows the
orthodontist to Figure 7: The third step is to find the lower canine crown length measurement and the subse-
quent positions for the mandibular brackets
obtain adequate
occlusion with premolar extractions. But when the bonding procedure.
•
and an esthetic orthodontist decides that it offers the best
option, the table may be individualized. To
Avoids bracket repositioning and/or
the introduction of excessive correc-

smile do this, the anterior segment is man-

aged as conventionally indicated in the •
tive wire bends.
Reduces chair time and unnecessary
GPS-A table, but the discrepancy between discomfort to the patient.
premolar and canine for every case will • Saving months of treatment, it be-
Specific Considerations
be 0.5 mm, and the discrepancy between comes an effective tool to motivate
  The maxillary second molars must
premolar and molar will be 1.0 mm in patients.
always be intruded. Its tubes are always
every case, to avoid interferences and • Allows better control of torque values.
positioned to slightly intrude these teeth
inadequate steps in these segments.
to provide a negative coronal inclination
  In general, this technique allows the
and avoid functional interferences.
Use of the positioner for vertical place- orthodontist to obtain adequate occlusion
ment of each bracket and an esthetic smile.
  The discrepancy between maxillary
  The positioning gauge that measures
incisors and the maxillary lateral incisor
the height to bond the brackets is placed
must be kept between 0.5 mm and 1 mm
in a slightly different way, depending on
to allow the movement of the mandibular
the segment of dental arch that is being
canine during protrusive excursions and,
considered.
additionally, to improve the smile arc.
  We suggest for incisor, canine, and
  Longer incisors require a larger height
premolar regions to use the calibrator
difference. For those situations, the table
placed at 90º respect to the tangent of
includes two additional options.
the middle zone. For the molar region,
it is suggested to place it parallel to the
  At the level of the mandibular molars, it
occlusal surface of each molar (tracing
is important to maintain an occlusal plane
an imaginary line between the buccal and
that grants correct coupling with the
the lingual cuspids of each molar).
antagonist teeth.
Advantages derived from the use of this table
Individualization of the table for cases
• A reduction of errors in positioning,
treated with premolar extraction
which can be avoided, due to better
  Today’s effective mechanics, combining
precision, Figure 8: Versatile high-precision position-
the use of mini-screws with passive self-li-
• Reproducibility, and predictability of er for proper location of each bracket from
gation appliances for en masse movement second molars to central incisors (GPS-A is a
the bracket bonding.
toward the place of molar extraction, has versatile high-precision positioner from Ortho
• It allows a practical, standardized
reduced the frequency of patients treated Classic Inc. at www.orthoclassic.com)

23 orthoevolve.com // © ORTHOEVOLVE 2015

Smile Arc Protection™

www.orthoevolve.com
© 2015 OrthoEvolve
All rights reserved.

Author’s Comments

Dr. Tom Pitts Dr. Tomas Castellanos

“With more Orthodontists developing skills at indirect bonding, we believe that the “SAP protection
for protocol for indirect bonding” will greatly improve consistency of esthetic results, while still
capitalizing on the doctor time savings associated with the indirect technique.”

Pitts T. Begin with the end in mind: Bracket placement and early elastics protocol for smile arc protection. Clin Impres. 2009;17(1):1-11.
1

2
Sarver D, Ackerman MB. Dynamic smile visualization and quantification: Part 1. Evolution of the concept and dynamic records for smile capture. Am J

Orthod Dentofacial Orthop. 2003;124(1):4-12.

3
Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent. 1958;8:558-581.

4
Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile. Clin Orthod Res. 1998;1(1):2-11.

5
Alexander W. Build treatment into bracket placement. In: The 20 Principles of the Alexander Discipline. Chicago, IL: Quintessence; 2008:59.

6
McLaughlin R, Bennett J, Trevisi H. Systemized Orthodontic Treatment Mechanics. Philadelphia, PA: Mosby; 2001:60-65.

© ORTHOEVOLVE 2015 // orthoevolve.com 24

 space is limited,
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the University of the Pacific and
founder of the well-respected
Pitts Progressive Study Club.

Dr. Pitts has been published in

multiple journals and clinical
publications. He has been actively
teaching the orthodontic
community in a variety of settings
both nationally and internationally
since 1986.

C o n t a ct U s Tod a y: 755 -720- 72 2 2 or25Vis it Us Online: www.ort hoevolve .c om

BUILDING BLOCKS FOR SUSTAINABLE MARKETING
How Are You Marketing Your Practice—Claims or Promises?
“We decry the unethical nature of advertising but we are jealous of its power. We strive for evi-
dence based, patient-centered treatment but we watch in frustration as “less skilled” practitioners
attract patients to their office with slick ads and clever copy.” - KK Orthodontist, California
Many of us share in this frustration. This orthodontist went on
to state “Ultimately the only cure for this problem is consumer/
patient education.” While I agree with this orthodontist that
education is the solution, I believe the solution begins with
training orthodontists on effective and ethical marketing practices.
It is easier to train orthodontists on how to effectively compete
against less sophisticated marketing activities than attempting to
change public opinion on a subject most of the public has little
interest in learning about. There has been a large paradigm shift
in what marketing strategies work. Many of the strategies used in
the last decade no longer work. However, many practices are still
being advised to use these outdated strategies.

My Story
My practice is located in a rural region of the United States known
as the ‘Four Corners.’ My practice is in the city of Farmington,
NM (127,000 residents in the county) and my location is close to
the borders of Arizona, Utah and Colorado. There are five other
orthodontic practices in Farmington. My practice is known for
“creating wide beautiful smiles without taking out teeth.” This is
my promise to the public that I have lived up to for more than 10
years. I use and market H4 bracket technology. This technology
has allowed me to treat 97% of my patients without extractions.
This reputation has helped me to thrive as one of the largest sin-
gle office, single orthodontist practices in the United States. I treat
more patients outside of my county than within, as our marketing
reach extends in a 180 mile radius of the practice. It is very com-
mon for my patients to drive past other orthodontic offices while
making the 2-4 hour trip to my office.

2015 Issue 2 // www.orthoclassic.com 26

 I have a 6,500 square foot practice with 16 orthodontic chairs,
a dental hygiene department with four operatories, and a dental
department with two operatories. While I am not a referral-based
practice, I remain friends with my local dentists and stay active
with the local dental society. I still really appreciate referrals from
my colleagues, but I do not depend on them. I have 31 staff
members and describe my management style as ‘staff driven.’

In the following sections I will discuss the marketing concepts

and approach that worked for my practice. I am sensitive to
others telling me the way things should be done and claiming
that he or she has it all figured out. I will confess that I do not
have it all figured out, but anticipating change and having a
process in place to handle change is something I do claim to
have down pretty well.

Marketing is a Planned Campaign, Not a Series of Events

I’ve read information and heard lectures that make marketing
sound so simple—“just do these marketing activities and you are
on your way.” Most orthodontic marketing is done as events and
tactics that are loosely tied to one another—this approach rarely
works. Orthodontic marketing today should be thought of as a
comprehensive campaign.

27 www.orthoclassic.com // 2 015 Issue 2

Marketing

A successful campaign takes time to develop and time to achieve

momentum. Growth from this campaign can be slow and steady RESEARCH
and also include periods of explosive growth. If you understand
that marketing is a process that needs a plan rather than viewing
marketing as a series of events, you will improve your chances of
PLANNING
success.
FOCUS
Developing a successful marketing plan and implementing a
marketing campaign is not simple—it takes research, planning
and focus.

PHASE 1: RESEARCH
SWOT Analysis
SWOT stands for strengths, weaknesses, opportunity, threats.
The analysis is used to evaluate your practice against the others.
My staff reviews other practice’s marketing activities and after
claims have been validated or invalidated, my staff and I compare
our practice’s strengths and weaknesses with competition. This
analysis lets us identify any opportunities and threats.
S TRENGTHS
If your SWOT analysis results in the need to refine your campaign,
I urge you to try and remain true to who you are and resist
the temptation to consistently play against the competition.
W EAKNESSES
Competing on cost is one of the hardest areas to resist. I
encourage you to market some of your messages about cost O PPORTUNITY
but on your terms. For me that means I do not play the “$$$ off”
coupon game. I am very willing to let a few of my competitor’s T HREATS
position themselves as the ‘low cost’ option. As a ‘place to go’
positioned practice my message on cost to the public is that my
treatment is affordable. My staff and I believe that if we can get a
prospective patient or parent to compare on cost the decision in
our favor is predictable.

After conducting a SWOT analysis, my team discovered a common weakness among the
competition. My team found that other offices offer vague information about their service fees. I
understand that many consultants recommend this type of ‘vagueness’ to get potential patients in
the door, but I disagree. Braces are huge financial commitment and many people simply want to
know what to expect. Obviously an exact figure can’t be given over the phone, but you should at
least provide a fee range and expectations for what will be collected at the patient’s first visit. This
transparency is important because it allows you to not waste time catering to “shoppers” that are
basing their decision solely on price. It’s also necessary to disclose your fee if you wish to perform
same-day starts at your practice.

2015 Issue 2 // www.orthoclassic.com 28

How Does the Public Perceive You?
Early on in the development of your marketing plan you should
have a set of questions answered. You want to fully understand
why someone would want to choose your practice over
someone else’s practice. First, I recommend that you ask your
staff, “What does the team think that the practice is known for?”
Second, ask your staff, “What do we want to be known for?” Work
with the team to minimize discrepancies between the answers
of these two questions. Third, ask a sample of your existing
patient population, “What are we known for and why did he or
she choose your practice?” Once these questions are answered
you can begin to develop a true story about the promises you are
going to make in your marketing plan.

Work very hard on defining this story for it is the backbone of

your plan. You may be surprised by some of the answers to the
above questions. It may take a few attempts to reach a consensus
with your team on your story and your promises. Staff belief
in the story and staff commitment to delivering on the agreed
upon promises is critical to the plan. If you have developed a
quality team before the discussions begin this process progresses
without negative side effects. If you attempt this discussion with a
poorly developed team the end result is unpredictable. Once you
have your story complete, it’s time to get the story and promises
out to the public.

29 www.orthoclassic.com // 2 015 Issue 2

Marketing

PHASE TWO: PLANNING

What’s Your Position?
Positioning is the start of establishing your brand. Positioning is
how you want the public to perceive you when they hear about
your practice. The three main positions in the orthodontic market
are price, convenience, and ‘the place to go’ (PTG). You can be
one or a hybrid of all three of these positions. While, most of us
would claim that our practice is a hybrid of one or more of these
positions, the public will usually identify the practice as being one.

When the public fails to distinguish between practices in a given

market, it’s called commoditization. Think of gas stations—most
of us go to the cheapest or most convenient location. Brand
recognition is usually not the dominant factor used when
choosing where to buy gas. If you are positioning your practice PRICE
in the market by cost alone, you are to some extent using the
commoditization factor. You want the public to have the belief
CONVENIENCE
that braces are all the same so people in the market for braces
should go to the cheapest location. Fortunately, many of us do
PTG
not want to be placed by the public into a commoditization (THE PLACE TO GO)
category. That leads us to the ‘place to go’ market position. To
achieve this position your practice needs to be viewed by the
public as being very different than the rest of the market. Your
goal is to have the public understand that your practice achieves
different results from the competition and that the experience in
your practice is noticeably different.

What Are Your Promises to the Public?

Once you decide on how you want to be positioned in the market, the next step is to decide what
promises you want to make to the public. ‘Promise’ is the term I prefer to use rather than ‘mar-
keting.’ I believe that as ethical healthcare providers we should view our marketing statements as
promises—promises that should be kept and not just false claims. However, before you let the pub-
lic know of these promises, you need to assess if you have the systems and staff that allow you to
deliver on them. I often see practices marketing what they want to be, but in reality are not. Hence,
these practices are not making a promise they are making a false claim. I call it ‘the disconnect.’ If
you and your staff can not consistently deliver what is being promised, then the public coming to
your office will notice ‘the disconnect.’ If you are positioning yourself as a PTG practice, you must
minimize disconnect between what’s promised and what’s delivered.

Many orthodontists are better at system development than staff development. It has been said that
a team is only as good as its leader. A high-functioning team has a low turnover rate, is self-disci-
plined, highly skilled and happy. The teammates are mutually supportive of each other and have su-
perior skill in problem solving, conflict resolution, and communication. If you feel that your leader-
ship skill sets need to reach a higher level there are many books and courses available to help you.

2015 Issue 2 // www.orthoclassic.com 30

Phase Three: Focus Marketing

Focus on Benefits Not Features

Most of us tend to market features rather than benefits. It’s easier
to create messages about features. However, the public responds
much better to benefits than features. Features are things such
as TADs, cone beam x-ray, hi-tech braces, etc. Benefits are what
the feature does for the person receiving the goods or service. It’s
safe to say that many of the features listed in ads and on websites
do not resonate as a benefit to the public. Remember people are
buying your smiles not your braces.

This holds true when the doctor markets himself or herself as a

feature. It’s difficult to talk about yourself and how wonderful or
great you are and turn that into a benefit to the patient without
sounding arrogant. Anyone who puts themselves as a feature also
fights the tendency to embellish the feature. It’s common to see SELF-LIGATING
orthodontists feature themselves as a “world-class orthodontist” BRACKET SYSTEM
or “quality above the rest.” Today it is easy for the public to fact
check such claims. One just types in “world-class orthodontist”
and the city to see what comes up. Not telling the truth or embel-
lishing one’s accomplishments can create quite a buzz if called
out by the public. One only has to look to the news anchor Brian
Williams to understand the perils of that form of marketing.

Now, tie your features to benefits. What I love about marketing

H4 technology is that is easy to showcase the benefits. “H4
braces” means nothing to the public as a feature. However,
“H4 system of braces” tied to “wide beautiful smiles without
extractions” is a message that resonates extremely well with the

31
Marketing

public. But this message alone is probably not enough. The benefit you really want is to show the
public is your outcomes using H4 technology. Using photos of finished patients shows the features
of SAP (smile arc protection) and H4 technology. But don’t use your typical final photos—save those
clinical images for other orthodontists. Use photos of patients in some type of activity or at an
outside setting. Be sure to show off their wide, beautiful smile.

Finding ways to express benefits from practice features is an activity that is best accomplished
through group interaction. Finding a campaign that focuses on benefits and resonates well with the
public and “has legs” is the real test.

Use Your Website to Showcase the Practice’s Benefits

Your website homepage is your practice’s introduction to the public. Don’t cram too much into
your homepage. A homepage should be like the cover of a good book—a book people will want
to open up and read. Have your homepage highlight what you are known for and include buttons
that lead the user to more detailed information within the site. I find that having my bio page written
from the prospective of a patient is best. Have a patient tell why he or she chose your practice for
their care. Staff bios are also an opportunity to highlight the practice—have the staff member explain
why they enjoy working at the practice in the bios. I also recommend a web page that contains your
patient of the month treatment photos and before and after photos.

You should have someone monitoring data on how your website is viewed and how your com-
petition’s websites are viewed. Your monitoring effort will tell you what pages are getting the most
viewer time. Have it in your plan to refine your web site regularly. Use your data from your website
evaluation process to drive your revisions.

Last, push yourself, your staff and your consultants to differentiate your web site from others in your
market by taking chances to look unique. You can visit www.Herman4Braces.com to see my web-
site and view my 2015 TV commercials.

Branding is What the Public Perceives about You

Many people are under the misconception that marketing a practice creates the brand. Branding
is what the public thinks of you when they hear your message or name. The day you opened your
practice is the day your branding process began. If you are branded something other than a ‘place
to go’ practice changing your brand through marketing will take time. If you are not well branded
the slate is clean and marketing can have a more profound impact on your brand. If your brand is
what you want it to be, brand protection requires constant vigilance.

Those of us who live the story surrounding our PTG position have a much easier time protecting
that brand than those practices not living the story. Practices telling a false story will receive a large
number of unfavorable ratings, and these ratings will erode the public’s trust in their brand. Social
media has definitely sped up the branding process. Many practices jump at activities to get their
name out there such as car magnets, billboards, commercials, etc. This activity is worthwhile if it’s
connected to your message. The main benefit of name recognition activities is to promote dialog.
Ideally the promotion will result in someone talking about you and your brand and having the oth-
er person say, “I have heard of that orthodontist.” The goal from there is to then have these people
engage in a positive conversation about your practice.

2015 Issue 2 // www.orthoclassic.com 32

 Marketing

Focus on Making the Pie Bigger

When I opened up my practice in 1998 I wanted to make the
market, or the “pie,” larger. I realized that it would be difficult as
the new guy to carve out a piece of the existing small orthodontic
market. So I started with targeting a radius of 120 miles. I mar-
keted heavily in a town two hours away because the town was
served by two orthodontists who came two days per month and
required a large down payment. As the plan worked, the radius
increased to 180-200 miles. The plan worked because I was able
to identify what consumers in this market wanted but were not
receiving from anyone.

Want to increase your market radius? Then you must understand

the law of multiplicity. The law of multiplicity is about the devel-
opment of micro markets outside of your normal target popu-
lations. Most of the time months go by with a few patients here
and there responding to your marketing efforts. Then, there are
periods where all of those efforts combine into 2-3 months of
explosive growth and that growth expands you into other micro
markets. Other micro markets that were not in your original plan.
In the ‘bigger pie’ concept, these newly discovered micro markets
are now on your radar and you just increased the size of your pie.
The more you invest in micro markets and the longer you make
that investment, the greater the growth.

When attempting to identify a micro market look at a specific eth-

nic group, a small rural town, a particular high school, etc. When
I think of a micro market I relate it to a tribal affiliation. Most of us
“I love coming to
Dr. Herma n’s office! My
seek some form of tribal affiliation. Be it a sports team, product,
new smile is beautifu l a nd service, school or town. Your goal for that target micro market is
it gives me confide nce!” simple. When people in that market think of braces they think of
*Actual patient
- Chelcey
of Dr. Herman your practice. You have a specific campaign for that micro mar-
Chelcey, Ra mah High ket that differentiates you from other practices trying to get their
attention. It is essential for your team to have a presence in the
Start the high-tech H4TM System of Braces for only $179!
Ask about our low monthly payments of $189 or less!
micro market—team members need to attend community events
(Value of $571. Offer Expires 3/31/13.)
and seek out opportunities in the area so you are not relying sole-
Call today to have all of your questions answered!
505.564.9000 | 1.800.4Braces
3751 N. Butler Ave. • Farmington, NM 87401
Visit us at Herman4Braces.com ly on paid advertising efforts to grow this micro market.

33 www.orthoclassic.com // 2 015 Issue 2

 Compare and the Choice Thanks and Gratitude
is EASY! I hope you got something out of this snap shot of what goes on
in the development and implementation of a marketing cam-
e Day as Yo
am
paign. I would like to thank my director of marketing of 15 years
u
S

rF
ces on the

Same
ree

Day
Consu

Braces
Angela Weber from OrthoSynetics and her outstanding team for
Bra

lta
t

t io
Ge n!

helping me develop and implement my practice’s marketing cam-

Tiffany, Farmington
Actual Patient of Dr. Herman
paign. I have been using passive self-ligation since 2002 and H-4
technology since 2013. It is the united efforts of the OrthoSynet-
START THE HIGH-TECH H4™ SYSTEM OF BRACES FOR ONLY $119! ics team, Ortho Classic team and my Four Corner Orthodontics
Ask about our monthly payments of $189 or less. Expires 4/30/15. Value of $631.
team that produced our 2015 marketing campaign.

www.herman4braces.com
© 2015 Four Corners Orthodontics.
All rights reserved.

Author’s Comments

Dr. David Herman

It is my hope that this article will stimulate discussions on effective practice promotion. As a health-
care provider, I believe that maintaining the public’s trust in my practice is my top priority. In order to
do this, I must consistently deliver on the promises I make to the public, invest in the further devel-
opment of my staff’s skills, and always keep my staff’s wellbeing in mind when making decisions.

2015 Issue 2 // www.orthoclassic.com 34

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