Issue 6 THE SECRETS OF A HIGH PERFORMANCE TEAM part 2

JuLY 2017

THE MAGAZINE

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Immediate, Light,
Short, Elastics
with Disarticulation

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Drs. Tom Pitts & Duncan Brown

PRACTICE SPOTLIGHT - DR. JEFF HASKINS

CONTRIBUTORS

Thomas Pitts D.D.S., M.S.D.

Ortho Country Orthodontics
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 UNLV 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.

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

Smile Zone Orthodontics
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 including creating effective
hygiene programs for patients and much more!

Jeff Haskins D.D.S., M.S., P.C.

Village Orthodontics
Dr. Jeff Haskins graduated from the University of Nebraska Medical Center with a Doctorate in Dentistry
in 1981. He then attended Washington University in St. Louis where he earned a Masters Degree in
Orthodontics in 1983. Dr. Haskins moved to Colorado following graduate school and established
Village Orthodontics in Aurora the same year. Dr. Jeff was featured as a TOP DOC in 5280 Magazine,
nominated by his peers every year from 2004 to 2015. In 1991, Dr. Haskins became a Diplomat of the
American Board of Orthodontics, joining the top 20% in his field.

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

Four Corners Orthodontics
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-li-
gation, staff-driven management and adding dental and hygiene departments to an orthodontic
practice. Professionals from all over the United States come to observe Dr. Herman’s staff-driven
management concept and see the success of his marketing campaign that brings in patients from
more than two hours away.

2 2017 Issue 6 // www.oc-orthodontics.com

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 PRACTICE SPOTLIGHT

BE PROACTIVE AND STAY RELEVANT

Jeff Haskins D.D.S, M.S., P.C

I
am the youngest son of four, quit’ drive in a time when being a It was during my junior year at the
born into a family of hard working scout was not considered being one University of Nebraska Dental College,
mid-west parents. We had a lot of of the cool kids. I worked in hospitals that I met a young instructor, Dr. Clarke
love and encouragement, but not during my summers and made the Stevens. Dr. Stevens took me under his
a lot of money. This was a great decision early on to look seriously into wing and was the driving force in my
combination to encourage me to dentistry and medicine. applying to orthodontic residencies. Dr.
become a high achieving, hard- Clarke Stevens has been an outstanding
working student. A funny story, just for the experience, OGS (Orthognathic Surgery) instructor
I applied to dental school midway
Growing up I aspired to be an through my junior year in college.
architect. My dad told me long ago, Low and behold, I was accepted
‘if your family name is not on the early for the next fall. The dilemma:
architect firm building, you will end up accept the challenge and go to
only a draftsman’; advice I truly took dental school? Then, if I didn’t like
to heart. My father was a mechanical it, apply to medical school? Well,
engineer and my mother was a nurse the rest is obvious; I graduated from
with a Masters in Guidance. I am also dental school and after attending the
one of 5 eagle scouts in my family; orthodontic program at Washington
my mother earned all five of them University in St. Louis, I entered the
(along with her sons) with her ‘never work force at the young age of 27.

Dr. Haskins with Dr. Pitts

4 2017 Issue 6 // www.oc-orthodontics.com
at the University of Nebraska medical you the most innovative way to This past August, Dr. Pitts was
center as well as an orthodontic create amazing ‘Smile Arcs’ vs the generous enough to spend a day with
innovator. You may know him for his previous ‘flat smile lines’. Additionally, me in my Centennial office treating
‘Wild Smiles’ brackets or from his cutting his 14 protocols serve as a great H4 patients - talk about learning
edge ortho meeting “Ortho Voice” which reference as you progress through first hand from the master! Finally, I
is held every September in Las Vegas. your first H4 and H4 GO cases. am part of Dr. Pitts and Dr. Duncan
I have been in private practice in In March of 2016, I was fortunate Brown’s 2017 two-year H4 Masters
the Denver metro area since 1983. to attend Dr. Pitts’ first in-office course starting this spring in Reno.
I am a solo cowboy opening three course at the McMinnville, Oregon
scratch offices plus adding three OC Orthodontics production plant, I have had the honor of having three
pediatric specialists in 2008. What now home for Tom’s Ortho Country special dentists influence my career
a game changer for a 52 year old orthodontic clinic. I actually had H4 path:

• Dr. John Seberg, my family dentist

in Hastings, NE. He encouraged me
to apply to dental school.

• Dr. Clarke Stevens of Omaha, he

gave me the confidence to apply to
orthodontic programs.

• Dr. Tom Pitts started molding me

in 1987. After 33 years, he continues
to be my clinical mentor in helping
me dramatically change my practice
staying relevant and competitive with
OC H4 and Pitts 21 bracket systems.

One of the most satisfying aspects

of my job is helping my patients gain
a confident outlook on life impart
due to their new amazing smiles
along with being thanked every day
orthodontist who was experiencing GO brackets placed and now am
for doing a job I truly love. At Village
somewhat of a plateau in production; experiencing firsthand the game
Orthodontics, we try and do all the
more dialog to come on how to changing arch expansion and ‘Smile
little things that enable us to have a
integrate pedo into your practice at a Arc’ changes in less than 12 months
thriving practice. You need to have
future Pitts meeting. of treatment. I also attended the 2016
fun but make sure it comes from
OC Pinnacle in Portland, Oregon and
your heart and not manufactured.
Dr. Tom Pitts’ OC Protocol is the first have hosted and attended several of
The addition of in-house pediatric
written journal that actually teaches Dr. Pitts’ one day protocol seminars.
specialists along with a staff that is

www.oc-orthodontics.com // 2017 Issue 6 5

 trained daily by a former Peniche offer retainers for life, and have an
warrior, enables us to not only enroll active progressive SEO program. In
90% of our initial exams, but start addition, we offer non-extraction
them the same day. treatment, utilize PSL bracket systems
and try to keep everything very
Private practice orthodontics is alive patient friendly. Use progressive and
and well. To compete today with all innovative appliances such as keyless
the delivery systems for braces and expanders, Carriere, and occlusal bite
Invisalign, you have to be a cut above. ramps greatly reduce the need to use
Incorporating the innovative Dr. Pitts’ appliances similar to a Herbst. Talk less
protocols to get that “WOW” smile and listen more, to offer the patient
and offering Invisalign are ways to treatment plans and outcomes they
keep your office cutting edge. The are looking for and not a treatment
final component to practice success, plan you assume they want. Always
in my opinion is, if you are going to practice with the mantra, “if your son
be competing for the same piece of or daughter was my child, this is what
the pie as 85% of the orthodontists I would recommend.” 33 years later,
in your communities, you have to my Village Orthodontics practice in
be different but exceptional. We Colorado, still feels relevant in our
have in-house pediatric dentistry, competitive orthodontic markets.

Dr. Haskins’ Top Tips:

• Hire, train and reward your staff - verbal and financial appreciation goes a long way
• Know what you are good at, don’t dilute your strengths by adding things like sleep apnea (unless you have passion for it)
• Align with pediatric dental specialist
• Realize that excellent on-time treatment will fill your exam slots faster than gifting your colleagues
• Don’t be afraid to try new things such as scheduling, satellite offices, SEO marketing, bracket systems, scanners, associates etc.
• Always strive to be debt free and keep overhead low
• Give the patient / parent more value than they expect

Meet Our Orthodontist

Undergraduate: University of Nebraska
Dental School: University of Nebraska
Dr. Jeff Haskins Orthodontic School: Washington University in St. Louis

Past President: Summit Orthodontic Study Club

Member: Diplomat, American Association of Orthodontists
Rocky Mountain Society of Orthodontists
American Dental Association JEFF HASKINS
Colorado Dental Association DR
Metro Denver Dental Society

Awards/Honors
Elite Invisalign Provider since 2011
5280 Top Doc every year since 2004
villageortho.net | 303.850.9253 Pitts Masters Course, 2017-2018

Charitable Foundations
facebook.com/VillageOrthodontics Dr. Jeff and his wife Kristina founded an Orthodontic ministry in 2008
called ‘Ortho 127’ to provide “no charge” orthodontic treatment to adopted
Instagram.com/villageorthoco children in the Denver area.
@VillageOrthoCO
He also hosts a ‘911’ campaign every fall to honor first responders with a
www.youtube.com/user/VillageOrtho sizeable ($911) treatment discount for their children.

6 2017 Issue 6 // www.oc-orthodontics.com

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www.oc-orthodontics.com // 2017 Issue 6 7

8 2016 Issue 6 // www.oc-orthodontics.com
I.L.S.E.
Immediate, Light, Short, Elastics
with Disarticulation

Tom Pitts D.D.S., M.S.D.

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

www.oc-orthodontics.com // 2017 Issue 6 9

 “Knowledge is a process of piling up facts; Wisdom
lies in their simplification” – Martin Fischer

H
istorically, the use of orthodon-
tic elastics for the treatment
of inter-arch tooth discrepancies
dates back to the dawn of ortho-
dontics when Calvin Case and
Henry Baker used natural rubber
products as “inter-maxillary anchorage”1 prior to the
1900’s. Edward Angle first described the technique
before the New York institute in 19022, and most
orthodontic patients treated since then have used
either inter-maxillary or intra-maxillary elastics at
some point in their treatment.

Despite their obvious significance in orthodontic

Figure 1: Transfer cases 18 months into treatment - Courtesy Tom Pitts 2017
mechanics, little research and only very basic articles
regarding the use of elastics has been done. Today
we’d like to give an introduction to our current
approach when using elastics (usually with disartic-
ulation) as an adjunct in “Active Early”3 treatment
protocols.

Exact forces required to move teeth

are not known
The force magnitude for “optimal tooth movement”
has been one of the holy grails of orthodontics since
Schwartz4 advanced the concept of “the force leading
to a change in the tissue pressures that approximat-
ed the capillary blood pressure, thus preventing their Figure 2: Transfer cases 18 months into treatment - Courtesy Tom Pitts 2017
occlusion in the compressed periodontal ligament”.
While there has been a good deal of animal research,
human studies have been very limited. Reitan’s study
in the 1960’s suggested that the optimal force level for
tooth movement was 5 N (approximately 50 gms) of
force. Clinically, it has been obvious to me that teeth
will move with forces that are much smaller than
commonly used if they are precisely applied5.

For years orthodontists, have had to resort to heavier

forces than we needed. Once we began using passive
self-ligation and taking IO photos every visit, I was Figure 3: Popular “blue grass” roller did not provide resolution of the AOB or tongue thrust -
able to see that we could use very light elastics at the Courtesy Tom Pitts 2017

very first appointment to attain desired changes (Fig-

ure 1-6). This is far more comfortable for the patient,
and we achieve better cooperation, as a rule.

With the widespread adoption of PSL approximately

20 years ago, clinical protocols have been developed
that reduce the level of applied forces to increase pa-
tient comfort while improving clinical efficiency for Figure 4: Pitts “Active Early” protocols: SAP bracket position, “Flipped” upper anterior brack-
me. Our ILSE (Immediate Light & Short Elastics) ets, Pitts Broad AW’s, ISLE (triangle elastics), NMI (squeeze exercises, lower tongue tamers) are
applied - Courtesy Tom Pitts 2017

© ORT HOEVOLVE 2017

10 2017 Issue 6 // www.oc-orthodontics.com
 7 WEEKS

Figure 5: ISLE protocols involved wear of “Vertical Triangle” elastics full time, and Pitts P.T. squeeze exercises.

protocols deliver light, precise forces in sup- achieve the desired results. “Every patient/
port of mechanics. ILSE and PSL are great every appointment” photos supports patient
marriage. In contrast to some contemporary compliance, and fully involves the patient/
protocols where inter-maxillary elastic forces parent in the treatment process by revealing
of 4.5 to 6.0 oz. are commonplace, “Active progress from the previous appointment.
Early” approaches seldom employ elastic
forces greater than 4.5 oz. and frequently 2.5 Routine intra-oral photos every
or 3.5 oz.
visit
To minimize inventory and simplify elastic
“Active Early” case management protocols
selection, our protocols use mainly six elas-
are very efficient, and it is important to keep
tic types, and most our treatment can be ac-
this in mind during esthetic orthodontic
complished with only four. We have 2 sizes, 7 WEEKS
treatment. This is not a “set it and forget
3/16 and 5/16 and 3 forces levels of each of
it” approach. Every appointment requires
these sizes 2.5, 3.5, 4.5 ounces.
a regular routine of photography, review
of patient progress, and adjustment of case
There are a variety of factors that management (where it is required). Use of
degrade elastic force over time treatment milestones allows this process to
be systematic - PRACM (Pano reposition
Both Latex and Synthetic (non-latex) elas- adjust case management). Progress IO pho-
tics and elastomers display a reduction in tos are most important for adjusting case
Figure 6: Excellent patient co-operation in elastics wear,
loss of strength when stretched over a peri- management and mechanics. and Pitts PT exercises contributed to the progress to
od of time, and exposed to various fluids that date in just 7 weeks. Notice the improvement in incisor
may be ingested during in vitro testing. Force inclination due to “Active Early” case management -
Derivation of ISLE - Immediate, Courtesy Tom Pitts 2017
degradation during function approximates
25% in the first 24 hours6, with most of ef-
Short, Light, Elastics
fect occurring in the first 3 to 5 hours7.
As with many other clinical advances,
Supported by NMI
With this in mind, we suggest changing ISLE and disarticulation protocols were
elastics after each meal, which applies a developed as a combination of luck and
experience. In 1977, when I was testing Mechanism was supported by
more consistent level of force supporting
mechanics. lingual appliances, I found that in deep neuromuscular intervention,
overbite cases with lingual appliances, the tongue tamers, and Pitts PT
Elastic compliance is critical to posterior teeth were disarticulated. The
posterior teeth came together by eruption
squeeze exercises.
attain a designed result and no intrusion of the upper anterior
teeth was necessary to reduce the overbite.
With “active early” esthetic treatment plan-
Leveling naturally occurred, but on some
ning protocols, elastic wear is critical to
cases it took some months for the posterior

© O RTH O E VO LVE 201 7

www.oc-orthodontics.com // 2017 Issue 6 11
 teeth to begin occluding. I began using
composite bite buttons behind the upper
centrals, which became known as bite
turbos (derivation of the name turbos is
unknown). However, not only did some
patients take a long time to erupt the buccal
segments, some would return on their
first visit biting behind the bite buttons
with the lower anteriors. I added some
short light elastics to mitigate against this,
using the lightest forces possible (2 oz.,
3/16”) to close the posterior bite. When
patients wore the elastics (full time), starting
with the first appointment, from the lower
6 to the upper 4, the posterior teeth were
touching in 6 to 8 weeks and biting behind
the turbos was no longer a problem. By
observing the IO photos, the AP corrected
slightly. There were no deleterious effects.
Today, we have developed ISLE protocols
Figure 7: In many Class II div 2 patients, incisor exposure is near ideal prior to treatment - Courtesy Tom Pitts 2017 and combined groups of elastics designed
to increase VIP (Vertical Incisor Position;
this acronym was suggested by Dr, Dwight
Frey) cant the occlusal plane, and broaden
arches-improving occlusion and esthetics
from the first appointment. This is a major
factor in being able to treat more cases non-
extraction with “WOW” esthetics.

A Practical Clinical Approach

“Active Early” treatment protocols are de-

signed to apply lighter forces for longer
durations earlier in the treatment cycle to
improve efficiency for the Orthodontist and
gentleness for the patient. Each of the
parameters of pre-bonding coronoplasty,
SAP/VIP bracket placement, use of
precise PSL bracket slots, practical torque
values, (inverting brackets as needed),
combined with appropriate disarticulation,
early elastics, and NMI (neuromuscular
intervention) improves esthetic and occlusal
results quickly with very light force levels.

By clinical trial and error, we’ve found less

need to distalize molars of many crowded
cases, due to our esthetic positioning of inci-
sors, torque control, and arch development
providing needed space. Light inter-arch
elastics save a tremendous amount of time
and effort in treating all different types over
malocclusions, with attendant esthetic en-
Figure 8: Protection of existing smile arc and incisor display is critical to esthetics. Eruption of the lower posterior hancement. Yes - we begin most treatments
teeth and protection of upper incisor position by SAP bracket position is supported by disarticulation and ISLE -
Courtesy Tom Pitts 2017 Pitts “Active Early” protocols: SAP bracket position, Pitts Broad AW’s, ISLE (Short Class II),
with light elastics at the first appointment.
anterior disarticulation are applied - Courtesy Tom Pitts 2017

© O R THOEVOLVE 2017

12 2017 Issue 6 // www.oc-orthodontics.com

Disarticulation and Early Elastics

The most frequent questions that we are

asked when teaching involves the case man-
agement techniques with elastics and dis-
articulation. One of the subtleties of case
management of continuous arch wires in
fixed mechanics is flaring associated with
relief of crowding and is counter to esthetic
or occlusal outcomes. We do not need to use
reverse curve wires with our technique. With
our active early protocols we can generally
treat non-extraction cases and end up with
proper inclination of the anterior teeth.

We advocate approaches that are simple,

efficient, effective, and predictable; for that
reason we do not use MEAW mechanics
(Figures 1-6). That is only needed when us-
ing twin-tie brackets.

Disarticulation

ILSE and disarticulation work together in

“active early” case management. Disartic-
ulation removes the occlusal influences of
malocclusion and permits selective eruption
and intrusion of teeth and arch develop-
ment to meet esthetic and occlusal goals.
Figure 9: Great improvement in only 6 weeks. “Every appointment imaging” reinforced the progress with the patient/
parent, and advancement of wires to 018X016 UltraSoft TA NiTi was possible. Today, I would place the bite openers
We use either Bandlock (blue) or Pink (turbos) on the upper first bicuspids with a bite ramp to let the lower jaw come forward. - Courtesy Tom Pitts 2017
Triad gel for posterior turbos (pillows)
or Triad rope (pink) for anterior turbos.
These materials are easily adjusted (reduced
or increased), distinguishable from natural
teeth (facilitating removal), and wear more
easily than enamel (preventing tooth wear).

Adjustment of the position or size of bite

turbos requires constant management, in
response to treatment response for maxi-
mum benefit. “Setting and forgetting” dis-
articulation is a common error.

Disarticulation strategies have evolved con-

siderably to improve efficiency and patient
comfort.

Anterior Bite Turbos: We use disarticu-

Figure 10: Great improvement in only 6 weeks. “Every appointment imaging” reinforced the progress with the pa-
lation that is more anterior in deeper bite tient/parent, and advancement of wires to 018X018 UltraSoft TA NiTi was possible - Courtesy Tom Pitts 2017
cases, reducing overbite through selective
eruption of the lower posterior teeth, and
intrusion of the lower anterior teeth, sup-
ported by SAP bracket placement and ILSE.
Where good upper incisor display is present,
anterior turbos behind the upper anterior

© O RTH O E VO LVE 201 7

www.oc-orthodontics.com // 2017 Issue 6 13

 teeth, provides rapid reduction of overbite,
while preserving enamel display. Several
years ago we found that placing turbos on
the upper cuspids, was more comfortable
for the patient, and still effective early in
treatment. Most recently, we have adapted
an approach suggested by others, including
Dr. Keith Sellers in Charlotte, using bite
turbos on the upper first bicuspids incor-
porating bite ramps to encourage forward
mandibular positioning (similar to “planas
direct tracks”). These turbos are still anteri-
or enough to allow eruption of lower molars
with light elastics, and clockwise tipping of
the upper occlusal plane for esthetic gain.
With the bite ramps on maxillary first bi-
cuspids it allows for more eruption of lower
molars than upper molars. When the cas-
es are nearly leveled, cuspid or bicuspid
turbos are repositioned anteriorly to the
maxillary incisors, allowing ideal overbite
protection, while maintaining incisor dis-
play, and seating the buccal segments. An-
terior bite turbos are maintained until near
the end of treatment, ensuring over-correc-
Figure 11: Continued improvement. As most rotations were completely resolved, finishing was possible with 020X020
Beta T with a minimum of AW adjustments, further adjustment of occlusion as the posterior teeth seat into occlusion. tion of the deep-bite. As an aside, upright-
8 months from beginning of treatment. - Courtesy Tom Pitts 2017 ing of the anteriors is easier when the ante-
rior teeth are not in occlusion.

Posterior Bite Turbos/Pillows have evolved

considerably, directed towards positive
adjustments of the occlusal plane, and
molar intrusion. They are used in anterior
open bite cases as well as high angle cases.
Upper or lower posterior bite turbos
are supplemented with PT exercises
(squeezing pressure on molar pillows,
activating the posterior fibers of the
temporalis muscles) to encourage favorable
rotation of the occlusal plane and intrude
molars. We suggest placing posterior turbos
in the depth of the occlusal fossa rather
than the cusp tips, frequently on the upper
first and second molars, and adjusted to
balance the occlusion. Posterior bite pillows
are removed when the ideal overbite
relationship is attained, so that the buccal
Figure 12: Finishing procedures involved continue wear of the light Class II elastic, and Down and Under elastics to segment relationships can be developed
complete seating of the occlusion. The anterior disarticulation can be removed once the posterior occlusion is fully
seated.
with finishing elastics and refined through
coronoplasty. We can expect to intrude the
molars 2+ mm with PT exercises.

© O R THOEVOLVE 2017

14 2017 Issue 6 // www.oc-orthodontics.com

Patient Compliance

The only way we achieve “WOW” esthetics

is wearing light elastics full time, immedi-
ately, and then continuing excellent com-
pliance throughout treatment, to minimize
treatment time and achieve esthetic goals. I
think that Dr. John Campbell’s esthetic treat-
ment explanation to his patients says it best,
“Elastics is not a part of your treatment, it is
your treatment!” We use any and all efforts
that develop a collaborative relationship
with patient/parent in elastic wear, explain-
ing the impact of elastic wear on esthetic/
occlusal results, describing the adverse ef- Figure 13: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017
fects of failure to comply. We also empower
the patient/parent role in achieving excel-
lent results. Matt Brunner approaches this
with NIMIT discussion (Now Is the Most BEFORE AFTER
Important Time) to reinforce the impor-
tance of elastic wear throughout the treat-
ment process, using clinical photography
both monitor progress and provide positive
patient reinforcement.

In Summary, as our guiding principles of

ILSE:

Shorter elastic stretch is better than longer

Groups of elastics are better than individual
Full time wear is absolutely necessary
(except for rainbow)
Immediate (first appointment) is a must
Figure 14: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017
Lighter is better than heavier

To Summarize:
We strive to develop protocols that are
effective, efficient, predictable, and produce
outstanding results with a more accurate
and tightened slot. In “Active Early” case
management, ILSE and disarticulation are
critical contributors. We hope that this
article will reduce some of the confusion
that has existed regarding their role in our
case management.

Look for more innovations on both the tech-

nology and case management sides, that we
will be releasing soon as the Pitts 21 system.

Until next time...

Drs. Tom Pitts and Duncan Brown Figure 15 & 16: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017

© O RT H O E VO LVE 201 7

www.oc-orthodontics.com // 2017 Issue 6 15

 Author’s Comments

Dr. Tom Pitts Dr. Duncan Brown

“Efficiency of treatment and the quality of the final result is highly dependent on elastic wear and disarticulation.
Mastering ILSE (immediate, light, short, elastics) and disarticulation will shorten treatment times, and improve the
quality of your esthetic results. With the introduction of Pitts 21 appliance system, and its revolutionary slot design,
using ILSE and disarticulation will be even more effective! Look forward to showing it to you!” - Tom Pitts

REFERENCES
01. Abel, M - “A brief history of orthodontics”, Am J Orthod Dentofac Orthop. 1990; 98; 176-182
02. Singh, V - Elastics in Orthodontics: a review, Health Renaissance, January - April 2012: Vol 10 (1); 49-56
03. Pitts, T - Active early Principles - Pitts Protocols Issue 2, 2015; 8 to 14
04. Schwarz, A - Tissue changes incident to orthodontic tooth movement, Int J Orthod, 1932
05. Ren, Y - Optimal Force Magnitude for Orthodontic Tooth Movement: a Systematic Literature Review, Angle Orthod 2003; 73: 86-92
06. Tong, W - Evaluation. Of force degradation characteristic of orthodontic latex elastics in vitro and Vito, Angle Orthod 2007; 77(4); 688-693
07. Gioka, C - Orthodontic latex elastics; A force relaxation study. Angle Orthod 2006: 76 (3); 475-479
09. Pitts, T and Brown, D - Overcoming Challenges in PSL with “Active early” H4. The Protocol Issue 4, 2015; 8-18
10. Pitts, T - Secrets of Excellent Finishing. News and Trends in Orthodontics, Vol 14 (April), 2009
11. Griselda, M, - Planas direct tracks in young patients with Class II malocclusion, World J Orthod. 2005 Winter 6(4); 355-368
12. Topkara, A, - Apical root resorption caused by orthodontic forces: A brief review and a long term observation, Eur J Dent 2012; 6: 445-453
13. Sergl, H - Functional and social discomfort during orthodontic treatment - effects on compliance and predict action of patient’s adaptation by personality vari-
able, European Journal of Orthodontics 22 (2000); 307-317

16 2017 Issue 6 // www.oc-orthodontics.com

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www.oc-orthodontics.com // 2017 Issue 6 17

Developing a High Performance Team
Teams Succeed based on the Strength of their Leadership.
By David Herman D.D.S., M.S., M.P.H.

PART 2 OF 2 “Clients do not come first. Employees come first. If you treat employees
For part 1 of this article
right they will take care of your clients.” - Richard Branson
see Protocol Issue 5

What you see is what you is replication of what was taught to Storming is the point where control,
coached: Training, maturation, increase self-confidence, discipline significance, and openness issues
problem solving, conflict resolution. and consistency of performance. cause friction within the team. It can
Monitored execution is evaluation of be short or endless. Norming is the
The biggest complaint I hear from what the trainee learned and practiced. stage that a large majority of teams
new staff about their old job was This is followed by re-teaching operate within. In this stage your
poor training. My training process and more practice until maximum team performs well but quickly reverts
is integrated in with my team’s competency is achieved. I recommend back to a storming stage if conflicts
maturation process. Mature teams about four hours of practice to every or problems arise. The performing
train faster and can handle more hour of teaching. I find that teaching stage is what a team strives to mature
complex skill sets than less mature without sufficient amounts of practice into. It is a stage where performance
teams. New staff learn faster when results in too many negative outcomes. is consistently good and conflict
placed on a mature team. In this Outcomes that severely impact the and problems are handled without
section, I will discuss the relationship trainee’s self-confidence and sense of reverting back to a storming stage.
between training and the team well-being. Do not expect to have a consistently
maturation process. high performing team unless your
All teams go through a maturation team is at a performance maturation
Training requires teaching, practice, process. The stages of this maturation level. Because storming results in
and monitored execution. Training process are: forming, storming, inconsistent performance, and is a
starts with teaching new skill sets and norming, and performing. Forming stage needed to be minimized, I want
requires hours to accomplish. Practice is about starting out. It tends to be to discuss the causes of storming
can require at least 35 work days to a short honeymoon period were all behavior in some detail.
reach minimum competency. Practice is good and expectations are high.

18 2017 Issue 6 // www.oc-orthodontics.com

Storming is the stage we all dislike
and it usually is due to three root
causes. First is Control: who bosses
who around?, who decides the course
of action?, who controls situations?.
Second is Significance: how do I feel
when I am in your presence? In your
presence, do I feel better or worse
about myself? Third is Openness; how
much information does someone
share? Too much communication too
little communication? These three
root causes all have a range, and those
team members that tend to be at the
more extreme ends of these ranges are
often involved in the most storms. about “things” and conflict resolution starts to build. A series of pinches
is about “people.” There exists many that go uncalled eventually result in
To get a team to a performance books on these two subjects. Having an emotional outburst and a crunch
maturation level, they need to be great problem solving skills mean occurs. At this point, emotion rather
trained in problem solving and conflict that all variables are assessed before than rational response rules the day.
resolution. Training in these two areas identifying solutions. The greatest My staff is trained to avoid crunches by
are of paramount importance in my reason for poor problem solving is calling pinches. My assistant coaches
training process. Problem solving is jumping to solutions. The biggest are involved most times in this process
reason for jumping to solutions is unless I am part of the problem or part
not identifying the root cause(s) of a of the solution. It would be rare for me
problem. The second reason for poor to be involved in this process. Most
problem solving skills is letting blame pinches are in their control.
assessment into the process.
Discipline: Players first concept
Conflict resolution is different than
problem solving because it gets One of the main reasons my staff
personal. We use the pinch theory for has so much empowerment and
conflict resolution. The pinch theory control is due to the fact that they
has been used for years in couples are well disciplined in behavior and
counseling. It is based on the belief performance. My staff stays focused
that little pinches that go uncalled lead while performing, takes corrective
to a crunch. When someone does not
say, “hey that pinch hurt” resentment

Shared Vision
Strategy
Empowerment
Accountability
Goals
Self-Directed
Processes
Push/Pull Positive
Involvement
Who are we? Who am I? Conflict Resolution
I get it!
At last - change! Coaching
Commitment
Excitment! Who’s steering this ship? Accomplishment
Respect
Wow - not enough What process? Growth
Leadership
hours in the day to What’s in it for me? NO STORMS!!!
Collaboration
have fun! Another change?
This is challenging!
Anxiety This is too hard.
Unity
What’s our vision? Not sure I can do it.
Decisions
Another screw-up?
Where are we going? Teamwork
Not sure we can do it.
What’s my place? This can be fun!
I’m tired, I’m depressed.
What’s the plan? What, another storm!?
I’m ready to give up.

FORMING STORMING NORMING PERFORMING

www.oc-orthodontics.com // 2017 Issue 6 19

action intuitively and responds positively with the needed skill sets but wrong coaches. I trained these coaches to be
to coaching. Training a team to be personality is more difficult and time extensions of me and I chose coaches
self-disciplined starts for me with my consuming. that would balance out my areas of
“players come first” philosophy. As a weakness listed in part 1 of this article,
coach (leader), my players (staff) are In my “players come first” environment, on the question, “Why not work with
the most important part of my practice fighting between staff has been me?” So, I chose assistant coaches
and my staff knows it. As stated in part significantly reduced. To reduce such who demonstrated good listening and
1 of this article, it is as a team, coaches behavior, all staff have leadership nurturing characteristics. This meant
and players combined, that the patients responsibilities. We all conduct informal that assertive type personalities were
become most important, When you performance evaluations on each other. not a good fit for this position. Next,
put your players first you develop a The evaluations are based on four main I took a firm stance with my assistant
unique relationship with each player areas. I call the process TLC +P, Trust, coaches that if I was not part of a
that shows him or her how much you Loyalty, Commitment, Passion. First, are problem or part of a solution then I
care and how important it is to you that you trusted to do the right thing and not would not be involved in the problem
they achieve success. In return, I expect over commit or under deliver? Second, solving or conflict resolution processes.
my players to be coachable and part are you loyal? Does the team know that I developed this coaching staff into
of being coachable is having the self- you are there for them and have their my core management group. The
discipline to “do what’s right.” back? Third, are you committed to the more relevant my coaches became to
team? How committed does the team the team, the more my quality of life
Doing what is right is another one of feel you are? This includes attendance improved. Each coach has responsibility
our ten core values. In my practice, and timeliness, as well as being present for a five or six person work unit.
undisciplined behavior stands out in the moment when performing. Once these work units matured into
and the team has pretty close to zero Fourth, are you passionate about what performance level teams it was the
tolerance of such behavior. As I added you do? Does it show through to core management group’s responsibility
staff to my team it became easier to teammates, patients and parents that to integrate these work units into one
hire people who were a good fit, and you really love being at the practice larger functioning operation.
eliminate early in the try out period and performing your skills? I have a very Because I want to create more leaders
those who were a poor fit. For my responsive team to coach so when a than followers, I am goal or objective-
team, the prima-dona, or self-centered team member needs to adjust behavior oriented rather than process-oriented.
applicants, were a poor fit. I have had in any of the TLC+P areas it can be I understand there are usually different
the prima-dona type make the team achieved with minimum drama. processes that can be followed to
but he or she had to change to be achieve a goal or an objective. I
more giving and less self-centered. Great Leaders don’t create encourage my leaders to think for
I want team members with diverse themselves about the process he or
personalities, and I strive to achieve followers they create more leaders she wants to use. This is the same
a balance of personality types in the critical thinking process that most
office. Too heavy of one personality As my practice grew, decentralization of us learned as residents. Most of
over another creates problems. When of the leadership was required. Studies us had several attendees teaching
we are looking for a new team member, show the ideal leader to team ratio us their way to achieve treatment
we hire for personality fit and train for is about six to one. I have 36 staff outcomes. A residency director did
needed skill sets. Training someone members, so I have five assistant not tell the attendees to teach just

20 2017 Issue 6 // www.oc-orthodontics.com

one methodology. Leaders who are
process-oriented are called micro
managers, poor idea if you want your
leaders to be critical thinkers. The
better method is to evaluate a process
based on its ability to efficiently and
effectively reach a goal or objective
and not on if it fits into the way you
would have done it. FAST

Creating an Environment of
Transparency and Options

Years ago I found that being opaque

about information hurt the team,
and being transparent allowed the SLOW
team to make better decisions about
their destiny. Controlling one’s own
destiny eventually became one of our
core values. When we first moved
toward transparency it took some
desensitization of the staff. Being direct Thinking Fast and Slow fast thinking mode of operation. It was
wasn’t as easy for a staff member easy to make reactive decisions that
to take as dancing around the bush. I incorporated the process of slow needed to be made quickly. It was
As the staff embraced transparency, thinking to improve my leadership difficult for me to get out of this mode.
meetings became extremely efficient abilities. Daniel Kahneman’s book,
and effective because we took a “Thinking Fast and Slow,” explains in I want to emphasize that this schedule
more open, honest approach to detail how the two modes of thinking had a huge impact on improving the
solving problems and conflict. Part of are different. Eight years ago I began operation of my entire practice. Think
the desensitization process includes working three weeks on and one week of it as a bye week, it affords my staff
training my staff to have long term off every month. I did this for a few time to conduct training, refine systems
memory about the teaching moment reasons, but one main reason was to and catch up on larger projects that
surrounding mistakes or failures, slow my thinking process down and cannot be done during a busy patient
and short term memory about the improve my leadership capabilities. schedule. It allows outside the office
emotional distress accompanying such As I moved on from a resident to an marketing activities. It also provides
a mistake or failure. Learn from mistakes orthodontist everything sped up. As my staff time to handle personal activities
and get over making them. Training staff office went from six chairs and eight without missing patient days. I am out
to own up to mistakes or failures made staff members to 14 chairs and 25 staff of the office during this week, which
“throwing someone under the bus” a members, it sped up more. Twenty- takes me emotionally out of the day
serious breach of trust to the team and five chairs and 36 staff members, that to day operations. I get out of my
hence, a rarely attempted tactic. included a dental department and a reactive mode and into a slow thinking
dental hygiene department, faster yet. mode. I spend time assessing practice
Adding to the environment of My world and what I had to handle management issues. I reflect on where
transparency is creating an environment expanded greatly. I developed a strong, we are and where we are going. I spend
of options. My staff are trained that
the locus of control of one’s destiny
is improved if one thinks in terms of
options when looking at solutions
to problems or conflict. If one has
multiple options, one rarely has to
compromise to reach solutions. My staff
recognizes that compromising has a
negative slant because it is an outside-
in approach. You are being forced to
give in by outside influence. If one
learns to explore options from other
people’s points of view then an inside-
out solution is possible and the locus
of control remains within each staff
member.
www.oc-orthodontics.com // 2017 Issue 6 21
 time thinking about my relationship Final Words: Turnover Kills
with each team member and where
that needs to go. I read coaching or Turnover kills. I have had the good
management books and take time to fortune of having many long term staff
think how theory in those books can be members. Out of 36 staff members, I
applied to what I want to accomplish. usually have a turnover rate of two or
Lastly, I spend time recharging my three per year. While staff leave for a
batteries so that I am ready to go variety of reasons, it is rare that a staff
for another three weeks of strong member leaves due to work related
performances. issues. If you significantly reduce
turnover, have a great training program,
The slow thinking process requires a a strong core management team and
huge amount of energy to accomplish. can solve problems or conflicts with
I start the process with a scenario in my efficiency you are well on your way to
head or sometimes written down, and developing a staff driven practice, and
over an extended period of time this well on your way toward having a high
scenario goes through a series of small performance team.
changes, or sometimes large wholesale
changes. The slow thinking process
requires a lot of time to reach a quality
result. It is the time issue that makes us
all prefer to use the fast thinking process
for so many of our management
activities. I plan for, and I need, a couple
of days to decompress from a busy
three weeks of being in the practice
before I feel up to tackling an issue that
requires a slow thinking process.

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.

22 2017 Issue 6 // www.oc-orthodontics.com

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