I. The ConceptWe can all remember the old story about five blind men trying todescribe an elephant. The guy with his arms around theelephant’s legs was confident that the animal was shaped like atree trunk. The one with his hands on the tail was convinced thatit was shaped like a rope, and the one with his hands on the trunkthought that the animal resembled a python, and so on. It was notuntil they put their assorted observations together that they got anunderstanding of the complete animal. In studying the structureof an orthodontic practice, we sometimes observe a similarphenomenon. Doctors who have been extremely successful atdeveloping a large referral base find themselves overwhelmed intrying to deliver treatment for these patients because theirclinical systems have not been properly organized. Conversely,we hear from doctors who have well organized clinical deliverysystems, but are unable to develop the management structurenecessary to expand their practice and referral base.

Although most orthodontists possess the ability to master theseconcepts individually, many struggle to conquer them all. Thishas been historically due to the lack of a comprehensive plan,which would allow orthodontists to systematically approach thedevelopment of a successful practice. With recent advances intechnology, we now have the necessary armamentarium to adopta comprehensive system that enables orthodontists to effectivelyand efficiently develop a successful orthodontic practice. Theseconcepts of efficiency and effectiveness were integralcomponents in the development of our treatment system.Although these two terms are used quite frequently, andsometimes interchangeably, we chose to focus on the synergythat is unleashed when the two are combined. The reason issimple. To be effective, we must do the right things. And to beefficient, we must do things the right way. By developing a

successful practice through a system involving effectiveness andefficiency, we do the right things right!

II. The Principles

A. A Strong Referral BaseWe all recognize that there are several methods of developing areferral base for our practices. These methods will vary,depending on the geographic location of the practice, theindividual personalities and preferences of the practitioners, anda number of social, cultural, and economic factors. No singlesystem is going to apply to everyone. However, certain centralthemes can be studied, and modified for application to individual circumstances.

The management challenges faced by the orthodontistencompass the processes required to encourage patients to cometo our office, and staff and patient management systems thatallow us to deliver our treatment without exposing ourselves toundue amounts of stress or frustration. A comprehensivediscussion of such management information would require manyarticles, and chapters in textbooks, but I would like to tantalizeyou with a simple question. Given that the family dentist is stillthe primary advisor to our patients, and therefore the gatekeeperthat directs patients towards the need for orthodontic treatment,has anyone ever actually surveyed general dentists to find outwhat prompts a referral to a specific orthodontist? Well, we did.And, instead of an arbitrary and subjective managementstructure, we have chosen to take direction from the familydentist in structuring our referral mechanism. Put simply, weasked them what they wanted, and made the process moreobjective, and less capricious.

Sondhi™ Signature Treatment SystemDoing the Right Things Rightby Anoop Sondhi, D.D.S., M.S.

Dr. Anoop Sondhi received his dental degree from the Indiana University School of Dentistry, and his post-graduatecertificate and M.S. in Orthodontics from the University of Illinois in 1977. Following his graduation, he was on thegraduate faculty of the Department of Orthodontics at Indiana University. Since 1988, he has been in full-time privatepractice in Indianapolis, and continues as a Visiting Professor for several graduate programs in orthodontics.

Dr. Sondhi has used indirect bonding for the past 20 years, and has presented seminars and continuing educationcourses to several dental and orthodontic organizations in the United States and Canada. He has also lectured inEurope, Africa, Asia, and Latin America. In addition to his orthodontic practice, Dr. Sondhi devotes a significantamount of his clinical work to the diagnosis and management of patients with disorders of the temporomandibulararticulation. Dr. Sondhi also serves as a consultant to the American Journal of Orthodontics and DentofacialOrthopedics.

System: An ordered and comprehensive assemblage of facts, principles,and doctrines in a particular field of knowledge or thought.

– Webster’s Encyclopedic Dictionary

B. Effective and Efficient ConsultationsIn order for us to use our time effectively, and for the patients andtheir parents to appreciate the value of the consultation, I believeit is necessary that the process be structured, organized, andextremely focused. Most orthodontists would agree that patientcompliance plays a significant role in the effectiveness of orthodontic treatment. Our treatment mechanics aresignificantly more effective and efficient, and the overall stresslevel in an orthodontic practice considerably diminished, if ahigh level of patient compliance is obtained. It is our belief thatthis process begins at the consultation, and we have tried to develop a consultation process that we believe enhancespatient compliance.

The process begins when the patient calls the office. This sets inplace a specific series of events that are designed to inform thepatient, allowing them to understand the amount of effort thatgoes into a clinical evaluation, and leaving no doubt in theirminds that they will be well cared for in our office. Tocomplement the implementation of our Signature System,instructional videos for orthodontic consultations, and fortemporomandibular disorder consultations, have been prepared.These videos have not only proved to be of interest toorthodontists, but have also proved to be excellent for stafftraining purposes.

C. The Essence of EfficiencyIt is our opinion that the efficient biomechanical delivery oforthodontic treatment can be studied under four differentcategories. They are:

1. Orthodontic Prescription Design

2. Orthodontic Appliance Design

3. Reliable and Consistent Bracket Placement

4. Appointment Intervals and Scheduling

1. Orthodontic Prescription Design

There are many pre-torqued and pre-angulated appliancesystems available to the orthodontic practitioner today, and theseprescriptions are based on a foundation of clinical principles, aswell as the personal and philosophical preferences of theindividual clinician. However, objective documentation on theefficacy of these various prescriptions has been lacking in theliterature, and most of the evidence presented appears to beanecdotal. Further, a clinician wishing to test a specificprescription is faced with the daunting task of having to treat asample group of patients, over a minimum of 2-3 years, todevelop an appreciation for the clinical details manifested by the prescription. This approach is, in our opinion, archaic and cumbersome.

Consider this: we routinely design supersonic aircraft and space-age vehicles, and develop them with CAD-CAM systems,without ever actually putting the first rivet in a piece of metal. Ifa supersonic wing can be designed, and expected to fly the firsttime with computer aided graphics, then it should certainly bepossible to design braces utilizing the same principle! It was ourgoal, therefore, to construct a virtual dentition, progress to thedevelopment of a virtual occlusion, and then to test the efficacyof our appliance design on the virtual dentition prior to applyingit on the patient. In addition, this gave us the ability to comparethe effects of different torques, angulations, and prescriptions ina totally objective manner. Figure 1, for example, demonstratesprecisely why a distal offset on a mandibular first molar tubemay prove to be undesirable. Indeed, in treating my ownpatients, I have frequently found it necessary to convert the firstmolar tube, and to place an offset in the archwire to recover aproper contact point between the first and second molars (Figure2). It became readily apparent, with this analysis, that a distaloffset on the mandibular first molar was generally undesirable(Figure 3), and that a distal offset on the mandibular secondmolar would prove to be beneficial (Figure 4A and 4B).Hundreds of such details were studied, and it became readilyapparent that the specific details of a prescription could beanalyzed three-dimensionally, and a fairly accurate assessmentof the expressed 1st, 2nd, and 3rd order movements could beestablished (Figure 5).

Figure 1: Occlusal view of mandibular arch, demonstrating undesirable effect of a distal offset in the first molar tube.

Figure 2: Occlusal view, demonstrating compensating bend in the archwire to overcome the effect of the distal offset on the firstmolar tube.

Figure 3: The undesirable effect of a distal offset on the mandibular first molar, analyzed through computer aided graphic design.

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We all recognize that there is a considerable degree of variationin human and dental anatomy. Some tweaking and detailing isalmost always necessary to obtain a refined treatment result.However, we have found that it is certainly possible to developan orthodontic prescription that would deliver a consistent resultin the overwhelming majority of patients. Figure 6 shows apatient with our prescription in place, with a completely straightrectangular archwire. Although it is evident that further detailsneed to be completed, our intent here is to demonstrate theefficacy of the prescription in developing the appropriate 1st,2nd, and 3rd order details. Figure 7 is a rendition of the aestheticand functional result that this prescription is designed to achieve.

2. Orthodontic Appliance Design

In utilizing the three-dimensional graphic analysis madepossible with computer aided design mechanisms, it is alsopossible to develop an accurate assessment of the differencesbetween different types of brackets. This, in turn, allows aquantification of the degrees of efficiency and effectiveness.The importance of an increased inter-bracket distance has beendiscussed for years, as has the difference in rotation controlbetween single and twin brackets. While there is little doubt thata winged bracket can combine some of the advantages of therotation control and inter-bracket distance, we do encounterproblems with archwire “binding”, and difficulty in plaque

Figure 4a & 4b: The improved molar contact relationship with a distal offset of the second molar tube, and no offset on the firstmolar tube.

4a 4b

Figure 5a & 5b: Examples of some of the details that were studied with the computer aided graphic analysis of a virtual dentition.

5a 5b

Figure 6a – 6e: Intra-oral views of a patient with our prescription in place. It is evident that this case is not yet completelytreated, but the photographs demonstrate the degree of finishing details achieved with completely straight finishing archwires.

6a 6c6b

6d 6e

control. It has been my experience that even the most fastidiouspatients will experience some difficulty in keeping wingedbrackets clean (Figure 8). Further analysis revealed that theMini Uni-Twin™ bracket design, first proposed and designed byDr. Thomas Creekmore, easily combined the rotational controlof a twin bracket, with an increase in inter-bracket distance, butwithout the disadvantages of archwire “binding” and plaqueretention due to the design of conventional winged brackets.

3. Reliable and Consistent Bracket Placement

It has been widely recognized for many years that accuratebracket positioning is of critical importance in the efficientapplication of biomechanics and in realizing the full potential ofpre-adjusted edgewise appliances. The accurate placement ofbrackets is greatly enhanced with indirect bonding, especially onposterior teeth.

Indirect bonding, in various forms, has been around for manyyears. However, many practitioners have been dissatisfied withthe concept of indirect bonding, because existing techniqueshave been relatively inconsistent and cumbersome, and havefailed to provide the savings in doctor and chair time thatindirect bonding should provide. This is mostly due to the factthat indirect bonding has hitherto been done with resins thatwere originally designed for direct bonding. Also, no organizedand cohesive system for indirect bonding was ever developed,and clinicians developed their own variations on this technique.

Having recognized this, we have developed, from the ground up,a comprehensive indirect bonding technique. It addresses thedeficiencies of previous techniques, and is presented as a

complete system. A new resin, designed specifically for indirectbonding, has been developed, and the results have proved to beexcellent (Figures 9, 10 and 11).

4. Appointment Intervals and Scheduling

With accurate placement of brackets, the use of efficient bracketdesign, and a well constructed prescription, it should be possibleto enhance the efficiency of treatment with appropriate spacingbetween appointments. It is almost impossible to over-emphasize the importance of this for our patients. In anoverwhelming number of the families who bring their children tous for orthodontic treatment, both parents work. For eachappointment, therefore, one parent has to leave their place ofwork, pick their child up from school, bring them to us for theappointment, wait while we perform the clinical procedures,return the child to the school, and return to their place of work.Depending on the geography and local circumstances, theycould easily lose approximately half their working day. If thenumber of times that they have to do this can be minimized, it isour opinion that this is a terrific service for our patients.

Before I go any further with this discussion, let’s get one thingstraight. There is no compromising with excellence. Thetreatment result should always be the best that we can possiblydeliver. However, if I can deliver the same degree of excellencein a total of 10-12 appointments, and another practitionerdelivers an equivalent result by seeing the patient for 20-22appointments, then I would submit that I have served the patientbetter. So, our overhead costs are decreased, and convenience tothe patients is increased – talk about a win-win situation!

Figure 7a – 7e: An example of the finishing details built into our current prescription. The details of the aesthetic and functionalresult can be readily appreciated. The enamel hypoplasia on teeth #7 and #9 will be restored.

Figure 8: Example of plaque accumulation around winged brackets. Note the area below the distal wing of the #26 bracket.This patient practiced good oral hygiene, but the excessive number of undercuts around the wings makes hygiene morechallenging.

7a 7c7b

7d 7e 8

Figure 9: Anterior view with indirect bonding trays in place.

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Figure 11a – 11f: Intra-oral views with initial archwire inserted. Please note that control of second molar position is achievedearly in treatment, requiring substantially fewer subsequent archwire changes.

11a 11c11b

11d 11f11e

Figure 10a – 10e: Intra-oral views of indirect bonded appliance placement. The greater precision in bracket placement can beeasily appreciated.

10a 10c10b

10d 10e

The following analysis is an excellent demonstration of theimportance of efficiency in biomechanics and appointmentsequencing.

Total treatment time = 20 months1st appt. – Seps. or Bonding Imps.*

2nd appt. – Bonding and/or Banding*

Last appt. – Debanding and Retainers*

Bonding AppointmentDirect – Doctor Time – 20-30 mins.

Indirect – Doctor Time – 3-5 mins.

If the patient is seen every4 weeks – Total appointments = 20

6 weeks – Total appointments = 14-15

8 weeks – Total appointments = 10-11

10 weeks – Total appointments = 8

12 weeks – Total appointments = 6-7

The maximum efficiency appears to be achieved when patientsare seen at 8-10 week intervals, since we must strike a balancebetween the appointment intervals, and the need to stay incontrol of the treatment.

Cost Per Appointment

Assuming a hypothetical treatment fee of $4,000, and a fixedcost of $1,000 per bonding and debonding, the fee generated perappointment would be…

4 week intervals – $150 per appointment

6 week intervals – $200 per appointment

8 week intervals – $300 per appointment

10 week intervals – $375 per appointment

Once we realize the cost per appointment, the importance ofminimizing bracket repositioning appointments becomesclearer. The rules should be simple: Schedule as fewappointments as possible, and do everything possible at eachappointment. One of the concerns I sometimes hear from ourcolleagues is that patients who are seen at 8, 10 or 12 weekintervals may not pay their treatment fees on schedule. Indeed,I frequently have colleagues tell us that their patients are in thehabit of making their payments during their monthly visits to theoffice. There is absolutely no question that it is not onlypossible, but necessary, to dissociate a monthly fee paymentschedule with the actual office visits for archwire changes,adjustments, etc. This is where the support mechanisms for ourSignature Series treatment system come into play. Appropriatemanagement materials, forms, patient education materials, andpresentation scripts to facilitate the implementation of theseconcepts have been prepared, and are presented as an integralpart of the overall system.

Conclusion

In every facet of orthodontic treatment and practicemanagement, there are a number of choices available to theorthodontic practitioner. There are different schools of thoughton practice management, office and staff management, and thechoice of biomechanical treatment strategies. Over the past 20years, we have worked to evolve and refine a comprehensivesystem, one that allows the efficient delivery of an orthodontictreatment result with a minimum level of inconvenience anddiscomfort for the patient, the orthodontist, and the orthodonticstaff. The seminars on this system will emphasize efficiency inappliance design and placement, and management systemsdesigned to deliver excellence in the treatment result. ■

*These are constant for every patient

Reprinted from Orthodontic Perspectives Vol. VIII No. 1. © 2001 3M Unitek