THE READERS' CORNER

Topics this month are open bite and practice consultants.

1. How do you distinguish between skeletal anterior open bite and dental anterior open bite?

Virtually all the clinicians used both cephalometric and clinical criteria to distinguish between skeletal and dental anterior open bites. Most respondents emphasized the cephalometric evaluation, including mandibular, occlusal, and palatal plane angulations; anterior and posterior face heights; and mandibular body, ramus, and gonial angle morphology.

Clinical gauges used by the readers were the degree of upper incisor exposure below the lip line, the length of the upper lip, the degree of incisor protrusion, and the amount and direction of the curve of Spee in both arches. There was considerable emphasis placed on the evaluation of past and present habits.

How do you treat them differently? What appliances do you use in each case?

The clinicians clearly believed they could correct dental anterior open bites with orthodontic mechanics such as tongue cribs, vertical elastics, and selective extractions. The procedure most often mentioned was to identify the habit causing the open bite and then try to break the habit.

There was a greater variety of responses on skeletal anterior open bites. About 60% of the respondents said that surgery would be their first choice, especially if the patient was older than 12 or 13. Some would try high-pull headgear, either alone or in combination with functional appliances, for younger patients. A few of the orthodontists said they used transpalatal arches or bite blocks to help control vertical development.

At what ages do you prefer to treat these cases ?

Respondents generally agreed that dental anterior open bites should be treated early (age 7 to 9), particularly if they could be attributed to habits. For skeletal open bites, nearly 40% said they preferred to wait until age 14 or 15 and plan for surgery. The rest preferred conventional orthodontic treatment, but were divided on whether to treat in two phases (ages 8 to 10 and 12 to 14) or wait until puberty.

How do you treat a bite that is entirely open except for contact on the terminal molars?

The clinicians leaned decisively toward a surgical solution, unless the problem could be identified early in the mixed dentition. Various treatment strategies were suggested, including bite blocks, magnets, and high-pull headgear. However, the most common suggestion was to remove the most posterior molar (usually the second molar) if it was thought that might help correct the open bite.

In anterior or posterior open bite, is tongue involvement primary or secondary?

Seventy percent of the respondents felt tongue involvement was secondary to anterior open bite, while 30% felt it was a primary factor. The readers were evenly divided as to the role of the tongue in posterior open bite.

Do you recommend tongue thrust therapy as an adjunct to open bite correction?

About 30% of the clinicians said they would recommend tongue thrust therapy, but more than 65% said they would not. A few were undecided, mentioning that they might try it if there was relapse after conventional orthodontics.

What is your percentage of success with anterior open bites? with posterior open bites?

Although many of the readers were not sure how to evaluate their success, most were confident of their ability to correct these problems. More than half the respondents reported success in at least 80% of their anterior open bite cases, with the rest listing success rates of 65-70%. A sizable majority also felt they had at least 80% success with posterior open bites, but about one-fifth of the respondents reported success rates of less than 30%.

Specific comments included:

"For cases with a long face and high lip line, I use surgical maxillary posterior impaction. For low-angle, short, or normal faces with acceptable lip line, elastics are used to close the bite."

"I only use myofunctional therapy if there is a persistence of the tongue problem after orthodontic therapy. Creating a normal functional relationship will usually allow for normal myofunctional operation."

2. Have you ever used a practice management consultant? If so, in what specific areas of practice management did you want the consultant to advise you?

A little more than half of the respondents reported having used a consultant. Most of them wanted advice in only one or two particular areas, the most common being staff relations and management (58%), financial matters such as cash flow and collections (47%), starting new patients and controlling patient flow (36%), internal marketing (31%), and scheduling (26%). Occasional mention was made of practice administration, overhead control, and computerization.

What did the consultant do?

In many cases the consultant would visit the practice, spend some time monitoring office procedures, review job descriptions, interview staff members, and then make specific recommendations in the areas being evaluated. These recommendations often centered on the goals of the practice and the processes by which current procedures could be changed.

Did you retain the consultant on an ongoing basis? If so, on what kind of arrangement?

More than 85% of the clinicians did not retain their consultants after the initial evaluation. The few who did either maintained monthly communication--sending reports and getting feedback--or contacted their consultants if they had specific questions or problems.

How successful do you think the consultant was in improving your practice in terms of increased case starts? practice income? staff relations?

Nearly 75% of the respondents felt their consultants had helped to increase their case starts, but most of these said the increases were quite modest and did not regard this as a major benefit of using a consultant. Nearly 90% reported increased practice income, with half of these indicating that their gains were limited. More than 80% believed their staff relations had significantly improved and were pleased with this outcome.

Comments included:

"Consultants can be beneficial--but you have to be willing to change. Often they don't have a 'compromise idea'--it's either their way or no way. "

"Be sure that the consultant is on the same wavelength as yourself. Poor communication and false expectations can shadow the true result. Hire a consultant on a fee-for-service, as-needed basis."

"If you feel the need--do it! If you are satisfied with your current situation--don't."

"Picking a consultant is no different from choosing any other professional service: (1) get recommendations from other practices, (2) ask many questions, and (3) think about how receptive you are to changes."

"The consultant told us to hire a communications coordinator and a clinical coordinator. We did! It has been very successful and less stressful for me."

"We are much better organized than before with good systems now in place. Excellent job description and procedural manuals established. "

"The consultant acted as a catalyst for change by surveying our practice, making recommendations with all participating in the discussion, and helping us to commit to achievable goals."

"Our staff relations are much better and communication has improved. However, once you start moving up the scale and baring your soul, it gets harder! We are constantly trying to overcome our preconceptions."

"You need to have the staff behind the whole idea of having a consultant come in to fine tune and help. You need to lay out ahead of time what your expectations are for the whole staff."

"It is very important to analyze the recommendations, commit, and follow through with the ones you feel are best for your practice. Someone needs to be accountable and dates set up for implementation . "

"Consultants can be viewed as 'doctors' capable of diagnosing and guiding problems. For a healthy practice in a thriving economy, they may act periodically as 'trainers' to be used only for tune-ups. In less favorable economic times, they can guide and motivate the orthodontist and staff to major paradigm shifts."

JCO wishes to thank the following contributors to this month's column:

Dr. A. Alan Akridge, Louisville, KY

Dr. Samuel Berkowitz, South Miami, FL

Dr. Barry E. Booth, La Grange, IL

Dr. Frederick A. Booth, Fayetteville, NC

Dr. Dennis R. Brenkert, Fort Collins, CO

Dr. Barry S. Briss, Chelmsford, MA

Dr. Robert S. Bushey, Englewood, CO

Dr. Ronald B. Cooper, Charleston, SC

Dr. Joseph S. Coward, Grand Junction, CO

Dental Specialty Associates, Solana Beach, CA

Dr. Herb Dulaney, Big Rapids, MI

Drs. Fraseur and Jones, Spencer, IA

Dr. Samuel Frydenlund, Ann Arbor, MI

Drs. Edward and Jeffrey Genecov, Dallas, TX

Dr. Jerry W. Gilliam, Spring, TX

Dr. Phillip M. Goodman, Cincinnati, OH

Dr. Lee Graber, Kenilworth, IL

Dr. Shigeru Kawanami, Gardena, CA

Dr. Louis J. Marconyak, Virginia Beach, VA

Dr. Don R. Miller, Paso Robles, CA

Dr. John F. Monacell, Sandston, VA

Dr. Gary D. Mundy, Fort Bliss, TX

Dr. Robert C. Nettune, Basking Ridge, NJ

Orthodontic Associates of Westwood, Westwood, NJ

Dr. T. Richard Perrine, Goldsboro, NC

Dr. Robert S. Portenga, Traverse City, MI

Dr. Marvin Rosenberg, Studio City, CA

Dr. Richard L. Schechtman, Jefferson Valley, NY

Drs. Robert T. Scott and Joan M. Stetz, Westminster, MD

Dr. John C. Serijan, West Yarmouth, MA

Dr. Edward Shehee, Pensacola, FL

Dr. Seiji Shiba, Los Gatos, CA

Drs. Frederic Sterritt and Rick Wright, Somerville, NJ