Office Visit: Dr. Robert ‘Tito’ Norris by Arselia Gales, assistant editor

Categories: Orthodontics;
Office Visit: Dr. Robert ‘Tito’ Norris 

by Arselia Gales, assistant editor
photography by Michelle Papp

Orthodontists spend most of their working hours inside their own practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Orthotown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of how they practice.

Dr. Robert “Tito” Norris says he sees the world not as it is, but as he’d like it to be. This mindset led the orthodontist to think outside the box and develop the Norris 20/26 Bracket System. Norris is a seasoned orthodontist who served as the chief of orthodontics at Misawa Air Base in Japan for three years before returning to the U.S. to open his own practice. A former lecturer with 3M’s Bottom Line series, he enjoys sharing his decades of experience with patients and orthodontists alike.

In this month’s Office Visit, we visit his LEED-certified office in San Antonio and learn what makes this engineer-turned-orthodontist tick. Norris also shares the thought process behind the Norris 20/26 system, starting from its humble beginnings 20 years ago to its development and production with Dynaflex.

Office Highlights

Dr. Robert “Tito” Norris

Graduated from: Howard University, 1995

Stone Oak Orthodontics,
San Antonio

Practice size:
Office #1: 5,200 square feet Office #2: 6,300 square feet

Staff size:

You have a background in mechanical engineering and describe braces as “engineering in the mouth.” How do you think your engineering background helped you succeed as an orthodontist?

In engineering school, I was trained to think in 3D on a Cartesian coordinate system. This mindset has been incredibly valuable over the past 30-plus years in visualizing forces, moments and vectors needed to optimize tooth movement and make 28 unique teeth fit together in a 3D puzzle. It has been helpful in designing and modifying appliances to fit specific and unique applications. To me, that’s a big part of the fun and challenge of orthodontics. Every patient has a unique set of teeth and, although there are many similarities, each person’s smile is as unique as their fingerprint.

I believe that it’s an orthodontist’s job to give patients the best smile possible. Sometimes this means mechanics. Sometimes this means incorporating other disciplines into the treatment plan, such as periodontics, oral surgery or prosthodontics. Having the ability to visualize what is possible is an important attribute. However, it’s a challenge to take this to the next level and visualize what their smile will look like decades later. Planning ahead for a smile that will last a lifetime is particularly rewarding.

You served as the chief of orthodontics at Misawa Air Base in Japan for three years. What was that experience like?

I have to say that those years were magical. As the only orthodontist on base, I was involved with every interdisciplinary patient that the 20 other dentists were treating. I was also able to scrub in on all of my orthognathic surgery patients, which was an incredible learning opportunity.

Practicing in the military is a unique experience for a number of reasons. First, finances are taken out of the equation, because all dental and medical treatments are complimentary for active-duty service members and dependents when overseas. Secondly, every patient shows up for all of their appointments; if they don’t, they can be reprimanded or written up by their commanding officer. Not only are they present for their appointments, but they are also punctual. It’s simply the military way of life.

I also had numerous opportunities to meet local dentists and orthodontists who were either in private practice or affiliated with universities. I was able to help some of them publish papers and lifelong friendships were forged.

When you returned to the U.S., what did you focus on? When did you open your first practice?

When I returned to the U.S. in 1998, I wanted to purchase an existing practice but there were none for sale in San Antonio at that time. So I decided to open my own office, which came to fruition in January 1999. My first office was 1,800 square feet and efficiently designed; I had been in offices in Japan that were less than 1,000 square feet and was constantly taking notes on how to be ergonomically efficient.

I had six treatment chairs and one TC room. Back then, we used paper charts and developed X-ray film in a darkroom. I had a small lab and did all of my own lab work until I hired my second employee, an assistant who was also a certified laboratory technician. (She’s still with me today, more than 22 years later!) I had to focus on getting my name out there and getting known in the dental community, so I visited many dental offices, held dental education events at local schools, sponsored school clubs and teams such as theater, soccer, baseball, etc., and held contests where kids could nominate their peers to receive complimentary treatment.

In 2010, your practice became the first LEED-certified orthodontic office in the world. What steps did you take to earn this distinction, and why was that important to you?

One of my mentors once told me, “Tito, whether you like it or not, you are going to be an influence on your patients and your community. It is completely up to you to decide what kind of influence you want to be.” I took that message to heart. I grew up as a Boy Scout—I was fortunate enough to reach the rank of Eagle Scout—and one of the core values of being a Scout is stewardship. So in 2007, I took the plunge and invested in a solar array for the office, which provided roughly one-third of the electricity needs for my suite. I signed an agreement with the local utility company so that the remaining two-thirds would come from “wind-tricity” [wind power from West Texas and the Texas coast]. This solidified our status because we were using 100% renewable energy to run our office.

Three years later, an adjacent space in our building opened up and I had an opportunity to expand. It was then that I decided to continue being an example of stewardship and create a LEED-certified office. One of my close friends, an architect, was very excited about the project. He and his team became fully engaged and were absolutely instrumental in managing the elements of LEED certification. Although LEED is about efficiency and conserving energy, it also encompasses a sustainable work environment where every room in the office has access to natural light. Employees are also encouraged to bike to work and exercise on their lunch hour. It’s really much more of a culture cultivator than many people realize.

In 2019, you were able to open a second practice. How do you balance your time between the two?

Well, because of the success at the original office, I wanted to make sure that the new office was constructed according to LEED specifications. When there is a blank slate to work with, one can come up with some interesting and creative designs. I’m very pleased with the result. It’s such a beautiful space and I love being there. Currently, I spend one to two days per week there and so does my business partner. It’s a slower pace, because it is a de novo startup practice, but it’s starting to gain some traction and is rapidly growing. I spend the remaining time at our main office, and it feels like a nice balance.

For seven years, you gave seven seminars a year to orthodontic residents through 3M’s Bottom Line lecture series, speaking on how to open and successfully run a practice. What was that experience like?

I have always wanted to give back to the orthodontic profession in any way that I can. This profession has been so generous to me and afforded me a wonderful working life. I’ve made a good living doing something that I love. That was the real genesis of participating in the Bottom Line lecture series. I wanted to encourage and help young residents start their own practices, rather than going to work for big corporations. My segment was entitled “Hanging Your Own Shingle.”

During this course, I shared how to go through the decision process of figuring out where to practice based on demographic data, growth patterns, lifestyle, etc. Then we’d go into lease negotiations, finish-out hints, tips and suggestions, bank loan proposals (including a pro forma cash-flow projection analysis), hiring employees, business planning, creating a logo and a website, and ideas for marketing oneself in the community.

I would give these materials to all of the residents and it was an extremely rewarding experience. Now, it seems like at every AAO meeting, someone will stop me and thank me for sharing all of those resources. Inevitably, my lecture gave them the tools and the confidence to open their own practices and they felt compelled to thank me years later. It continues to be a very sentimental experience.

In addition to gaining notoriety from your lecture series, a popular bracket system is named after you, the Norris 20/26 system. How did you come up with the concept, and what sets it apart from systems that were previously on the market?

The idea actually came to me when I was in dental school, working at an orthodontic office during the summers. From an engineering standpoint, it simply didn’t make sense that the largest wire in the 0.022-inch slot office was 0.019-by-0.025 inches. When asked why we didn’t fill the slot, the orthodontist replied that a larger wire was just too heavy and would break brackets, resorb roots and cause more pain to the patient. I asked why we didn’t instead use a bracket that fit the 0.019-by-0.025-inch wires that we like to use, but it didn’t exist.

I’ve been told that I don’t see the world as it is, but instead see it as I’d like it to be. I don’t know whether that’s a compliment, but in this case, I simply couldn’t get the idea out of my head.

We finally have a bracket that fits the wires we like to use, making the system unique. I like to compare it to going from driving an old farm truck, where there is slack or slop in the steering wheel, to driving a Formula One race car, where each of the steering wheel’s subtle movements takes you exactly where you want to go, fast ! The increased control is present in all three dimensions: torque, tip and rotation. So as long as the brackets are accurately placed, the wires can bring the teeth to the finish line with unprecedented efficiency.

How involved were you through each phase of production? What was the entire process like?

Although I’m known to delegate duties at my office, I was very hands-on with this project. This had been my brainchild for more than 20 years, and I wanted to make sure that the subtle nuances that a clinician would desire would be fully integrated into the bracket.

The system needed a beefy, dependable door that never fails, an internally ramped door that aids in wire seating, and a base that enhances bond strength and decreases bracket failure significantly. It also needed a door that is easy for a clinician to open and close and uses a reciprocal-force mechanism so the tooth does not feel the pressure of an instrument pulling or pushing to open and close the door.

I wanted it to be hypoallergenic, smooth and comfortable, and have adequate undertie wings for elastic chains or accessory appliances. I wanted beefy dependable hooks and swappable brackets to minimize inventory. For instance, there is one bracket that serves all maxillary premolars and one for all mandibular premolars. One bracket serves all lower incisors, one bracket serves the upper right and lower left cuspids, and another serves the upper left and lower right cuspids. I’ve been so impressed with the support that Dynaflex has given me all throughout the process.

What’s it like to have a system named after you?

To be quite honest, I was against the idea! I wanted to contribute something to the profession, but I really didn’t want my name on it. I was eventually persuaded by the number of precedents in our profession, many of whom I hold in extremely high regard. So, kind of like a new pair of shoes, it took a little getting used to, but now it’s starting to feel a little more comfortable. I still feel a little awkward when I see my name and photo in trade magazines, but I’m getting used to that as well.

Overall, I must admit that I’m humbled and proud that a company like Dynaflex would believe in me and in my system and support my efforts to help educate my colleagues and share what I’ve learned about efficiency and predictable results with this system.

Top Products

3M Transbond LR adhesive for lingual retainers and XT adhesive for brackets. Tried and true bond strength. Consistent. Dependable. Ideal consistencies for both applications.

Biomaterials Korea MSE appliance. This is our go-to MARPE appliance for skeletally based maxillary expansion in teens and adults.

3M Forsus. With more than 20 years of use, this product is the most dependable noncompliance Class II corrector that we’ve tried.

Rocky Mountain Energy Chain. This product continues to outperform all others over an 8- to 10-week interval.

Isoglide Spring. This device is a lifesaver for impacted canines. It significantly reduces the number of appointments and allows us to extend time between appointments during the forced-eruption phase of treatment.

Precision Aligner Buttons. Amazing, dependable bond strength with a beefy pad and a generous, comfortable undercut, making it easy for patients to insert their elastics.

Tell us about your treatment philosophy. What do you focus on the most? Do you find yourself using the 20/26 system often?

My treatment philosophy is to educate patients as to the possibilities available to them—to not just straighten teeth but to take a holistic approach to treatment planning that maximizes breathing, health, function and aesthetics for the rest of their lives.

Sometimes this means that we need to get the bones in the right place. Sometimes we need to grow their bones. Sometimes this means that we need to add or subtract soft and/or hard tissues surrounding the teeth. Sometimes this requires skeletal anchors such as TADs or bone plates.

I believe that broad arches allow more room for the tongue, which brings it upward and forward, out of the pharyngeal airway. I believe that all humans should breathe through their noses, because our noses warm, moisten and filter the air we breathe into our lungs. I also believe that full lips and broad smiles are more aesthetic. Although we do treat a fair number of patients in our practice using aligners, when push comes to shove, our most challenging cases are treated with the Norris 20/26 system.

What cases do you enjoy the most?

love taking a patient from the state of self-consciousness to a state of self-confidence. I love cases where we can really make an indelible impact on someone’s self-esteem. I love having a deep knowledge about what various adjunctive resources and procedures can do for a patient. My most rewarding cases are the interdisciplinary ones, where a patient is completely transformed and is given the smile of their dreams.

Any other bracket/product developments in the works?

Yes, we’re working on a clear version of the Norris 20/26 system, and we’re constantly listening to doctors and their feedback so we can make this system the best that it can be.

What advice would you give to an orthodontist who is just starting out?

Take every opportunity available to educate yourself. The amount of knowledge I’ve gained since graduating from residency is staggering. Join a study club or group so you can learn about periodontics, oral surgery, cosmetic surgery and cosmetic dentistry. Meet as often as you can with your local specialists in these fields and learn from them.

Use high-quality appliances on your patients with which you have the most control and can treat them most efficiently. Be a bold and compassionate leader to your team. Set a great example. Implement systems as soon as possible, as often as possible. Never stop learning.

Every quarter, you close your office to do volunteer work around the community. Tell us about that. Why is that important for you and your team?

We just returned from working at the local food bank today! Mahatma Gandhi said, “The best way to find yourself is to lose yourself in the service of others.”

When we are together as a team working for the greater good, wonderful things happen. All of the little stuff at the office that we thought was so important gets put into perspective: We have well-compensating jobs in an air-conditioned environment, making people smile for a living. We should all be grateful for our positions in life, and sometimes the “volunteaming” is just the right thing to reset our mindset and allow us to see just how wonderful we have it.

At times, we have interactions that are quite healing for the team. It is common for friendships to be forged simply because the volunteer work puts people together from different areas of the office who might not normally interact or work together.

What’s life like outside of your practice? What do you do for fun?

I swim with a masters swim team three times a week at 5:30 a.m. This is my meditation: It clears my mind, invigorates my body and prepares me for a fantastic day. On other mornings, I work out with a personal trainer, focusing on balance, strength, endurance and flexibility.

Evenings are spent with my wife and our youngest daughter. We love to cook together. Weekends are usually spent at the lake boating, stand-up paddleboarding, sailing, Jet Skiing, wakesurfing and wakefoiling, eFoiling, kayaking, cycling, etc. We enjoy entertaining and we also love to travel.

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