Industry Insights: DynaFlex by Dr. Robert (“Tito”) Norris

Categories: Orthodontics;
Industry Insights: Dynaflex 

Systems = Efficiency. Education = Empowerment.

by Dr. Robert “Tito” Norris

One of the tenacious lessons from the AAO’s Mastering the Business of Orthodontics online program through the Wharton School of Business is that variability is the bane of efficiency. In other words, systems and efficiency go hand in hand. I like to believe that our practice has established solid systems in virtually every area, but because I subscribe to the Japanese philosophy of kaizen, I know there’s always room for improvement.

Kaizen is the concept of focusing on the activities that result in “continuous improvement” of all business functions and involve all members of the organization. As business owners, we don’t always need to personally implement these changes, but it does mean we should educate our team members and empower them to execute improvement opportunities. After all, who better to develop a better way to do something than the person who actually does that task on a daily basis?

In this article, I hope to share some systems and efficiencies we have implemented in our practice and provide some suggestions on how to get buy-in from your team members so an ownership mentality develops within each of them.

Efficient use of virtual screenings
Starting with the new-patient process: Online scheduling has arrived and it’s here to stay. I believe many orthodontists fear gaping holes in their new-patient exam schedule because of no-shows from patients who scheduled online—and in our experience, those feelings are justified.

But rather than scrapping the entire concept, we implemented free 15-minute virtual screening exams with a treatment coordinator (TC) for patients who schedule online. This allows a minimal outlay of resources to ensure:
  • The patient is serious about treatment (because they showed up on time for their virtual appointment).

  • The patient has seen their dentist within the past year and has clean teeth that are free of caries and periodontal disease.

  • All insurance paperwork, medical history and personal information has been received and is accurate.

  • The TC can establish a relationship with the patient and provide them with some cursory information based on a virtual “look-see” of the patient’s occlusion. Our experience is that once a relationship is established, the patient is much more likely to attend an in-person comprehensive new-patient examination, where photographs, radiographs, CBCT and airway analysis are prescribed and explained.
Another key element to the new-patient exam is that all decision-makers in the family need to be present—either in person or virtually—so in the event the patient is ready for treatment, a decision regarding treatment can be made immediately and a same-day start can ensue with a scan for aligners or braces.

Starting with restored teeth

In cases where braces will be used to treat the patient, any worn teeth should be provisionally restored to their natural length and ideal anatomy with composite resin before braces are placed (Figs. 1a–1c). This systematic approach is called preorthodontic bonding, and it provides a three-dimensional blueprint for communication between the orthodontist and restorative dentist.

Provisionalizing the patient’s dentition to an ideal anatomy eliminates any guessing as to how much intrusion or extrusion is needed for the final restorations, and orthodontic treatment can be completed much more quickly and efficiently. Any final restorations are completed at the end of orthodontic treatment.
Industry Insights: Dynaflex
Fig. 1a
Industry Insights: Dynaflex
Fig. 1b
Industry Insights: Dynaflex
Fig. 1c

Indirect bonding using the Norris 20/26 System

Indirect bonding (IDB) is a standardized procedure we’ve done since our practice opened in 1998 because it requires zero doctor chair time (DCT)—the most valuable commodity in the practice.

With IDB, bracket positions can be accurately assessed and placed without the encumbrances of the lips, tongue, cheeks and saliva. Whether performing this task virtually or the old-fashioned analog way of in-house manual bracket positioning, doctor time tends to be only a few minutes and can be accomplished between patients or after hours, so DCT is not utilized.

Through years of trial and error and standing on the shoulders of great teachers who have come before, a bracket placement guide for the Norris 20/26 System (DynaFlex) has been developed that emphasizes the importance of the smile arc.

One systematic element of the Norris 20/26 System is its passive/active self-ligating door. The door remains passive during the first two wires (0.014-inch and 0.018-by-0.018-inch nickel titanium) and becomes active as soon as an 0.019-by-0.025-inch wire is engaged in the 0.020-by-0.026-inch slot. It remains an active bracket system, providing excellent 3D control until treatment is complete.

The self-ligating feature of the bracket eliminates variability in steel-tying an archwire by clinical assistants (CA) who are inconsistent with leaving the pig-tail mesially or distally, occlusally or gingivally, and loose or tight. Opening and closing a dependable, well-crafted self-ligating door with a reciprocal opening mechanism is also much faster than placing and removing a wire ligature tie or O-ring.

Another protocol during the bonding process includes placing anterior bite turbos to disarticulate the patient and free up the two arches to start aligning immediately, without the constraints of interocclusal interferences and contacts.

Even during the preparation of the teeth there are systems in place. Color-coordinated microbrushes are used for their corresponding bonding agents—green is for etchant, yellow is for sealant and purple is for porcelain bonding agent.

Yet another consistent method during the initial bonding appointment is to trim and cinch the 0.014-inch NiTi archwire distal to the second premolars. This prevents comfort visits caused by the wires sliding and poking the patient.

Case study

A 14.7-year-old Hispanic patient presented with a Class I skeletal pattern and moderate crowding of both arches (Figs. 2–4). During her first clinical appointment, Norris 20/26 brackets were bonded and 0.014-inch wires were placed (Fig. 5).

Another protocol is to bond tubes to all accessible second molars at the second appointment, when an 0.018-by-0.018- inch NiTi wire can be inserted into them (Fig. 6). When a CA has skillfully prepared and isolated these teeth, the procedure for bonding four second-molar tubes takes less than four minutes of DCT. Early light (2-ounce) elastics are typically prescribed at this appointment when indicated.

The third appointment in our practice is systematically called an “archwire bump.” During this appointment, 0.019-by-0.025-inch arch NiTi wires are typically placed, and elastic wear is assessed (Fig. 7). Sagittal elastics are often increased to 4 oz. This appointment typically consumes only one or two minutes of DCT.

After the third appointment, patients are typically using elastics to help correct their malocclusion, and this is when remote monitoring can be helpful. Rather than appointing a patient for an arbitrary time to return, a patient can be remotely monitored and summoned into the office once elastic wear has achieved its desired clinical goal. This patient completed her treatment in six appointments (Figs. 8–10).

Industry Insights: Dynaflex
Fig. 2
Industry Insights: Dynaflex
Fig. 3
Industry Insights: Dynaflex
Fig. 4

Industry Insights: Dynaflex
Fig. 5
Industry Insights: Dynaflex
Fig. 6
Industry Insights: Dynaflex
Fig. 7

Industry Insights: Dynaflex
Fig. 8
Industry Insights: Dynaflex
Fig. 9
Industry Insights: Dynaflex
Fig. 10

Empowering team members
All of the aforementioned systems align with our core value (CV) of efficient time management, one of seven CVs our leadership team developed. Having an ownership mentality is another, and providing continuous educational opportunities inspires team members to execute tasks confidently and assume an ownership mentality. These educational opportunities can be daily chairside tricks and tips, as well as participating in online CE events, regional and national meetings, off-site retreats and study clubs. In fact, we feel so strongly about this that lifelong learning is another CV. This continuous investment in CE pays handsome dividends in developing, maintaining and empowering a world-class team.

As leaders, we can always improve the manner in which we empower team members when we delegate to them. One of my favorite ways is the empowering handoff. This is a simple concept whereby the doctor says to the patient, “I’m going to turn this next step over to Sally. She’s amazing, and she does it much better than me. So, I’m going to leave you in her very capable hands.”

This not only instills confidence in the patient and the parent but also bolsters the team member’s confidence and reinforces their feeling of being valued, respected and appreciated. When one’s entire team feels this way every day, they take more pride in their work and have overall better job satisfaction.

Over the past 30 years of being a dentist and orthodontist, I’ve learned that developing strong systems within the practice leads to efficiency in all areas. I’ve also learned that training, educating and supporting one’s team members can empower them to lead with excellence.

Learn more about the
Norris 20/26 System in person!

Dr. Robert “Tito” Norris’ two-day extensive course is held twice a year in San Antonio. The 16-CE-credit course, which features live patient demonstrations and hands-on learning, is limited to 10 doctors per session. Course details and dates can be found at

Author Bio
Robert Tito Norris Dr. Robert “Tito” Norris graduated from the University of Texas Health Science Center at San Antonio School of Dentistry, then completed a residency at the VA Medical Center in Washington, D.C., and orthodontic specialty training at Howard University. After serving as a U.S. Air Force orthodontist, Norris returned to San Antonio and opened a private orthodontic practice. He holds several patents and trademarks, and is the inventor of the Norris 20/26 Passive Self-Ligating Bracket System.

Norris is board-certified by the American Board of Orthodontics, and is a member of 10 dental organizations and study clubs. He lectures internationally on topics including efficiency, sustainability, customer service and aligner treatment.

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