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Technological Differences by Dr. Bryan Lockhart

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Categories: Imaging, CBCT, and Radiography; Practice Management, HR and Accounting;
Technological Differences

How digital treatment planning options increase practice efficiency

by Dr. Bryan Lockhart

Merriam-Webster defines efficiency as the quality or degree of being capable of producing desired results with little or no waste (as of time or materials). To me, “desired results” is the critical piece of that phrase, because if quality is lost during the process, so is the efficiency.

In orthodontics, efficiency means not wasting time (the doctor’s, the team’s or the patient’s), simplifying and maximizing productive mechanics while minimizing unproductive ones, and using resources to aid in its manifestation. Time is the most valuable possession we have and we all should value it. It’s one of the few things we can’t get back, and this applies to not just us doctors but also our team members and, perhaps more importantly, our patients.

From a clinical perspective, freeing up time allows us to deliver our talent in a more intentional manner and create an atmosphere in which we do more at each appointment to ensure cases finish on time or early. This becomes self-serving in the sense that as you finish more cases on time or early, you’ll free up even more clinical time, which provides an opportunity for you to become even more efficient with your treatment.

This orthodontic efficiency carousel benefits everyone: Patients get the smiles they’ve desired in a timely manner, team members get to work in a low-stress environment, and doctors get to see and take pride in the fruits of their labor.


Digital appliances
From a clinical perspective, the best-case scenario is one in which we get the best results in the shortest time with the fewest visits. (Sounds eerily similar to the definition of efficiency above!) This will not be achievable 100% of the time but it should be the goal, with no compromises in any category. Every bit of technology that gets implemented into my offices has to strengthen one if not all of those categories.

The profession is moving in the direction of digital customization. Until recently, customization was largely centered around clear aligner treatment, but today’s custom fixed appliances, such as labial braces (Lightforce, KLOwen, Braces on Demand) and lingual appliances (InBrace, Brava) allow orthodontists to minimize some inherent inefficiencies of stock prescription brackets and standard archwires. Digital custom solutions aren’t totally new, but new technology and materials have led to improvements in areas that lacked in previous options.

With this new generation of custom appliances come excellent advantages that benefits everyone involved—doctor, team and patient. Remote monitoring (Grin, DentalMonitoring), for example, turbocharges what we can do in terms of patient satisfaction and fewer visits. When we bring patients into the office only for impactful appointments—wire changes, refinement scans, etc.—the additional clinical time lets us do more with the patients who are scheduled. Here are a few specific values of a completely or mostly digital orthodontic office.


More detailed review of records and treatment goals
Digital treatment planning forces orthodontists to follow important steps in the diagnosis and treatment planning process. It’s easy to get comfortable with having a basic treatment plan and to become reactionary throughout treatment. This is what I typically did with traditional stock appliances, but the cases I took time to thoroughly diagnose and treatment-plan turned out better. When using custom appliances, forms have to be submitted, which means I have to put a better effort into establishing my treatment goals and mechanics on every case.


Treatment planning in a prescriptionless platform
Another aspect of digital appliances is digital treatment planning in which preprogrammed prescriptions of tip, torque and ins/outs are irrelevant. The ability to put teeth where they belong and have each individual tooth have its own prescription is something that previously had been available only with clear aligners but now is doable with fixed appliances as well—and without the patient compliance issue.

With digital treatment planning, the ability to see occlusograms and cross-sections of the teeth to evaluate overbite and overjet, or to place a grid to evaluate symmetry and view the teeth and occlusion from any angle, is unmatched. Analyzing Bolton analysis and using superimposition to evaluate dentoalveolar changes are just a few examples of the amount of detail that can be gleaned from digital treatment planning. Simulating multiple treatment plans, such as restorative or extraction cases with multiple possible extraction patterns, is powerful not only in helping us create the proper treatment plan but also in educating patients and referring doctors. The adage says, “A picture is worth a thousand words,” but a dynamic digital model that can be shown from different angles and narrated by the treating doctor to explain their thoughts has to be worth at least a million!


Consistency among assistants and doctors
Variation of skill sets among assistants can have a huge impact—favorably or unfavorably—on the efficiency of a case. Differences in placing brackets or other analog appliances can lead to treatment time being extended. Digital appliances, meanwhile, have a treatment plan that’s established before physical treatment begins, so the clinical mechanotherapy can be simplified because all of the major treatment planning decisions have already been mapped out. Treatment simplification gives the best chance of repetitive and reproducible results.

The advent of digital orthodontics has flattened the learning curve for inexperienced assistants. From their perspective, the procedures for all the digital custom options are essentially the same: Start with records and a scan, and after the doctor completes the setup, some sort of indirect bonding procedure is performed. From the attachment trays for aligners to the transfer trays for custom lingual or labial braces, it’s the same workflow, which means it’s easier to get assistants up to speed. A lot of other procedures still have to be learned, but the ones that keep the practices growing—exams and starts—are essentially not affected.

Shortly after our practice reopened after the COVID-19 shutdown, we had a complete staff turnover for our five clinical assistants in just one month. That’s a catastrophic event for any office, and while it was for ours too, because we were a highly digital office we could train five new team members, fresh out of assisting school, in a matter of a few weeks. We used one “calibration day” to teach them how to take records and scan and filled in gaps along the way, but we knew how important it was to continue growing the practice. We built up their knowledge base as time went on and eventually weathered the storm.

I have walked the walk and experienced firsthand the benefits of digital orthodontics. This is not just theory!


Conclusion
The evolving digital landscape in orthodontics has not been unanimously received with open arms. The idea of coexistence hasn’t materialized, and some orthodontists believe they need to choose one side: Either you’re a traditionalist and this new digital technology is all lies and propaganda, or you’re a digital orthodontist and everything before now is antiquated and useless. Obviously, neither is true, but this dichotomy exists to a certain extent.

Some orthodontists view digital treatment options as a detriment to our profession—“dumbing it down” and making treatment planning more accessible to those with less training, which could commoditize orthodontics and make it more about profits than delivering care. To take it a step further, some will say this is a corporate takeover that will lead to orthodontists being led like sheep by these digital orthodontic companies. We have to remember that orthodontics is still an art and a science, which means it will always be difficult to develop a cookbook that will be consistently successful across the board. Providers will still have to understand biomechanics and adapt according to the patient’s individual biological phenotype, so orthodontists will still hold the power.

I think we should look at these advances as tools to amplify and boost our orthodontic knowledge and skills. Digital technology is not here to replace the research and knowledge that has laid the foundation for the orthodontic profession; instead, we should use it in conjunction with prior experience to get the best outcomes we can. This in turn will raise the bar of excellence, which will help distinguish the specialty of orthodontics.

Furthermore, those of us denouncing the digital revolution have to appreciate the fact that we’re enjoying the benefits of orthodontic advances up until this time—digital radiographs, digital charts, digital photography, pretorqued brackets and nickel titanium wires, to name a few. I’m sure developing radiographs and photographs in the darkrooms led to good quality records, but the time it took to develop them (not to mention retakes if something was incorrect!) would destroy the workflow in today’s offices. Similarly, bending stainless steel wires for torque, rotations and ins/outs could be carried out by skilled practitioners, but engaging NiTi wires in a bracket with predetermined ins/ outs, tip and torque is so much more efficient. I wasn’t around the profession when those items were being introduced, but I’m sure there were detractors.

Having members question new technology will always happen and, in fact, is needed! Healthy skepticism will help minimize groupthink and hold us accountable as a profession. Alternatively, criticism out of fear will only hold the profession back. We have to ask ourselves, “Is our skepticism healthy or is it provoked by fear?”

I believe the future of orthodontics to be bright. There will be orthodontists or companies who will use this technology to cripple our specialty, but I have faith that the overwhelming majority will use it for the greater good.
Author Bio
Dr. Bryan Lockhart Dr. Bryan Lockhart is a board-certified orthodontist with two practices in Charlotte, North Carolina, where he practices with his wife and fellow orthodontist, Dr. Lauren Rennick Lockhart. He attended dental school at the University of North Carolina at Chapel Hill and earned a certificate in orthodontics from Jacksonville (Florida) University. A frequent speaker on digital orthodontics, Lockhart also has developed his own clear aligner brand, Dualine, and holds patents for an orthognathic device and a practice management software program.
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