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Custom Braces: Reflections From an Early Adopter by Dr. David Richter

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Categories: Orthodontics;
Custom Braces: Reflections From an Early Adopter   

by Dr. David Richter

During my 29 years of practicing orthodontics, I’ve always been an early adopter of new technology—but if something doesn’t work, chances are I’ll never use it again. I’ve now started more than 1,100 cases with custom digital braces, and they’ve worked so well, I believe I’ll never go back to treating patients with conventional brackets and wires.

I have a huge amount of respect for orthodontists who’ve taken systems that tie our hands behind our backs and still were able to provide excellent care. They are true artists! But why wait for years of experience on a steep learning curve? Our patients are our priority, and if we can provide better care in a shorter treatment time, we owe it to them to embrace technology that will provide that.

Reflecting on my experience going through digital transformation—a buzz phrase in industries outside of orthodontics—there’s a lot of change management that clinicians have to learn to navigate when adopting any new system or solution. When aligners were introduced as a treatment option, for example, it took a lot of time to learn to plan digitally and think through staging, attachments and more.

Even today, many orthodontists are still on the learning journey with aligners, which have become a multibillion-dollar segment of the orthodontic market. But most practices have adopted the technology and tools required to offer this treatment solution to their patients, and this has opened up more adult case starts. Even so, fixed appliances remain the majority share of the orthodontic marketplace, and custom digital is starting to take off, with multiple companies taking up the charge.

Digital is becoming the norm, not the exception. So, what’s holding back the flood for a lot of practice leaders?

I hear three primary assumptions in conversation, paired with an obstacle many of us face (or even contribute to): that our industry is more change averse than some. Any disruption to our day-to-day operations is daunting to even think about, much less execute. We’re still kind of achy from the most recent digital revolution, wondering if it’s worth it again with new, emerging technology, even if all the promises play out. Also, our teams are often part of that reluctance.

In short, most of us get stuck in our comfort zone waiting for early adopters to make the case for us. We celebrate change in the name of clinical excellence, but hesitate to jump in until a large majority is already on the bandwagon. From where I’m standing as an early adopter of custom digital for fixed appliance therapy, here are my reflections on assumptions holding back progress in orthodontics.

Assumption 1: Pricing is prohibitive.
Advancements in technology in our profession have always been welcomed with open arms but viewed with a skeptical eye. We love the prospect of providing more effective and efficient treatment, but many of the benefits presented to us fall short. One of the questions is always about the cost of this new technology. In this instance, we presume that custom is too expensive so it doesn’t justify the cost.

There are several custom options out there, but my practice uses the KLOwen Custom Digital Solution, which costs around $500 per case—about 25%–35% of what some aligner systems do—and comes with a complete workflow to support the custom digital solution. Considering the cost of brackets and wires, depending where you purchase them from, that’s very competitive. Not all custom options are cost-prohibitive.

My practice has seen year-over-year growth since late 2019, when we made the switch to custom. In 2020, we went all-in, and by 2022, we saw 40% growth. The average number of patient visits fell from 25.5 to 16.5, with a reduction in repos (5.3 to 1.2) and broken brackets (4 to 1.5), while nearly cutting treatment time in half. By 2023, we were down to an average of 13 appointments and 14 months per case, with no repos anymore. My team is pretty happy about that, and I’m excited to see greater efficiencies still improving, even 1,100 cases in.

Assumption 2: IDB alone will be enough.
Another assumption is that indirect digital bonding alone (bracket position) is enough, which isn’t true. It isn’t just about bracket positioning; it’s about starting with the end in mind by putting the teeth in the proper position and building a bracket with the right torque, tip and position so when we get to our final wires, the teeth are in the position they need to be. Indirect bonding (IDB) with conventional brackets doesn’t solve for that, but custom plus IDB plus digital treatment planning does.

Assumption 3: The switch will be simple.
Another faulty assumption is that new technology is going to be the “easy button.” In reality, all new technology requires a transition and modification of how we provide treatment, patient experience and how we run day-to-day practice operations.

Having a completely digital workflow is going to take some effort: Most teams don’t like change, and during the transition to a custom bracket solution—or any new orthodontic technology, really—it’s important that as the captain of the ship, you stick to the plan, provide development opportunities and adopt a change management philosophy. You must consistently inspect what you expect along the way.

Provide your team with the tools they need to be successful. From my experience, I would expect about an 18-month transition into custom, not because it takes that long to implement but because your conventional cases are still playing out—on much longer treatment timelines than the custom cases. To get the most out of any solution, what matters is that you don’t dabble. If you just try a few cases and wait to see the outcomes, your team isn’t going to adapt and it will become frustrating for everyone. If you dabble, you’re setting yourself and your team up to fail. Starting six to 10 cases every month keeps the habits and rhythms fresh, so the process becomes second nature.

Connecting the dots: End-to-end digital practice
Virtual monitoring is one of the coolest things that came to our profession during the pandemic. We see the benefit in aligner treatment with significantly reduced visits. With this technology, appointment intervals and time out of work or school reduces impact on our customers, and for my team, this paired with custom digital orthodontics has been a game-changer. Patients want personalized care and there’s nothing more individualized than a custom prescription, custom IDB, custom digital treatment planning and remote monitoring all in one. In my opinion, custom orthodontics is the new standard of care—in every aspect of patient experience.

Now that KLOwen offers a custom metal self-ligating solution, we’re pushing the limits of what efficiency means. For more than 20 years, I used self-ligation and love the benefits of it, especially early in treatment. Currently, I’m implementing virtual monitoring with the self-ligating custom solution and I expect to see a significant reduction in visits per patient.

With remote monitoring, patients don’t have to come to the practice as often because we have the confidence the wires are fully engaged. We can use bio-force wires and have patients come back when they’re ready for their wire changes, Class II correction with elastics, closing extraction sites with Class I elastics, and any other part of treatment that requires patient compliance. Other practices are implementing this and seeing up to a 50% reduction in visits.

Beta clinical trial cases featuring the KLOwen Custom Metal SL Solution are happening now, including the ongoing case shown in Figs. 1 and 2. Thus far, we have been pleased!
Custom Braces: Reflections From an Early Adopter
Fig. 1: Initial records, Oct. 20, 2023
Custom Braces: Reflections From an Early Adopter
Fig. 2: Progress, Jan. 22, 2024


A few closing thoughts
Ten years ago, I almost left the profession because I didn’t know how to manage my business, and I struggled desperately to provide good finishes in a timely manner.

After leadership coaching, I learned a lot about myself and how to be a better leader, and with a digital custom system, I can now finish my cases and feel great about the care I’m providing for my patients. To be honest, I feel like I’m just getting started again! The amazing feeling of providing excellent finishes to our patients in a shorter treatment time is something we all want. I’m grateful for the opportunity to have been part of the first wave of this custom digital transformation— and that my team was willing to see the vision as something we owed to our patients as much as ourselves.

The next big thing is here. It’s time to reflect on what’s holding you back. Regardless of which custom fixed-appliance solution, remote monitoring or aligner system you choose for your practice, becoming an end-to-end digital practice is a competitive advantage you can’t afford to ignore. Your future patients won’t!

Head online to check out Dr. David Richter’s orthodontic practice!

Dr. David Richter’s Colorado practice was featured in an Office Visit profile in the September 2022 issue of Orthotown. To discover more about how Richter transformed his mindset—going from burned out to burning with a new passion for practice, click here.

Author Bio
Dr. David Richter Dr. David Richter is in private practice in Greeley, Colorado, and has been named a Top Dentist by 5280 magazine every year since 2014. Richter is a scientific advisor for KLOwen and a member of the American Association of Orthodontists, the Rocky Mountain Society of Orthodontists, the Spear Study Club, the Mountain West Dental Forum and the Seattle Study Club. He also holds a patent for a visual articulator, which allows dentists to naviate 3D data to help correct jaw movement, and has a patent pending for an advanced retainer design.



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