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Orthodontic Articles & News by Dr. Scott Frey

Taco Bell addict. Board Certified Orthodontist at Hatcher & Frey Orthodontics. Click here to Facebook me / Stalk me on Instagram

Top 3 Reasons to Optimize Your Forces with Invisalign

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Aligner Biomechanics

Optimized Your Forces

We have discussed in previous posts how to navigate the optimization hierarchy, optimization thresholds, and why orthodontists struggle optimized attachments, but recent discussions have made it clear that it might be time to reinforce some of the basic logic behind utilizing optimized features with Invisalign. Without it orthodontists are using an inferior product.

There are 3 main reasons why choosing to optimize your force systems should be a no-brainer:

  1. Force Systems Backed Up by Data – Using force systems derived from extensive testing and data analysis from thousands of matched cases, removes the potential for observational bias and will always be a superior option. Although many orthodontists still feel nostalgic towards traditional attachments, opting to use outdated mechanics when an optimized solution exists is simply not science based.
  2. More Efficient ClinChecks – You will be far more efficient in designing your ClinChecks by working collaboratively with the Invisalign System’s AI engine instead of allowing your time to be consumed by manual attachment design. Allowing the software to design attachments, while making intuitive decisions about optimization selection, allows orthodontists to focus more time on diagnosis and movement planning and frees up substantial time to make your digital workflows much more scalable.
  3. More Esthetic for the Patient – Since optimized feature sets rely mainly on aligner forming features instead of changes to tooth shape, optimized attachments end up being much smaller and less prevalent than going the traditional route. Attachments that are less noticeable and having fewer attachments overall is always welcome by patients.

SmartForce Optimization Thresholds

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Aligner BiomechanicsSmartForce Optimization Features

Effective utilization of Invisalign’s optimized attachments and features depends on a number of factors, not least of which is proper selection from the optimized attachment hierarchy. However, to be able to leverage the attachment hierarchy efficiently the orthodontist must first understand the various manufacturing thresholds for optimizations.

We have laid out all the SmartForce Optimized Attachments and Aligner Features in the table below so that you can determine which combinations of optimized features have been triggered by your prescribed treatments.

The rest of this post is available only to orthodontists and orthodontic residents registered with the Ortho Cosmos

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You Can Only Sell What is True

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Truth

The idea that “selling” orthodontic treatment is some sort of trick of influence is incredibly misguided. The reality is that you can only sell what is true.

If you can’t deliver on your promises, people will know. If what you are offering your patients isn’t “true” for them, they will seek treatment with someone who better understands their needs. End of story.

Treatment goals are treatment goals, and as healthcare providers providing the highest level of care should not be a question, but the idea that your proposed “solution” is the best or only way to address your patient’s needs is merely your opinion. The patient may not find that to be true. The concerns, emotions, and beliefs that patients hold when they come to your practice and develop during treatment are real to them, and they should not be dismissed by an overly paternalistic, “Daddy knows best” approach to treatment.

Being a good “salesperson” is about delivering true patient-centered care and learning to listen so you can design a treatment approach and experience that is an optimal fit for the individual. 

Unmasking Pathological Skepticism

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You Know Nothing Jon Snow
Forging Doubt

Manufacturing doubt is not difficult, because in science all conclusions are provisional, and skepticism is intrinsic to the process. However, just because we don’t know everything, that does not mean that we know nothing. In fact we know quite a lot, but it is about what we do know, and what we can begin to uncover, that merchants of doubt want to conceal.

The term pseudo-skeptic refers to those who declare themselves “skeptical” of a concept when in reality they would not be convinced by any evidence. By redefining their own credulity and bias as “skepticism” they attempt to claim the moral high ground in any discussion to exempt themselves a logical critique of their argument. This practice of faith-based disbelief is not scientific in the least and is deeply unhelpful to the specialty. Forging doubt, especially in the teeth of scientific evidence, in order to protect the status quo only erodes the potential for meaningful progress and serves to lowers the bar for care.

A goal of proper skepticism is also to reveal the deception of dubious doubters so that the magic behind their tricks disappears. Thus it is important that we unmask common characteristics of pathological skeptics, so that we are not fooled by cheap card tricks. The differences between pseudo-skepticism and skepticism appear in the conduct of an individual’s actions and statements. The following are common characteristics of pseudo-skeptics in orthodontics:

  • Does not question anything from established scientific institutions, but takes whatever they say on faith and demands that others do the same. Views the scientific establishment as a religion and authority to be taken on faith and never questioned or challenged. Fails to understand the difference between the scientific process/methodology and the scientific establishment.
  • Assumes that the scientific establishment is objective and unbiased, and free of politics, corruption, control, censorship and suppression for no other reason than blind faith in authority. Science is a tool and methodology, not an authority to be obeyed. It is important to be able to understand the difference between the scientific process and the scientific establishment.
  • Resorts to various logical fallacies. Most often appeals to authority, appeals to ignorance, appeals to tradition, and moving the goal posts to institute hurdles against new concepts.
  • Assuming their criticisms require no burden of proof.
  • Double standards in the application of criticism. Only applying “critical thinking” to concepts or treatments that oppose tradition, but never to the status quo itself.
  • Immediately judges as false and debunks any scientific data that contradicts their paradigm. Especially if the source of the preliminary data is outside the “scientific” establishment.
  • Automatically dismisses and denies all data that contradicts tradition or orthodoxy.

5 False Patient Experience Assumptions

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The Patient ExperienceDon’t Assume that You’re Delighting Patients

Many orthodontists still fail to understand the impact that the patient’s treatment journey has on their practice’s reputation and overall practice health. In part, this is due to the fact that most practice metrics fail to examine the patient journey adequately, and without actionable information numerous assumptions are formed about the patient experience instead.

Here are the most common false assumptions that I see regarding customer experience:

  1. If someone has accepted treatment, this is evidence that they had an ideal customer experience. 
    Don’t mistake a patient’s determination to receive care for customer satisfaction. Many patients’ perceptions about their need for treatment will motivate them to soldier their way through a frustrating treatment process to get what they want – but, they are far less likely to share their experience with their friends and their frustrations will dissuade potential patients from seeking treatment.
  2. Sub-optimal patient experiences happen in isolation.
    It is rare that a patient will experience a singular sub-optimal event, all too often poor customer experiences happen in multiples. You may be aware of your average wait times, number of repair appointments, occasional patient reports of discomfort, etc. but how many of your patients are being frustrated with all of the above.
  3. The best way to increase patient starts is to drive more new patient exams through external marketing.
    Without optimizing the treatment journey for your patients, practice growth becomes a frustrating process that requires a larger marketing budget and more effort to compensate for a less than ideal patient experience. This is not a sensible investment plan, but one that is commonplace.
  4. The patient’s treatment journey happens in a vacuum
    While patient’s begin treatment without much perspective, their perceptions about your care will continue to develop over the course of each appointment and, perhaps even more importantly, from experiences during treatment outside of your practice. Throughout the process they are comparing their experience with that of their friends, and they are developing other opinions about orthodontics and the delivery of care in general from what they hear in the news and from advertising. If their treatment experience is significantly out of step with what they see around them, they may have started treatment, but they will not be as big of an advocate for your practice.
  5. I survey my patients and that tells me all I need to know. 
    Surveys are definitely a critical piece of the jigsaw, but not all patients are as forthcoming with their frustrations for many reasons leaving you with only small sample to shape your decisions. When negative feedback is received, it is often something that a number of patients have experienced and have not taken the time to voice it.

Nobody wants to act on false assumptions, but these are very common misconceptions that are negatively affecting practices and the specialty as a whole. The good news is that all these can be addressed by digging deeper into our patients’ experiences so we can start to assume a little less, and earn a lot more.

ClinCheck 5.2 Updates

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Software UpdateClinCheck 5.2 Software Updates

This weekend Invisalign is launching their revamped educational portal as the Invisalign Online Academy and releasing ClinCheck 5.2 software with some very useful features so make sure you remember to update.

Here is a breakdown of the key features in the ClinCheck 5.2 software update:

  1. Education at Your Finger Tips in ClinCheck
    – Launch the education tool directly from ClinCheck
    – Toggle between Related Information and Similar Treatments.
    – Search the Invisalign Online Academy content
  2. Improved ClinCheck Notes/Names
    – Capture relevant internally facing patient notes and rename ClinCheck treatment plans
  3. Enhanced multi selection tools to remove Power Ridge and Bite Ramp objects
    – Remove Power Ridge objects one by one from each tooth and from both sides of teeth in one click
    Power Ridge Removal
    – Remove a group of Virtual Bite Ramp objects with one click
    Bite Ramp Removal
  4. IPR Improvements & Arch Widget Tool Redesign
    – When ordering additional aligners, the previous IPR values that were performed can be entered in the Rx form.
    – If performed IPR values are received, they will be shown as historical IPR values in your ClinCheck treatment plan.
    – Arch Widget tool in ClinCheck Pro has been redesigned with improved functionality
    IPR and Archform Tool

Top 7 Reasons Why People Struggle with Optimized Attachments

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The Struggle is RealWhy do so Many Struggle with Invisalign’s Optimizations?

I frequently hear orthodontists lamenting the advent of Invisalign’s optimized attachments. I think this frustration stems from several factors all of which result from an inadequate understanding what these optimizations are and how they are meant to function. To think of optimized attachments as simply little bumps on teeth made for pushing is the fundamental misconception. As opposed to conventional attachments, which are simply crude handles, optimized attachments (and features) have moved away from the old approach focused only on changing the shape of the tooth and are almost entirely reliant upon aligner forming elements in order to produce customized force systems based on the prescribed movements.

This dramatic shift in thinking has been driven by the huge piles of treatment data gathered by Invisalign, free from the observational bias of the individual. Failure to acknowledge data-driven optimizations and attachment design is simply not science based and utilizes Invisalign as an inferior product so it is important that you able to keep pace with the current best practices. We will spend some time helping you treat your patients more efficiently with Invisalign by briefly examining the Top 7 sources of operator error with Invisalign’s aligner optimizations.

The rest of this post is available only to orthodontists and orthodontic residents registered with the Ortho Cosmos

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Rejecting Facemask Fundamentalism

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Facemask TherapyFacemask Fundamentalism

It has been well established that the early correction of anterior crossbites is beneficial for jaw development1 so certainly interceptive treatment to resolve crossbites is advisable. However, there seems to be significant confusion in the orthodontic community about what exactly people are achieving with certain treatment modalities.

I continue to be astonished by the persistent dogma that reverse-pull facemasks “protract the maxilla”  because a comprehensive and unbiased examination of scientific evidence reveals this to be little more than wishful thinking.

  1. There is zero evidence of any anterior displacement relative to controls of actual skeletal structures, such as the zygoma, pyriform aperture, etc. with facemask therapy.2,3,4 The sutural strains produced (with or without any expansion protocol) with a facemask are several hundred fold lower than the frost thresholds required for any orthopedic effect based on finite element analysis.5 Why a dentoalveolar landmark like A-point, which is known to remodel significantly in response to both retraction and protraction of the dentition, has served as the basis for assess the “skeletal response” in so many papers makes very little sense.

  2. The counterclockwise rotation of the maxillary occlusal plane is a hallmark of dental movement and not an orthopedic effect. The data on Bone Anchored Maxillary Protraction (with infrazygomatic plates) resoundingly confirmed Ricketts proposal that the center of resistance for the maxillary bone (not the maxillary dentition) is at the pterygoid plates. Thus, true orthopedic traction of the maxilla will exhibit a clockwise rotation and not the counterclockwise rotation that we try to mitigate during facemask therapy.6

  3. Although palatal TADs due to their easy and predictability of placement have been proposed as an alternative means of bone-anchorage, their addition does not improve the effects on the maxilla. In fact, the palatal TADs actually seem to reduce the effects of maxillary traction on A point, backward rotation of the mandible, and any positive dental “side effects” in the maxillary arch.7 Anchoring the dentition to TADs is a strategy that is better suited for hyperdivergent class 3 patients where vertical side effects may be less desirable, but it does not translate into an improved effect on maxillary hypoplasia.

The bottom line is that the clinical effectiveness of a facemask is entirely due to dentoalveolar changes and an improvement in sagittal position of mandible. There is no effect on mid-face, and if that were required then a surgical procedure or bone anchored maxillary protraction should be explored as an option for that patient (though better long term data on BAMP is still needed).

Facemasks are certainly more cost effective to use than many alternatives; however, the same basic outcome that you are prescribing with a facemask can be achieved just as effectively using appliances that facilitate better compliance and are less traumatic to patients.

References:

  1. Tollaro I, Baccetti T, Franchi L. Craniofacial changes induced by early functional treatment of Class III malocclusion. AJODO 1996;109(3):310–8.

  2. Pangrazio-Kulbersh V, Berger J, Kersten G. Effects of protraction mechanics on the midface. AJODO 1998;114(5):484–91.

  3. Arman A. Evaluation of maxillary protraction and fixed appliance therapy in Class III patients. Eur J Orthod 2006;28(4):383–92.

  4. Masucci C, Franchi L, Defraia E, Mucedero M, Cozza P, Baccetti T. Stability of rapid maxillary expansion and facemask therapy: A long-term controlled study. AJODO 2011;140(4):493–500.

  5. Holberg C, Mahaini L, Rudzki I. Analysis of Sutural Strain in Maxillary Protraction Therapy. Angle Orthod 2007;77(4):586–94.

  6. Nguyen, Tung, et al. “Three-dimensional assessment of maxillary changes associated with bone anchored maxillary protraction.” American Journal of Orthodontics and Dentofacial Orthopedics 140.6 (2011): 790-798.

  7. Ngan, Peter, et al. “Comparison of two maxillary protraction protocols: tooth-borne versus bone-anchored protraction facemask treatment.” Progress in orthodontics 16.1 (2015): 26.

Best Practices for Invisalign Concierge Patients

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Invisalign Concierge Invisalign’s Concierge Program

In early 2017 Invisalign began rolling out a new program to better engage with patients who are interested in enhancing their bite and smile with clear aligners, using “smile concierges” to help guide patients to orthodontic practices offering a high level of care with Invisalign. As with anything new, there has been a fairly steep learning curve both for Invisalign and the orthodontists being connected with these potential patients.

I had an opportunity to briefly speak with the head of Invisalign’s concierge program over lunch yesterday, and I wanted to share some important updates that have happened recently and discuss best practices in handling patients coming through the Invisalign concierge system.

The rest of this post is available only to orthodontists and orthodontic residents registered with the Ortho Cosmos

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It’s All About the Journey

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Appreciate the JourneyThe Journey is What Matters

Evaluating the quality of your practice model based solely on patient starts and treatment finishes overlooks the most substantial portion of the care you provide, the patient’s journey. The time spent with our patients throughout is the most impactful portion of the treatment process, yet it often receives the least amount of attention. How your patients’ feel about your brand and what they tell their friends, as well as their desire to do so, is the result of all their interactions with your practice, so delighting patients at every step of the way should be your mission.

An integral part of designing exceptional patient experiences is also considering the appliances and treatment approaches that are used to achieve similar goals. Yet, all too often I hear dismissive statements like “all appliances can deliver the same outcome” and decisions being made on the basis of the doctor’s comfort level with a particular treatment. Experience driven treatment is not appliance drive treatment. It is simply the recognition that appliances should be selected in order to provide the best possible experience for the patient.

To develop a better understand how our decisions impact the patient’s journey, it is helpful to map out the patient’s (and parents’) entire treatment experience and examine what they thinking and feeling throughout the process. This should be based on a real information about their behavior, thoughts, and feelings throughout their journey, paying attention to key “stress points” like an initial phone call, initial appliance placement, repair appointments, etc. A very basic example of what a various treatment journeys might look like for different appliance choices is show below:

The Patient's JourneyOn one end of the spectrum you see a treatment approach where the patient’s experience has been exceptional across the board; while on the other end, we see a fairly generic brand experience where uncomfortable, outdated appliances are used, creating a substantial decline in the patient’s experience during the treatment phase. The cumulative differences between the two experiences represent a huge missed opportunity to drive word-of-mouth referrals and better patient motivation.

Ironically, most orthodontists are completely unaware of any problems in their approach because their patients are all on similar treatment arcs and there is little outside perspective. Both the doctor and the patients have simply accepted things as the way things are, and the only way to break the cycle is by actually performing a critical examination of patients’ treatment journeys using qualitative and quantitative measures.

By visualizing their journey in this fashion, the focus can now be on engineering an optimal customer experience that drives value and practice growth. Unnecessary pain points can be identified and eliminated, and investments made to create more positive movements in the patient’s journey. Treatment goals are extremely important, but the patient experience is just as important so it should not be overlooked.

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