Sean Holliday, Author at The Ortho Cosmos Page

Using 3D Builder in Orthodontics

May 18, 2017 by Sean Holliday Leave a Comment

The hidden truth is that there are several CAD software platforms available that are free and can help with basic functions and improve the experience with 3D printing. The advantage is that even a novice can get their feet wet in the 3D printing arena and prepare prints that are effective and well prepared.

3D Builder is a CAD software available in Windows 10 that allows for several basic functions that serve in preparing models for orthodontic purposes. Let’s review a few functionalities:

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Risks of CAD Software in Orthodontics

May 16, 2017 by Sean Holliday Leave a Comment

As 3D printing increases in utilization, the usage of CAD software becomes an important step in this digital process. It allows orthodontic labs to take a raw digital image and turn it into a useful design that can be 3D printed. The disadvantage of CAD software in orthodontics is that most of it comes at a significant monetary investment with upfront purchases and monthly service costs. For the basic user, and brand new owner of a 3D printer, this is can be quite a realization.

Fortunately, there are inexpensive workflows and free software solutions that help those starting the journey into 3D printing. The peril lies in the fact that I often see the temptation at “working” the CAD software much more than is necessary. Keep your uses of CAD software to a very specific goal, and consider all options as more efficient workflows become available.

The facet of time efficiency is a key component, especially bringing digital workflow in-house. It is up to each doctor and in-house lab to determine their time efficiency, labor costs, and material costs to make the best decision in a digital workflow. Some steps are a no brainer bringing in-house due to improvement in patient experience, savings in lab fees, and faster turn-around. In some circumstances, I see a lot of doctor time consumed, or inefficient digital workflows used, that would be best delegated. Sometimes that delegation should be to outside labs that have greater expertise and efficiency than a less experienced in-house lab setup. Other solutions include investing in training for a highly effective lab team.

To avoid risks in time consuming CAD workflow, consider proper lab delegation and lab training. Leverage your team and delegate accordingly. Whenever you incorporate new processes into your practice, take a look at the big picture. Start lean and mean, and don’t hesitate to invest in efficient software that saves in labor costs. Improving your lab team’s experience and ability are key to minimize risking increased doctor time in lab procedures.

Adding Bases to Orthodontic 3D prints

May 11, 2017 by Sean Holliday Leave a Comment

To base or not to base, that is the question: Whether tis nobler in the mind to suffer additional 3D printer workflow. That is a question that is common these days as 3D printing grows in orthodontic practices. On the one hand models with bases look so nice, and seem to fit our traditional expectations of a study model. On the other hand, how much resin and time do you need to put into these add-ons, and are they even necessary?

Whether you do this workflow step or not, depends on the purpose of your 3d print. I will be reviewing some of the reasoning behind adding bases to dental arches, and how that decision impacts your 3D prints, especially if you are using the Form2 printer.

If the model’s intended use is for presentation, then a nice base is recommended to prepare the model for display. A base makes the model more presentable and gives a flat surface where supports could be avoided in the print process. The flat base and the print could be further improved by hollowing the model. As long as the wall thickness maintains a good dimension, the print will have reduced amount of resin. The software that hollows a base, though, is not readily available. To add bases to models, software such as meshmixer, 3D builder or OrthoAnalyzer can be integrated into your workflow.

Save the time in preparing the print by taking the clean stl into your preform software and add supports. The supports will give a stable, mesh base to the print that allows the lab access to the model to make appliances, while decreasing the amount of resin. In the example print (Fig 1) the upper arch impression will be used to fabricate a hawley retainer for a patient completing Phase I treatment. Without a base, the model’s volume is 23.4 mL and would take 2 hours and 3 min to print.

Contrast that to the same model with a flat base where the volume increased to 30.1 mL and would take 2 hours and 43 min to print (Fig 2). Not to mention the laboratory staff time it took for the base to be added to the model.

Dental arch scans are often a raw image captured with limited extensions into the vestibule and lack the traditional rolling that we see in other impressions. When there is limited data of the tissues around the teeth, the 3D print may need greater thickness so it is not damaged in the printing process or when making the desired appliance. In these circumstances, it is important to reinforce the print. When vacuum-forming an appliance, an uneven base with a thin profile will likely crack the print due to the lack of structural support. Adding a base to these prints will gain the strength necessary.

Adding bases to prints can seem like a tedious process, but setting preferences in your digital lab will help drive the proper workflow.

Outdo Yourself

May 10, 2017 by Sean Holliday 2 Comments

An interesting fact about orthodontists, is that we are driven people. Top of the class, best grades, and a competitive nature are all common denominators in our specialty. I have noted that in school, competitiveness becomes an important part of advancement since scholastic achievement is often measured by your ranking. Fast forward to professional, and business life, and you realize the rules of the world are just a bit different. We are misguided at times because teachers favored the best student. In real life, patients don’t regard your grades and class rank as valuable. There is no study, that I am aware of, where your academic ability was in any way related to your success in the business of orthodontic practice. And yet our competitive spirit continues.

It can be a never ending battle of frustration if our goal is to beat the rest. Ultimately, there is going to be someone better, faster, cheaper, more popular than you. This sense of competition is not unique to the orthodontic profession. Not at all. There are competitive business strategies all across industries. This leads to the concept of finite players vs. infinite players:

The joy comes, not from comparison, but from advancement” – Simon Sinek

I, like many of you, have a competitive spirit. And yet I find the most fulfillment in outdoing myself, than beating someone else. Constant and never ending improvement is one of our mottos. For the team, for myself, for our practice.

Orthodontic Software Integration With Your 3D Printer

May 6, 2017 by Sean Holliday Leave a Comment

Buying a 3D printer is one level of investment into a more digital workflow. If you plan on acquiring digital scans, there are many software solutions that cleanup and modify your scans for better, and more useful prints. Here’s a summary on several of the players:

Meshmixer – This software aids in cleaning up models and manipulating stl files. Although cumbersome for anyone who is not familiar with CAD software, it has nice features that can help prepare models for 3d printing. A great feature of meshmixer, is that it is free.

3D Builder – Speaking of free, this hidden gem is already available for anyone who has Windows 10. This software is easier to use than meshmixer, and can clean up cases to flatten models, add bases and label models with its text writing tool.

Easy Rx – This cloud based software organizes lab workflow to prepare outgoing lab cases or to better leverage your in-house lab. 3D printing workflow is nicely integrated to clean up casts and prepare them for any 3d printer. You can track cases, create reports, and lab slips for all types of appliances. It is a very intuitive system that aims to improve the efficiency of your lab.

Clincheck – Did you know you can 3D print models coming from Clincheck? STL files can be exported from the initial stage and the final stage of Clincheck. Remember, Align Technology is one of the first and largest 3D print manufacturers in the world.

Orchestrate 3D – This program allows for modifications to scans which include cleaning up scans, sectioning, virtual removal of brackets, adding pontics, adding attachments and tooth movement to fabricate appliances. There are options to have full control, or for an additional fee, setups can be prepared for the office.

Ortho Analyzer – This software from 3Shape is a suite of different solutions for 3D modeling and digital treatment planning. With this software you can create digital study models including virtual bases, and perform treatment planning and case analysis using 3D and 2D tools, virtual setups, and digital articulators.

Elemetrix – This cloud based software from Suresmile allows for diagnostics, IDB setups and designing aligner therapy. It can integrate with scans and CBCT images. Once the treatment planning is completed you can export stl files that can be loaded into your 3D printer to manufacture the appliances.

Exceed – The developers of the former Orthocad IQ IDB system have started the Exceed lab. They offer a digital workflow where intraoral scans can be processed into their IDB system or clear aligner therapy that can be performed using in-house 3D printing.

Improving Invisalign Efficiency

May 5, 2017 by Sean Holliday 2 Comments

Extracting Efficiency

The use of Invisalign has continued to increase over the years. Greater utilization has led to an increase in applicability and more interest for the improvement of this product. In order to offset the lab fee, it becomes imperative to gain clinical efficiencies in the use of clear aligner therapy. Especially if you want to avoid the top reasons why orthodontists disapprove of Invisalign.

Two years ago, we tracked a series of consecutively treated cases from my practice. As we analyzed the treatment times, number of appointments and other trends, we determined two main areas that would improve the value of Invisalign treatment to both the office and the patient. The two opportunity areas we focused on were decreasing the total treatment time and the total number of appointments.

Invisalign is a system that determines the number of stages in the treatment when a clincheck is developed and has best practices “rules” that affect the length of treatment. In order to make an impact in the efficiency of Invisalign, it became apparent that several changes would have to be considered in the planning of the treatment and in the execution of the delivery. Let’s take a look at some of the tools that can be used to improve the efficiency of the appliance:

7 day Aligner Wear

Accelerating the change of aligners will decrease the treatment time. In our sample, we reduced the average treatment time by 20%. The question is, does an increased rate of change affect results and increase the number of refinements? In the cases from my practice, 7 day aligner wear was only implemented in the final 6 months of treatment for most of these treated cases. Although I do not have a large enough sample yet to compare that was fully treated with 7 day aligner changes, this treated sample had an evident reduction of treatment time and no increase in the amount of refinement efforts. Since all of our Invisalign cases have now fallen into 7 day wear protocol, we are looking forward to seeing a greater gain in efficiency.

Optimum Staging

Going to 7 day wear, but doubling the number of aligners does not gain efficiency. It is important to maintain proper force systems in the appliance, and maintain a number of aligners that matches the amount of movement necessary to achieve the desired clinical result. Significantly increasing the number of aligners will degrade the amount of force delivered in each aligner, and this can affect the moment to force ratio and aligner optimization.

Effective Use of the Refinement Time

Scanning patients while they are in active aligners keeps momentum of treatment going. The advantage of an intraoral scanner is that scanners allow us to scan during active aligners instead of removing attachments and stopping elastics with PVS. This will also degrade the force systems. We don’t put patients on hold with braces, which could make aligners less efficient if not addressed. We are proactive scanning patients several aligners before completing the aligner series so the patient can continue movement while refinement sets are being prepared. In order to be more efficient, consider not putting the patient on hold while the refinement is being developed.

Decreasing the Number of Appointments

Increasing the time between appointments is a sure fire way to decrease the number of appointments. In our patient sample, we decreased the appointment visits by 46%. Since patients are changing aligners at home, periodic checks and adjustment visits are not needed on the same intervals of fixed appliances. Because there are no wire changes, patient appointments can be extended by 12 weeks, or sometimes more. The key factor here is setting an interval that keeps the patient engaged with the practice, and does not allow loss of tracking or compliance issues go undetected too long. Patient education, problem solving tools, and a team effort in promoting compliance are key before implementing extended appointment intervals.

Until clinical studies are published that reveal the effect of changes to the Invisalign protocol, it is a challenge for clinicians to determine the best course for both patients and practices. Using practice data that is relevant to your patient base and systems is a useful way to check trends and monitor clinical efficiency. I hope sharing some basic analytics will guide you on your journey to improve your Invisalign efficiency.

Orthodontics is Like a Circus

May 1, 2017 by Sean Holliday Leave a Comment

Orthodontic practice can feel like a circus some days. A series of patients are late to their appointments, one of your clinical assistants called in sick, and your phones are off the hook calling in for emergency appointments. We have all been there, but the circus I’m really talking about is the circus industry. Specifically, about the changes to the circus business that led to the closing of Ringling Bros. and Barnum & Bailey Circus.

At its prime, the Ringling Bros. and Barnum & Bailey Circus was a popular family outing. Over time, expenses grew, ticket prices did not, and concerns over the use of animal acts led to public concerns over the industry. This year, after 146 years of performances, this American icon has hung up its big tent.

The competitor in many ways is time. It’s a different model that we can’t see how it works in today’s world to justify and maintain an affordable ticket price. So you’ve got all these things working against it.” Kenneth Feld – CEO

15xp-circus-master675 — Todd Heisler/The New York Times

As market trends continue to change and other players enter into the orthodontic space, is the private practice of orthodontics headed in the path of the traditional circus?

Where most circuses were competing with each other over market share of a decreasing demand of traditional acts, a lack of change in the circus experience was leading to a downward spiral of the industry. By contrast, the circus has been reinvented and successfully invigorated by Cirque du Soleil. Their focus was on changing the experience: taking the popular and cost effective strategies of a circus act, and raising the experience to the level of theater. This tapped into a client base that saw the circus act from Cirque du Soleil more as a broadway show, than a sideshow act.

In less than twenty years since its creation, Cirque du Soleil achieved a level of revenues that took Ringling Bros. and Barnum & Bailey (the once global champions of the circus industry) more than one hundred years to attain.

What can we learn from Cirque’s success?

The key factor in their success is differentiation. Create an uncontested space where competition is irrelevant. Cirque du Soleil has learned to generate and capture new demand. They also broke the value and cost trade off that plagues many business models. In many ways, we can still create great value to patients and decrease practice costs with the efficiencies patients expect.

It’s generally believed that the way to beat your rival is to outperform or outpace them. But in business, the better way to win is to create uncontested new market space where no competition exists…Cirque du Soleil designed the classic symbol of the circus with a glorious external finish and a higher level of comfort, making its tent reminiscent of the grand old circuses. Gone were the sawdust and hard benches. Acrobats and other thrilling acts retained, but their roles were reduced and made more elegant by the addition of artistic flair and intellectual wonder to the acts.” – Mauborgne & Kim – This is how Cirque du Soleil reinvented the circus

We are at a crossroad, where we are moving from an industrial economy to a service economy. Patient experience is king, and straight teeth and quality outcomes are no longer a differentiator, but the price of entry. Through technology and economies of scale, delivering the product of straight teeth will reach a large scale where orthodontists can no longer compete by cost and sustain a viable business. The key differentiator is delivering unparalleled patient experience by offering those aspects that are difficult to replicate by achieving an incredible office experience, unrivaled customer service, shorter treatment times, greater comfort, and better convenience. Ultimately, take the best aspects of orthodontic treatment and reinvent the experience. Seems tough? If it was easy, everybody would be doing it… and that’s the whole point.

Want to learn more about Cirque du Soleil’s philosophy for success? Check out: The Spark

Technology Can Be A Catalyst To Grow Your Practice

April 28, 2017 by Sean Holliday Leave a Comment

By definition, a catalyst is a substance added to another substance, to accelerate the rate of a reaction. The catalyst is not consumed in this process and may be used many times before it loses its effectiveness. The issue with a catalyst, is that it does not cause a reaction by itself.

Consider practice growth as the result of a reaction. Technology is a catalyst that will not lead to a result unless a base reaction is present. Simply using scanners, 3D printers, cone beam, or Invisalign will not guarantee success. Toys are just that, unless they add value to patients, and lead to return on investment to the practice.

By itself, technology will not grow your practice. There are many toys and applications to chose from these days. In most circumstances, there is a sales team that will show you how that new device, application, appliance, or equipment will lead to practice growth. There are key things that must be in place to maximize the benefit of a technology add.

The base reaction to practice growth is the right type of practice culture. Your team culture, outstanding service, and the right practice model for your demographics are key steps that need to be in place to facilitate growth. Once the base reaction is in action, it is important to have processes that are congruent with technology.

If you integrate a piece of technology in your practice, consider ways to enhance how the technology adds value to patients and make that message a standard script in your office.

Have a team culture that promotes the benefits of technology.
Use technology to improve the patient experience.
Highlight your team’s special experience with the technology.
Emphasize how your skills with the technology benefited the patient’s treatment.

For many of us, we invest in technology to improve our practices. It becomes more important what you do with that technology, than simply buying it. The key to grow is taking that digital tool and use it to enhance what already makes your practice unique.

The Future in Orthodontics is not 3D, it’s 4D

April 26, 2017 by Sean Holliday 1 Comment

Orthodontic treatment continues to evolve. Our digital future means additional diagnostic tools and treatment modalities that augment and expand the application of our specialty. The application of 3D printing into orthodontics was introduced by the Invisalign product. By using 3D printing technology which was developed by Charles Hull in 1983, and sold by 3D Systems, Align Technology added a niche into the orthodontic market.

The current technology in 3D printing has been evolving in manufacturing functional parts and expanding the applicability of this process. As patents have expired in the 3D printing processes, we are seeing the commoditization of 3D printing. This is one of the reasons why this process has become so popular. The next evolution in the process has been in the expanded consumer access to lower cost solutions to enter the space. What was once only available to large manufacturing corporations and commercial laboratories, can now be owned and operated by orthodontic practices, schools and even the average consumer.

The challenge with 3D printing, is that it is a static process. In the dental industry, this digital process facilitates static restorations and provides an opportunity to improve the efficiency of laboratory workflows. When it comes to orthodontic treatment, our treatment is dynamic. 3D printing serves an immediate benefit for growing study models for traditional lab fabrication. This benefits offices in removing the alginate or PVS impressions, but leaves the untapped potential of the digital tools. When making a series of aligners, movement can be staged and adjusted in sequence to turn a static model into a series of models with a progression of movements. In order to change a static process into a dynamic appliance, the future for orthodontics is in 4D printing.

4D printing is a digital process that takes 3D printing materials and adds the 4th dimension of time. This is accomplished by adding movement into the 3D printed parts and manufacturing appliances that change in shape over time. The stimulus for such movement is a change in temperature, a charge or kinetic process that alters the shape of the 3D printed object. Think of it as adding a Niti wire to move a tooth vs. a series of wires with progressive bends to achieve the desired tooth position. When you think of it in that dynamic, you can realize that in the same way Nitinol wires revolutionized bracket systems, 4D printing can revolutionize the future of digital orthodontic treatment. Whether they are fixed or removable, 4D printed appliances would improve the efficiency of treatment and utilize digital workflows to incorporate many of the imaging and diagnostic tools we have available today.

Think that 4D printing is science fiction? Take a look at some of the projects today developing the science of 4D printing and shapeshifting architecture.

When investing in those new 3D printers, be cautious of making large capital investments in a fluid and highly evolving industry. Material science and new methods will continue to change the way we practice and get me excited to think of what the future holds.

The Art of the Presentation

April 20, 2017 by Sean Holliday Leave a Comment

There is a lot of anticipation of all the great information available at the AAO meeting. Vendors will be launching their new thing, and a select group of presenters will rise above the fear of public speaking and put their information for all to view and critique. Being there myself, I can attest it takes many of hours of preparation to put a presentation together. Going public on a topic of interest, and speaking in front of a room of your peers takes a whole other skill and a lot of courage.

Facility with public speaking is not a gift granted at birth to a lucky few. It’s a broad-ranging set of skills” – Chris Anderson, Author, TED Talks

Presentations are both an art and a science. At the risk of sounding like a presentation snob, have you thought about the things that make presentations memorable? The design, the delivery, and the subject are all critical. A presentation appeals to a classic form of human communication: Storytelling.

When you are sitting in the lecture hall listening to that next presentation. Think about the special tools that presenter put together to keep you entertained, and consider what made the lecture drive you to take action on what you learned.

The Passion

Charismatic speakers don’t just happen. The charisma that they instill into their presentation is often a result of the passion they hold for the subject matter they are presenting. It is often palpable when a presenter is passionate about the message they are delivering to the audience. Passion can surpass experience, since the audience can accept nervousness from the delivery for the fact that the presenter’s message is delivered with compelling emotion.

The Length

My grandfather once approached his preacher after Sunday service and let him know he appreciated the sermon, “but”, he said, “you did not talk about, what I wanted you to talk about.” The preacher looked puzzled, and asked my grandfather: “What did you want me to talk about?” “About ten minutes”, answered my grandfather. So what is the right length of a presentation? That depends on the subject matter, but if you take the TED stage as a consideration, they have limited presentations to 18 minutes. Some presentations are well suited for sixty minutes, but longer becomes more perilous. Shorter presentations can be more challenging that longer rambles since it forces the presenter to distill the most critical information down to the maximum impact for most people to absorb that information.

The Slides

Ever wonder how much text should be on a slide? Most presentation coaches will recommend the less writing, the better. Some presenters use the slides as a crutch to deliver the message which could be better received as a memo or a handout. Text on slides distracts from the verbal message, and bores the audience. Part of the art of presentation is putting great slides together that support the speaker’s words, instead of replacing them. The visual appeal of a presentation is a key component of the slides being a visual aid vs. a report on data.

Communication is about getting others to adopt your point of view, to help them understand why you’re excited (or sad, or optimistic, or whatever else you are). If all you want to do is create a file of facts and figures, then cancel the meeting and send in a report” – Seth Godin, Author, Really Bad Powerpoint

These are a few areas that presentation gurus highlight as critical to an effective presentation. Next time you sit in the lecture hall, focus on not only the message from the speaker, but take a look at the skills they have set on display for delivering a message in front of all those attentive eyes and ears in the audience. You may notice that the most memorable lectures from this upcoming meeting truly deliver on the art form of storytelling.