Blog - The Ortho Cosmos

Is the Future of Orthodontics Human vs. Machine?

June 15, 2017 by Sean Holliday Leave a Comment

Augmented Orthodontics

Technology augmented orthodontics is the future of our practices. Human intelligence, intuition and passion will still remain valuable, despite the expansion of the digital world. But yet there is a sentiment of fear that machines will take over. This rhetoric of humanity vs. technology is becoming more common as technology advances throughout many industries. This perception makes many orthodontists fear for their jobs.

We must face our fears if we want to get the most out of our technology, and we must conquer those fears if we want to get the best out of our humanity.” – Garry Kasparov

Back in 1997, the world champion of chess, Garry Kasparov, was defeated by IBM’s super computer, Deep Blue. The world of chess wanted a human chess champion. And yet a machine won against a human. Despite the machine’s victory, there are more chess players today than ever before. And many of them are playing a collaborative game of chess, where chess players compete each other with a computer by their side. Where the skill of human to computer interaction outplays human skill or machine skill alone.

What will it be like to work with a computer by our side? Human intuition with machine calculation. Human strategy with machine tactics. Human experience with machine’s memory. Human connection facilitated by machine efficiency. The challenge will be in developing the best interfaces for collaborative work that take the strengths of both of the proverbial opponents and turn man vs. machine into man enhanced by machine. Where the value of each practitioner will be amplified by their skill at integrating technology into their treatment.

In the future, effective orthodontic practices will work by the combined effort of a human with an intelligent computer at our side. Combining our strengths will greatly enhance the work we perform. This will allow us to better work on the human relationships with our patients. With current technologies, this future is beginning to be a reality. This holds many more opportunities. Let’s keep in mind that we cannot cease to make progress. We have to speed it up.

Machines have calculations. We have understanding. Machines have instructions. We have purpose. Machines have objectivity. We have passion. We should not worry about what our machines can do today. Instead, we should worry about what they still cannot do today, because we will need the help of the new, intelligent machines to turn our grandest dreams into reality… If we fail it is because we grew complacent and limited our ambitions.” – Garry Kasparov

iTero TimeLapse Technology

June 14, 2017 by Scott Frey Leave a Comment

TimeLapse Technology

As part of the recent iTero 1.5 software release, orthodontists now have access to Invisalign’s TimeLapse Technology on our Element machines. This feature takes historical scan data and compares it to the current scan in a visual manner, allowing patients see changes in their tooth wear, tooth movement, and changes in gingiva over time. You can see how this TimeLapse feature works in the videos below.

Tooth Movement TimeLapse

Tooth Wear TimeLapse

Gingiva TimeLapse

The TimeLapse feature is mainly targeted at increasing utilization of this technology with general dentists who would be tracking these types of changes at routine cleanings, but orthodontists may find some applications beneficial such as assess the extent and nature of orthodontic relapse after treatment and generating examples of treatment changes to demonstrate to patients.

I will say there is huge potential in the future for this technology because it will help facilitate better collaboration and more effective referrals between family dentists and orthodontists once Invisalign is able to generate a more integrative cloud based infrastructure. I looking forward to it!

Accuracy of iRecord vs Invisalign Scans

June 13, 2017 by Scott Frey 1 Comment

iRecord Scan Accuracy

Many of you have probably heard that you should always use the dual scan capability on the iTero when scanning for appliances or 3D printed models because the iRecord scans are “less accurate.” I have heard this as well so naturally, I raised this question with the iTero engineers on a call last week discussing their scanning technology and development timeline.

As it turns out, there is no difference in data capture or in accuracy between the iRecord and Invisalign scans. However, up until recently, voids were not visualized on the iRecord scans, while voids have always been displayed on the Invisalign scans. Since gaps in data were not being displayed with standard iRecord scans, scans were being submitted with lots of voids and the software was having to compensate for these lower quality scans. Many orthodontic labs were receiving these files as well giving them a false impression about relative scan qualities between intra-oral scanners.

Fortunately, this issue has been fixed by recent updates for the Element scanner, but most doctors are completely unaware about these changes and how to insure that they are activated. To activate the data alerts on the iRecord-only scans, simply hit the toggle to the upper left of the dental arch selector. There is a similar toggle to the lower left of the dental arch selector that activates and inactivates the colors scans as seen in the image below.

As you can see when the voids are colorized they are far easier to see, and you can much better assess scan quality before submission. Without the color in the image below on the left, smaller voids and especially inter-proximal voids could be easily missed.

When the scan is in full color mode as opposed to the standard greyscale scanning mode, the voids will appear blue rather than red.

It is important to note that these updates (and will be the case other future software updates), are only available on the iTero Element scanner. Thus, if you are scanning for iRecord models on either then 1st Gen or 2nd Gen iTeros you will want to use the dual scan mode or very carefully review the scan quality before submission.

Can We Treat Challenging Malocclusions with Invisalign?

June 12, 2017 by Sean Holliday Leave a Comment

The patient demand for aligner therapy has grown over the years, and yet the challenge as orthodontists has been proper case selection and learning what types of patients can be treated with Invisalign. Every appliance we use has limitations, and aligners are no different. The opportunity we have is that technology has advanced the effectiveness of aligner therapy and increased the range of treatable malocclusions from Class I crowding to a range of problems that were once thought to be unachievable.

There are many perceived aligner therapy limitations. Let’s review some of those areas that are commonly perceived as beyond the reach of aligners, and review a few Invisalign treatments that addressed these malocclusions:

Significant AP Correction

Class II, division 1 malocclusion treated with Invisalign and elastics

Deep Overbite

Deepbite — Excessive overbite treated with Invisalign Teen

Anterior Openbite

Significant Root Movement

Bicuspid Extraction Therapy

There is a common misconception amongst the public and the orthodontic specialty that orthodontists are in the business of braces and wire bending. As patient demand shifts to expecting the same results from orthodontists but in more convenient and comfortable modes of treatment, it is important for us to remember that we are not in the braces business. Our specialty should continue to focus on the results we want to provide patients, and continue to explore modalities that fit into the experience patients desire. Properly implementing aligner therapy into an orthodontic practice does not have to compromise on these expectations.

3D Printer Maintenance – Bottom Up Printers

June 9, 2017 by Scott Frey Leave a Comment

Caring for Your 3D Printer

One of the benefits of ‘bottom-up-and-peel’ style 3D printers is that they tend to have fewer mechanical parts that require attention. However, all 3D printers requires proper care and maintenance to continue humming along well and turning out accurate prints. When you purchase and unbox your new printer you’ll receive some additional instructions from the manufacturer about upkeep, but here are some good rules to follow when caring for key components in these types of machines.

Maintaining Resin Tanks

Bottom-up printers require a peel step between each layer to release the freshly cured layer from the build window at the bottom of the resin tank (typically made out of silicone) so over time the material on the build window will being to ‘cloud’ significantly and require replacement. How long the resin tank lasts is a factor of the build window material, the properties of the resin, and the number of peel steps that occur over a particular region on the build window. The build windows in the Form2 resin tanks are rated for 5000 peel steps with their V3 resin, so the rough math is one resin tank per resin cartridge (you want to keep them paired off) to maintain high quality prints.

You can extend the lifetime of your resin tank by printing with the largest acceptable layer thickness (Z Res) without compromising accuracy (100microns for orthodontic models), and by varying position of your prints on the build platform to more evenly utilize the build window. The Form2 dashboard can help you watch for even utilization by showing you a heat map of your prints on that particular resin tank as you can see below. Once they integrate this data into the PreForm software it will be even more useful.

It goes without saying that you should handle the resin tanks while wearing gloves and avoid touching the curing window. Fingerprints, dirt, or any smudges that could interfere with the light transmission through the curing window will negatively impact your prints. If you were to accidentally smudge the underside of the curing window, you must clean it using Novus 1 acrylic cleaner on a paper towel or microfiber cloth.

Isopropyl alcohol should not be used on any of the acrylic surfaces because it can cause cracking, and no chemical cleaners should ever be used on the inside of the resin tank since it could impact print resins. The resin tanks are more of a disposable item so cleaning the inside is largely unnecessary. If bits of cured resin were to find their way into the resin tank due to a failed print, you should filter them out by pouring the resin through a 190 micron paint filter.

Mirrors and/or Projector Lens

High quality optics are important for accurate and successful 3D printing, so you will need to avoid introducing dust or dirt into the machines and be careful not to smudge optical surfaces with residual resin or oils from your hands. The optics deck on many newer 3D printers are sealed to help avoid dust getting in, but either way you should keep the lid closed on your printer as much as possible to keep dust from getting in.

While changing resin tanks or in the even of a failed print, the mirrors and/or projector lens should be inspected to make sure they are in fact clean. If they were to become dirty, a damp microfiber cloth or compressed air dusters can be used to clean their surface.

Build Platform

Build platforms are extremely resilient and rarely need to be replaced during the lifetime of your printer. As long as there aren’t sharp bits sticking out from part removal/resurfacing that may puncture the silicone curing window in the tank, there is no need to replace the build platform, but they should be cleaned throughly with a cloth between prints. Chemical cleaners should not be used on the build platform to avoid introducing them into the resin during printing.

General Upkeep

Although this would be rare in an orthodontic lab, if the resin sits for longer periods of time it may need to be gently mixed to avoid settling of particles with some types of resins. In the Form2, you can simply remove the wiper and gently sweep it left and a right to make sure the resin is mixed. It is a good idea not to mix it while in the machine in case of a spill so you should remove the resin tank prior to mixing. Outside the machine, you should keep the resin covered as much as possible.

Although isopropyl alcohol is used to wash printed parts and remove residual resin and is readily available, it should not be used to clean any of the acrylic parts on the machine like the hood or resin tanks. The isopropyl alcohol will crack the acrylic over time. Instead these acrylic surfaces should be wiped down with an acrylic cleaner like Novus 1 on a paper towel or microfiber cloth.

Challenge Everything in Orthodontics

June 8, 2017 by Sean Holliday Leave a Comment

The information age offers so many advantages. Data is more freely accessible. Forums are allowing us to better share information. We can be better connected, and gain more. The problem is that with increased sharing, more caution is also indicated. I would ask you to consider that we should not have a cynical perspective, but we should carefully evaluate what we consume and question current thought.

Challenge status quo. Challenge business advise. Challenge clinical advise. Challenge technology buys. Challenge gurus. Challenge consultants. Challenge publications. Challenge research. Challenge bias. Challenge your perspective. Challenge everything.

You should even challenge what I’m telling you now. Questioning advise is a natural and healthy approach to all the information we gather. There are many motivated influences in our world. The business and future of orthodontics greatly depends on us being well informed. Take a skeptical approach, and test things for yourself.

I am not supporting to live a life of disbelief. Don’t accept naysayers at face value either. Remember that just because there isn’t sufficient evidence, doesn’t mean it doesn’t occur. Just because someone discovered the world was round, did not suddenly make it so. But it was the challenge to a long held belief that finally revealed the truth.

Trouble with Transparency Under the Sunshine Act

June 7, 2017 by Scott Frey Leave a Comment

Time for Transparency

In order for fellow orthodontists, as well as the general public, to adequately assess for conflicts of interest and general bias, all monetary contributions from companies and organizations made either directly or indirectly to doctors must be publicly disclosed in some fashion. The Physician Payments Sunshine Act, passed in 2010, was an attempt to provide greater transparency; however, the law doesn’t adequately cover all streams of income that can flow from manufacturers and distributors. This means that many doctors are on the honor system to provide this information and it allows for some to keep the origins of their income concealed.

Each year, the previous year’s data for Open Payments is submitted from manufacturers by March 31st, and they allow a 45 day process for dispute and review before the information is published to the Open Payments Database on June 30th. If you are interested, these payments made directly to doctors can be looked up for anyone you are curious about using the Open Payments Data Search Engine. Our concern however are the payments that are going unreported and do not appear on the site.

While the Sunshine Act requires medical product manufacturers to disclose to the Centers for Medicare and Medicaid Services (CMS) any payments or other transfers of value made to physicians or teaching hospitals, transfers of value that are made to a third party that isn’t a doctor or teaching hospital do not need to be disclosed creating the potential for abuse.

Clever individuals and groups are able to essentially ‘launder’ money provided by companies through educational organizations, industry magazines, educational grants for meetings or forums, vendor fees at the same meetings, internet groups, etc. because these entities do not have reporting requirements under Sunshine regardless of whether or not the entities are owned by a doctor or a group of doctors. In the instances where these entities are doctor-controlled, once the money goes in they are able to reroute the funds to themselves, pay it out to affiliated doctors or speakers, or pass the funds between other organizations and groups that are aligned with their interests and working towards the same end. Furthermore, preferred pricing on products extended to key accounts are not adequately disclosed.

Naturally, we are beginning to see more and more organizations like this popping up with affiliated doctors organizing themselves into what can only be described as “mutual admiration societies” to help establish credibility and coordinate promotional efforts. Since the industry money is being ‘cleaned’ by passing it through or amongst these entities first, these doctors can also technically deny that they receive compensation from these companies, and without them opening their books completely it essentially impossible to distinguish funds that are provided by manufacturers from those that are earned by other means (ticket sales, membership fees, etc.). They are basically on the honor system to disclose any potential conflicts of interest.

There are plenty of other forms of bias out there that can cloud research and recommendations, but financial conflicts are an extremely important disclosure to make. The dilemma we now face as a specialty is that we simply may not be able to get straight answers from the types of entities we have outlined here on the sources and extent industry financing the receive. Therefore, we must consider the information flowing from these organizations, and their affiliated doctors, with increased skepticism and challenge.

In the interests of greater transparency, we list all disclosures of any financial relationships our doctors have either directly or indirectly with companies or any of the entities in question on our Speakers page under the About tab.

The Value of Leadership

June 6, 2017 by Sean Holliday Leave a Comment

The orthodontic team is a dynamic group of people collaborating towards a common purpose. Highly effective teams can achieve remarkable things and they have a common thread. “Winning” teams sustainably work on building a team culture that allows them to do so.

Organizations that exhibit real greatness combine talent, relationships, and innovation in a variety of ways for the sake of achieving a shared goal.” – Don Yaeger

They have an understanding of who they serve and why. Effective teams bring unique talents that complement those of their other members. These teams also have alignment and understand the direction they are following. Last and certainly not least, great teams have great leadership.

Effective leadership is undoubtedly the key to any organization. The challenge is that most people are placed into positional leadership. Leadership that is given by title does not a great leader make.

It’s not leadership by position that allows people to succeed: it’s the capacity to influence the thoughts, the feelings, the emotions, and the actions of other human beings.” – Tony Robbins

What makes a great leader? Many believe that leaders should be enthusiastic, passionate, genuine and energetic. Besides the hard work and passion, a great leader also has a high degree of emotional intelligence. Great leaders share some common traits that lead to measurable results, where those traits boost a company’s performance. (Daniel Goleman)

Self-awareness – Great leaders see themselves and their businesses clearly. They understand their strengths, weaknesses and those dynamics in their organization.

Self-regulation – Leaders should create an atmosphere of fairness and trust by controlling their feelings. Great leaders think before they act.

Motivation – A great leader should have passion for work and desire to raise the performance bar in those whom they lead.

Empathy – In leadership, it is important to maintain effective group dynamics and teamwork. An empathetic leader does not demoralize those around them by understanding their emotional needs.

Social Skill – Effective leaders work well with a team and are great at persuading others.

These leadership skills are key components to a successful organization. Besides drive, passion and emotional intelligence, I would also add that the most effective leaders create a culture of leadership. This culture is key to sustainable success by nurturing leadership development from within the ranks. This promotes better habits and behaviors for a “winning” team.

True leaders don’t create followers. They create more leaders.” – Tom Peters

Whether we like it or not, each of us is in a leadership position. Leading an orthodontic practice and an orthodontic team is a skill in it of itself. It takes hard work and fortunately, we have great examples that help guide us to understand the value of leadership.

Introduction to Selective Laser Sintering

June 5, 2017 by Scott Frey Leave a Comment

What is SLS?

SLS stands for Selective Laser Sintering. This 3D printing technology uses a laser to harden and bond (sinter) small grains of plastic, ceramic, glass, metal, or other materials to build a 3D dimensional structure inside a hot chamber with the temperature just under the material’s sintering point. During the SLS process, the laser traces the pattern of each cross section of the 3D design onto a bed of powder. After one layer is built, the bed lowers, a roller transfers new powder to the sintering bed as needed, and another layer is built on top of the existing layers. This process is repeated until the object is complete, at which point it must be uncovered from within the un-sintered powder, and cleaned before it is ready for use. The SLS process is visualized in the diagram below:

SLS printers can use a wide range of materials including metals, always in powder form, but most often they are polyamides (Typically PA12, like Nylon) that can have additives including materials like glass and aluminum to change properties such as color, strength, flexibility, stiffness etc.

Since the product lies in a bed of powder, one of the major benefits of SLS is that it doesn’t require the support structures that many other additive manufacturing technologies use to prevent the design from collapsing during production. With no need for support structures, this technology is suitable for interlocking parts, moving parts, living hinges and other highly complex designs. You can also utilize the build volume more effectively than with SLA.

Although the use of powder provides a few advantages by serving as a support medium, the powder also raises some safety concerns. Breathing apparatuses and ventilation need to be considered, depending on the type of material.

In the future, SLS technology will likely have some applications in orthodontics because of the unique material options and the fact that it is capable of producing intricate and highly durable parts. However, the post-processing time required to uncover the prints is significant so there is less benefit to producing objects where SLS will not save your significant assembly time.

Posterior Openbites with Aligners

June 2, 2017 by Sean Holliday Leave a Comment

A common issue seen with aligner therapy is the development of posterior open bites. This problem appears to have become more common place as aligner treatment has increased. More evidence on the occurrence of posterior openbites and the etiology is needed, and most practitioners are having to deal with this pain point.

Some of the theories about posterior open bites come from various anecdotal observations. The most common being that aligners cover the occlusal of the posterior teeth. Therefore, occluding on the aligners, especially in brachyfacial patients, tends to develop this issue. I believe that is a factor in select patients. The most common reasons I have seen posterior open bites develop stem from the lack of occlusal corrections that are not fully incorporated into the virtual treatment plan. Other reasons are related to unfinished corrections that are primary factors in developing anterior interference.

Next time you see a posterior open bite develop, keep a few factors in mind so you can properly address this issue:

Upper Incisor Inclination

Lack of torque on the upper incisors can lead to heavy anterior occlusion that discludes the posterior teeth. Therefore, developing a posterior openbite. Full incorporation of lingual root torque, plus careful incorporation of incisor retraction in the treatment plan are important factors to consider when preparing your clinchecks.

Deep bite torque — Both lack of torque and incomplete curve of Spee correction contributed to the posterior open bite

Curve of Spee & Lack of Space

Leveling the curve of Spee in treatment is a very common factor in the appearance of posterior openbites. Deep bite cases should be corrected with proper leveling, which requires additional space in the dental arch. Much like reverse curve arch wires are used in fixed appliances, a reverse curve aligner staging technique that provides sufficient space within the arch is critical to avoid heavy anterior contacts and an open posterior occlusion. This is exacerbated when the patient has a deep bite and undergoes Class II correction. If the leveling is not completed as the overjet decreases, a posterior open bite will worsen.

Clincheck Overjet

The virtual overjet in the clincheck is an area I recommend you focus as you develop your plans. Many doctors want the clincheck to show ideal “anterior coupling” and contact. Since there is a layer of plastic and a variable posture from extended wear of a series of aligners, the virtual treatment plans should be tailored to finish with no anterior occlusion.

AP Correction

Lack of AP correction and minimal overjet that is common in Class III cases will also lead to heavy anterior occlusion and posterior open bites due to the fact that elastics have not been worn or have not completed their correction. In these cases, continuing elastic wear is important to regain posterior occlusion. Once overjet is gained, the heavy anterior contacts are resolved and posterior contacts are achieved.

Bolton Discrepancy

In the presence of a tooth-size discrepancy, the resulting lack of overjet can also contribute to a posterior open bite. Addressing this factor via maxillary restorations or mandibular IPR are possible solutions to be considered. As I stated previously, the clincheck should be critiqued to avoid a plan that has minimal to no overjet.

Anterior Extrusion

Many Clinchecks I have reviewed have maxillary anterior extrusion in the presence of a normal or even deep bite. Although a plan to improve the smile line by anterior extrusion may be indicated in some cases, my experience is that this is commonly incorporated into Clinchecks even when this goal is not desired. Carefully monitor the anterior movements in your cases, and remember that the lower incisor intrusion that is necessary to allow for the maxillary teeth to extrude, is not 100% expressed without overcompensation. I have done a “forensic” review of many cases, where a more predictable movement (upper incisor retraction with simultaneous extrusion) is incorporated with a less predictable movement (pure lower incisor and canine intrusion), without proper safeguards to compensate for the varying degrees of expression in this appliance.

Second Molars

Finally, I would like to make a case for the positioning of your second molars. These teeth will impact your posterior occlusion, and I have seen many cases where they were ignored, and molar extrusion was incorporated on the maxillary arch that lead to an occlusion only on the incisors and second molars. When you desire proper posterior occlusion, don’t ignore some of the posterior teeth that contribute to that occlusion.

« Previous Page
1
…
6
7
8
9
10
…
14
Next Page »