Alginate Mixing!

Just thought I'd post a short video on how we mix alginate in our practice.

The process is clean and easy with a short learning curve. No more messy mixing bowls!

Important Tip: use the cheapest, thinnest plastic baggies you can find with foldable tops. The thinner the easier it is to mix. DC

Things I don't use, things I don't do

If you read these blogs you know my goal is to have an efficient, low overhead practice. A big part of that is having a treatment philosophy/technique that doesn't include a lot of gadgets. As I've written before this is my opinion only and if you use these techniques/appliances please don't feel I'm putting you down because I'm not dammit!

Additional Anchorage Devices

     TPA, Nance, Headgear- I never use these for anchorage. Once in awhile a Nance for space                  maintenance. Haven't used headgear in 20 years
     TADs- Use rarely to protract a lower molar or intrude a molar

      I'm not sure what the big deal is regarding anchorage. Maybe it's because I rarely extract lower           bicuspids, but I just seldom need maximum anchorage. If I'm needing some help I use class 2             elastics.

Herbst/Class 2 Correctors

      I don't use fixed Herbst due to breakage, need for banding, etc. I don't use some of the other Class       2 correctors due to cost and similar issues with breakage.
   
     What I do use for full class 2 nonextraction profiles are Removable Herbsts. I have amazing                 success with these appliances when used on selective, motivated patients.

Invisalign
   
     I've discussed this in another blog. I don't use Invisalign because I feel I can get teeth straighter,          faster, and less costly with traditional twin brackets. And we offer ceramic at no additional cost.

Computer Aided Bracket Placement

     Too costly for me. I can find the correct spot to put the bracket on the tooth 95% of the time.

Accelo/Vibrating thingies

     I don't need the teeth to move any faster. A .012 NITI moves teeth plenty fast for me. I also don't        want to be hitting my patients up to buy more stuff at my office. We're good at selling braces to          our patients so that's what we concentrate on.

Ok short Blog that's it for now! DC

Reasons why I don't do Invisalign

Reasons Why I don't do Invisalign. (Am I crazy or what?)

Ugh I've been dragging my feet on this blog entry.

PLEASE know that these are my personal opinions, and my decision is not a moral one or based on some treatment superiority complex.  In fact it could change at any time and one year from now who knows  I could end up  being  an elite provider of some sort! So if you do IA know that I absolutely respect your decision and am a little envious that you've made it work for you.

PLEASE also know that I move teeth every day with plastic. We re-set our retainers for very limited movements like ortho relapse, and my goal is to have a scanner and 3D printer in house hopefully by the end of this year to allow us to dial in more precise movements.

SO WITHOUT FURTHER ADIEU HERE ARE MY REASONS I DON'T DO INVISALIGN:

Evil Empire

Nope this isn't one of my reasons. Yes, Invisalign is happy to get their product to as many GP's as possible, and yes they market directly to consumers (which can make us feel helpless at times), but those things don't really bother me that much.

Bottom Line: Invisalign is a business that is in business to make a profit (like us). They have a product to offer, and we can decide if it is in our best interest and our patients' to use it or not. Our arms are twisted at times, but it's still our decision.

Cost

BIG FACTOR in my decision. I couldn't tell you at this point if Invisalign is $500 a case or $1200 but it's certainly much more than I pay for brackets, wires, adhesive, etc. I've finally got my supply costs down significantly, and it's going to take a magic wand AND a miracle to get me to start paying those huge supply bills again. And even if you increase your fee the extra amount, by the time you spread the treatment payments out and are competitive with your down payment requirements it never really seems to cover the added cost, does it?

It's not (as) efficient

I don't think plastic can move teeth as effectively as braces can do in a shorter amount of time.  Don't get me wrong I've seen excellent cases posted by great clinicians on Orthotown and elsewhere and I really feel the results are very good; even better than I expected. However I'm not sure too many could argue that the results wouldn't be better with fixed appliances in a shorter time period.

So actually I do feel Invisalign can be EFFECTIVE when the cases are chosen carefully. But I still feel it is not as EFFICIENT as fixed appliances.

I'm a perfectionist, and The patient demographic is the exact group that is probably not the best fit for Invisalign

Ok hang in there with me on this one. I am NOT a perfectionist with my treatment results. Yes I try my best to get "perfect" results and I think I do a pretty good job but I don't kick myself if I can't get it perfect. I don't spend several extra months in braces trying to get the perfect result.

 But what I am a perfectionist in is patient satisfaction. I'll go the extra mile for patients doing re-treats for no cost, multiple retainers with re-sets, to try to help a dissatisfied patient (this drives my staff crazy and they often feel I should "cut the cord" but hey I gotta be me).

So here's my reasoning on this. My pickiest patients are adults. That's not to say  I don't enjoy treating them.  I absolutely feel it makes me a better Orthodontist when adults test my skills. But I know when we get to the finish line if the patient is not extremely satisfied I'm going to be pushing to put some appliances on to try to get things as perfect as possible.  And of course I won't be charging them, especially if I already up-charged for invisalign.

IN SUMMARY:

Some adult patients can very picky. And this group can overlap somewhat with those desiring IA.

They have paid a premium to avoid braces. And so have I!

Treatment time in general is longer than fixed appliances, often with modified treatment goals.

The last thing at the end of treatment I want to do is try to persuade patients to let me put appliances on them to get the result we both desire.

FINAL MESSAGE:
So my conversation with a typical adult (often female) Invisalign seeking patient goes something like this:

"Yes I've done some Invisalign, but with clear braces I'm able to have full control over your teeth so I can really  BROADEN your smile, and straighten them as perfectly as possible in a much shorter time, for a lower fee."

This conversation usually leads to a start in fixed appliances, although I'm sure I've lost my share of patients to more experienced IA users. I've also potentially lost patients who never came in for an exam in the first place because "You don't do Invisalign." I know the latter is true because I've done re-treats on several of these patients in my community.

SO THAT'S WHY, AT THIS POINT, INVISALIGN IS NOT FOR ME.

THANKS FOR READING!

Self-Ligation or Tried and True Twins.....what to do?

*** Please note that this blog is a reflection of how I choose to practice Orthodontics. I don't use it to cause anyone to feel bad about the treatment decisions they make. One of the best (and we're one of the few remaining professions that can still say this) aspects of running your own practice is making the choices and decisions that YOU fell good about. That's what gets me excited about coming to work every day. Okay almost every day!

When Damon brackets first came out, I was super excited to try them out. As a matter of fact Dr. Damon practiced only 90 minutes from my own practice, so another Orthodontist and I contacted him and ended up checking out his practice first hand. Now whatever you think of Dr. Damon via his brackets, marketing, etc., I came away with a great impression of him. I not only learned about his "new" bracket system, but I was impressed with his excitement for Orthodontics, rapport with his patients, and graciousness to allow us to visit his busy practice. He was just a super guy and he made us feel very welcome.

So I purchased and tried several cases, then I tried some other self-ligating, but I always came back to twin brackets. So here's my comparison:

COST- this is a blog about reducing overhead, so cost of supplies definitely gets first billing. For Damon brackets and other self-ligating brackets the cost seems to be anywhere from $4-$11/bracket. Seriously is anyone actually paying $11 for a bracket? Yes they are because I've heard it first hand from some young practitioners! Last year between new starts, rebonds, partial treatment and re-treatment I probably put on 9000 brackets. At 11 bucks that's $99,000 in brackets. At a low of $4 that's $36,000 in brackets.

You can get excellent quality twin brackets for 50 cents each, so my cost for brackets last year was 4500 bucks. To me that's a HUGE savings. A savings I can use to treat myself, pay taxes, give more to charity, or completely fund another employee ($14/hr is roughly $28k/year in wages).

EFFICIENCY- the value of clinical efficiency is extremely important. One of the best ways to reduce overhead is to streamline treatment modalities, and FINISH cases on time! (see earlier blog posts). I have seen no difference in the literature or my own self ligating cases of faster treatment times. So in terms of treatment time I see no advantage of one over the other.

Another aspect of clinical efficiency is chair time/appointment time. Here I have to give the nod to self ligating brackets. My normal adjust appointments are 20 minutes and after the learning curve for SL brackets I could probably get normal appointment times down to 10 minutes, thus reducing labor costs. So that is a definite advantage of SL brackets.

But here's the rub. Is it that advantageous to reduce appointments to 10 minutes? If all your adj appts fill your schedule in 10 min increments and patients are even a little bit late there's no wiggle room for unknowns. For instance I like to rebond brackets. If we have a normal 20 minute adjust and I see a bracket off position, we just rebond it. That's one of the ways I feel I can keep my treatment times short. With 10 minute appointments that wouldn't be an option. You could argue maybe I should use SureSmile or something and that would help but then we get into cost/benefit again and for me the added cost isn't worth it.

Also, I do think 10 minutes is kind of a short patient interaction, and if little Johnny is done before mom has parked the car then more often than not you may have some 'esplaining to do.

MARKETING, or SL vs. Colors

I would argue that the biggest reason Orthodontics has become a rite of passage for middle school kids and has exploded in the last 20 years is the introduction of colored O-ties. (With payment plans being a close 2nd). I know we'd like to think it's due to our advancements in technology, decreased pain of adjustments, etc, and to some extent it is. But hands down, the funnest and most important decision kids in my chairs (and many adults, too) make is what Holiday, sports team, dance recital, etc they need to match with their choice of colored o-ties. You get a 12 year old girl in your chair with 2 friends she brought from school and you'll be amazed at the color choice discussions that arise (of course many of you see this every day). Either way, it's a marketing dynamo, because it gets people excited about braces!

So why take that away? Sure you can tell the 12 year old that colors just slow things down but I don't think she's buying it. Or you can add the colors on the SL brackets but once that's done the only advantage I feel you have (time of appointment) has just been lost. I have more than a few SL transfer cases scream with delight when I changed out there appliances with "colored" ones. I'm not lying it just happened last week!

True, there is some Marketing you'll be missing out on as well. You won't be part of the "club" that uses SL appliances, and they've done an excellent job of marketing themselves, to their credit. But with the money you save you could hire a full time practice marketer that I'm sure could overcome that issue, if in fact it is one.

Okay I'm rambling now. As always, comments are welcome. And if you use SL please know I commend you for practicing the way YOU choose! That's what it's all about.

DC

Fees Fees Fees!

04/24/2013 by Dino C

FEES FEES FEES! Is it the price, or the VALUE?

There's been a lot of talk about fees lately so of course I'll give my 2 cents!

When I started my practice 20 years ago there was one other practitioner in town. I opened my own place with no patients and basically charged the same fee (maybe slightly lower, can't remember) as the other Orthodontist in town, which compared to surrounding cities was average or slightly lower than them.

About 3 years later, I bought the existing Orthodontist's practice and until about 3-4 years ago was the only Orthodontic practice in town.

From DAY 1 all I ever read or heard from consultants, accountants, etc, was to automatically raise fees 3% or more each year. They constantly pushed the math which says you can raise fees x amount, and lose x plus y number of patients and still make more money with less patients to worry about!

I never signed on to this. As the only one in town for 15+ years, I didn't want to give anyone a reason to go out of town to get their treatment. As towns around me were raising fees, I kept a lean, mean operation with excellent treatment and customer service, a great facility that has been updated several times, at an excellent price. Not super low by any means but definitely average or below average for my state.

Now, fees are really a very personal thing. And if one's philosophy is to charge high fees I HAVE NO PROBLEM WITH THAT WHATSOEVER!

My philosophy for average to low fees revolves around my statement above plus:

Market/Market Share- not only do I want to expand my market share (the pool of ortho patients looking for a provider), I also want to expand the Market itself (any patient who can benefit from orthodontic treatment). I feel by keeping fees "affordable," many patients who would never have thought of getting treatment done can consider it because it is not prohibitive to them. I feel I have really succeeded in my area in increasing the Market, not just Market Share.

Competition- When Dentists providing ortho or other Orthodontists coming into the area consider competing with my office, they need to consider not only our excellent customer service and hi-tech facility, but they have to consider our low fee as well. Sure they can try the "charge more" perception of higher value but once patients come into our office they see the extremely high value we already provide at a super-reasonable fee. That's tough to compete against.

The "sleep at night" philosophy- again this is a personal thing. I feel I have a pretty easy gig. Yes as a business owner with staff issues, business debt, etc, it's not the easiest job in the world but in general it's a pretty nice lifestyle. In fact, I wouldn't trade it for most any career I can think of! So I feel better (probably a rationalization, I know) when I know that in my community I'm not pushing the top limit of price point all the time.

I think the most important point in setting your fee is that you need to create VALUE. If your fee is high, you need to make sure the value is there to warrant the higher fees. The value can be in the form of excellent treatment results, great customer service, facility amenities (coffee, ipads, etc.). But this value isn't worth a thing unless you can properly communicate it to your patients.

Ok that's long-winded enough!
Comments welcome!

Nickel and Dimin'

I really don't like being "nickel and dimed" and I guess that probably shows in my practice philosophy.

For instance, since DAY 1 in my practice (20 years ago I hung my shingle and started from scratch), I have never charged for records, radiographs, recall exams, initial exams, extended treatment, broken brackets, replacing or repairing a wire on a visiting out of town Ortho patient, and many more items. Do I think it's wrong to charge for those things?   NO. Believe me, I've listened to many consultants, etc, who told me my time is too valuable to be giving it away and patients need to be kept mindful of that value by being charged a fee.

In fact until about 5 years ago I didn't even charge for lost retainers unless the patient lost over 10 or so! You don't think that drove my staff crazy? I finally began a policy where patients would receive 2 free retainers if they lose them (or don't wear them so they don't fit anymore) and after that we charge $75 each. I still don't charge patients if they are just worn out. I figure if they wear them so well they're worn out I'll reward them by replacing them at no charge.

So, that certainly is a lot of lost income, right? And I'm probaby being taken advantage of quite often, right? Absolutely! I mean, our time IS VALUABLE and we shouldn't be giving away this stuff for free, RIGHT?

Well here's the way I look at it.

I'm a big ticket guy. I'm asking these families to pony up 5k for braces. And what I want is EVERY single person I come in contact with who needs and desires braces to pay me 5k for it. But I also want them to know that I appreciate them spending that kind of money for my services and I don't take it lightly. In fact, I want them to know that if they commit to spending that kind of money with me that I'll take care of them. I'll see them for recall for 4 years and 4 panoramic films and not charge them a thing. If they break several brackets I'll needle them and if it gets worse we'll have a chat with parents about extending treatment time, etc. But I don't charge them extra. And if they come in my office 10 years after debond and want a replacement retainers because they've worn them out I'll replace them at no charge.

Know why? What happens 10 years after your braces are off? Families get started, friends ask who that nice Orthodontist is, families of 6 come in for initial exams and records knowing that they won't be charged initially. Sisters move to town and have braces-age kids and get recommended to that "nice Orthodontist."

So for me, it's about selling the value of a five thousand dollar case to new patients, not supplementing income from existing ones. It's about Goodwill and the value that creates for your practice when your patients discuss you and your practice to others in the community. To me, that Goodwill has been priceless!

Comments welcome!

Rever$e Curve Archwire$

In my never ending battle to reduce overhead, I strive to keep my inventory down (see "Archwires" blog post for a more info on this). One great little technique to save supply costs is to put your own reverse curve in your archwires.

Items needed:

Archwire
Cotton Pliers
(is that simple or what?)

Just use the edge of the cotton plier handle (I tried regular ortho pliers but the handles are too rounded). Make sure you tweak it pretty good to permanently deform the wire, or else you will just temporarily deform it and the inherent memory of Nickel Titatium will work against you.

The video above is of me putting reverse curve in 2 archwires. The first is a 16x22 Thermal Nitinol, the second is a .018 Nitinol. It may take a few times to get the hang of it but after that it's pretty easy. When I first started this technique (Thanks for the tip Dr. Bellon!) I made sure to check if the wires "held" their shape and in fact they do if done correctly.

Besides saving money on expensive pre-curved archwires, this technique enables you to put more/less reverse curve, or unilateral reverse curve!

Good Luck!

Ok let's talk about software

***Long Post, entirely PERSONAL OPINION***

I remember I think it was around 2000 or so (don't hold me to that date) my brother and I were walking the AAO exhibition hall. OrthoTrac was the biggest vendor by far. I was kind of on the lookout for a new software program, and I was AMAZED at the amount of salespeople they had and square-footage they took up on the floor. There must have been 75 plus mini-consultations going on with Orthodontists, staff, salespeople, software demos, etc.

My brother said, "Wow. Maybe you should check them out. Everyone seems like they are signing up."

I said, "Those people are making a deal with the Devil!"

Now, I didn't really think OrthoTrac was the Devil. What I was getting at was one of my biggest pet peaves in life. I HATE BEING NICKEL AND DIMED!!!

When I buy a software program (or anything for that matter), sell me the whole thing for a fair price. Don't sell me the basic package for 30k then say:

"Oh you want the treatment card? 3k more."
"Oh you want imaging too? 5k"
"More than 2 workstations? 225/workstation"
"Animated cartoons with braces education? 1500"

At the time, I was using klunky old DOS Based Orthosoft. It was great and did pretty much everything for ONE PRICE! The only thing it didn't do (this was pre-email reminders, etc) was incorporate imaging.

With that in mind I hung on to Orthosoft for several more years, until finally taking the plunge and purchasing a new program. For me it was AOS (Advanced Orthodontic Systems).

So what follows are the features I'm happy with in AOS and some features I wish were better.

The Good:

1. Cloud Computing

This is the best feature of all. NO SERVERS TO DEAL WITH. So no EXPENSIVE server hardware, no networking software to have to continually upgrade, no daily backup tapes to worry about. Any old laptop can access the software from ANYWHERE. This is super-important because I don't have to constantly invest in faster, RAM hogging workstations. The software is run as a 'thin client' so it takes up very little memory and processing speed.

So the cloud computing feature alone has saved me tons of money already.

2. All Inclusive Package for One Fee (plus monthly subscription rate....)

Okay I couldn't get away from some other charges. I bought the software, which includes everything all of the other programs charge you extra for, for one very reasonable price.

I do have to pay a monthly fee, but this is mostly for licensing (from Microsoft, etc) but it also includes in it the yearly support fee, so I don't get hit with an annual fee of upwards of 3500 or more each year.

3. Small Company

This allows us to get quick answers from emails, phone calls get right through to tech support (or they return the call quickly). You don't have to fill out some "tech support case #2245-7" questionaire and wait for someone to respond.

Since it is a small company, we may miss out on some leading edge things (however we do have the ability to email all of our correspondence to GP's, Patients, etc), and there is the possibility that the company could close it's doors, but so far it seems to be clearly more of and advantage than a disadvantage.

4.  Has all the bells/whistles (mostly..)

Ability for multi doctor, multi locations (I have 2), can have patient check in/out. Good insurance tracking, recall tracking, etc.

Good appointment book, ability for doctor-time scheduling etc.

Here are some negatives:

1. No Seamless Imaging Integration

I currently use VixWin for my imaging program. AOS has the ability to import images and radiographs into each patient file, but the process is time consuming, and although the AOS program is very fast over the internet, when images are added everything slooooows dooown.

It would be nice if they could get this worked out, but in the meantime I just have Vixwin opened seperately to access images, so not that big of an issue at this time.

2. No text message/email reminder system

Don't get me wrong, AOS and Televox have provided me a pretty seamless integration for this feature, so all my patients who opt in are sent text/email reminders.

I just don't see why it can't be done with AOS only. It seems like a pretty easy feature to add, and I wouldn't have to pay 2 companies to get it done!

3. Steeper Than Average Learning Curve

Like most software programs, AOS has some aspects that are just counter-intuitive. Some of the reports, accounting and insurance set-ups, etc, took awhile to get figured out. We do fine now (bought the program in 2009), but it took awhile.

4. Not very "Sexy"

Since it's a small company with a relatively small number of users (I don't know how many), I can't go to their big booth at the AAO and get first class treatment and talk it up with all the other users. Of course this isn't a huge deal since I'd much rather save tons of $ every year, but it would be nice if maybe they would create a user's group or interactive portion of their website (which is somewhat outdated) so that Users can share information and ideas.

Okay that's about it. Whew!

As always, comments are welcome!

Chairside Efficiency!

Broken brackets, emergencies, late patients, afternoon rush..... what to do? Is every afternoon an exercise in triage? What are we getting done here?

In order to control overhead, it is absolutely critical to keep patient treatment times on track. In our office over 80% of our patients are treated in 14-18 months. This is the single most important aspect of overhead control. More patients that are in treatment cause more emergencies, more hygiene problems, more missed appointments, etc, that drag down your bottom line.

So the strategy I use is to use EVERY appointment to get the most treatment done to further the goal of finishing in the short amount of time.

Example one:

Patient comes in with LR6 off, she's wearing elastics. We are busy but not slammed. Her appointment is in 4 weeks. My assistants rarely even ask anymore. Just get the tooth ready and let's put the bracket back on. Yes I know we're busy and a wire clip would take 30 seconds while a rebond in this case about 10 minutes. But I want to get her done! I don't want to delay treatment another month. We already had to get a chair ready, etc., and she's here now so let's do it! (not yelling just excited)

Example two:

Patient has a wire poking badly and needs to come in. Goes to school 20 miles away (happens a lot in my area). We are very busy. No broken brackets. It's on the schedule for "emergency 10," so 10 minutes are allotted. At this point we will do the entire adjustment, even though we are very busy. Reasons? Again, they are already in your chair. Also, if you do the ADJ appt now, it frees up another appointment when they were due to come in (possibly opening up one for an EXAM). Finally, the parent is super happy that you just saved them another 40 mile roundtrip visit and time out of school in 1 week.

Now, you may think these examples are obvious. But actually you'd be surprised how many emergencies are treated quickly with no one knowing when the next appt is scheduled, where the patient is arriving from, or where they are in there treatment.

The point here is to use every appointment to it's fullest.

This probably brings up issues in some minds like "well our policy is ____________."

Of course, I have an opinion on that too, so the next blog will address, "I'm sorry, that's our policy."

Stay Tuned!

Archwires!

How many types and styles of archwires do you use?

This can be an inventory/stocking/overhead nightmare! So my strategy is to both reduce supply overhead and increase treatment and office efficiency by reducing the types and styles of archwires I use.

Again, here's my 2 cents:

Upper/Lower Nitinol archforms:

 Don't order both. Just order and use either upper or lower. I've always used just one type here. I just don't think it makes a difference with something as flexible as nitinol. Some may say that if you don't use both upper and lower that the teeth won't interdigitate or perhaps you can end up with a wider mandibular arch causing antererior/posterior crossbites, but I just haven't seen it clinically. Ever.

Ovoid/narrow/euro, etc.,:

Again only one shape used here. The alternative can be a real headache if you are trying to match each patient's natural arch form with your current stock. I always use a rounded, ovoid arch form. For everyone. Once we're into steel wires, if needed they can be reshaped to customize the arch better. But in nitinol for me, its ony one shape.
Sizes:

Of course this depends on your prescription so I'll just list my typical sequence (.018 Roth):
.012 Nitinol (Love this wire!)
.016 Nitinol
16x22 Thermal Nitinol or 17x25 Thermal Nitinol
16x22 SS (if needed)

Often nonextraction cases are debonded with U/L 17x25 Thermal Nitinols.

The goal is to use a prescription and treatment mechanics that utilize only a few wires. Some times I venture from this (I use .018 nitinol that I put my own reverse curve in, etc.), but again for the 70% of patients this is the norm.

Consider the effect on overhead: the bulk of my wire orders are 4 wires. Contrast this with someone who typically uses 6 wires x U/L x 2 or 3 arch forms and all of the sudden you are stocking 24 different wire types and sizes rather than 4. That alone is an overhead burner and labor/charting/inventory intensive.

Bonding vs. Bending

I typically don't bend wires. I have several rebonds during treatment, so once the brackets are exactly where I want them the wires usually don't need any bends. Now, if I have a patient scheduled for a debond the next appointment and #8 is tipped slightly lingual then I will put a quick bend if for something like that.

This strategy can be a tricky one in an effort to control overhead. I will definitely go through more brackets and thus more overhead with bonding instead of bending. However I feel that my clinical efficiency is improved and treatment time reduced such that it makes up for it. Also, since the brackets are now so inexpensive (blatant commercial see www.cxorthosupply.com), I feel the impact on overhead isn't as great.

Well that's it for archwires!

As always, comments are welcome!

Dr C

BT's: what are they good for?

So are there any of you that consistently use BT's on patients? If you already are very familiar with them this blog may not be too useful but I hope you enjoy it anyway. As always, comments are welcome!

At our office, BT is an alternate label for Bite Turbo. I'm not sure if that name is trademarked, so we've always just called them BT's.

BT's are additional amounts of bonding material we apply to selected areas to open the bite and guard against tooth bracket contact.

Here's the scoop:

Since I bond ALL TEETH, it's super important for us to limit broken brackets in order to, 1: reduce treatment time, 2: save chair time, 3: keep down emergencies, all resulting in 4: REDUCED overhead!

Although the obvious use is to guard against broken brackets, perhaps just as valuable (and possibly more so) is the desirable effects BT's can have on treating certain malocclusions. For example, if I have a 14yo patient with 100% overbite, I place BT's on the lingual of #8 and #9. If the laterals are lingually displaced (as in Class 2 Div 2) I'll place them lingual of #7 and #10.

By opening the bite, the occlusion and muscles of mastication are "disengaged" and extrusion of the premolars and molars occurs extremely fast. As you may know this very thing has been accomplished with Bite plane (or bite plate) retainers for years, however it's faster to apply and more predictable with BT's.

Alternatively, on a high-angle or open bite patient I generously apply BT's to the lower 1st molars. This of course opens their bite even more, but the added bite pressure on the lower molars is an intrusive force and can help you with your bite closing mechanics.

Here a few things to remember when using BT's:

1. Don't forget about them! If you are using class II elastics BT's that are still hanging around can interfere with your class II A-P correction. Also, they look pretty silly on retainer models or in hygienist's chairs! Some practitioners use a different color adhesive so that it easily identifiable during treatment and at debond.

2. Be careful to use bonding adhesive which does not have too heavy of filler that it can wear down opposing enamel!

3. Inform the patient and parent, especially adult patients, that their back teeth aren't going to touch for the first part of their treatment! I make sure adults know this is going to significantly reduce their time in appliances (which it does), because it's definitely not a comfortable bite for them in the beginning.

One final thing on BT's. Several companies sell instruments to help form and apply BT's. Also, metal BT's (official "Bite Turbos") are available also. I've just found adding the adhesive myself is the easiest, most inexpensive way to go. I usually just use extra adhesive flash from the brackets when I place them at the Full bonding appointment.

Well that's it for BT's! Another critical element I use in my practice to increase efficiency and reduce overhead!

Molar Bands vs. Molar Tubes

In my practice I will do almost anything to avoid banding a molar. Ok so if it's a gold crown I'll try a bracket once (believe me I've used metal primers, diamond burs, cyanoacrylate, everything!) and if it comes off it gets a band. But any other time molars get molar tubes. And don't even get me started on bicuspids. I think I've banded 2 in 18 years! Here's why to me molar tubes are far superior:

Placement- Nothing speeds up treatment (or complicates it) more than precise positioning of brackets and tubes. It can be the number one overhead reducer in a practice in the form of reducing treatment time. Bands just aren't as accurate.

Hygiene/Caries- Besides being very difficult to clean around, if the band cement gets contaminated or washed out, the risk of caries is super high. Often you don't know they are loose until it's too late.

Inventory- I don't want to have a jillion (yes jillion) sizes and brands of bands all over the place. It's a huge cost to stock them, and then when you change companies you don't know what sizes are compatible, etc. Plus they're expensive per band!

Chair time/patient experience- Separators take time and can be an emergency appointment. The assistant has to fit all the bands so when you finally come to the chair there are like 22 of them scattered around with spit all over them. It's gross! Plus, it's too old school. It doesn't project an image of an efficient, streamlined practice. I have parents and adult patients say all the time "this is too easy, when I was young they had to fit these huge metal rings around my teeth!" and I say "yes, we don't use bands here unless we absolutely have to." (I use them for RPE's)

Spaces after Debond- There's not much getting around it. With bands, after the braces are off there are going to be food traps. Most may go away over time and I guess you can close them with a Hawley (does anyone use Hawleys anymore?), but a stubborn food trap is a B*** to close post Ortho and the General Dentists/Hygenists tend to frown on them....

Okay this post is getting long I could add a few more things but those are the most important to me.

Now of course molar tubes have some issues too. Like they come off! And whatever you do don't bond them lower to keep them out of occlusion! (See "precise bracket placement"). So you need to use BT's (additional 'glue spots' on selected teeth- to be discussed in future blogs) if you are going to use molar tubes. And yes there is a cost if they come off (replacement tube, chair time, emergency appt) but if you pay $1 tube (see Cxorthosupply.com- blatant commercial) and do some things to minimize breakage the benefits still BY FAR outweigh the disadvantages!

So bond those molars for fast, accurate, hygenic treatment!

012 Nitinol- God's Gift to Orthodontists!

*NO RELIGIOUS OFFENSE INTENDED*

Well this is the first blog entry for a subject near and dear to my heart. Especially in the recent economic climate and with increased numbers of orthodontic competitors, it's becoming more and more important to maintain a manageable overhead in your Orthodontic Business. I'll try to update this blog each week or so on tips and tricks I've learned over 18 yrs to keep my overhead low, mechanics efficient, and the number one cost-saver, minimizing treatment time.

COMMENTS ARE ENCOURAGED

So here we go...

.012 Nitinol

I don't know about any of you, but in our Orthodontic Residency we used modern techniques, straight wire appliances, and all kinds of nitinol wires, but before I started my private practice I had never used .012 nitinol. Starting wire was .014 (for an .018 slot) or.016 (for a .022 slot). These wires worked well. But I have to give credit to my brother (thanks Larry!) for introducing me to the .012. Nothing has sped up my initial aligning phase like .012 nitinol. It has truly shaved months off of my average treatment time! In fact the main reason I don't use expensive self-ligation brackets is that I just don't need them for quick alignment. I have the .012!

With the .012 you can get immediate engagement in 95% of the brackets, and you get a super light, gentle force that often results in limited or no pain for the patient after the full bonding appointment. I rarely ligature tie rotated teeth at the first appointment, but that's an option for me at the next visit with some of the stubborn rotations. Usually after the 2nd visit alignment is complete.

Now, if you are using the .012 you need to be careful of certain things. No gum! I tell patients that possibly later in treatment they can chew sugarless gum but not in the initial phases. Also, if I don't need the molars right away I still bond them but I only place the wire U/L 5-5. That way if the patient does bite something hard I don't have to worry about an emergency appointment where the wire has come out of the 6's. Also if they happen to break off the tube on the 6's (I rarely use bands- future blog subject) there isn't a long wire poking them.

So if you haven't already tried it, use .012 nitinol!

www.cxorthosupply.com

Future blog subjects: bonding vs. banding, BT's, efficient use of chairtime.

05/02/2022 UPDATE

Crazy this was over 10 yrs ago...

So I'm going back over these blog posts and commenting about anything I may have changed my mind on since posting. 

In this particular Blog even though it's been 10 years I really haven't changed much, but I've added a few things:

* Still use .012 NITI in 99% of cases as starting wire

* Still only initially engage wire U/L 5-5 to reduce emergencies

Things I've added

* Sometimes I even use .012 THERMAL NITI to get initial full engagement with severely crowded teeth.. Now this is a very flexible, super light force wire that does not fully rebound so don't expect severe rotations to fully correct. 

* I've added small and large eyelets as KEY in my starting regimen. They work excellent for engaging lingually displaced teeth without the need for coil springs in many cases!

Here's a typical case where initial eyelets were used:

Day of Initial Placement

                                        2nd Adjustment

Let me know your thoughts! I'll update a couple of these blogs each month to show what things have stood the test of time in my office!