For those who decry technology’s role in the orthodontic workflow, a common argument is that technology dehumanizes the patient experience. The orthodontist’s focus is directed at the screen rather than the patient. Yes, technology increases efficiency and effectiveness, but at the cost of the patient connection.
Michigan-based orthodontist Christian Groth, DDS, MS, of TDR Orthodontics, begs to differ. He believes the opposite is equally true. It just comes down to how the orthodontist uses technology.
Old School Start
Groth is the product of, what he calls, “a very old school” orthodontic residency program: The University of Michigan. The program was hands-on—bending wires, fitting bands. “I did one clear aligner case in my residency and I had no self-ligating experience. We didn’t have scanners; although we did have digital radiographs and cameras,” he recalls. If you think this was decades ago, it wasn’t. Groth completed his residency in 2012.
But that’s what drew Groth to Michigan. “The fundamentals were super strong. I knew I could go out of Michigan and do anything. I could bend wires with the best wire benders in the country—and if you can do that, you can do anything else.”
That’s not to say that Groth wasn’t interested in the technology; he just had to take the initiative to learn about it on his own, choosing to focus his research on suresmile. With James A. McNamara, DDS, MS, PhD, as his advisor—someone who as Groth puts it “is always pushing the limits with technology”—Groth not only tested the efficiency of the system and its outcomes, he used the opportunity to see how a number of practices were using technology. One of those practices was TDR Orthodontics—the practice he joined out of his residency.
“The practice I’m in, I believe, has always been very different from the average practice,” Groth says of the 30-year-old practice started by Scott Tyler, DDS, MS, and John Dumas, DDS. “Scott is a unique guy. He commands a room. He’s just an amazing personality and one of the smartest business guys I’ve met. He’s always thinking 10 steps ahead. And then John is also one of the smartest guys I’ve ever met. He’s the systems guy. Scott and John will come up with an idea and John is the guy that says, ‘We’re going to get this to work, and this is how.’”
More than anything, Groth was impressed by their commitment to cutting edge technology—a commitment that they had made years before, becoming one of the largest suresmile practices in the country before Groth joined.
But that commitment to cutting edge technology comes with an important caveat. “We have made a commitment as a practice to cutting edge high tech, but with what we call ‘high-touch orthodontics,’ where we’re using this technology to increase our efficiency, and also increase our ability to connect with our patients.
“There’s a stigma that technology causes us to draw back and treat from afar. But with something like indirect bonding, where I don’t have to bend wires chairside, or clear aligner treatment and the 3M Oral Care Portal, [they] allow me to do my homework behind the scenes. So, when I’m at the chair, I’m not spending my time bending wires, repositioning brackets, trying to figure out what I am doing wrong here. Instead, I’m spending my time chatting with the patient, chatting with the parent, and I think that is a big connection piece—and it’s a huge part of our practice.”
The Commitment to Digital
As Groth sees it, the beauty of TDR Orthodontics is that the partners take on the projects that interest them. For Groth, this meant taking the lead on the practice’s transition to digital intraoral scanning. When the practice was approached by a company to work on the development of its clear aligner module, Groth took the lead. In the process of incorporating the scanning technology to implement the clear aligner system, Groth stopped and asked his colleagues, “Why are we still taking impressions?”
That was 2013, not quite a year after Groth joined the practice. And that decision to go impression-less was pivotal. It marked the moment the practice went all in on technology, making the commitment to a full digital workflow.
“Everything we’re doing now has come out of that,” says Groth.
The Right Time for Indirect Bonding
Today, according to Groth, TDR Orthodontics’ workflow is just that, entirely digital. With the practice’s 3Shape TRIOS and Align Technology iTero intraoral scanners at his disposal, Groth can get started with a patient’s case at the initial visit if they indicate they are ready to go. “It doesn’t matter if I’m using braces or clear aligners—everything is based off an intraoral scan,” he points out. This technology eliminates an additional appointment and allows the patient to start treatment sooner.
“I can do whatever I need to [after the patients leaves]. I can send the scan into the 3M Oral Care Portal to get my 3M Clarity Aligners, or I can route it into the 3Shape OrthoAnalyzer to design my indirect bonding trays. Then the next visit is delivery of the aligner or placement of braces with directly-printed indirect bonding trays,” he adds.
The transition to indirect bonding is recent for Groth. “Eight months ago, my indirect bonding experience was two cases in my residency in which 80% of the brackets came off when I did the indirect bonding trays. So, my history was really bad,” he shares. But the practice wanted to find ways to improve accuracy of bracket placement, reduce the amount of time the patient had to sit with isolation, and reduce breakage
Using the 3Shape software, Groth can treatment plan and then print the indirect bonding tray via the practice’s own lab. “I’m not having the lab technician fabricate it; it’s done on the printer. It takes about 30 minutes to print the trays,” says Groth.
Key to this transition was the practice’s switch to the 3M APC Flash-Free Adhesive System several years before.
“We have four offices and about 60 staff members. We went through a period where we were having a lot of breakage. As we tried to isolate what was going on, we found inconsistency across the assistants as far as getting the glue on the bracket. The pre-coated brackets completely eliminated all those variables.
“[Investing in the 3M APC Flash-Free Adhesive System] was a decision we made because any cost savings of going to a less expensive bracket that’s not pre-coated goes out the window if the brackets are coming off,” he says.
With the confidence that the bracket wasn’t going to come off, and knowledge that the practice had a 3D printer, the EnvisionTEC Vida, that could print accurate models, Groth finally felt comfortable making the switch to indirect bonding. “It wasn’t until the marriage of the 3M APC Flash-Free Adhesive System, direct printing, and 3Shape that it made sense,” he says. Today the practice has a debond rate of 2.3%.
The Aligner Transition
The switch to indirect bonding isn’t the only major transition for TDR Orthodontics in the last year. With the influx of new companies into the clear aligner space, the practice, which has historically been a large Invisalign practice, decided to explore its options.
Groth, who is spearheading the practice’s transition, started with 3M Clarity Aligners and has been happy with the choice.
“I started with really simple cases, but now I’m doing full-on cases that I’d be doing with Invisalign traditionally,” he says. “My goal now is to push the limits. I want to see how much I can do with [Clarity Aligners].”
The one factor that worried Groth during the transition wasn’t the product itself, it was patient pushback. “I honestly expected a lot of pushback from patients because they come in wanting Invisalign because it’s a name brand—like Kleenex,” says Groth. The reality has been the complete opposite; not a single patient has balked at using Clarity Aligners instead of Invisalign, especially once Groth points out that the main difference is the labs.
“I’m directing this. I’m micromanaging your movement. I am doing everything. They are just the fabricators,” he says of 3M and Align Technology. “Part of the messaging from me, and from our practice, is that this is all coming from us. You’re not buying Invisalign treatment. You’re buying orthodontic treatment.” And more importantly, they’re getting the personal attention of the TDR Orthodontics team.
A huge factor in Groth’s choice to transition to Clarity Aligners was the 3M Oral Care Portal. “For me, the technical aspect of it, with the portal, was huge,” says Groth, who appreciates the portal’s measurement, movement, and communication tools, including its treatment simulator, as well as the ease of navigation.
The plastic—that was number two. Groth likes that the Clarity Aligner plastic is less flexible than recent versions of Invisalign. “I think [Align Technology] swung the pendulum too far, [making] Invisalign too flexible,” which he says creates some difficulties with movement. However, Groth does concede that the stiffer Clarity Aligner plastic can make getting trays to fit in cases of extreme lower crowding a bit difficult. For those cases, he still uses Invisalign for now.
At the end of the day, what has impressed Groth the most has been how seamless the transition has been. “I think that’s the biggest thing for me. I was so comfortable with the Invisalign software. We’ve treated like 4,000 Invisalign cases. I know that software like the back of my hand. But getting into the 3M Oral Care Portal was so simple. I expected there to be a huge learning curve, and there really wasn’t. They did such a good job intuitively planning it out,” he shares.
Groth is pleased with the evolution of online portals like the 3M Oral Care Portal. “It used to be the online portals were just our way to get cases. When you go back to the original Invisalign site, the original ClinCheck, it was a viewer. The technician sent us a case back. We had to type [our comments]: change this, do that. The evolution of these portals has turned them into something that allows us to control treatments—which is what I want to be able to do.
“Orthodontists, we’re all picky; and I don’t want to have to go back and forth half a dozen times when I can drag the tooth into the right position and I’m done. So that’s been huge. Any portal that doesn’t allow you to make direct changes is automatically behind the times.”
One of the key outcomes of the practice’s commitment to a fully digital workflow was the creation of its own lab: Motor City Lab Works in 2014. The lab, initially set up to serve TDR Orthodontics and a few orthodontist friends, today runs four 3D printers, employs nine full-time specialized staff members, and serves over 300 offices around the country. As Groth puts it, the lab maintains a narrow focus—printing models, clear thermoform retainers, indirect bonding trays, and mouthguards; doing aligner setup and fabrication; and most recently adding direct metal printing of separator-less bands to its service list. The narrow focus allows the lab to focus on doing things well. “We don’t want to be the lab that does everything—quality slacks a little bit when you do everything,” says Groth.
Housed in the same building as the lab is the other out-growth of the practice’s commitment to digital technology and streamlining workflows: “The Hub.” Occupying one-third of the facility, the Hub houses the practice’s billing functions and call center. The practice centralized its billing at this location, forgoing financial coordinators in each of its offices. When a patient or parent has a financial question, the practice’s specialist reaches out with an answer. Meanwhile, all calls to the practice, which relies on Ortho2 Edge’s cloud-based practice management software, are routed to the call center, which is able to track which office the patient is calling. The benefit of this centralized facility is that there is always someone available to answer a call and, more importantly, the front office staff in each of the practice’s locations can focus on the patient and/or parent standing in front of them—all a part of that high-touch orthodontics the practice has committed to.
Another part of that high touch philosophy was the creation of a position for a recall coordinator 3 years ago. Instead of relying on a recall system to track patients who aren’t yet ready for treatment, the practice has a single employee who works in concert with the doctors to provide patients with consistent monitoring and communication. Once a patient is ready for treatment, consults are a non-issue, says Groth. The recall coordinator has already put in the time building the practice’s relationship with the patient.
Yes, the relationship with the patient is a key factor of TDR Orthodontics’ success, but for Groth there is an additional factor at play: The relationship between TDR Orthodontics’ partners.
“I don’t like to use the word ‘magic,’ but the synergy among the three of us—when we’re sitting around a table, whether it’s dinner, lunch, whatever—we keep pushing each other to continue to innovate as much as we possibly can.” And that commitment to innovation is what will continue to help the practice navigate the technological changes to the orthodontic workflow and maintain its commitment to high-touch orthodontics. OP