Creating Consistency from Bonding to Finishing with Passive Self-Ligation

Alison Werner (00:05)
Hello and welcome to the orthodontic products podcast. I’m your host Alison Werner for orthodontists looking for ways to reduce variability streamline clinical workflows and create more predictable treatment from bonding through finishing passive self-ligating systems offer a solution in this episode sponsored by Dynaflex. We explore why some clinicians are moving toward passive self-ligation not as a magic bracket, but as part of a broader systemized approach to treatment planning execution and efficiency joining me to talk about this is Dr. Jason Sherbel a board certified orthodontist

practicing in Southeast Michigan who shares how adopting a passive self-legating philosophy has helped his growing startup practice standardized mechanics empower his team and support a technology driven approach to care. Here’s our conversation.

Alison Werner (00:50)
Dr. Sherbel thank you so much for joining me.

Jason Sherbel (00:53)
Yeah, thank you for having me.

Alison Werner (00:54)
Great, okay, so to start us off, can you tell our listeners a little bit about your practice and how long you’ve been practicing?

Jason Sherbel (01:00)
Yeah, so I’ve been practicing for about five years. I actually practice with my wife. She’s also an orthodontist. ⁓ We actually started our practice right out of residency. ⁓ you know, a startup is probably something we can chat a lot more about in those ⁓ issues. But ⁓ yeah, our practice has grown quite a bit in the last ⁓ five years. And as that’s happened, we’ve had to adapt kind of new systems and technologies to kind of help us with that. ⁓

Alison Werner (01:14)
Yeah.

Mm.

Jason Sherbel (01:29)
But overall, you know, our practice I would say is mostly kids. Like our comprehensive, maybe like 60%, 60, 70 % kids, 30 % adults. And about, I would say a third of our practice is actually phase ones in general.

I also, I completed a mini residency at University of Michigan in dental sleep medicine. And so I’ve been learning a lot more about airway. And ⁓ as that’s, as I’ve been learning more and educating myself, I’ve been getting a lot more referrals from things like some ENTs to help with kids for not, not really dental reasons, but for some medical reasons, like with breathing airway, like the kids who’ve already had a tonsillectomy and are still having breathing issues. so my practice just kind of recently has been also ⁓

Alison Werner (01:57)
OK. Yeah.

Jason Sherbel (02:22)
a little bit more focused on sleep and airway. And so that’s been a fun journey too.

Alison Werner (02:27)
Okay, okay. So you started talking a little bit there about the type of cases and that you’re predominantly seeing kids, but I just wonder, can you describe your overall clinical philosophy when it comes to treatment planning and mechanics?

Jason Sherbel (02:40)
Yeah, so ⁓ for one, ⁓ I would say that I think when you’re treatment planning a case, ⁓ a quality treatment plan is important, but you need to also have ⁓ proper execution. And so ⁓ as I’ve gone through the years, I used to treat every case in a super unique way, making decisions on the fly for everyone. ⁓

that worked really well in the beginning when I had all the time in the world. And then as the practice grew and ⁓ we were getting more patients, we became busier. I realized I needed better systems ⁓ in my practice to actually be able to get those ⁓ clinical results. so ⁓ lately I’ve been trying to leverage a lot more technology to kind of help us with that. And so ⁓ we’ve switched to more passive self-ligating brackets. We incorporated digital

Alison Werner (03:11)
Mm-hmm. ⁓

Jason Sherbel (03:39)
indirect bonding. ⁓ And we even have a CBCT now like a cone beam so that we can ⁓ actually integrate ⁓ the roots and whatnot with with indirect bonding when placing brackets. A little bit more accurately, I can actually see the root while I’m placing the bracket on the computer. And that’s helped us ⁓ be able to, I guess, grow more ⁓ responsibly where we can grow but I ⁓ pay ⁓ care isn’t being

Alison Werner (03:50)
Okay. Yeah.

Jason Sherbel (04:08)
diminished or an afterthought, it’s actually, we’ve actually been able to get better results with that.

Alison Werner (04:13)
Okay, so let’s dive into our topic and you brought it up a little bit there is the passive self-ligating systems. So what originally got you thinking about moving toward a passive self-ligation system and what problems were you hoping it would solve in your practice?

Jason Sherbel (04:29)
Yeah, so, you know, ⁓ when I was in residency, I was exposed to several different bracket systems, right, and treatment philosophies. And it gave me the opportunity to see firsthand the strengths and weaknesses between these different systems. But my biggest takeaway was simple, that there is no magic bracket, right? Good orthodontics comes from thoughtful treatment planning and careful execution. Now, that being said, the bracket system you choose can absolutely help solve specific problems in your practice.

Alison Werner (04:57)
Mm-hmm.

Jason Sherbel (04:58)
Right? And so, like I had mentioned, when Mary and I started our practice right out of residency, early on, we had all that time in the world. If a patient had ran long, it didn’t matter. If a patient needed an repositioning, no problem. There’s no one waiting in the waiting room, right? But as our practice grew, and it grew rather quickly, these inconsistencies in the way that we practiced started to compound.

Alison Werner (05:12)
Yeah.

Mm-hmm.

Jason Sherbel (05:20)
And so appointments ran longer than expected. Patients were waiting in the waiting room a little bit longer. Total treatment times were stretching beyond what we had projected. And we kind of knew something had to change. And so when we stepped back and analyzed the practice, ⁓ we didn’t find actually like one single big problem, right? We found dozens of small inefficiencies, right? And individually, they were very minor, right? But collectively, they were affecting our workflow.

Alison Werner (05:37)
Okay.

Okay.

Okay.

Yeah.

Jason Sherbel (05:47)
⁓

our energy, you know, and ultimately our results. And so that’s when we knew something had to change. And that’s what got me thinking more about passive self-ligation. ⁓ I was more of chasing more of consistency.

Alison Werner (05:50)
Mm-hmm.

So can you talk to me about the

you kind of identified and what you were hoping to attack with a new system?

Jason Sherbel (06:10)
Yeah, so, okay, you know, sometimes a patient would come in for their first visit after bonding and maybe one or two teeth were still rotated. You know, we all kind of experienced that.

Alison Werner (06:19)
Mm-hmm.

Jason Sherbel (06:19)
⁓ they were properly figure

eight tied, but the elastomerics, you know, loosened over time. So when the patient came in for their visit, the wire was no longer. You know, fully engaged. so instead of progressing to the next wire, you might just retie staying that initial wire for a little bit longer. ⁓ and if you’re seeing the patient every eight to 10 weeks, you’ve, you’ve now just effectively added eight to 10 weeks to their treatment. Right. And so, you know, now steel ties can.

Alison Werner (06:29)
Mm-hmm.

Yeah.

Mm.

Jason Sherbel (06:44)
reduce that issue, but they also introduce another variable, right? They’re very technique sensitive. And so not every assistant ties the same way. And so not every tie is equally tight, right? I can’t tell you how many times a patient would come back with a steel tie that maybe wasn’t quite tight enough to fully engage the wire to the back of the bracket, right? Now, was it the assistant? Did the assistant not tie it tight enough? Or did it start to loosen or untwist over time between appointments?

Alison Werner (06:55)
Mm-hmm.

Hmm.

Right.

Jason Sherbel (07:11)
⁓ We may never know, but either way, that’s an inefficiency, right? And so what I appreciate about passive self-legging brackets is that when the door is closed, right, that wire is engaged as fully as that system allows, and it removes any assistant-dependent variability. know, once the door is closed, there’s no slack of that door over time, right? And so as our practice scaled, that kind of consistency mattered more and more. ⁓ And, you know, once that was kind of, ⁓

Alison Werner (07:15)
Yeah.

Mm-hmm.

Mm.

Mm-hmm.

Mm-hmm.

Jason Sherbel (07:41)
I guess, taken care of, that now led into better archwire progression. So with conventional ligation, part of every visit involved checking, the teeth fully tied in? Is this patient actually ready for the next wire? That takes a provider’s time, but it also adds another level of decision-making.

Alison Werner (07:52)
That’s enough.

Jason Sherbel (07:59)
And usually the provider’s time is the bottleneck in the practice. I know it is for ours. And so with passive self-ligation, if the doors are closed and your archwire sequence is standardized, assistants can now confidently begin progressing patients to the next wire before you even sit down, right? Your assistants now have this autonomy. It empowers your team, right? It improves your practice flow. And it does this without compromising care. Because if something is more efficient, but compromises on care,

Alison Werner (08:04)
Mm-hmm.

Wow.

Mm-hmm. Yeah. Yeah.

Jason Sherbel (08:27)
that’s not good trade off, right? That’s a non-negotiable.

And so once that was standardized, right, now we can start talking about repositioning appointments. You we realized our repositioning appointments were very inconsistent.

Alison Werner (08:42)
Okay.

Jason Sherbel (08:42)
Some patients

were repositioned at visit three other at visit eight, right? It depended more on how things were progressing than on any true system. And so once we standardize our wire sequence, now that changed. Now patients are in predictable wires at predictable visits, right? Which made repositioning timing much more consistent and predictable. know, I know, I know when a repositioning is coming and now our team knows when a repositioning is coming. There’s less.

Alison Werner (08:46)
Mm.

Mm-hmm.

Mm-hmm. Mm-hmm. OK.

Jason Sherbel (09:08)
reacting and decision making and more just planning and flow, right? And that kind of systemization really kind of reduces friction across the entire office, right? ⁓ And another element that I don’t think I ever really hear people talk about is ⁓ decision fatigue, okay? ⁓ You know,

Alison Werner (09:16)
Yeah.

Okay.

Jason Sherbel (09:28)
As orthodontists, we see dozens of patients a day and every single one requires a decision or multiple decisions, right? know, wire progression, mechanics, elastics, ⁓ repositioning, anchorage considerations, right? You know, I grew up playing a lot of chess and I always think about like those grandmasters who would play like 10 boards at once. Like they would move from table to table. They’d like analyze the position, make a strategic decision, then move on to the next board.

Alison Werner (09:32)
and

Jason Sherbel (09:56)
That’s what I feel like we do as orthodontists all day, right? Except instead of chess pieces and chess boards, it’s like with teeth and occlusion, right? And by the end of the day, know, decision fatigue is real. Like, you know, my brain feels like mush almost. And so when I reduce the variability in ligation and sequencing and repositioning,

I also reduce the number of micro decisions I have to make, right? And that mental clarity alone, I think has value, right? It’s not just, you know, the inner peace it gives you, but also like the bandwidth to make better decision on other things that need your attention. So, ⁓ yeah, you know, I don’t think passive self-ligating brackets are magic, but they definitely solve a lot of ⁓ certain issues in my practice.

Alison Werner (10:19)
Mm-hmm.

Alison Werner (10:41)
So can you talk to me about what you were looking for when you were evaluating different PSL options and what stood out to you about the Norris system and why did you feel like this was the right fit for your treatment philosophy?

Jason Sherbel (10:54)
So good question. So when I decided to explore

self-ligating brackets, I quickly realized there were a lot of options. And each bracket has their own strong claims on why theirs is the best, right? But as I said many times, there is no magic bracket. But what really stood out to me about the Norris system is that the bracket was an 0-2-0 slot.

Alison Werner (11:02)
Mm-hmm.

Jason Sherbel (11:20)
⁓ In residency, I’ve treated cases with both 018 slot, 022 systems. I heard arguments from different professors for why they preferred one over the other, and both.

sides have valid points, right? So the advantage of an 0.18 slot is earlier slot fill. So you fill the slot sooner, which means earlier torque expression, less play or slop between the wires and the bracket. And that tighter, you know, wire slot relationship can translate into more precise control earlier on in treatment, right?

Now the trade off is that you’re limited the size of wires you can use. know, if you’re probably finishing, if you’re in an 018 slot, you’re probably finishing in like a 16 x 22, right? Rather than an 18 x 25 or 19 x 25.

And that makes certain mechanics like, let’s say, leveling a curve of spee more dependent on adding like a reverse curve or other compensatory bends to get the job done. Now, on the other hand, proponents of 022 argue that the additional slot size allows you to progress to heavier working wires like a 19 x 25, which can provide more control in certain mechanics like leveling curve of spee But the trade off there is there’s more play earlier on in treatment with the torque expression not being

Alison Werner (12:24)
Thank

Jason Sherbel (12:31)
utilized really at all till later in treatment. So even in residency, I asked myself and my professors and classmates, you

Alison Werner (12:38)
Thank

Jason Sherbel (12:39)
What about an 020 slot, right? If the advantage of an 018 is earlier engagement and reduced slap, right? An 020 slot moves you closer to that precision, right, compared to an 022, but it still allows you to get to your 19 x 25 wire. So for the vast majority of cases, that gives you the working dimensions you need without any of the additional play in an 022 system. And so, you know,

Alison Werner (12:41)
Okay. ⁓

Thank

Okay.

Mmm.

Yeah.

Jason Sherbel (13:04)
I always like to make the counter argument point to make sure I’m being honest, right? And so, you know, realistically, the strongest argument for an 022 then over an 020 would be for providers who want to use, let’s say, a 21 by 25 wire, right? Because that wouldn’t fit in an 020. But if you were to ask the reason why they’re using a 21×25 it would be to fill the slot to get more torque expression. And an 020 slot, you get that same expression now with a 19×25.

Alison Werner (13:10)
Mm-hmm.

Mm-hmm. Yeah.

Mm-hmm.

Jason Sherbel (13:33)
Right.

So, you know, at the time I hadn’t seen many mainstream 020 options. I think they were pretty much non-existent and ⁓ essentially none in passive self-ligating for sure. So I started with an 022 twin and loved it. Right. ⁓ But when I was evaluating passive self-ligating systems and saw that Norris offered an 020 slot, that immediately aligned with like my mechanical philosophy and what I was already gravitating toward. And ⁓

Alison Werner (13:43)
Yeah.

Mm-hmm.

Okay.

Jason Sherbel (14:01)
you know, once I’ve committed to, I’ve been very happy with the decision and, you know, have gone all in.

Alison Werner (14:05)
Mm-hmm.

Yeah. Talk to me about your onboarding of the system. Did you start with a few cases? Did you go all in? And what were those initial cases? What did you see in those initial cases in terms of the efficiencies? How long till you saw those efficiencies?

Jason Sherbel (14:23)
So I ended up just going all in. ⁓ And, you know,

Alison Werner (14:23)
Yeah. Okay.

Jason Sherbel (14:29)
I also kind of paired me going all in with the Norris bracket with also leveraging digital technologies like indirect bonding. And so, you know,

immediately ⁓ I saw better efficiencies at my practice, right? So ⁓ the brackets were being put on indirectly. Now, granted, that means I had a lot more homework. I was doing a lot of work on a computer. still ⁓ am. But I didn’t necessarily need to be sitting at the chair the entire appointment now for the bracketing, right? I could come in at the end, check the brackets, make sure things are engaged. And now I can be doing other things like consultations or seeing other patients and making bends and wires for finishing. ⁓

⁓ the bottleneck being me, the provider, ⁓ I was reduced in half. I had more time to do things. It wasn’t people always waiting on me, right? But ⁓ the Norris system itself, what it allowed for was…

All my assistants now were tying in the exact same way. The door was closed. Okay. It’s tied in. And so then that means we are going to be able to get to the next wire, next time they come in. So now when the patient were to come in for the next visit, they’re already grabbing the wires. They’re untying. even maybe starting to tie in before even sit down. Right. And so now that would reduce the bottleneck even more. So my, they don’t have to wait for my go ahead for certain things. They kind of know what I’m going to say as long as the wire is going to fit. it, it’ll

Alison Werner (15:31)
Mm-hmm.

Thank

Yeah.

Mm-hmm.

Jason Sherbel (15:57)
The only time that they wouldn’t have to do it is if they left the door open, right? And that would be a learning lesson saying, hey, look, the door was open. Now that tooth didn’t move. Now it’s just staying the same wire. it immediately ⁓ gave it so I had more of my time back. And when I say time back, I don’t mean relaxing. It means more of my time to go be doing the other things that other people are waiting for.

Alison Werner (16:02)
Thank

and

Right. Yeah.

Yeah, absolutely. Okay. So for orthodontists who are curious about a PSL system, but haven’t kind of taken that leap yet, what advice would you give based on what you’ve learned so far?

Jason Sherbel (16:32)
So for me, passive self-ligation helped solve specific inefficiencies and problems that were affecting our practice flow, which also meant it was affecting our results. It wasn’t about chasing something new. It was about addressing real variables that were compounding over time.

And if you’re using twin brackets and your systems are dialed in, your workflow is smooth, and you’re not experiencing any of the inefficiencies I described, then maybe there isn’t a reason for you to change. Twin brackets work. They’re great orthodontists worked for decades with them. But if you are starting to notice smaller consistencies, variability and ligation, unpredictability in early treatment, challenges as your team grows with training and things like that, and you’re looking for ways to reduce or eliminate those variables,

Alison Werner (17:18)
Okay.

Jason Sherbel (17:19)
Passive self-ligation could be a very effective tool. It definitely was for me. You know, it worked because it aligned with how I wanted to practice. And with the right system in place, you know, it would work for anyone. But, know, don’t just switch because you think it’s like magic, right? It’s not actually a shortcut. It’s a system. And if you value reducing variables, simplifying team training, you know, creating a more standardized workflow, passive self-ligation can absolutely support that.

Alison Werner (17:26)
Mm-hmm.

Yeah. Yeah.

Okay, well before we finish up, I’m just curious, can you talk about like, know, what excites you about the future of orthodontics or what do you have your eye on at this point?

Jason Sherbel (17:56)
Yeah, so, you know, it’s quite recently. once I started doing like indirect bonding, incorporating Norris and passive self-ligating, ⁓ it kind of opened my eyes to just leveraging technology in general, right? And I just mentioned with the CBCT, that’s actually relatively new. We just got one ⁓ late last year. And ⁓ the sole reason was ⁓

Well, should say sole reason, two of the reasons really were we wanted to evaluate better. Like I there was a canine coming in, how it was affecting, was it resorbing a lateral, where it was, the position, you know, instead of having to refer a patient out ⁓ for that CBCT, we can kind of take one in-house for them. ⁓ But the real driving factor of why I wanted one was I realized after starting indirect bonding, there were options for me to actually see the actual roots of the teeth.

Alison Werner (18:44)
Mm-hmm.

Jason Sherbel (18:45)
while I’m placing the brackets on a computer. Before that, I thought that would have been like an impossibility. But when orthodontists reposition, we’re looking for things like where things aren’t level rotations, but also we take a pan to evaluate the roots, right? And we see that root is tipped, okay, we reposition the bracket to fix it. But what if that can be eliminated? And so with the incorporation of like cone beam with indirect bonding, ⁓

Alison Werner (18:47)
Hmm.

Okay.

Mm-hmm.

Jason Sherbel (19:15)
I am able to actually place the bracket exactly along the long axis of the route. Now I have an actual representation, right? And so instead of looking in the mouth and essentially guessing, right? Or looking at a pan, which is distorted in its own, right? You can actually be more thorough at your initial bonding. And it makes me think as I get better and better at using this system, can I?

Alison Werner (19:25)
Mm-hmm.

Mm-hmm.

Mm-hmm.

Jason Sherbel (19:39)
eliminate the repositioning appointment in general, right? ⁓ And so, you know, I’ve, it’s really this whole passive self-ligating sparked like this interest in me. just like, okay, what else can I do to be more efficient, you know, in my practice? Now that I’ve seen the benefits, I’m just like, you know, I’m hungry for more. Like, how do I, how do we become more efficient? How do we become, you know, how do we reduce treatment times? It’s better for not just the practice, but for our patients, right?

Alison Werner (19:42)
Right.

Yeah.

Yeah.

Yeah, well, Dr. Sherbell, thank you so much for joining me. I really appreciate your insights on this topic.

Jason Sherbel (20:12)
Yeah, well, thank you so much for having me. You know, it’s an honor. Yeah. Thanks again.