Why Dr. Tito Norris Switched Aligner Systems: A Lesson for Orthodontists

Alison Werner (00:03)
Hello, welcome to the Orthodontic Products Podcast. I’m your host, Alison Werner. Today we’re diving into what it takes for an experienced orthodontist to rethink their aligner system and why that decision might be worth considering for your practice. guest is Dr. Robert “Tito” Norris, an orthodontist who made the switch after years of working with one of the major aligner systems. Initially skeptical, Dr. Norris found himself frustrated by clinical limitations, operational hurdles, and patient outcomes that didn’t always meet expectations. What changed his mind? In this episode sponsored by OrthoFX, he shares what pushed

him to explore alternatives, what he discovered in the process, and why the transition made both clinical and business sense. If you’ve ever questioned whether it’s time to reevaluate the tools you’re using, this conversation is for you. Dr. Norris, it’s great to talk to you again. For

who

Tito Norris (00:47)
Thank

Alison Werner (00:47)
listened to the podcast, you have been a guest before, so thanks for joining me again.

Tito Norris (00:52)
A

pleasure to be here. Thank you so much for inviting me,

Alison Werner (00:55)
Great,

okay, so to get started for our listeners who aren’t familiar with your career, can you kind of share how long you’ve been in practice and tell our audience about your office in San Antonio? But also I know in talking to you that you studied mechanical engineering, which has shaped your understanding of aligner science. So can you also talk about that background? ⁓

Tito Norris (01:12)
sure, maybe I should start there and you know.

Alison Werner (01:14)
Okay.

Tito Norris (01:16)
College at UT Austin and studied mechanical engineering. And there’s a few of us out there in the orthodontic world who have an engineering background. And to me, I think it just kind of gives us a nice foundation regarding forces, vectors, moments, ratios. And then there’s a component to my studies that included a deep dive into material science. So understanding some of the molecular biology, some of the mechanical properties of the materials that we work with, having that background in material.

science has been very helpful throughout my career and so you know finishing up dental school and that was in Austin UT. Finished up dental school San Antonio, Washington DC for residency and then Air Force actually stationed in Japan where I

the chief of orthodontics which just means I was the only orthodontist in Japan and then following that I came back to San Antonio in 98 and opened Stone Oak Orthodontics. So for the past, I’ve been an orthodontist for over 30 years and been here in San Antonio in private practice for nearly 26 years now, 27 years, something like that. And along the way I’ve seen a lot of changes, know, and

Life comes at you fast. So right about 1999, this company called Invisalign, well even actually before that, when I was in residency, I was moving teeth with plastic, using the Sheridan technique, so some air rotors stripping, we would actually reset the teeth in plaster models, alginate, all that kind of thing, and just use a series of these clear aligners to move teeth.

Alison Werner (02:35)
Mm-hmm.

Tito Norris (02:59)
forward here we are 99 this company comes out that looks we’re gonna we’re gonna move the teeth digitally make this series of aligners so I was already kind of comfortable with it when it first came out but it was billed as sort of a orthodontics light if you will right they wanted us advised us to stay in the shallow end of the pool and did it really kind of do some you know Class I minor crowding a little bit of space closure that sort of thing well very quickly I sort of pushed the envelope and did a few

Alison Werner (03:09)
Mm-hmm. ⁓

Tito Norris (03:29)
interdisciplinary

cases because in my practice it’s pretty much always been about 50 % adult interdisciplinary cases. So if I’m have a tool, I need a tool that works for those sort of applications. so this sort of got the attention of Align and I got invited to be on their speakers bureau and their alpha group and eventually got invited to be on their clinical advisory board where the eight of us actually

designed attachments that most people are using these days. We sat in room in California and came up with some attachments designs and staging and things like that. had a long history with Align. I’ve spoken all over the country, actually all over the world for Align, everything from Japan to Europe. I had my systems deeply integrated with Align Technology since that time, since 1999.

Alison Werner (04:15)
Yeah.

Tito Norris (04:26)
⁓ What we found along the way is that, know, for some types of movements in particular, patients would just have, you know, multiple iterations of ⁓ case refinement and we still couldn’t really get there, right? There was just some movements that were just kind of tough. ⁓

Alison Werner (04:40)
Mm-hmm.

Tito Norris (04:49)
And so clinically, I’ve always sort of likened the analogy of basically aligners to sort of golf, if you will. So in the golfing world, you’ve got par three, par four, and par five holes. So that’s sort of taking it back to a parallel universe in the orthodontics where you’ve got kind of simple, medium, and challenging cases.

Alison Werner (04:58)
Mm-hmm.

Right.

Tito Norris (05:13)
So you take your driver and boom, you drive off the T-box and you hope that you can get it kind of close to the green on a, let’s call it a par four case. That would be amazing, right? If you can get it kind of close to the green and now you’re chipping, right? And that chipping would be your first set of refinement aligners, if you will. And you’d like to get it reasonably close to the hole. And then your second set of refinement would be like putting. So that sort of became the

Alison Werner (05:35)
Yeah.

Tito Norris (05:43)
analogy

that we shared with our patients and you know kind of always expecting sort of like two you know two series of aligners if we could on a moderately challenging case and then for things that are more challenging you know maybe maybe three sets of refinements and maybe occasionally on an easier case you get it done with you know one set of refinements but very few cases finish just like right on the money nailed it first time you know hole-in-one type of thing right.

Alison Werner (06:09)
Yeah.

Yeah.

So was there a particular moment, bring it fast forward, was there a particular moment perhaps a challenging case or a patient outcome or a recommendation from a peer that kind of transitioned your thinking of, need something else?

Tito Norris (06:26)
Yes, as a matter of was. And it was one particularly tough patient, and that patient was me. So I was in position where I ⁓ developed sleep apnea.

Alison Werner (06:32)
⁓ okay.

Tito Norris (06:40)
needed to treat myself orthodontically. And I wanted to use the aligners And so I heard about this new technology through OrthoFX. So I did a little test on myself and I used myself as a guinea pig. And so I scanned myself and I sent that scan, the same scan, I sent it to the three companies. I sent it to Align Technology, I sent it to Angel Aligners, and I sent it to OrthoFX.

And I got all three of those, ⁓ know, I treatment planned them all the same, you know, the same number of stages, same number of expansions, same number of everything. They were identical treatment plans, if you will. So I got all those aligners back and I was sitting right here on my desk where I’m sitting right now. And I basically took out the, you know, the Align, first aligner for Align Technology and put it in. And I said, whoa, like.

Alison Werner (07:16)
Mm-hmm.

Tito Norris (07:35)
that’s a lot of pressure on my teeth. And having had orthodontics in the past, I’m pretty familiar with the amount of pressure that is on my teeth. I’ve actually, this would be my fourth go round of orthodontic study. Some experience with what it feels like to put in like an equivalent wire in a parallel universe.

Alison Werner (07:36)
Yeah. ⁓

Okay.

wow.

Tito Norris (07:57)
So when I put the first aligner in from Align Technology, it felt as if I had put in a 19×25 TMA or even stainless steel wire. Like it was, whoa, like a lot of pressure, right off the bat.

Alison Werner (08:08)
Mm-hmm. Mm-hmm.

Tito Norris (08:10)
And

so I said, wow, that’s a lot. Maybe more than I would really want to put on my teeth in the initial stages of treatment. So I took it out, I grabbed the Angel aligner I put it in, and same thing, just a lot of pressure. And I would judge it to be over 1,000 grams of pressure. So well over two pounds of pressure on my teeth.

Alison Werner (08:14)
Yeah.

Mm-hmm. Mm-hmm.

Tito Norris (08:37)
And then I picked that out and I put in the OrthoFX on aligner and it was, it was just easy. It was just soft. was just very elastic and very comfortable and it went on without a problem. And I mean, it was if someone had just placed like an 012 or 014 nickel titanium wire, you know, in my brackets in my teeth. And so I thought to myself like, wow, this is, you know, if this can move my teeth and this can get me my results.

Alison Werner (08:48)
Mm-hmm.

Mm-hmm. Yeah.

Mm-hmm.

Tito Norris (09:06)
Well,

this is what I want to do for myself, right? So I went through my series of aligners with OrthoFX and nailed it. Hole in one and it was 25 aligners and I got exactly the amount of expansion that I wanted to get. It ended up with 10 millimeters gain in arch length and no refinements, not even any attachments actually. So…

Alison Werner (09:09)
Yeah. Yeah.

Yeah.

Mm-hmm.

Okay.

Tito Norris (09:35)
So I said, yes, if this is what I chose for myself and what I truly feel is best for myself.

you know, I probably need to start offering this to my patients. so, so if you look at the, you know, the actual, let’s go back to like the material science and what’s behind it and why is this, you know, so much softer and gentler. You know, most aligners out there are made from a multi-layer material. Okay. So it doesn’t matter if you’re 3M aligners, or Ormco aligners, or Invisalign aligners I mean, they’re all like a multi-layer material and that material was

Alison Werner (09:44)
Yeah.

Yeah.

Tito Norris (10:12)
invented by a man named Loc Phan And he is an molecular biologist who basically came up with this concept of this multi-layer material in about 2012, 2013. So this technology is basically kind of like 12, 13 years old. And…

You know, and it worked at the time and it was the best that we had at the time, but there’s something new and different and quite frankly better now. And the same scientist, Loc Phan has come up with a plastic that mimics nickel titanium. Okay? So all of the aligners out there, all the other aligners out there, I should say, really mimic the force level somewhere between TMA and stainless steel.

Alison Werner (10:31)
Mm-hmm.

Okay.

Tito Norris (10:55)
So as orthodontists, we’re kind of familiar with that. I mean, back in the seventies, right? And the orthodontists, didn’t have any choice. They had to move teeth with stainless steel. But what happened was eventually this new material called nickel titanium came along and it was just a much kinder, much gentler way to move teeth and teeth could move faster with less root resorption, more predictably. And so basically everybody moves teeth now with nickel titanium, and especially in the initial phases of treatment.

Alison Werner (10:58)
Yeah.

Tito Norris (11:25)
And

then once teeth get aligned and straightened, yeah, you might go to heavier wires to move teeth on those wires, but you don’t necessarily want to move teeth with those wires because it’s too heavy of a force, right? So if you look and measure the force that all of these multi-layer plastics are placing on the teeth, they’re somewhere between 1,000 to 1,500 grams, okay?

versus these OrthoFX, these truly super elastic aligners where there’s an air layer trapped in between ⁓ the ⁓ two layers of the plastic, a very thin flexible inner layer and a more rigid outer layer. And the air is almost like a Nike Air shoe. Like you put the energy in it and it stores that energy within the air and then it basically slowly and gently expresses it towards the teeth. And so now you have a force level that really never gets over 200 grams.

Alison Werner (12:01)
Mm-hmm. Right.

Okay.

Tito Norris (12:18)
and quite frankly that’s all you need for any type of tooth movement. It doesn’t matter if it’s translation, tipping, torquing, you know, whatever rotations, all you need is there under 200 grams. And so not only that, this material, all the other aligner systems out there, they have a quarter millimeter worth of recovery and a quarter millimeter worth of ⁓ basically movement programmed into each aligner. Well, these OrthoFX aligner actually used to have

Alison Werner (12:31)
Yeah.

Yeah.

Tito Norris (12:48)
four times that.

So they’ve got a millimeters worth of recovery and a millimeters worth of programming you can put into it. So what you have is an aligner that has a lot more range or elastic range, a lot more flexibility. So you end up using fewer aligners. And because that inner layer is so thin, it’s incredibly intimately adapted to your teeth. And it’s able to find these little teeny tiny undercuts that a multi-layer plastic

can’t. So now you need fewer attachments because they are much more retentive because they adapt to the teeth much better. You’re working with a super super thin inner layer of plastic and that’s the plastic that is intimately attached to the teeth.

Alison Werner (13:39)
Mm-hmm. So,

okay, so…

I know that OrthoFX has two clear aligner options in its portfolio. So I’m curious, which aligners did you work with in terms of your treatment? And then if you could talk a little bit about the difference between those two aligners, because we have the FX clear that has the 22 hour wear time requirement, which is the same as leading aligner brands. And then we have ⁓ the AirFlex, which has been shown to remain effective with the daily wear time as low as nine to 12 hours. So what was your experience? And then what can you say about those?

two options.

Tito Norris (14:12)
So

at the time I treated myself, I didn’t even know about those two differences. mean, I was just kind of blindly going into this. So I ended up with the FXClear product, which was very comfortable for me. But having studied a little bit more and talking to some people at the company, the AirFlex is even more comfortable, even more elastic. And so that’s essentially what I’ve been using for my patients ever since, ⁓ is that product.

Alison Werner (14:38)
Mmm, okay.

Tito Norris (14:41)
And we’ve actually done a little in-house study and looked at our finished cases and here’s what we found. We found that the OrthoFX aligners have half the number of attachments, basically half the number of ⁓ aligners, almost half the number of refinements, and much fewer appointments, right? Because if you have fewer refinements, you have fewer appointments in the office.

Alison Werner (15:06)
Mm-hmm.

Yeah. Yeah.

Tito Norris (15:11)
And if you can move teeth gently with lighter, gentler, more physiologic force, how can you go back to putting a heavy 1,000 to 1,500 grams of force on the teeth? I I find it very difficult ethically for me to go back to doing that to my patients.

Alison Werner (15:30)
Yeah.

Yeah.

Tito Norris (15:34)
because I know better now, right? And so that’s sort of, you know, my message to my colleagues is that, you know, there’s something out there that’s better. And what is our job as specialists is to know what the best products are out there, right? And to offer those best products to our patients. So we now have a product which is truly a super elastic.

Alison Werner (15:40)
Yeah.

Yeah.

Tito Norris (15:58)
It’s a hyper-elastic product. does not obey Hook’s law. It has an incredibly ⁓ friendly, what’s called a hysteresis loop, ⁓ which means the loading and the unloading curve is very, very light, very gentle. It works over a long range of action, much like a very light, ⁓ early nickel titanium wire. And that’s the best way I can sort of describe it. So I guess my… ⁓

Alison Werner (16:02)
Mm-hmm.

Mm-hmm.

Okay.

Tito Norris (16:23)
I’m imploring my colleagues to ask themselves and look into themselves in the mirror. Do you want to use a plastic that basically works like you’re moving teeth with stainless steel? Okay, or do want to use a plastic that moves teeth like you’re working with nickel titanium? I think the answer is pretty clear.

Alison Werner (16:25)
Yeah.

Mm-hmm

Okay. Yeah,

okay. And then in terms of the wear time difference between those two options, the 22 hour standard, industry standard, and then that nine to 12 hour, what have you seen with your patients and the cases you’ve treated?

Tito Norris (16:53)
Well,

I’m kind of like Elmer Fudd, if you remember him from the Bugs Bunny Show. I’m really quiet about the fact that they can get by with wearing their aligners only 12 hours a day. ⁓ Because whether you’re talking about cardiovascular medications, diabetic medications, or aligners, compliance rates are usually about 50%.

Alison Werner (16:56)
Yes, yes.

Okay. ⁓

Tito Norris (17:15)
OK? So if we can ask for 20 to 22 hours a day, maybe we’re going to get 9 to 12. And then, hey, we win.

Alison Werner (17:22)
Yeah.

⁓

All right, that’s fair. And then for those patients who might actually be really good at compliance, maybe they can get the nine to 12. Yeah. Okay. So what has the impact on your office been of adopting the OrthoFX system, just like in terms of like staff workflow, training or support?

Tito Norris (17:34)
Well, their teeth are just going to be really, really awesome. And they’re really going to attract great, you know, because they were fantastic.

Yeah, there’s really, you know, anytime you implement change into an office, typically there’s a pain point, right? Because you’ve got new systems, new software, new things. From a team perspective, there’s virtually no change, okay? I mean, the boxes come in the same shape as the previous boxes we were using. They can sit in side by side, they’re just a different color. You know, the attachments go on in a very similar way, except they have an improved

attachment material that never sticks to the aligner because the same scientist, Loc Phan has this amazing no stick. It’s like a Teflon pan for aligners. So attachments are a breeze. I’ve been working with them in terms of improving their attachment design to make those more friendly, make them more effective, because like I said, I’ve got some background with this. So that’s definitely coming along. so really, I mean, from

a patient’s perspective, they’re just going to put them on and they’re just going to be like, ⁓ wow, this isn’t going to be bad at all. Right? From a team perspective, really what it means in your office is you’re going to have fewer refinements and fewer appointments. So that’s kind of a win-win situation for everybody, your patients and your teammates and your profitability of your practice, quite frankly, if you can get it done with fewer appointments and get things done more accurately.

Alison Werner (18:59)
Yeah.

Yeah.

Yeah.

Tito Norris (19:21)
So

in terms of a workflow, this is not one of those workflows that upsets the apple cart. Like if you’ve got your systems dialed in, you just kind of take out one cog in the wheel for another, and now you just have a high performance aligner where you didn’t before.

Alison Werner (19:31)
Mm-hmm.

Yeah, okay. So to close us out with kind of the ongoing innovation in aligner technology and kind of shifting patient expectations, why do you think now is the right time for orthodontists to reevaluate the systems they’re using?

Tito Norris (19:53)
I think it’s a great question. ⁓

I think that very often we get very blissfully comfortable in what we’re doing. And if you remember, it wasn’t too long ago where we were very uncomfortable with aligners as a profession. And damn, those aligners and GP’s are going to be doing them. And was just a lot of them. And aligners were like, arrows, arrows at the aligners. Well, aligners are pretty well accepted now. But it took sort of a paradigm shift to get there.

Alison Werner (20:11)
Mm-hmm. Yep. Don’t trust them for everything.

Tito Norris (20:26)
Now most offices, they’ve got scanners, they’ve got aligners, and they’ve got systems within their office to deliver aligners. so really, the big difference is now that we have an aligner that’s, we have all the other aligners out there, right? And then we’ve got this superior aligner, which mechanically, from a mechanical engineering perspective, from a physiologic perspective, there’s nothing like it.

is simply nothing like it. There’s nothing even close to it. It is far superior. There’s actually a study that looked at the effectiveness of all the current aligner systems, the multi-layer plastics. And basically, whether you’re tipping, whether you’re torquing, whether you’re rotating, the mean effectiveness of those aligners was somewhere around 45%.

Alison Werner (20:59)
Yeah.

Tito Norris (21:21)
A similar study was done with the OrthoFX aligners and the mean effectiveness was 84%. So roughly twice as effective with all the movements. So if you have an aligner system that delivers more gentle forces here for patients, that’s more comfortable for your patients, that you put on and off half the number of attachments, okay, the team loves that, right? A lot fewer, the patients love that, that there’s half the number of attachments we used to have.

Alison Werner (21:41)
Right.

Yeah.

Tito Norris (21:49)
And now you’ve got an aligner that performs twice as good as the previous aligners you were using with 84 % effectiveness rather than 45 % effectiveness.

I mean, this is just such a no-brainer. To me, it’s just really hard for me to go back and for me to put in ⁓ an aligner that I know is putting 1,000 to 1,500 grams of pressure on my patients when I could be giving them and prescribing them an aligner that’s giving 200 grams of pressure. As an orthodontist, I just can’t do it anymore.

Alison Werner (22:04)
Yeah.

Yeah, yeah.

Well, I really want to thank you for kind of sharing your experience. And I really I was not expecting you to say that you were the patient. So I think, you know, that’s just a really unique perspective, because how often and how often do you does an orthodontist hand a patient three different aligners and say which one feels most comfortable? So, you know, I think that’s right. Right. Mm hmm. Yeah.

Tito Norris (22:40)
Right. Right. Yeah, I mean, you wouldn’t do it. I mean, you’d never do it on a single patient. You’d never order multiple aligners But I wanted to try it. I wanted to see it and feel

it for myself. And to me, the proof was in the pudding. so I, you know, and it was, was handy and it wasn’t even close, right? It was, it was not even close.

Alison Werner (22:59)
Yeah, yeah, yeah.

Well, I think the lesson to your colleagues is go try orthodontics on yourself some more time.

Tito Norris (23:06)
Yeah,

maybe a team member, right? Go ahead, order a set of aligners and order a set of OrthoFX and have your team member report on what they feel. And I guarantee you, they’re going to be OrthoFX every day, all day, all the way, because it is way, way, way more comfortable and more predictable.

Alison Werner (23:11)
Mm-hmm.

Yeah.

Hahaha

Well, Dr. Norris,

thank you so much. I appreciate it. Great talking to you again. Thanks. Definitely. Take care.

Tito Norris (23:31)
Sure thing else, it’s always a pleasure and look forward to our next conversation.

Bye bye.