Pacific Coast Society of Orthodontists Bulletin Spring 2021 - 47

Doctors

Presentation Summary

In-House Digital Orthodontics:
Lessons From the Past Four Years
Dr. Bruce P. Hawley
Lynnwood, WA
PCSO Bulletin Contributor

Presented by Dr. Jep Paschal at the PCSO/RMSO/
MSO/SWSO Annual Session, Oct 2, 2020
It is now possible to plan treatment, design,
manufacture, and distribute clear orthodontic
aligners at a fraction of today's typical cost. Dr.
Paschal reviews how to implement the in-house
production of clear aligners from the consultation
room to the delivery appointment, along with a
few lessons he has learned along the way.

Dr. Jep Paschal
Paschal Orthodontics

Dr. Jep Paschal believes that the most dangerous
phrase in any language is " we have always done
it this way. " The old modality was that patients fit
into one technology; the new modality involves
multiple technologies to fulfill both patient
needs and desires. In orthodontics, we have seen
technology move from brackets to aligners to direct-to-consumer aligners. A " braces or aligners "
approach has moved to an " aligners and braces "
approach, with a higher cost to the patient. Dr.
Paschal is moving into a more fluid system with
in-house aligners and braces, all in an effort to
decrease the time in fixed appliances for the
patient. (He finds that more than 12 months with
fixed appliances becomes increasingly difficult for
patients.) He no longer considers aligners as his
most effective orthodontic modality, and he uses
braces as his " heavy lifting " appliance. He often
takes a " sagittal-first " workflow, beginning with a
motion appliance, then moving into aligners, and
subsequently doing refinements and detailing
before moving into retention.
Challenges and Suggestions
Dr. Paschal views several challenges with today's
aligner market: a lack of control, time-consuming
treatment planning, difficult communication,
long lead time, high laboratory cost, and potential
loss of one's " brand " to the manufacturer. We all
need to learn how to be superb digital lab technicians. People who seek direct-to-consumer orthodontics may not be our real orthodontic market.
He estimates that there are 122 million individuals
in the United States who have a need or a desire
for orthodontics, as compared with the 4.5 million

Spring 2021    PCSO Bulletin	

patients now being treated orthodontically. We
need to deliver trust and value to our patients
through the customer/patient experience, decreased treatment time (especially in braces), and
making the complex predictable. People tend to
buy based on the experience, not necessarily the
quality of treatment or work rendered, and the
reality is that the better business will " beat " the
better clinician. In addition, offering our patients
payment options beyond the active treatment
time is a safe thing to do, given that 95% of patient financial defaults happen during treatment.
Digital Lab
The design and manufacture of appliances can
be accomplished by an outside lab or an in-house
lab. Various combinations are possible, such
as having an outside laboratory do the design
but print in house, or vice versa. Projects can be
designed and manufactured by the outside lab
entirely or can be done totally in house. Think of
patients as a virtual type of entity, beginning with
a scan, going to a plan, and then printing and
manufacturing. The Trios, Kulzer Cara i500, and
Planmeca Emerald scanners are all good, in his
opinion. Acquire amazing scans and be as critical
of your scans as you are with impressions. Look
for distortions, bubbles, and holes. Record the gingival tissues as with an impression and determine
whether you are going to capture palatal tissues
or not. The artificial intelligence will recognize
the teeth but beware of the scanner incorrectly
" filling in " things that are not actually there.
Three-Dimensional Printing
Dr. Paschal stresses that the three-dimensional
printer in the orthodontic office needs to be
maintained. He has four in use at any given time
and keeps one in reserve as a backup for aligners
and retainers. Each active printer is generally in
use for about 18 hours per day. In the printing
process, liquid acrylic is solidified by the lens,
layer by layer. Three such printer brands can print
in under an hour: Form Labs 3B (his first choice),
SprintRay Pro, and Envision TEC. Areas to keep
in mind include the file-to-finish time, accuracy,

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Pacific Coast Society of Orthodontists Bulletin Spring 2021

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