Introducing the "Orthodontic Products Podcast", a journey into the dynamic realm of orthodontic innovations. Each episode dives into fresh research, transformative technologies, and the methodologies redefining the field. Expert interviews seamlessly blend with in-depth analyses, offering listeners a comprehensive look into the ever-evolving world of orthodontics. This isn't just a podcast—it's a portal to the future of orthodontic practices and breakthroughs.
Hello and welcome to the
orthodontic products podcast.
I'm your host Alison Werner.
Today we're kicking off our 2024
season with Dr. Robert Tito
Norris. I had the privilege of
profiling Dr. Norris for our
September 2020 Cover Story of
the magazine, which at the time
coincided with the launch of the
Norris 20/26 passive, self
ligating bracket and wire system
he developed with Dynaflex. And
now we have him back to talk
about the systems, products and
technologies he has employed to
achieve clinical excellence so
efficiently, and how that
translates into a better work
life balance. Dr. Norris, thank
you for joining me today.
Thanks for having me, Alison. I
really appreciate it.
Great. So for those in our
audience who aren't familiar
with you, can you talk about how
you got into orthodontics and
your current practice? Sure,
well, I guess I gotta go all the
way back to college. And first
of all, I should probably say
that I'm in treatment myself,
right now I have MARPE and a
nice little gap between my two
front teeth, and I'm not
enunciating as clearly as I
might otherwise. I've gotta big
old custom MARPE in the roof of
my mouth. Okay, so back to back
to college. I was studying
mechanical engineering at UT
Austin. And my whole life, I
really wanted braces for the
first time. I had job insurance
and I had no money. And so I
wouldn't I got orthodontic
treatment while I was in
college. And just kind of
sitting there in the chair, when
I had this epiphany. It's like,
you know what, orthodontics is
just a lot like engineering to
the mouth. And there's actually
a person attached to it. And not
only that, the person has, you
know, has feelings, it has
definite, definite emotions
attached to their teeth, and
their smile, and so forth. And I
noticed myself as my tooth
became straighter, just becoming
more confident in myself and my
smile. And to me, it was an
amazing transformation. And the
fact that I could use my
engineering training and the
ability to think in three
dimensions and solve three
dimensional puzzles, to apply it
to this, this profession. So I
made kind of an about face and I
left the College of Engineering
went into pre dent, and it was
able to kind of quickly get
those prereqs taken care of, and
then you know, sort of like the
rest of history, if you will. I
have to say that when I was
studying engineering, I mean, I
could do it, I could force
myself to do it. But I didn't
love it. And I'll never forget,
like my first week of dental
school when the dental anatomy
professor assigned us a book
chapter to read. And then I read
it. And I just was fascinated
with the anatomy of the teeth
and the fact that every tooth
has a different function in the
mouth and a different shape to
perform that function. And so I
ended up staying up all night,
you know, up late, I read that
whole book that night. And that
had never happened to me in my
educational career where I was
just like really passionate
about something. And from that
point on dentistry, just and
orthodontics was just no longer
a chore. I mean, it was really,
it was a pursuit of a passion
that I still have to this day.
And so you know, all through
dental school all through
orthodontic school, I just
absolutely love studying this
stuff and kind of pushing myself
to learn more and stay on the
leading edge of what's out
there. And and that that's part
of what led me to some of the
things I've come up with over
the years.
Okay, and so you're practicing
at San Antonio.
That's correct.
Okay, so, um, what I want to
talk, I know you have a very
busy practice, you're treating
over 900 cases annually, you had
mentioned, we had talked
earlier, and you mentioned that.
So I want to talk about how you
create efficiencies in your
office and the systems you've
employed to treat, kind of with
your visits while maintaining
those, you know, those
impeccable finishes that you
want. So what is key to creating
that treatment efficiency while
maintaining excellent outcomes
in your office?
I mean, I hate to boil it down
to just one word, but it really
is just one word and it's
systems. You've gotta have
systems from from the, for the
moment that the patient enters
or calls the office, there's a
system to how we answer that
phone. It's a very systematic
new patient examination because
there's a lot of lot of data
that we'd have to collect in a
new patient exam. And we look
very thoroughly into things.
What's the position of their
skeletal bones? What's the
what's their airway situation,
how they're breathing? Are they
sleeping, you know, we're
looking at them, facially. I
love I love David Sarver's,
macro aesthetic, mini aesthetic
micro aesthetic evaluation, so
we incorporate that into the new
patient exam. We incorporate
Bill Robins core diagnostic
process into the base exam. And
I do have a partner and
associate So we each have to
have that systematic approach to
the way that we assess and
diagnose patients. Furthermore,
we've had to have systems about,
you know, how the braces are
placed. And so indirect bonding
has been kind of a hallmark,
actually, I've been doing it
since residency really helps,
you know, that bracket accuracy,
just getting gets his braces on
just at the right positions. And
that has been really, really
helpful in terms of creating,
you know, just just parity and
equality in terms of our cases,
because we all get to look
through the same set of eyes
that how those brackets should
fit the teeth. And then, of
course, you know, with the
advent of a more accurate
bracket, wire interface system,
and the Norris system whereby we
no longer have all the all the
slop that we had, when we were
doing an oh two bracket system,
we now have a bracket that
actually fits the wires that we
like to use. So you know, part
of that systematic treatment of
a patient is to treat a patient
using three or sometimes four,
orthodontic archwires, right. So
that just really reduces the
number of thumbs in the pie
there and really helps us
maintain our consistency no
matter who's treating the
patient, you know, we can we can
start them very efficiently we
can we know exactly what's going
to happen at the next
appointment. All those
appointments are very
systematic, and, and the data
really speaks for itself. And
that is if you look at what's
published out there, through
American Journal of
orthodontics, and also JCO, you
know, to get a good finish, the
average is somewhere between 20
and 26 appointments, which is a
lot. And so we're recruiting
patients in literally half of
those numbers of appointments.
Right now, our numbers are 12
appointments for teens and 13
appointments for adults. And so
that is, that's really key and
to kind of keep an eye on the
prize and look at how it's like
a game, right? And you've got to
keep score, right? If you want
to win the game, you got to be
able to keep score. So we
actually have a column within
our EMR software, we happen to
use too often. Where we have
created a column where you have
to fill in okay, this is
appointment number one, this is
appointment number two. So it's
pretty easy for us to go back
and countless number of
appointments, and we're really
focused on that in terms of, you
know, how efficiently can we
treat every single patient and,
and get a great result, right?
Because we have to have that go
through another set of systems,
another set of checklist, if you
will, with before the patient
get the braces off, you know,
what's their incisal display and
repose? What's does their
smilearch like, where are the
buccal corridors, how's the
occlusion? You know, all these
little things, that we all have
to go through the same
checklist. And that is a system
within our practice. And even
after the braces come off, and
we start looking at things such
as you know, gingival margins,
and we look at some of the micro
aesthetic issues there, you
know, it's a coloration of the
teeth simply changes some teeth
and some buildups you know, all
those things are once it gets a
systematic approach to how we
how we view things. We do have a
number of aligner patients in
our practice as well. And that
is a fairly efficient way to go.
But aligners just can't do
everything. So that's what we
got to embrace. We do a number
of interdisciplinary treatments
in particular, we we've kind of
known for patients who are
having airway issues. In fact,
that's why I've been treatment
myself as I've developed sleep
apnea. As I've turned 50, I kind
of developed sleep apnea. And so
now I'm, you know, treating
myself and honestly, it's the
last 10 nights I've slept better
to have in years and years is
pretty amazing.
Okay. So you mentioned those
interdisciplinary cases. Can you
talk at what how does the
workflow change does the
workload change anyway with
those cases to maintain your
standards?
It does. Okay. So one of the
things that is the hallmark of
most of our interdisciplinary
cases is that a lot of those
cases are going to have wear on
the teeth and basically, this is
almost half our practice. 50% of
our patients are adults. And
those patients that have worn
teeth, missing teeth, fractured
teeth, whatever. The first step
is, well when evaluated gingival
architecture and see if they
have APE altered passive
erection, that's usually the
first step is to get them back
to a periodontist, establish
proper gingival architecture.
Once we have that, then we can
go ahead and send them to the
dentist and have them build up
those teeth so that now we're
dealing with basically virgin
looking teeth they provisional
buildups on those teeth, so that
now we can use use that as a
three dimensional blueprint for
communication between us and the
restorative dentist because
eventually those teeth are going
to be restored with you know,
some long-term provisional,
something of porcelain usually.
But if they can do it in
composite, or some other resin
ahead of time, before they get
the braces on that it really
helps us because now we have an
accurate incisal edge from which
we can measure our bracket
position. And it just helps the
treatment go so much more
efficiently. Furthermore, when
you when you a lot of these
patients have like anterior wear
and maybe not quite as much
posterior wear is but when you
when you build up the teeth
anteriorly you're left with a
kind of a little bit of a
posterior open bite, because
we're gonna put them in some
bite turbos and so. So you're
able to use extrusive mechanics,
which are much faster than
intrusive mechanics, because
many, many dentists will say,
hey, you know, intrude these
teeth for me, in the talking
about the maxillary anterior
teeth, give them some
restorative spaces, they can
then go back and lengthen the
teeth at the end of the
treatment, we'd like to do it on
the front end, where we just
restore the teeth on the front
end, and then we can extrude the
posterior teeth into occlusion.
And that's a much more efficient
way to treat these patients. And
many of these patients finished
in under under a year. Selecting
the treatments that are that are
most efficient and selecting an
appliance it's most efficient
for each particular case.
But then you have those systems
in place where you have kind of
that checklist to know what to
go through so that you can
maintain that efficiency as
you're going through even if the
case is a little different or a
little more complex.
Absolutely. And we've got
different checklists for
different types of patients. For
instance, we've got a lot of
what we do to cuspid
substitution. So we have a
number of patients who are
missing maxillary lateral
incisors. And in my practice, we
simply don't treatment plan
implants, we always do custom
substitution on these cases. So
we have a very systematic
checklist of what needs to
happen step by step in order to
produce a beautiful smile. And
to do it in a systematic manner.
And there's certain times that
we do each of these different
steps and it's everybody in the
practice knows it and we sit
down the assistants know what's
going to happen. And it really
helps things run very smoothly.
Can you talk a little bit about
what it entailed to set up
something like that a checklist
or a system? Can you take an
example of one checklist or
system you've put in place? And
what kind of thought process
went into it? And what kind of
data went into creating that?
Sure. So let's just take the
example we're just talking
about, let's say cuspid
substitution case patient was
was missing their maxillary
lateral incisors. Okay, so from
the new patient exam, I mean,
obviously, we want to the
beginning point of the of the
treatments where ultimately
where do you want your maxillary
incisors to fit in the face, the
maxillary incisors are the
central focus of the smile,
okay. And in many of these
cases, feel they need to be
maybe even a little bit more
forward than where they are
right now. And so, you know, we
before we even bond the case, we
will go ahead and convert the
cuspids to the laterals. And
then we'll basically use some
coil springs to push those
maxillary teeth into the correct
position within their smile, but
vertically, and then we look not
only where they are, up and
down, but also left and right
and make sure we don't have a
cant going on. And also AP, we
want to have the right smile
projection of those teeth. Once
we get that set, then the next
step is for us to basically lock
those teeth into place, we use
something we call a y-bar. All
right, and it looks like the
letter Y goes the roof of the
mouth. And it leverages off of
two palatal tads. And this would
be a system where you know, the
assistant knows I mean, step
one, they already know that
we're gonna be doing those,
those cuspid conversions, okay,
so they have everything set up
for us to do the cuspid
convergence. Step two, they know
that we're going to be pushing
the teeth of the popcorns beans
already ready. Step three, we
know we're going to be putting
in the y bar. So we'll have all
that the TADs ready for us to
insert that and the lab knows
how to build the appliance and
assistants actually deliver
those appliances. And then, you
know, when we're protracting the
posterior teeth, you know, the
assistant knows that we gotta
have buttons on all the four
fives and sevens too, because
we're gonna protract for the
facial to the lingual. So all of
those little steps this this
team knows the team knows every
single step along the way. How
do they know because we've done
the training. Okay, so we have
an in house, one of our lead
clinical assistants is our is
our clinical trainer. And so we
reviewed these cases, and any
new patient or any new employee
basically goes through this
training manual and knows these
steps step by step by step. So
there's really no surprises
here. And it just, we have such
an amazing, talented team of
people because we've we've
brought them up that way we
brought him through the farm
league, and now they're playing
in the pros. And they I mean,
when you're a pro you don't you
don't miss a step because you've
done it so many times. You've
practiced it so many times. And
so now it's game time and you
know what needs to be done.
Everything's out, everything's
ready to roll. So when I sit
down, you know, boom, they just
hand me this, this, this and
this and you you know, I'm out
of there. It's just, it's just
simply a matter of training, got
to have those training. And that
training has to be such
systematic and different levels
of expertise among the clinical
assistants as well. And
everybody has a little ladder or
little little carrot to get to
the next level, because that
next level, obviously means
better compensation for you when
you master the clinical acumen
that it takes to do some of
these more complicated
movements.
Now, a key component of great
outcomes and efficiencies is the
products and technologies you
employ. And as you mentioned,
you have developed several
orthodontic products over time
that do just that. So can you
talk about the products and
technologies that are key to you
getting the facial aesthetics
and finishes you want, when
you're treating patients in your
practice?
Well, I think that's a great
question. I mean, you know,
obviously, the Norris bracket
has been, you know, the hallmark
of our practice here for the
last seven years. And in the
whole thing, it's all about
finishing. And for the first
time, we actually have a bracket
that fits the wires that we like
to use, most people finish it in
19/25 wire, and with a 20 slot
bracket, you can get a really
nice torque control of these
teeth and great rotational
control. So it's just really
control and finishing what it's
all about, you know, when I've
talked about those efficiency
numbers, in terms of, you know,
12 or 13 appointments, you know,
we don't, we don't make up that
ground in the first two or three
appointments make up that ground
in the end in the finishing
appointments. Because the teeth
move, you know, you put a little
bend in the wire and the tooth
goes exactly where you want that
to be because there's no slop in
the system. The system is a very
tight, it's the difference
between, like driving like an
old farm truck with a bunch of
slack and the steering wheel
versus driving like a Formula
One race car, where because
exactly where you need to be. So
in a way, this has made us
better orthodontists because
it's made us better bracket
positioners. And we've got to be
extremely accurate with our,
with our bracket positioning. So
you know, first and foremost,
it's just, you know, that system
right there, the smaller 020
bracket system fitting in 19/25
wire, that's the biggest thing
in our practice, okay. Beyond
that, I mean, we obviously we
love in ART spring, it helps to,
you know, control that torque a
little a little more on the
interior teeth, it's very, we
love the CS springs for class
three patients. We love the
motion appliance for early you
know, kind of class two type of
stuff. And yeah, those are those
are mostly, you know, other
other other things, you know,
like for instance we've got a
handpiece, multiple handpieces
every chair, you know, with
light, we've got great lighting,
we've got suction, we have great
air, I mean, it's just easy when
you sit down, everything's right
there, you don't have to ever
get up and get anything. Okay.
Ergonomically, you know, we did
a whole thing when I built the
office in terms of ergonomics,
and I wanted every assistant to
have everything. So we have a
lot of duplicity at each chair.
No one ever has to get up to get
a plier. You don't pick it up at
the wire, you don't have to get
up to get anything, because
every unit is self contained
there.
So it's not just about having
the products in the moment of,
you know, applying the braces or
moving a wire, I think it's
having everything in place, from
the instruments to the chair to
just be able to get going right
then in there.
Execute. Okay, execute right
there. And there's no delays. So
it's yeah, that's a that's a
that's a, I think I recently saw
a patient in a friend of mines
office, I'm not going to mention
it, but oh, my gosh, you know,
the burs were over there, and
the handpieces were over there.
And it was just like a madhouse
trying to get what I needed down
into this one room with this one
patient. And, you know, and I
realized, yeah, you know, it's
an investment to have all those
things, you know, it's have
everything in each of your
treatment rooms, I get it, but
it's a one time expense. And
once you'd have those things,
you know, they're going to be
there for years and years to
come. And you're going to save
on, you know, just simply time.
I mean, that's your most
valuable asset. And so, you
know, I mean, it's sort of like,
what is it pennywise pound
foolish or something like that.
And so I'm more than willing to
make those investments to for
the ergonomic efficiencies that
we get out of it, as well.
Yeah. Well, I was my next
question was going to be how
does this efficiency tie into
profitability? And you kind of
talked about there about making
that investment up front with
your office design and, you
know, making sure you have the
resources to accommodate all
those patients to begin with.
But can you talk a little bit
more about how these
efficiencies within your
treatment have helped with
profitability?
Well, sure, um, you know, the
thing is, listen, every case
should we've kind of broken down
to how many appointments did I
did it take me to finish that
case? Okay. So if it took you
let's just take an example.
Let's say $5,000 case, and took
you 10 appointments, okay,
that's $500 per case, right? So
the same case $5000 case, if it
took you 20 appointments to
treat that case, well, then you
made $250 per visit. All right?
So the efficiency and the
profitability is pretty obvious
the least number of appointments
is making more profitable. And
yes, we all care about profit
and so forth. But I'm, I'm just
at this point in my career, I'm
more interested about time.
Okay. So I mean, imagine we have
roughly 2000 patients in
treatment, right? And we're able
to treat those patients with
half the number of appointments
that we might otherwise treat,
or they might be treated in
another office. So, so what I
mean, what does that what does
that mean? I mean, that's,
that's, that's 1000s of
appointments that we've saved.
And so what do you want to do
with that time? For me, that's
more of a life balance type of
question. And, you know, I, I
love what I do. I love
orthodontics, but I also love a
lot of other things. You know, I
love travel, I love skiing, I
love my family. You know, it's
it's nice to have that sort of,
you know, ability to have some
time off to sharpen the saw to
go to meetings to do other
things. I don't feel like I'm
just, you know, always at the
office, because I'm not.
Okay, well, that was gonna lead
into my next my next question is
actually going to be about the
fact that you know, you do
lecture frequently you do
conduct in office courses. So
I'm guessing these fewer
appointments, which frees up
that time is allowing you to do
those things. So can you talk
about that work and kind of the
topics that excite you that you
enjoy lecturing on?
Well, there's no way that I
would be able to do all the
other things that I do. I mean,
I'm a competitive swimmer. I
lift weights three days a week,
I go surfing on the weekends,
you know, I take 15 weeks off
every year, you know, whether
it's in meetings, or lecturing,
or whatever. And there's just
there's absolutely no way I can
do that stuff, if you know, if I
weren't extremely efficient at
the office. And that's the only
way that's ever going to happen.
And so when I give the courses,
you know, when one of the things
I mean, obviously, I'd love to
talk about efficiencies, I like
to teach people how to be
efficient, not only like how to
place the brackets on the teeth,
but the systems and how to use
for your archwires and all those
kinds of things. What excites me
most I mean, honestly, I love
interdisciplinary care. And I
have for a long time, I think
it's, it's, I think it's next
level orthodontics, I think you
have to think quite a bit on
some of these cases. And, and
some of these can be the most
rewarding cases, when you're
really changing someone's life
if they've got, you know,
missing teeth, worn teeth, and
they live like this. And they
feel like they're almost
invisible. And you give them
this new big brilliant smile.
And they just I mean, they're in
tears, they just they feel self
confident rather than, you know,
self conscious, you can really
change someone's someone's life.
But I think as I look at at the
future of orthodontics and
what's what's on the horizon,
what's what's happening, I think
the biggest area for growth is
going to be in the area of
airway friendly orthodontics.
And I don't want to beat people
over the head with this, but my
practice has changed
dramatically in the last 10
years. And, you know, we're
helping people in ways that
we've never been able to help
them before. And, you know,
patients come in, and we go
through a whole exam, and you
know, they just came to
straighten their teeth, and they
end up you know, improving their
airway and they're sleeping
better, they're breathing
better, and their life has
completely changed, you know,
whether it's children or whether
it's adults. You know, now we
have those technologies to to
help everybody. Basically, I'm
kind of living proof right here
with my MARPE going on. I'm 57
years old, I'm very hard headed,
and I got a skeletal split of my
maxilla. And I basically
resolved my sleep apnea here in
a relatively short period of
time. That was unheard of when I
graduated from residency 30
years ago. And that we would be
you know, not just straightening
teeth, but really helping people
live better lives, live longer.
I mean, just simply speaking,
you know, if you can resolve
someone's sleep apnea, you've
given them 10 years to their
life. That's phenomenal. Yeah, I
mean, what's your most precious
valuable asset it's time and
time and time you've given 10
more years of life. So you know,
for those who have not gotten on
the I want to say bandwagon but
who have not gotten educated
themselves in terms of the
benefits of a MARPE or a custom
MARPE dun procedures, sharpe
procedures, those kinds of
things. If we're not looking at
airway, you're never going to
find it in dentists are in a
very dentists and orthodontists
are in a very unique position to
recognize early signs of airway
problems. Everything anything
from just like snoring to tooth
grinding, okay, open bites,
tongue thrusts, all these kinds
of things can have to tie into
that the airway component So
that's one of my favorite
lectures to give. And they tend
to be very eye opening for a lot
of patients, and they go back
and they look at their patients
with a different, totally
different way. And and now that
we have all this all these new
tools at our disposal, I mean,
orthodontics has been through a
major overhaul here just fairly
recently.
Yeah. I know. Before working on
orthodontics magazine, I
actually did work on a sleep
medicine museum or magazine. So
I'm actually curious, have you
incorporated questions about
sleep habits and breathing into
your patient evaluations?
Absolutely. That's a seminal
part of it. In fact, the
Chervine Sleep questionnaire is
its diagnostic. It's actually,
for instance, remember, when you
were a general dentist, like if
someone brought to you, like a,
like a bitewing X ray, and it
had a, you know, it looked like
a cavity, a caries lesion on
there. I mean, you were pretty
much committed to it, you
couldn't ignore it, right? Like,
you would have to treat that
cavity or at least inform the
patient that you have a cavity
that needs to be treated, or it
could turn into a root canal, or
you could lose a tooth. Well,
the Chervine sleep
questionnaire, which is part of
what we do, you know, for
kiddos, and we have another one
for adults, it is a validated
instrument. In other words, you
know, if if someone answers, you
know, eight or more on that
Chervine sleep questionnaire,
you can send that to an ENT, and
they can't ignore it. For years
and years and years, I was
trying to do more airway stuff,
and if sending these patients to
these local ENTs. And there was
a well, yeah, they have class
three tonsils, but you know,
I've seen bigger, insurance
isn't going to cover it unless
they've had so many infections.
Meanwhile, you know, the poor
child is not sleeping, not
thriving, they're struggling,
they're they're mouth breathing.
It's, it's really, it's really
been a shame that we haven't had
the support, but once you kind
of educate your colleagues and
align them and show them what
you can do, and how they can
help as well. It's really,
really great to have that
interdisciplinary team on board
with everything.
Going back to your lecturing and
everything, and you're in-office
half his courses. Do you have
anything coming up in the next
few months?
Absolutely. Well, there's
there's two courses coming up.
One is next month, that's going
to be in Scottsdale, and I'm
lecturing with Chad Foster
there. And that's going to be
focused really more on
orthodontic aesthetics and
finishing. And that's, a course,
that we've given several times.
And the feedback that we've
gotten has been has been really,
really positive, very eye
opening for a lot of people.
He's got some really, really
great stuff to share. And of
course, we both make some
contributions there. And then we
do an in house course twice a
year, every May, and every
October. And those can be found
on the Dynaflex website, if you
just open up dynaflex.com and
it'll pop up right there. Yeah,
once you're up to date in office
course, and we cover everything
from indirect bonding MARPE even
systems within the practice, you
know how to answer the phone? We
do. Yeah, I mean, we actually is
very much involved in taking
excellent records. You know,
Disney level service, team
building training, you know, all
is a pretty comprehensive thing.
And then we go through airway we
get through interdisciplinary
care, cuspid substitution, solar
transplantations. It's more of a
hands on type of thing.
So Excellent. Well, Dr Norris
thank you so much for speaking
me today. I really enjoyed our
conversation and I hope our
audience finds everything you
had to say really helpful,
because I think it was.
Thank you so much Alison. It's
been a pleasure.
Great, great. Yes. Great to see
you again, too. Okay, take care.
As always, thank you for joining
us. Be sure to subscribe to the
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time, take care.