July, 2003

Interview with Dr. David Sarver

En Español

Charlene White

What technology do you believe will impact the orthodontic office in the near future?

Dr. Sarver: Is it fair to say that the picture is unclear right now because there are so many different developing types of technologies? There are many pieces of a larger puzzle not yet connected. What do I think the larger puzzle is? In other words, what is the big picture that we as orthodontic clinicians are looking for? The big picture, at least in my mind, is patient specific treatment planning, from macroesthetic issues to mini and micro issues. In macro-orthodontic planning, this means visualization and quantification of dentoskeletal diagnosis and treatment planning, from growth modification, dental movements, and surgical changes which can greatly affect the patient’s facial appearance. In mini-orthodontic planning, developing technology may lead to precision placement of appliances for both occlusal design and smile design. This precision of bracket placement may occur at an unprecedented degree to the micro-orthodontic goal of actually visualizing occlusal contacts attained with certain bracket placement! In terms of orthodontic appliance design, the past 25 years of straight wire appliance use has produced an enormous leap in quality of treatment, and treatment efficiency. We now have developing elements of three-dimensional imaging, changing bracket placement ideas with targeting instrumentation, and image calibration of the smile framework with targeting of bracket placement to desired smile design. I think that is going to be one of the biggest changes in the next five years for us is our concepts of bracket placement. Right now we have these tables that clinicians publish where you should place brackets on every patient. Every patient gets the same bracket placement. The changeover will be that every patient will get a different bracket placement dictated by their specific lip/tooth relationship at rest and on smile. The problem is right now is how do you know where to put them then? I understand the concept, but how do I specifically know where to put them? That is the technological challenge. We want to be able to measure and direct bracket placement according to new criteria but being quantitative about it. That is what I see as my next development challenge is pulling those concepts into reality, and is an area I feel we have some really significant technology in development.

The next big thing probably is the next logical step from Straight wire appliances, but with a broader application of the tenets of Straightwire philosophy that will require a real shift in how orthodontists think. In order to clarify my train of thought for this interview, let’s look at the history of the development of fixed appliances. Until the late 1970′s, orthodontists placed plain vanilla brackets on the teeth, and patient-specific archwires were laboriously fabricated by the orthodontist on a case by case basis. The development of Straightwire appliances greatly reduced the amount of archwire manipulation, but when you think about it, the appliance prescriptions are built to various goals of occlusal design and the 3 dimensional placements of the teeth and roots is based on the assumption that the jaws are pretty much in an orthognathic relationship. The patients who fall outside the range of who fits the brackets, then either compromises are accepted, or we are required to make specifically designed archwires to finish the case. Where does technology have the potential take us the next step? There are two possibilities; one-intraoral scanning and archwire robots to fabricate patient specific archwires as we did before straightwire appliances. Two; patient specific CAD-Cam bracket technologies. I have had the opportunity over the past several years to be involved with other clinicians in Dr. Craig Andreiko’s Ormco Insignia project, developing CAD-Cam technology for the design and fabrication of patient-specifically engineered brackets. Here’s the idea-produce a three dimensional models of the patients malocclusion, use software to design where you want the teeth to be placed, and then have the brackets manufactured to that patients specific prescription needs. This project has a lot of potential and has been tested for a decade. I can say that in my experience thus far, it works extremely well and is very efficient. But other technological applications need to be weaved into the process, specifically imaging calibration to take the occlusal design to the smile framework, so that our developing changes in bracket placement concepts can be incorporated into bracket design. Whether the Insignia appliance will finally gain acceptance is going to depend on the usual issues of cost, understanding of the concepts, further development from a dental-centric appliance to a broader vision of smile design, and acceptance of the learning curves required for any emerging technology. I am still a big believer in the power of digital imaging for communication and treatment design. We are pretty accustomed to using imaging as record storage and some communication in orthodontics today. Interestingly, I met with an endodontist this week who was talking about how performing a root canal in a microscope and being able to show a patient a picture of a cracked root from the inside of the tooth. Patient response has been enormous for him, but this is a road we have already traveled as orthodontists. We all understand the communications and marketing aspects of imaging. What we have as a profession not realized is its real impact in treatment planning visualization. I think we are still behind the curve on that. It is kind of clear but it is also unfinished business that a lot of stuff has already been developed. Only a percentage of us have really learned how to use it.

How have you used the current technology that you have in your office to better communicate with your patients?

Dr. Sarver:Most of the orthodontists who read your newsletter are probably aware of all that has been written on imaging and profile projection. What has really been a big eye popper for me is the recent work on smile analysis, the ability to visualize smile arc and incisor display, and quantify movements to improve the esthetics of the smile, and then have technology give us feedback on how we want to place our bracket systems to achieve the smile results that we demonstrate on the computer screen.

As a close to home illustration, I recently completed treatment on my Treatment Coordinator Tricia, who worked in my office for over 20 years before she decided that she wanted orthodontic treatment. She wanted her smile changed simply because she has watched me image patients and show them how I wanted to increase incisor display or curvature of the smile. She looked in the mirror and recognized that her smile could be improved dramatically, even though her teeth were well aligned. They just did not fit her smile framework in tune with our new smile esthetic concepts, and Tricia felt she wanted the change in her smile that we could give her. We performed an imaging session on her smile and visualized potential changes, and bingo-just like any patient-she liked it and decided on treatment. My task was to be sure to quantify bracket placement and reshape teeth to arrive at the designed treatment goal.

I think for me personally, that smile design is the new vista in orthodontics. Our sudden interest in this area is a bit odd, since, if you ask a lay person what an orthodontist does, the answer is that we make smiles. But as a profession, we have been focused on treating occlusions and profiles but with lesser attention to smiles.

That is interesting. I was watching The Today Show this morning and they were interviewing an expert and he was asked the question why he thought that Laci Peterson case is so popular in America with actually 18,000 a year being murdered. What was it that made her stand out? The answer was it was her smile that captivated America. Her beautiful smile.

Dr. Sarver: It is becoming more and more important as orthodontists that we recognize the importance of that story, because that is what the public expects from us and wants to buy. Unfortunately, they come in to see the orthodontist and we start waving our hands around in the air describing overjet and stuff like that. I am in no way discounting our professional obligation to inform patients as to the functional issues we may see, and always do our best to provide excellent care in all phases of orthodontic treatment. But as dentists and orthodontists, we tend to put guilt trips on each other that if you treat a patient for their chief complaint, which may simply be smile appearance, and if we finish without a perfect Class I occlusion, then you are guilty of something. I hope that in the future we quit putting guilt trips on each other and concentrate on what patients are telling us.

What are your favorite high-tech equipment items or items that you are using in your practice at this time?

Dr. Sarver:There are some things that work behind the scenes. For me, patient confirmation telephony has been pretty crucial in terms of recall and efficiency of appointment management. The oddity about this computer application is that it operates “behind the scene” but it has a large effect on my operation that I just don’t get to see directly until the end-of-month management reports. I don’t know how you feel about it for your clients; I guess you still recommend it. It is not a sexy thing that you see patients go “Wow!” over, but from an office management and patient flow standpoint, it is a pretty important piece.

The second thing for me is the use of direct clinical examination quantified through the use of databasing programs. This concept is described in several places; my book on Esthetic Orthodontics, The Graber Vanarsdall textbook, the new Contemporary Treatment book just out. This process will be also be described in a 2-series article that will come out in the AJODO in July/August. These articles will emphasize how orthodontic treatment planning is changing from a records-based model and cephalometric target to a new focus on the clinical examination and emphasis on the soft tissue based treatment planning schema of lip and incisor relationships, with assessment and quantification of speech and smile animation. What the data basing program does is it allows me to go through that exam efficiently, thoroughly and also have the information at my fingertips when I need it to make decisions.

Is that the OrthoCat program?

Dr. Sarver: Yes. But I don’t want to emphasize particularly the product itself, but emphasize the movement of our vision away from the cephalogram and to the patient. This technology forces you to do that. Not only forces you, it makes that your focus. It reminds me of when video imaging was introduced in the late 80′s. Studies performed at UNC demonstrated that patient response to treatment plans presented conventionally with models; cephalograms and pictures compared treatment plans presented using video imaging. In the imaged group, the patient felt the most important thing they wanted from treatment was an improved appearance. In the conventional presentation, they would point out a tooth they didn’t like. The view has been broadened from what I term a mini-aesthetic view, which is a tooth out of line, to a macro-aesthetic view in which the overall facial appearance is considered.

How many people are walking around ignorant not knowing what they could have had, including the orthodontist? Imaging is a way for you to look at the patient in ways you haven’t looked at them before. You can modify the image to test out treatment ideas before you actually deliver treatment. Think about the use of computer design in other areas. Boeing designs an airplane on the computer and it rolls out in production. They do not build models and mock-ups any more. That is “wired” production. They just do the designs and the wind tunnel testing on the computer. Then they roll out the product. That is how they compete. They do not have to spend all this money on building a prototype to see if it crashes. They already know. Of course, there are so many variables in human growth and development, but if we had as much money devoted to our product development (orthodontic treatment) as Boeing has, then maybe we would have the algorithms in our computers to give us a more refined planning process. This would give us a new level of confidence in our treatment planning. For example, instead of putting on brackets and seeing what happens, imaging technology may give us a more direct route to our end by allowing us to, as Holdaway said, “Treat with the end in mind”. .

Dr. Sarver, that certainly brings up a question that I know many orthodontists have and that is where they are going to go to learn and be trained on all of these concepts.You have an excellent workshop that you started presenting in your office in Birmingham. Can you tell us a little about that?

Dr. Sarver: I started an in-office course is two reasons. To lecture to a group for three hours and try and teach the myriad of conceptual changes that occur with the shift from our traditional model and cephalometrically based treatment planning scenario to a soft tissue based diagnostic scheme. For me, it can’t be done in three hours. It has to be done over a time period in which the orthodontist is given the evidence that backs up these conceptual changes, uses the technology to image, develop and quantify the treatment plan, and then cement these concepts through case development like the Harvard Business School. This is where you are given a case and challenged to diagnose what you were given and taught the first day and then mixing in the use of computers so the orthodontist taking the course can sit down and use the computer to modify images to make decisions, communicate with patients and the verbal scripting that goes with all of that. It is like graduate school, you can’t go take a weekend course and learn orthodontics. It takes an investment of time. I have been very excited about the responses I have received from the people who have taken the course. It is a lot of hard work for me, but the feedback has indicated that it is worth while.

Obviously, your office is heavily inundated with computer equipment. How do you and your staff deal with daily computer glitches?

Dr. Sarver: I have talked to a couple of orthodontists who have made a position in their offices for a technology person. That may be something we are all going to have to look into. In my specific case, my brother serves as an information technology director in my office. His function is not just to keep things running, but he also serves as an interface between me and the companies like Orthotrac and Ormco so I can focus on my practice and they build the software without me having to sit down at a computer. That is not a good use of my time. My time is best used being an orthodontist.

So you believe the orthodontist is going to have to have a part-time employee or contract someone on their team to delegate to so they can focus on the patient?

Dr. Sarver: There are always software and hardware glitches. All the companies would love to tell you that they do not have them, but they do. Anyone who owns a computer and turns it on knows that things don’t always work they way you want it to. Here in Birmingham, Joe takes care of several offices sort of unofficially. Guys call him all the time asking him for help and advice. So orthodontists can even share a technician. If I did not have Joe in here full-time, I would probably approach several orthodontists, or even dentists, and try to pool resources for an employee to take care of us. On the other hand, I think that sometimes we under-estimate our staff. My business manager, Lani, was extremely capable in keeping things running before my brother ever arrived. It used to be that new employees were intimidated by the computers; now they can’t wait to get into it. They love it. The people who work for us should not be under-estimated as to their abilities because there is no computer school. The only way you learn computers is get in there, play video games and learn them. You do not have to have a Masters from MIT to do that. Using determination and some smarts and have at it! If I did not want to go and hire a programmer guy, I would identify someone on my staff who was into it, excited about it and say ok that is going to be part of your job.

Well, that was wonderful Dr. Sarver. Thank you so much.

Interview by:

Charlene White