September 13, 2021
by Tim Dumore, DMD, BSc, MSc, FRCD(C), DipABO, FICD, FPFA
Last year, Dr. Tim Dumore added fully custom 3D-printed tooth moving tools from LightForce Orthodontics to his treatment options. LightForce, which is headquartered in Burlington, Massachusetts, has developed a cloud-based platform to create patient-specific 3D-printed ceramic brackets delivered in patient-specific indirect bonding (IBD) trays that are 3D printed from a proprietary material.1 Dr. Dumore digitally plans and controls every aspect of the treatment plan as well as adjustments. Dr. Alfred Griffin III researched and developed the system, and LightForce received FDA clearance in 2019. The system also is Health Canada approved. As an avid enthusiast of technologies that provide state-of-the-art care to his patients, Dr. Dumore discusses his experience with the LightForce System.
What introduced you to LightForce technology?
The orthodontic world is evolving, and it is important to be aware of new tools. I have always been a tech-forward guy and an “early adopter.” For example, I was the first orthodontist in Canada to adopt the Planmeca digital ceph-Pan, iTero®, and Objet 30 Printer. After a recommendation from a trusted colleague, Dr. Lou Shuman, I decided to give LightForce a try. Adding new technology can be a challenge, not because of the technology itself, but because everyone gets accustomed to “the way we have always done it.” One of my assistants once asked why we add new technology when our usual protocols are just fine. Even if we do not use our technologies on each and every patient all the time, the practice cannot grow and even may become stagnant if we don’t embrace change.
Did you already have a digital practice?
We do all of our aligner setups with uLab, and we 3D print the models for in-house aligner fabrication (using both Stratasys® Objet Eden260V and EnvisionTEC printers, and soon SprintRay), so we already are comfortable with a digital workflow. For our fixed-braces cases, we have been doing a hybrid digital approach, where we scan the patient, print the models with our 3D printer, and I do a physical IDB, positioning the brackets on the models. So before LightForce, I was only partially taking advantage of digital efficiencies.
I enjoy doing virtual setups for braces like I can now do with the LightForce system. Because the set-up process is fully digital, I am not stuck at work at the end of the workday trying to finish setups. I can do those on my computer whenever I want to. If I want to leave early on a Friday, I can get it done on a Saturday morning. And the setups are quick and very accurate. When I get back the technician’s setup, I see very minor adjustments. These efficiencies built into LightForce save time.
What are some of the efficiencies of LightForce?
Many orthodontists practice with a similar workflow. You put the braces on and go through an initial phase level of leveling, aligning, and de-rotating teeth. Then, you might have a repositioning appointment to take an X-ray, closely look at any brackets that need repositioning, and reposition any brackets that you are not satisfied with. Then, you proceed to the working phase and then, finishing. With traditional braces, the simplest or hardest case still has to go through that process to get full alignment and fine-tune before finishing.
One of the benefits that attracted me to LightForce is the digital setup – you are able to plan and see your final result when you start. And the brackets are 100 percent custom 3D-printed and custom manufactured for each patient – even the base is custom, an exact match to the surface of the tooth. The digital initial alignment eliminates the whole concept of repositioning appointment for most patients. With analog braces, you typically have to stop and reposition, step down the wire, and then wait until the next appointment for it all to start working.
With traditional braces, at the last part of your treatment, the doctor needs to do detailing, bending the wire to fine-tune the positioning. Although I enjoy bending wires and having the opportunity to talk to patients, the patients don’t necessarily want another appointment in their already busy schedule. With the fine precision of the LightForce System, the number of detailing appointments for most cases is going to be close to zero. LightForce will get as close as possible to my prescribed results, and in the few cases where detailing is needed, we can use finishing aligners. So patients can get their braces off much sooner and get a better result, and without so much chair time, there’s less wear and tear on this old guy’s body.
What effect does LightForce on other efficiencies?
Detailing appointments are time consuming. Every doctor is different, but it takes at least 10 minutes of my time for detailing, and if I can eliminate three or four of those per day, I have room for another appointment in the schedule! I have an established practice, and we are booking appointments several months out. One of the reasons that I wanted to implement LightForce was that I needed to free up time in my schedule to fit some new patients into the practice. It seems like a good problem to have! We could lose potential patients if they have to wait too long.
Also, patients appreciate that they don’t have to add another appointment to their already busy schedules. Teledentistry (like Dental Monitoring) has been helpful in this aspect. Some of our patients live outside of Winnipeg and travel up to 4 hours to our office. Using teledentistry options to track these patients eliminates costly and time-consuming visits. We don’t need to ask a patient to drive 8 hours round trip for a rubber-band check to see if their Class II is progressing. With teledentistry, we can check them on a weekly basis and give them feedback.
With LightForce, patients only need an appointment every 6-10 weeks depending on their treatment plan. Even patients who live nearby don’t have to miss school as much using this efficient 100% custom 3D-printed bracket system. Some orthodontists may feel that by not bringing the patient in for an appointment, they are not getting appropriate care. But, because the system is so individualized and custom, tooth movement is working according to plan without needing unnecessary office visits. And adding the teledentistry option to the mix, we may actually get better insight because we are communicating with patients more frequently. I can see if dental hygiene is a problem, if a bracket is broken, or if aligners are not tracking.
How does having LightForce differentiate your practice?
I think a lot of orthodontists would be happy treating teenagers with simple orthodontic cases to keep life easy. The reality is that there is increased competition by GPs for the simpler cases that can be treated with clear aligners. The level of difficulty of the average patient who sees an orthodontist has increased. One of the ways to differentiate yourself is to undertake more complex and interdisciplinary cases. My practice has a strong focus on that, and LightForce fits well in that respect.
How are the 3D-printed brackets different than traditional brackets?
The 3D-printed brackets are printed to fit the patient’s individual tooth anatomy, fitting exactly on the tooth. And brackets are delivered preloaded into IDB trays for easy and accurate placement. The system also works with my wire preferences. We use .020 slot size, since, in my opinion, it has all of the advantages and a great compromise between the .018 and .022 wire. LightForce can custom print .020 brackets. Then, my first wire of choice is an .014 NiTi, and the second is a .020 squared wire, that gives great early torque control. Angulation is important, but torque is the secret sauce. Orthodontists often focus on torque, but then they never fill the slot. It seems like the treatment misses out if prescription is not expressed. So with a .020 squared wire in a LightForce bracket, the torque is corrected much sooner. When detailing the final tooth positioning, we often look at a tooth and estimate that maybe it needs 10 degrees of torque, but maybe that is too much or not enough, and then the patient needs to return, and you adjust it again. With LightForce, you have the perfect bracket, and the torque is prescribed. As long as you fill the slot and let it work for a period of time, it will move the teeth exactly where you want.
Since you have experience with interdisciplinary cases, how does the LightForce System work when collaborating with other specialists?
We have a Seattle Study Club group in Winnipeg and spend a lot of time collaborating. It used to be difficult to get numerous colleagues to travel to someone’s office after work, but today, with digital technology and Zoom, it is easy to share digital records between the doctors. For example, once my digital treatment plan is completed in LightForce software, I can pull up the patient’s digital files and ask the restorative dentist, ‘How does this look to you? Are you happy with the positioning of this tooth?’ Since the treatment plan also contains the end result, I can show the restorative dentist exactly where the tooth will be positioned at the end of treatment. That’s huge. Years ago, orthodontists had to do a diagnostic set-up. It was very labor intensive – take a plaster model, section the teeth, and reposition them in wax. The hardest part was transitioning that analog model to reality.
With LightForce, once the orthodontist positions the teeth on the digital model, the brackets are custom 3D-printed to specifications so they move exactly into my pre-planned space. The scan can also be sent to the patient to confirm that he/she is satisfied with the tooth position. That way, there are far fewer surprises at the end of treatment. Instead of using cumbersome study models, a digital scan can be sent to any collaborating dentist. He/she can look at that digital file magnified 10 times from different angles. That really facilitates interdisciplinary treatment.
Also, communicating with digital systems far outweighs communicating through a series of letters. “Snail mail” works as long as everyone is “ccing” everyone else, but mailing letters and copying X-rays is time-consuming, and sometimes information is lost in misinterpretation. But if we communicate directly and look at the LightForce setup, it is much more exact, and restorative dentists can offer suggestions like adjustment for clearance for bridge. It’s a great way to collaborate.
Do you do any hybrid treatments?
With a digital workflow, combining LightForce and aligner treatments is easy. Some patients start with braces and transition to aligners, or have one arch in braces and one arch in aligners. When a patient really wants aligners, often the trick is finding the “sweet spot” between them both. For example, opening a deep bite with aligners is tough and unpredictable. We can tell the patient if he/she starts with LightForce, we can reach the goal faster. When I offer someone hybrid treatment, the sooner we can reach the tooth movement goal with braces, the sooner the patient can get into aligners. LightForce is going to get the patient to the goal faster than with traditional braces because you eliminate the whole traditional level, align, de-rotate, reposition work. Of course, some patients still don’t want braces. Most people are open to negotiation, if they know they will achieve a better, faster result if they can accept braces for a short period of time. I advise – wear your elastics, keep your teeth clean, don’t break stuff, and we can have your braces off in a year and, if needed, finish your treatment with aligners. Most don’t even mind because the LightForce white brackets are aesthetically pleasing. And the newest addition to their bracket choices is a translucent bracket, a great innovation.
How is communication with LightForce?
Besides the clinical aspects, I think it is impressive that the company listens to feedback. They want to hear from doctors, and are responsive to suggestions. As great as this system is, in time, I expect more improvements more quickly than the average product because they are focused on getting it right.
What is your advice to orthodontists who are thinking of implementing LightForce?
In our practices, it’s as if we sail a big ship every day, and I know that it is difficult to change course. I would advise to stretch your comfort zone and try it. Most orthodontists would agree that the added efficiencies make it more than worth the investment. And I think that patients like the idea that their braces are customized specifically for their teeth. It’s like having customized clothes instead of buying them off the rack. LightForce makes the whole process seamless. I’m so impressed with this company. Orthodontics is evolving, and LightForce is at the forefront of change. You can still put a stock bracket on a tooth the way you always done it, but why not treat patients faster with more predictability? In some respects, I feel I owe it to my patients to offer this technology.
Oral Health welcomes this original article.
About the Author
Tim Dumore wakes up every day thankful that 35 years ago he considered that dentistry as a career choice. He graduated from the University of Manitoba, Faculty of Dentistry in 1991, supported by the Canadian Armed Forces, and was then stationed to Cold Lake, Alberta for four years. During that time, he developed an appreciation for all aspects of dentistry. A budding interest in orthodontics lead to three years at UCSF Graduate Orthodontics. He then returned to Winnipeg where he has practiced for the last 23 years. Dr. Dumore’s practice philosophy centers on incorporating technology to benefit patients, a special interest in interdisciplinary treatment, and nurturing and enabling his amazing team. He is co-director of the Winnipeg Progressive Dental Study Club, a Seattle Study Club affiliate.