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Surgically Facilitated Orthodontic Therapy (SFOT) - Dr. Drew McDonald
Episode 55527th March 2023 • The Best Practices Show • ACT Dental
00:00:00 00:41:26

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Surgically Facilitated Orthodontic Therapy (SFOT)

Episode #555 with Dr. Drew McDonald

With new technology and advanced procedures, you can give patients better results faster than ever. Dentistry is evolving, and to highlight the importance of 3D imaging and surgically facilitated orthodontic therapy, Kirk Behrendt brings back Dr. Drew McDonald with his best practices for maximizing case outcomes and preventing the results that you and your patients don't want to see. Stop hiding in the past with 2D! To learn how 3D and SFOT will increase your patients’ quality of life, listen to Episode 555 of The Best Practices Show!

Episode Resources:

Links Mentioned in This Episode:

CBS News story about AGGA:

Surgically Facilitated Orthodontic Therapy (available April 2023) by Dr. George Mandelaris and Dr. Brian S. Vence:


Chicago Study Club:

Stay tuned for Dr. McDonald and Dr. Courtney Lavigne’s courses, fall of 2023!

Main Takeaways:

Learn from the mistakes of AGGA.

Embrace 3D. 2D imaging is no longer enough.

Never expand without proper teeth and bone assessments.

Slow down. You can't analyze everything in a limited amount of time.

Thoroughly understand what you're working with before starting treatment.


“There's a lot of controversy going on right now, especially because of the CBS News story that came out about the AGGA appliance, which is an Anterior Growth Guidance Appliance. It’s an orthodontic appliance that's trying to move teeth. But what was happening to these cases that are being shown on TV is that the patients’ bone levels, in terms of their alveolar bone, was very likely not assessed before that patient got into treatment. And so, what happens is, you can only move teeth so far because there's an envelope around bone, around the roots, that keeps the teeth stable. If you push those teeth beyond what the capacity of that bone has to handle that, then you can push teeth right out of bone. You can expose roots. You can cause teeth to die. You can cause severe recession. And I can't tell you how many times I see adult patients in my office that have been through some sort of orthodontic treatment in their life, and a lot of times, they have significant bone issues where you're trying to move teeth and that bone is thinner. And you're at a high risk getting into this orthodontic case if you try and move those teeth in that thinner bone.” (5:33—6:42)

“What surgically facilitated orthodontics is is that we can utilize our periodontist colleagues a lot in these situations. And if we’re able to diagnose that patient’s bone conditions — or their alveolar phenotype is the fancy word for that — before we start our orthodontic treatment, a lot of times, these patients, we can work together with our periodontists to do bone grafting or soft tissue grafting along with the orthodontic tooth movement. And what ends up happening is a much more stable result. We’re preventing things like recession from happening along the way.” (6:44—7:17)

“One of the other big benefits [of surgically facilitated orthodontics] is that teeth move about 50% of the pace faster than they would without utilizing the surgical techniques. And so, a lot of times, patients, especially adult patients who really don't want to be in treatment very long, this becomes a bonus for them because they get in and out of treatment faster. And they're happy because they're not having unforeseen recession. They're not having trouble with their teeth. They’re not having loose teeth that are about to fall out at the end of treatment. But it really all comes back to, we need to be diagnosing at a higher level before we get into these orthodontic cases. And that involves, as a minimum standard of care in orthodontics, utilizing a CBCT. And that is 100% where the profession needs to go.” (7:18—8:07)

“Whenever you start diagnosing cases of ortho, there are really four regions that are very important that you need to look at, one of which is the upper anterior bone around the front teeth. Why would that be important? Well, if you're going to move those teeth and flare them, or retract them, or whatever tooth movement that you're going to do, it’s a good idea to know if there's adequate bone to handle that type of move. On the other side, in the lower anterior, that is the highest frequency area to have thin bone. And we know from certain types of growth patterns, especially people with jaw joint issues that have thinner bone in the lower anterior, a lot of times, or open bite cases. And so, if you're trying to correct that bite issue and we don't have great bone, we’re asking for trouble. And so, again, those are two of the most important areas.” (9:44—10:35)

“The other areas that are very important are in the back, our posterior teeth. Especially in today’s world where we’re doing a lot of expansion and trying to help expand the maxilla for breathing issues and all of that, if we’re doing an expander that bases off of the teeth and has the potential to tip those teeth or push those teeth out, then we need to know, does that bone in that area have enough thickness to handle that movement as well? And also, if we’re going to expand the maxilla, the mandible has to go with it, and we have to upright those lower teeth. If we don't have great bone around those lower back teeth to upright into, we’re going to see a ton of recession. And very likely, we’re going to see an unstable result.” (10:36—11:21)

“Traditionally, in ortho, we've thought of utilizing periodontists and all these surgically facilitated techniques as maybe a little bit of overkill because, ‘Oh my gosh. We’re asking a patient to go do this surgery along with orthodontics. And if all we were telling them was that it might speed up your treatment,’ which, we’ve known that for a long time. That's been since the ‘80s with the Wilcko brothers. Dr. Frost had also pioneered that. In general, that was our only excuse to get someone to go to a periodontist back in the day. And so, a lot of patients would go, ‘Eh, I don't really care that much about that.’ And what would end up happening is that we'd see recession when we thought we weren't going to. So, again, this is where the 3D world and CBCTs have changed how we execute plans, is it allows us to see the enemy before we get in on the treatment plan. If we see that bone has areas of concern, then we should get them to our periodontist before treatment so that they understand, ‘If I do this procedure, I'm going to have less likelihood of having recession and problems later.’ And so, that's really where the 3D world is changing the way that we interdisciplinarily work together, if that's a word. Essentially, it opens up our world.” (11:47—13:03)

“If our patients see they’ve got that thinner bone, a lot of times, they ask me, ‘Okay. What do I do? I don't want that recession. I don't want problems with my teeth. I can see how thin that bone is.’ And that's where, again, it opens up the conversation that you need more involved treatment. And patients say yes to that more involved treatment.” (13:04—13:21)

“A lot of the older — in any profession, not just ortho — they say, ‘Hey, we've always done it with this set of imaging. Why do we have to move into this?’ And oh, by the way, there's so much fear about a 3D image possibly adding more radiation to the patient . . . And they base a lot of decisions on old material. And what I mean by that is that today’s 3D X-ray machines, cone beam CTs, when we do a light scan on an orthodontic patient, we’re doing less radiation in one 3D image than we are from a panoramic X-ray and a ceph X-ray, which are two-dimensional images. And so, if you're going to sit there and say 3D is overkill because of radiation purposes, I think that that argument is by the wayside, at this point. Again, that's based off of old CT images, which are heavy radiation. Cone beam CT is much different. And so, we have to start changing that narrative that we’re over-irradiating our patients when we have these newer tools to be able to have a much better radiation level for them than what our old images used to provide.” (14:02—15:18)

“The way we’ve always done it needs change.” (15:36—15:38)

“You can't see joints or airway issues on patients without 3D, in a lot of these cases. And I should clarify that airway issues, especially pharyngeal airway issues, they're visualized. They're not diagnosed on an X-ray. The X-ray is a helpful tool. However, what orthodontics really needs to be is so much more than teeth. Because what puts a patient in our chair and creates malocclusions are airway issues, tongue issues, TMJ issues. And to execute how we correct those, we have to see all of these things. Otherwise, if we overlook them diagnostically, they're going to come back to haunt us. And what's dead will never die. We are going to be chasing and chasing a malocclusion because we didn't get to the root of the problem. We can only see that with imaging. And 2D imaging is not enough anymore.” (15:48—16:43)

“When we come out of ortho school, we know that there are certain things that we don't want to stress with tooth movement. One of those is if we have thin tissue. That was always the traditional thought is, ‘Oh, look at the gum tissue,’ because we could see it at the surface. It’s right there in front of us. And so, a lot of times, there are adult patients, and it’s been well-established that a patient needs to be periodontally stable before going into orthodontics. I don't know that everybody who starts orthodontic cases observes that, sometimes, because I've seen a lot of problems after ortho that come up.” (17:22—18:00)

“In general, I think every orthodontist and every periodontist out there understand, in common, that there's a risk for periodontal issues when you get into ortho. But we’ve always looked at it as, ‘Is there already recession, or is the gum tissue thin?’ What we need to wrap our heads around is, where is the bone? So, back to playing together, this is where the imaging facilitates conversation. Basically, in my world, we do our diagnostics with our CBCT, MRI, whatever else we do. But with that, I put together a whole presentation that shows those levels of bone to the patient. And then, with my referral to the periodontist, it has those same pictures of...