Negaar Sagafi, DDS, Bethesda Orthodontics, talks about BRIUS, a new technology in Orthodontics.
Do you treat both adult and pediatric?
SAGAFI: Yes. I would say my patients range from probably around seven years of age as needed and I’ve got patients to, like, 79 – 80 years of age.
Talk to me about the BRIUS. A lot of our viewers probably have not heard of it. What is it? What is it designed to do?
SAGAFI: BRIUS is an incredible game changer in the world of orthodontics. And what I love most about it from the patient perspective, not just the provider perspective, is that I think it provides better care for our patients – more comfortable care, a better care, a faster care. I think everyone sort of sees orthodontics as a teenage year’s initiation and it really doesn’t have to be that with BRIUS. Not just because it’s on the inside and thus it’s more aesthetic and more pleasing, but we’re just doing better care with the type of movements that are happening for the teeth and the accuracy that we’re receiving. The care that we can give is just more superior. Patients are able to floss. Like, they can’t floss as normally as they would if they had orthodontic treatment on the outside? With sports even it’s much better because if you’ve got lots of kids that will pick up a basketball game, a football game, and they won’t wear their mouth guards. And if they have braces on the outside and they get hit, unfortunately, then their lip is stuck in their braces. But when it’s on the inside, you have the protection of bracing the teeth together so you can take the impact of any trauma that may come but you’re not having any soft tissue damage. What I do love a lot about BRIUS is in terms of its biomechanics being different and efficient and much more superior has to do a lot of what we call independent tooth movement. You know, Newton’s third law of physics doesn’t change. Action-reaction applies to labial braces, to lingual braces, to BRIUS. However, the way it’s applied and the way the forces and the moments are split and the anchorage – it makes a big difference.
It’s something that’s on the inside, which sounds so counter-intuitive to what we’re all used to. Can you explain why on the inside?
SAGAFI: Well, BRIUS can also be on the outside. But we have thought about, if we’re going to take all the beauties of what orthodontics can accomplish, from when it comes to function and aesthetics, and we’ve also looked at some of the disadvantages, the BRIUS is able to apply or deliver a much better combination of all of those things. So why not have it on the inside? So lingual orthodontics has been around for multiple decades and there are pockets in Europe that are really concentrated in Germany and in France and doing lingual orthodontics. But even the lingual orthodontics is very different than BRIUS. BRIUS, the way it works, it doesn’t have the conventional wires that either the labial or the lingual orthodontics has. It basically is a nickel-titanium alloy which has shape memory, so it can be shaped to what needs to be done for the patient from the beginning. And as I mentioned, the accuracy is incredible. So, the bracket positioning for the operator is already preset by artificial intelligence, it takes out a lot of human error in terms of when it comes to technicality but not when it comes to our brain power. We’re sitting down, the orthodontist is the one who’s doing the treatment planning, who is taking the patient’s desire and following through with what the plan is and setting everything up. And then the BRIUS is actually moving the teeth from its initial point to the final point that it needs to go to. And this is all done, as I mentioned, with the nickel titanium pre-shaped wires that bounces back, basically.
You were talking about teeth moving independently, can you explain how that works?
SAGAFI: It’s great. I love it that you picked up on that immediately. So, with a conventional orthodontics, we have a wire that basically connects throughout all the teeth together. If, for example, you and I want to move a tooth down, the two teeth next to it are going to move up. That’s your action and your reaction. So, they’re not moving independent of each other. What BRIUS is providing is, instead of connecting the brackets and the teeth together, each tooth has its own independent bracket and has its own independent spring that connects to what we call a stability bar or an anchorage bar. So, they’re all connected to a bar, but they’re not connected to each other. If a tooth needs to go to the right, it’s not going to worry about the other teeth, it’s going to move to the right and it will move as efficiently as it can. It doesn’t have to worry about the responses or side effects that we have, which means in orthodontics, the way I like to explain it is we’re always looking at potholes on a road. You’re trying to avoid the potholes and you want to get the straightest line that you can find. And because of physics and because of the action and reaction, you’re always considering that. You also have patient compliance to think about. And depending on how compliant they are, in terms of their instructions that they follow with you, their hygiene, it’s going to make a big difference. When it comes to BRIUS, you’re doing independent tooth movement, you are avoiding as many of those potholes as possible. Basically, with BRIUS what we can do is avoid those potholes that are on the road, the side effects that we would have. Also, if we’re putting less responsibility on our patients, which BRIUS actually allows us to do that, then the treatment is going to go smoother. Because invariably a lot of our patients are teenagers and it’s hard to get compliance from them at times for sure. And I love to say that we do see a ton of adult patients now. Certainly, orthodontics has gone that direction in the last 10, 15 years where we have a good number of our patients, and our practices are adults. And I would say I have patients from 10 years old or 9-year-old in BRIUS through 60s and 70s.
How do you go from planning stages to insertion?
SAGAFI: Basically, our consultation appointment, once we know what our patient’s goals are, I think BRIUS is an option for pretty much every patient. What I like to think of it as is the Ferrari of moving teeth. So, if you want to get to your goal, this is a very aesthetic way to do it, very great functional way to do it. Our patients, once they’ve decided to move forward, we do a scan on them, which is only a series of photographs. We take the X-rays that we need to make sure that the bone, the periodontium, the roots, the teeth are all safe and sound and basically we provide that data to BRIUS, the company. As orthodontists, we’re the ones in the driver’s seat along with our patient. We dictate what kind of treatment we want to provide. And along with their team, we work on a planner that we call. Once they put everything together, we receive all the information and we’re actually able to see the patient’s teeth move, it’s a video of their teeth. Once we send our patient’s data to BRIUS, then we also dictate the instructions that we give for the treatment plan. And it takes a couple of days to receive back what we need from them in terms of seeing how they’re visually moving the teeth. We actually get a video and we – the software is incredible. I’m actually able to sit there, click on every individual tooth, move them in the direction in the amount, the angulation, torque, tip; everything that I need to do. So, I’m able to provide a kind of care that I normally can’t do as well when I do labial brackets and traditional brackets. It gives me a window into this incredible technology. And once we do that and we approve the case, we can even go over it prior to approval with our patients, see if they have any questions, they can get a visual of where they’re going. And once we approve it, a couple of weeks of basically manufacturing and shipment. The beauty of it is every spring, there are thousands of springs, and the analysis that’s done behind the scenes, the biomechanics that’s looked at, the moments, the forces; it’s so accurate that it just makes the treatment go much smoother for the patients and the efficiency is incredible. I’ve had patients say, no, I’m not really interested in treatment on the lower, I really want to just fix the couple crooked teeth on the top. They get started. We get an email three weeks later saying the experience has been fantastic, the movement has been so fast, I’d like to go ahead and get, you know, the bottom done as well.
So how do you affix them? Usually behind? Can you talk about that really quick?
SAGAFI: Absolutely. The process of bonding a bracket to the tooth, whether it’s on the outside or inside, is the same. Once we basically polish all the teeth and prep all the teeth, we have these 3D printed custom-made aligners that we use, they’re trays, basically, that are housing all the patients’ brackets; we call the indirect bonding. Once we’re able to place multiple brackets on, let’s say, the upper arch and then on the lower arch, once we have the tray in, we cure the brackets, they already bond on there. The brackets each have little cleats that we call that we open them and that’s the housing for the spring of the BRIUS to attach into it. We attach the BRIUS, we close the spring, we put some permanent wax for them, you’ve probably heard of the orthodontic removable wax, that patients use consistently. We put that on there for them. Give them instructions and the basic instructions really is expect their teeth to move in the next hour or two. It’s going to get a little bit uncomfortable. Get some quick lunch, get some Advil, Tylenol, whatever you normally take for a headache. And within a week or so maximum, most patients are super comfortable. Their speech has adjusted to it, their tongue has adjusted to it, they’ve gotten very comfortable. And within the first few weeks, they really aren’t thinking much about the appliance itself in their mouth but kind of enjoying the actual movements that they’re seeing.
How does this compare to Invisalign? Where you don’t have those brackets on your teeth that you’re looking at. How do they compare?
SAGAFI: I think that’s a great question because aligner therapy, whether it’s Invisalign or other companies, has been also a really nice change for orthodontists in the last 10 years. But I think of the difference between BRIUS and there’s multiple differences, actually between BRIUS and aligners in terms of capabilities and also compliance, and some of those things are plastic doesn’t really have the ability to move teeth unless they move the roots of the teeth that are in bone as well as something that actually attaches to teeth. Now, we’re able to move the teeth with aligners and the roots, we’re able to get movements that we wouldn’t expect a few years ago. Which is a great option still for patients. However, I am more confident then when a patient of mine needs a particular care or you want to deliver the 100% perfect setup to a patient, to do fixed appliances versus a removable. Where liners fall into that category. At the same time, the aligners have the compliance factor of 18 to 22 hours of use. I’ve had adult patients that have come to me that say ‘I’ve been a two-timer aligner patient’. And because I know, when I go to my meetings, I can remove it. And because I know, when I don’t feel like wearing it, I can remove it. I haven’t accomplished my goals and it’s been seven years. And now they’ve done BRIUS, they’re happy and it’s fixed and they get the results that they need. So, compliance, whether it’s for teenagers and adults, can be an issue. I hate to say it, for a lot of teenagers, they don’t even keep their aligners very clean. They pop them right back on after they’ve had lunch. So, you’re packing food against your teeth, you know, for hours even if their compliance is good. But when you have, let’s say, BRIUS, or even outside braces, it’s a self-cleansing area. You’re drinking, your saliva; it’s helping to self-cleanse the areas. There are pros and cons with both systems and I think it’s also very much patient-dependent as to what they’re looking for.
Does BRIUS move the teeth faster and how much faster than traditional?
SAGAFI: We’re seeing about 30 to 40 percent faster at least. And again, like I said, at least. And there are cases where we might purposefully slow down treatment if the patient has some bone loss or gingival issues. In adult patients, we would tweak things and if the patient follows our instructions and they’re not breaking the brackets, we’re at least seeing 30 – 40 percent, in some cases, 50 – 60 percent faster.
You’re talking about in terms of months or years instead of two years, one…
SAGAFI: I was the first orthodontist patient that BRIUS had. And Mehdi himself, Dr. Peikar, the founder of BRIUS, actually bonded BRIUS on me. And I was ready to put braces on the outside for myself, I needed to do some tweaking. And when I came across BRIUS and was introduced to the company and had BRIUS bonded on myself, I was expecting to have had labial braces for about eight to 10 months by my own calculations, and I needed it in four months, everything was done. I ended up just keeping the BRIUS in my mouth because, during my consultations as I was introducing it to my patients, they could see it and it was a good opportunity to first-hand experiences before I also started to really believe in it and see my confidence level just increase in the kind of movements that it could do. And now I don’t hesitate to offer it to any patients. It does go faster.
Now, do the springs of the brackets come off the guide wire? Does everything come out when you’re done?
SAGAFI: Yes, everything comes out when you’re done. The appliances, the brackets, the springs, the BRIUS portion is all used to move your teeth. Once the movement is accomplished, then we go to a retention protocol, which independent of what kind of appliance you use, whether outside braces, aligners or BRIUS, it’s a protocol that orthodontists would then follow. Yes.
How much more expensive is it than traditional braces or than Invisalign?
SAGAFI: You know, when it comes to the economics of it, it’s really not that different. The fact that there’s a third-party company that’s involved, so from the orthodontist standpoint, there is a laboratory fee when you’re working with someone to set something up or manufacture for you. What we tend to do, we offer it pretty much at the same price of the labial braces because we think it does balance off, both for us and both our patients in terms of timing, in terms of our patients being happy, in terms of referrals that they give us. So, it really doesn’t make a big difference. The beauty of it is we do see labial bracket patients every four to six weeks. When it comes to BRIUS, I have patients in New York, I have patients in Philadelphia, I have patients all over the place that will come in and I don’t have to see them once a month. I can see them every eight to 10 weeks. I see some of them every 12 weeks because of the preplanning that we have. And there are other technologies that we combine with it, such as dental monitoring. Which is a technology out of Paris that I have patients basically scan their teeth once a week and I can watch them and I can tell them, ‘OK, now I need to touch your teeth, would you please make an appointment and come and see me this week or the following week?’ The fact that the patient actually doesn’t have to be in the chair and takes up, let’s say, the assistant auxiliary time, all of that, when you balance it out, it actually works out well for everybody. And it’s a busy world. Everyone wants to be able to maximize their time, both for us and our patients, and we love it that we can actually provide that to our patients.
Talk to me about teeth scanning. How do you do that?
SAGAFI: It’s great, when we do the teeth scanning, we have a very high-tech machine that we use. When my patients do their teeth scanning, they have a very cool machine that they use. They have a scan box and literally they can put their phone into it, and they do three six-second scans for me. And I can see their teeth in the front, on the sides, open, top, and bottom. When it comes to my teenagers, their parents are also a secondary text message on it and email. And I can actually communicate with them on their app, they can send me messages, I can take pictures of a scan they’ve done, draw on it saying, ‘hey, you know, this area right there – I need you to brush a little bit better there.’ So that’s how we do it. And all of my BRIUS patients, I have them on this scan because I want to monitor them and see what’s going on.
What percentage of your patients are on BRIUS?
SAGAFI: A lot more, and more as they’re getting more and more exposed to it. I would say safely we have, at this point, 40 percent of our patients are BRIUS patients. What I like to do when my patients come in for a consultation, I think every person is different. They’re looking for different things. I’ll have some kids that are excited about the colors. They want to have those colors on the outside and match it up with their team sports. And then I’ll have patients, you know, that really don’t want anyone to know, and they could be very young that they are having orthodontic treatment, or they’re nervous about things. I’ll give them all their options and tell them why I think one could be better than the other depending on what type of patient I also have, you know?
What’s usually the total? I mean, it’s different for every patient, but what is a ballpark for the traditional bracketing, for the Invisalign and then for BRIUS?
SAGAFI: From what we know nationally, each area of the country you’re going to see various numbers, OK? And I think what traditionally sort of has been a number that most of us have heard for a very long time is around $5,000, $6,000, $7,000 in various parts of the country. It will hover around that for a comprehensive case, OK? Certainly, the type of care that you’re able to give, the type of customer service that you’re able to give, that makes a big difference for all of us, you know, in different parts of parts of the country, will also change some of those prices, OK? Well, what’s interesting to think about though is these numbers that I’m giving you now and I’ve been out practicing for several years, are numbers that, when I wasn’t even dental student, that I would hear from orthodontist friends of my mom, who was a pediatric dentist, OK? And I do recall one of them one said, when he went to school, and he’s been practicing for 30 years, it was $11,000 to go to orthodontic residency per year. Now, orthodontic residency is about $70 to $80 thousand per year. And I remember him saying that you’d buy a Volvo, it would be, like, $5,000 and now you’d want to buy that Volvo is $35,000. So, he was telling me that we charge $5,000 then $6,000 then $7,000 and now we’re charging the same. However, price of living has gone up, price of materials has gone up, everything has gone up. I think there has to be a healthy shift with that. It is not easy to be able to maintain a certain quality of care when it comes, not just from the orthodontist, but from the team and from the team that needs to be trained properly, that needs to go to a lot of courses and see courses and have what we do a lot in the office. Yesterday, we had two hours of training. And this is, you know, constantly happening. When it comes to those factors, it makes a big difference to be flexible to be able to get the care that you want.
How long have you been offering BRIUS and how long has it been around?
SAGAFI: So BRIUS has been around officially for about four years, and I was involved with the company from its inception and have been fortunate to have gotten to know them. And since then, I’ve been basically working with them on multiple levels in treating patients using BRIUS. And what I do, I lecture, to bring on more orthodontists to provide this kind of care for our patients. I really think it’s something that, in terms of public health, it’s really important. It’s a company, it’s a technology that actually will make a big difference. And I do think Dr. Peikar, the founder, he’s brilliant, he’s humble and he asked some simple questions and wanted to answer them with some complex physics that he loves, and he’s been able to manage that. It’s important to me for us to make a change in the industry, and so we lecture together and on different platforms to introduce other orthodontists.
Is there conflict of interest?
SAGAFI: Basically, I mean, I don’t receive royalties, but I do get compensated for my time for when I give lectures. And I do have shares in the company. It’s something I absolutely believe in, and I think it’s wonderful, so I’m a believer, so I invest in it, absolutely.
So, you lecture for BRIUS?
SAGAFI: I do, yeah. I think everyone should know about it.
Is there anything I didn’t ask you that you want to make sure that people know?
SAGAFI: I can think probably of a few other things too, but I think it’s been really actually interesting for me when I’ve had patients that have BRIUS, let’s say, on their upper teeth and traditional braces on the lower where they were concerned about just the aesthetic factor and said they didn’t want someone to know that they were getting orthodontics, but they chose to do bottom outside braces, whether if it’s metal or ceramics. And to know how much they actually prefer the BRIUS, not because of the aesthetic factor but because of the comfort, because of the fact that they can floss, because of the fact that they just feel it’s actually more comfortable. And they also think that their dental discomfort is less. Because every time, when I see a patient with outside braces, I am sort of activating things where, for the next few days or sometimes for the next week, the patient is rather uncomfortable. With BRIUS, it’s a continuous small amount of force that’s ongoing on a daily basis. As I said, I can let my patients go for eight, 10, 12 weeks at a time. The activation is small forces but continuous. It’s sort of like being on that marathon that you’re running slowly versus doing a sprint stopping and going again. So that’s actually been nice to get a lot of patient’s feedback from that as well.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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