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Digital Indirect Bonding Demystified: How to Choose a System and Get Started · Orthodontic Products Podcast

• Alison Werner (00:05) Hello and welcome to the Orthodontic Products podcast. I'm your host, Alison Werner. Today we're taking a closer look at a technology that many practices are curious about, but are often unsure about how to approach. That's digital indirect bonding. Interest has grown rapidly as early analog methods have given way to sophisticated digital platforms. Yet the landscape feels crowded and constantly evolving. For orthodontists trying to understand where to begin or how to compare systems like LightForce, KL Owen, DIBS AI, and the newest offerings from major orthodontic manufacturers, the learning curve can feel steep. To help make sense of it, I'm joined by Dr. Jeremy Manuele, a Las Vegas-based orthodontist who has spent years testing, refining, and fully integrating digital indirect bonding into his practice. He breaks down how the technology has matured, what really separates the leading systems, where CBCT and remote monitoring fit in, and what practices should expect during onboarding. Whether you're evaluating your first cases or looking to refine your approach, This conversation offers a practical roadmap for navigating the transition to digital indirect bonding. Here's our conversation. Alison Werner (01:08) Dr. Manuele it's great to have you on the podcast again. Dr. Jeremy Manuele (01:11) Yes, thank you for having me, Alison. Glad to be back. Alison Werner (01:14) Great, okay, so this time we're gonna talk about digital indirect bonding, as I said in my introduction. So before we dive in, I'm interested in how your bonding protocols have evolved over the last decade. Dr. Jeremy Manuele (01:25) Absolutely. Yeah, so I would say I've always had an interest in indirect bonding. So I was introduced to more primitive forms of indirect bonding way back in residency. And it always resonated with me because at the time, you had these providers who were known as being master bracket placers. And they had these amazing finishes. And everybody had their own technique as far as how they would put the braces on. depending on which faculty I asked which day, I might get a different answer on what's ideal. Alison Werner (01:35) Mm-hmm. Dr. Jeremy Manuele (01:55) And some were selling like jigs and depending on if you put it on the tooth this way or that way or you know, it just seemed very, very subjective. And it seemed like some people just gravitated and mastered it, Alison Werner (02:02) Mm-hmm. Dr. Jeremy Manuele (02:06) it really something that was easily reproducible to the masses. And so for me, it always made sense like, well, if we can position these brackets in an environment that is more conducive than looking inside of the mouth with the saliva and loops and this angle and that angle and the patient moving, like it would just make sense that we could get those brackets in a better spot. And if we can get the brackets in a better spot, we should be able to finish faster and or better. And so that was kind of my interest initially. We started out doing, you know, memisil on models and suck downs, you know, different techniques to try and transfer the brackets from what we had placed on a stone model onto the mouth just through traditional indirect bonding methods. And when I joined, the practice I joined in 2014, they already had an indirect bonding system in place. So it was again analog, you know, or old school what we'd call now indirect bonding Alison Werner (02:55) Yeah. Dr. Jeremy Manuele (02:56) where we pour out a model and we put the brackets on the model. At least we could see the model, right? We could see the teeth, we rotate it, we could look at the panel if we wanted at the same time. And we put the brackets on and we transfer them with the transfer trays. And we don't have to go into the details of the issues with analog indirect bonding. But I had been following and wanting a company to come up with digital indirect bonding for a long, time. My first experience with it was actually with Insignia, which is one of the earliest players. That was Ormco product. ⁓ And I actually really Alison Werner (03:01) Yeah. Dr. Jeremy Manuele (03:25) enjoyed the digital indirect bonding of insignia. Now the system had other problems and I don't believe it's around anymore. Maybe they're using some of the technology for their newer indirect bonding sure. But I had a challenge more with the braces and the wire component in the finishing of those cases than I did with the bracket placement individually. so we fast forward and now we get to an environment where finally someone almost outside the space comes in and decides to start developing indirect bonding as their sole focus. So that's when Ortho Select came ⁓ along, which most people know today as DIBS or the Digital Indirect Bonding System. And so very early on when they were developing their software, I was very interested in what they were doing. And so they were running with this at a level that no one else really had before. was really their only product. this digital indirect bonding, they wanted to master it, they knew it was possible, they felt like ⁓ that if they could, that it would be a huge value add to multiple practices around the world and that it would be worth it. And so I've been following them and using them on and off ⁓ for a long, time. Finally it got to the tipping point where it made sense to transition all of my cases over to digital indirect bonding and I did that about three years ago now. But until then I just kind of dabbled in it because again I wanted to make sure that whatever system I did adopt would withstand Alison Werner (04:37) Okay. Dr. Jeremy Manuele (04:44) the test of time and would be good enough to last. And so that's when I jumped on and it has been a game changer. What I will tell you is that once you jump on to any indirect bonding system today, there's multiple good ones out there, it's going to change your practice tremendously in good ways. It's going to change your workflows, it's going to change your work-life balance. And we can talk about all of those things because it's here and it's not going away. And so I think about it like, you when doctors come up to me and it's like, well, why would I indirect bond or digital indirect bond? And I asked them, well, Well, why wouldn't you digital indirect bond? You know what I mean? You turn the question back on them and of course the barriers come up But you think about that if you went to a car dealership you wouldn't go in, know to the Mercedes dealership and say hey Can you give me that technology from you know, 2010 like, know, I loved it, know, it was great You know, can you just put that in my new car? Like you would never do that But yet in orthodontics we have all of this available to us But yet so many practitioners are so reluctant to to onboard it It's like, you know, they don't you know, maybe they don't feel it's mainstream or they don't know how to or they don't know what the disruptions are Alison Werner (05:28) Yeah. Mm-hmm. Dr. Jeremy Manuele (05:43) So my goal today is to talk about some of those things and really bring awareness to some of the trials that practitioners will encounter and also some of the hang-ups that we often hear questions that people have and maybe a different way of reframing or thinking about that hopefully in a way that helps to grow your practice and really grow you as a practitioner to be honest. Alison Werner (06:06) Okay, so then you touched a little bit on it there, but let's go a little further. Why do you think orthodontists should invest in digital indirect bonding? Dr. Jeremy Manuele (06:14) Yeah, so here's the thing. So digital indirect bonding is going to do probably two main things for you. You know, three main things. Let's talk about first ⁓ it's going to increase your efficiency in practice. Okay, there's multiple levels to efficiency. There's doctor time efficiency, there's chair time efficiency, and there's overall treatment efficiency number appointments. Okay, so digital indirect bonding is going to improve all of those things, but not immediately and not all at once. So the other reason, and we'll talk about that more, other reason I would consider doing it is because it will actually save you money if you do it correctly. One of the big barriers with digital indirect bonding is the cost. Everybody focuses on the initial cost of whatever it costs like tomorrow to do this on every single one of your cases. But cost is so much more nuanced conversation than the price of any technology. We know that with 3D printing. We know that with everything that we incorporate into our practice. There's always an actual cost to integrate it. But then there's the unseen costs or the costs that play out throughout entire treatment that need to be talked about or discussed as well. And then finally, the third one is the results. I mean, you will elevate your practice to a new level, to a new standard of care for yourself if you're able to optimize your bracket placements. And by optimizing your bracket placements, you'll also be able to optimize your systems to support those bracket placements being more ideal. And so, you'll be able to walk away from your cases having undoubtedly a higher quality of finish in general than if you were to continue with a less accurate method of treating. Alison Werner (07:45) Okay, so then let's talk about the different systems that are out there and the kind of the differences. So we have KL Owen, LightForce and the Dibb systems. Talk to me about what are the differences there? Dr. Jeremy Manuele (07:58) Yeah, those are probably the main three players in the game today. And there are some very important differences. And I love talking about those three first because it really highlights those differences in a unique way. And so I'll actually start out by talking about LightForce because LightForce is out of those three, the only one that is truly 100 % customized in every aspect of the digital indirect process. So essentially starting from a CBCT root integration, the brackets that are placed on the teeth are actually 3D printed. And so those brackets are designed and customized not only to the tip torque angulation that the tooth needs to arrive at its final position, but it's also fabricated according to the actual tooth anatomy of the patient. So if they have a weird cusp that sticks out here, or they have this bulge in their tooth, or they have a little divot, or whatever the anatomy of the tooth is, where a stock bracket may not sit on it quite as ideally, ⁓ Alison Werner (08:30) Mm-hmm. Dr. Jeremy Manuele (08:55) LightForce accounts for that and within their software, it's going to create the bracket to fit snugly against that. Now, I'm not a huge LightForce user. I have done a couple of cases. I like their technology. I think it's good. I'm glad that they're in this space because I think they have a huge value add as to what they bring to our profession from a technology standpoint. In fact, I treated my youngest daughter with LightForce. And so, yes, I think there's a lot of good things there. For me, it is a little bit cost prohibitive. ⁓ I think last time I checked, they were around a thousand dollars a case, which is Alison Werner (09:04) Mm-hmm. Okay. Dr. Jeremy Manuele (09:25) quite significant depending on the volume of your practice. And so for me, it became a conversation. And the other thing for me is that I was a self, I am a self-ligating practice in LightForce, an active self-ligating practice in LightForce at the time was a twin practice. I don't know if they have any indirect bonding or passive self-ligation at some point. I know they were talking about it, but I know primarily those who are using it are using twin brackets. And so it's a much easier transition if you're a twin bracket practice already to integrate something like that, that's already twin. Alison Werner (09:26) Mm-hmm. Yeah. Okay. Dr. Jeremy Manuele (09:55) And so those were my kind of my pros and cons with LightForce now The next one is KL Owen and KL Owen is super interesting And so what they did is is they sort of took the principles of LightForce But they modified it in a way where their system is is semi customized And what that means is that instead of having every single brace on every single tooth? ⁓ Unique to that patient and and having custom pads that bonded the patient. They do have stock brackets I think currently they have twin brackets and they also have a passive self-ligating option the last time I checked. And so they have bracket systems. Now these are stock brackets but where it's unique is that instead of just putting those stock brackets like you have one stock bracket for the first molar and the second molar and the second premolar and the canine, they have an array of brackets per tooth. So you're going to go into the software and set up the case and then the software is going to pick for you not necessarily the maxillary right canine bracket, it's going to pick for you the bracket that would Alison Werner (10:29) Okay. Dr. Jeremy Manuele (10:55) go on that tooth based on the final position and its tip torque needs. And so it will select out of a larger inventory. So they have more than just 32 brackets. They have a larger inventory of brackets. And then the software selects, hey, for this case specifically, with where the facial anatomy is, this is the bracket that's going to fit the best. Alison Werner (11:00) Mm-hmm. Yeah. Dr. Jeremy Manuele (11:14) So now additionally that gets them I think from their research about three to about three percent. They're about three percent away from perfection with that method. And then the way they try to get that additional three percent is that within the software themselves instead of just taking that bracket and placing it flat up against the surface of the tooth what they do is they actually modify or slant or tilt the bracket any which way they need to in order to try and recapture that last three percent deficiency you know compared to LightForce if you're Alison Werner (11:22) Okay. Dr. Jeremy Manuele (11:44) to compare apples to apples. Another comparison is that they are significantly cheaper. I don't use KLOwen and currently. Will I someday? I don't know. Maybe. I do like the technology. I'm not a passive self-ligating practice. I'm not a twin practice. So I would have to switch my brackets in addition to my workflows. And so I haven't done that yet. But last time I checked, they were around $400 a case-ish. And I think that includes the brackets, four to five, which again, when you do the math on that, that's pretty reasonable and significantly less Alison Werner (11:46) Okay. Mm-hmm. Yeah. Okay. Dr. Jeremy Manuele (12:14) than LightForce and so that's kind of how they came in. They actually were using DIBS software initially. Again, DIBS was one of the early players in perfecting this digital indirect bonding software. So they used their software initially and I believe since then they've either licensed it or redeveloped their own or they moved to a slightly different platform where they do their setups now. Alison Werner (12:15) Mm-hmm. Right. Dr. Jeremy Manuele (12:34) So lastly, let's talk about DIBS. And this is the system that I currently use, DIBS AI. ⁓ And what DIBS AI is, is it's very similar to KL Owen, except you do use your own brackets. So I don't know, it's very customizable as well. So just understand, the way that I use it may not be the exact same way that everybody else who uses DIBS uses it, but the way that it's presented and the way that I've always used it, you have one bracket per tooth, like traditional orthodontics. So I'm not necessarily swapping brackets per tooth or getting any kind of ⁓ additional Alison Werner (12:39) Okay. Dr. Jeremy Manuele (13:04) customization that way. I do do the slight the tilting of the brackets to improve accuracy and or to be able to modify the prescription slightly. But it's not going to select a different torque. It's not going to select a different tip based on the movements of the case or where those teeth are. So any of those fine tune details that need to be worked out toward the end, I would work out with you know with with traditional arch wire adjustments detailing things like that. And so that's kind of the the long and the short of DIBS Now with DIBS, you use your own brackets and you have options as to how you do that. So in my practice, ⁓ for workflow advantages primarily and turnaround times primarily, what we do is we send the case off and then we have the setup completed. So I will approve that setup and then we will print those indirect 3D printed bonding trays in our office and then we will load those trays with the brackets and we will deliver it. And we can do that turnaround time, we do it consistently in a week, but in a pinch we could do in as little as three days. And so that's the workflow that we've established just to be able to get the cases going a little bit faster. Most doctors who use DIBS will use their kind of standard workflow, which means that they will send off the case. Same kind of process in the beginning as far as getting it approved, but then DIBS will print the trays for them. They will load the brackets for them at no additional charge, which there is some technique sensitivity to that. So I would encourage users who are first starting out with them to take them up on that. ⁓ And then ⁓ they will send it to you. They'll mail it to you. Alison Werner (14:05) Okay. Dr. Jeremy Manuele (14:35) and you can then deliver it. So you just have the trays, you put the glue on and then you cement them and deliver them. So that's kind of the more traditional way of using those. Now there are other players and newer players in the space which I know less about but we could talk about or if you want to focus on some of the aspects of the three major players there we can do that as well. Alison Werner (14:46) Yeah. Yeah. Yeah, no, I'm curious what you've heard in terms of the other players that are, because I know Ormco just recently rolled out their new one. And then I know there's another one that I am forgetting. But I'm curious about where you think those are coming, where they're kind of coming into the game, because with talking about Light Force, K.Lo and DIBS, you kind of gave the spectrum of where you can enter kind of price wise or even just, ⁓ you know, Dr. Jeremy Manuele (15:05) Yeah, 3M has one, uLab has one, yeah. Alison Werner (15:21) your choice in brackets. So I'm curious about your thoughts on those. Dr. Jeremy Manuele (15:26) Yeah, so DIBS, obviously you can use any bracket, so the bracket doesn't become an issue at all. Now, if you are looking at other systems like Ormco users, I think it would be worth looking at their digital indirect bonding system. There were many aspects of the initial insignia that I actually really liked about their digital indirect bonding system at the time. So I'm not an Ormco user, so I don't know all the details about that, but if I was an Ormco user, I would definitely be looking into that system and see how easily or not it could integrate. ⁓ Alison Werner (15:31) Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Okay. Dr. Jeremy Manuele (15:56) because obviously they designed that entire system around working with their brackets. so, know, whereas, you know, DIBS has been around a while and they play with, you know, a lot of brackets. They have all the major brackets. But again, this whole entire system with Ormco was designed around their brackets. 3M or Solventum the same way, right? So they have some cool things. They have flash-free bonding if you're into that. And they have developed their system, I would imagine, primarily around 3M products. So if you're a 3M user, then I would say yes, absolutely check it out. I don't know what the workflows are. I don't know what the costs are. Alison Werner (16:00) Yeah. Mm-hmm. Yeah. Dr. Jeremy Manuele (16:26) are the things that I would be evaluating ⁓ if I were to be, you know, looking at incorporating indirect bonding in my practice for the first time. Alison Werner (16:34) Well, it sounds like if you have a bracket system that you really like, first look and see what that company offers in terms of ⁓ digital indirect bonding. Or then if you do have a bracket that doesn't have a digital indirect bonding option at that time, find those system agnostic options. Dr. Jeremy Manuele (16:53) For sure. You know, I would look at both because here's the thing when you're first getting in, I would look at DIBS and whatever the local native system is to your brackets. And the reason for that is they've been in the game the longest. And so there's a lot of things that they've already worked out that other companies may not have gotten to yet. And so just from an educating myself standpoint, I would I would kind of see what those features are. Like, let me just give you one quick example. So one is is sub gingival bracket placement. So this is something that we could never really do on stone models. We would try to we'd sit there and try to like, you know, carve or div it out the Alison Werner (17:02) Mm. Okay. Yeah. Dr. Jeremy Manuele (17:23) so that we could place the bracket a little bit lower because we knew that's where the bracket needed to go. But we didn't really have a good way of getting it there. And the gums of course are elastic. So you can push it down a little bit and the bracket can stay on the tooth. What DIBS did is they sectioned the teeth separate from the gingiva. And so you can literally slide that bracket underneath the gums in the software. And you can also see the exact extent of that. And so that's a real, real big difference in the ability to place brackets, especially in teenagers and growing patients and patients who have erupting teeth. Alison Werner (17:27) Mm-hmm. Mm. Dr. Jeremy Manuele (17:53) It can make a very, very significant difference in the practice. So other companies, there's like uLab and Archform, I know they both have indirect bonding systems as well. At least at the time I was evaluating them, they didn't have the ability to do that, right? And so that for me was something that discouraged me from doing more with those other companies that may have had other advantages because that was a big priority to me. Now if you know what all of the features are, you can kind of determine for yourself what features are most important. Alison Werner (17:56) Yeah. Mm-hmm. Okay. Dr. Jeremy Manuele (18:23) to you with the way that you treat it in your practice. But I would absolutely, I I talked to as many companies as I could before making that decision. Because again, you want to get this right in your practice. You don't want to just go, you know, get back to your practice next week and just, you know, throw it through a whole new system out there and then have it be a complete disaster. You want to be confident that you know, that people are using it, that they're getting good results with it, that you have the support that you need, and that it is going to tie back and incorporate well with with the brackets that you're using. Or, you know, if you're willing to switch, then you know, being able to switch. Alison Werner (18:28) Mm-hmm. All right. Yeah. Well, I want to move on to kind of an imaging component because you mentioned CBCT earlier. And so how important is CBCT integration? Do you always need it for digital indirect bonding Dr. Jeremy Manuele (19:03) Yeah. Yeah, so that is a question I get all the time. And most people, when they first hear about CBCT integration, they just automatically associate it with accuracy. That's like the one thing that they always think about. And that's a good association, right? If you can see the roots of the teeth, it is going to be more accurate. But I mean, truthfully, like some doctors care more about accuracy than others, right? I mean, if you want to get through the case ⁓ and you want to get a nice smile that looks nice, do you need that level of precise accuracy in your setups or is looking Alison Werner (19:13) Yeah. Mm-hmm. Dr. Jeremy Manuele (19:34) the crowns the teeth sufficient. And I think you could argue that either way, right? Many practitioners say, well, we've been getting amazing smiles and bites for years, know, board quality, all the things, you don't need it. And so I'm not going to argue against that. Do you need CBCT integration to get good results? No. I practices do it all the time. So do I do CBCT integration on all of my setups? Yes. And accuracy is only a part of it, though. And here's the part that a lot of practitioners don't think about. It's the time savings. So when you integrate a new technology, into your practice, the number one commodity that you need is your time. And you are going to have to look at these setups, right? You're going to want to look at these setups. And I guess maybe you don't have to, maybe there are practices that don't. But if you want to really dial in and get the most precise journey from A to B, you as an orthodontist have more skill in knowing where those brackets should be placed and knowing how those teeth should be aligned than anyone in your practice, right? So you want to make sure, in my opinion, that you are reviewing these setups. And so you need to get as fast at reviewing these setups as possible in order to minimize your time. Now as soon as you get faster than your time to direct bond a patient, you win, right? So if your time to direct bond a patient is eight minutes, let's say you're, you know, whoever, maybe you're Jamie Reynolds and you're a rocket, right? I mean you just, you direct bond cases like amazingly quickly. If you're like eight or nine minutes... Alison Werner (20:49) Yeah Yeah. Dr. Jeremy Manuele (20:54) it's totally doable to get your DIB setup time down to five minutes or less. And so again, other softwares, who knows, maybe they're faster, maybe they're slower, I haven't used them enough to really dial that in. But that is definitely a question that I would ask doctors who are using those products is how much time, once I get good at it, is it going to take me to approve these cases? Now when you have those roots available to see, the question about where that tooth needs to be and your confidence in where that tooth needs to be and how it needs to look is increased tremendously because you can just Alison Werner (21:11) Mm-hmm. Dr. Jeremy Manuele (21:24) You can say, there's nothing majorly off here. And when we started to integrate these roots it was amazing because now we get fast forward to the repo appointment. And guess what? It looks just like it did in the setup. It's like, hey, I made the roots parallel in the setup. And now we're here at the repo appointment. It's like, look, the roots are good. And that doesn't mean we never have to repo. But ⁓ in our practice now, we repo zero brackets more than anything else. So the majority of our cases, we repo zero brackets. The cases that we do repo usually are one Alison Werner (21:27) Right. Mm. Dr. Jeremy Manuele (21:54) the two. And then occasionally you'll have an outlier. And typically this is where like maybe a tray didn't get seat down all the way or something else happened in the initial bonding that we didn't catch. And so then we get to the repo and it's like, we got to repo like all five of those brackets on that side or whatever, or the front brackets or whatever it might be. But that's, you know, that's very much an outlier at this point in time. Alison Werner (22:08) Okay. Okay. Okay, so that was actually gonna be my next question is how do repos and bracket failures compare with a traditional bonding? Dr. Jeremy Manuele (22:21) Yeah, so here's something that's really interesting. When I first started doing DIBS, when we switched for all of our cases, we didn't immediately switch our appointment protocols. We were still kind of treatment planning the appointments the same way that we always had. So we had like what we call a Pano plan repo appointment, where we would take the Pano and we would look at all the brackets and the root positions and we would say, next time when you come in, we're gonna repo one, two, three, four, however many brackets. And then depending on how many brackets we thought we were gonna need to repo, we would then Alison Werner (22:32) Okay. Right. Dr. Jeremy Manuele (22:51) then schedule an appropriate amount of time to be able to do that. And so that's how we had kind of always done it before. And so when we first incorporated the technology, we didn't change that. We were still doing this Pano plan repo and then this repo visit. The other thing I will tell you is that ⁓ we didn't trust our placements enough in the beginning. So we would see something in the mouth or we would see something on the X-ray and we would get worried about it. So we would repo it at that repo visit. What we've learned to do is to trust our bracket placements Alison Werner (22:57) Okay. Dr. Jeremy Manuele (23:21) a lot more. So now if we see something that we don't think is 100 % there, because we're maybe not in a full-size arch wire yet, then we'll leave it, especially if it's something that's easily detailable. So if it's like a quick in-out, if it's like a quick tip, if it's something that we can detail very easily, then we're gonna leave it at the repo appointment and see once we get into our fuller size wires for finishing if it plays out or not. The majority of the time it does play out. And when we learned that, we were able to eliminate completely that planned repo appointment. Alison Werner (23:22) Hmm. Dr. Jeremy Manuele (23:51) We now take that pano the same day as we plan their repo. again, the majority of the cases, we just transition into their finishing wires. Or maybe we need to pick up sevens that weren't in or whatever. We'll pick those up and go that way. But if we do need to repo, we have the time there. And again, it just never messes with our schedule because we know we're not going to be replying seven brackets. Alison Werner (24:14) Okay, okay. So I want to go back. When you were talking about CBCT integration, you mentioned how you get faster, you know, as you do this and look at the talk to your peers about how long it's taking them to do this workflow. So talk to me a little bit more about what is the learning curve for digital bonding? Dr. Jeremy Manuele (24:21) Yes. Yes. Yeah. Yeah, so I'll start with the doctor learning curve. So the doctor learning curve, you have to learn the software. That's the biggest thing. Indirect bonding in the mouth, you could take the training and you could have that down as a doctor pretty good. You're not even going to probably be doing it. Your team's going to be doing that. And so as a doctor, the biggest thing that you have to learn is the software itself. You have to learn how to manipulate the teeth. You have to learn how to move the teeth. You have to learn how to change the angulations and all those things. For me, it was... Alison Werner (24:39) Okay. Dr. Jeremy Manuele (25:02) was challenging at first, because at the time I was integrating them and when I was even just kind of piloting them or using them on a smaller basis before I started using them full time, ⁓ things were changing constantly. And so it was like there was this update and that update, and so it was kind of hard to keep up with. Now that they've sort of hit their flow with DIBS AI, it's much, much easier because the major revisions to the software aren't happening. They'll still have updates and new features and capability, but it's not like the workflow is changing significantly. And so initially, what you want to do doctor is you want to spend your time learning that software. So hop on calls with the software trainers. really, really, that time that you spend with your trainers will pay itself off, regardless of what system you're using. Like talk to the trainers about the software. Do your first 10 cases with them. Have your office manager coordinate it. Like whatever you can do to spend time. Talk to other doctors. Like once you get your feel for it and you say, OK, you I've done like 10 cases, I've done 20 cases, I've done 50 cases. Now go talk to some other docs who are doing it. ⁓ Have them watch you do a case and see what they think. well, that's cool. You do that that way. Well, this is the way I do it, and this is why. And pick up those tips. Commit to spending, let's say, the first six months learning and refining that software. It's not going to take you six months to learn it. but commit to spending that time not only just to learning it until it's functional, but to really learn it at a level that you feel almost like a master at it. That time will pay you back over and over and over again on every single case that you have to set up for the rest of your career. so spend the time up front on the software. Now let's talk a little bit about the integration as a whole in the practice. ⁓ So now if you're switching from some other form of digital indirect bonding, it's probably not gonna be that big of a deal. Alison Werner (26:38) Yeah. Dr. Jeremy Manuele (26:47) There's more in common with these systems, I would say, than there is not in common, even though there are a number of differences. But if you're switching from direct bonding to indirect bonding completely, that's a big transition. ⁓ Go in there with the correct expectations. There will be issues There will be things that come up just because you're not familiar with digital or any type of indirect bonding So utilize the training that the company offers, of course, so watch the videos They send you in advance have your team watch the videos have the trainers come out and do your first few cases with you And just know that there are going to be things that come up So one example is just you know, very very simple like for DIBS as an example You have to make sure the brackets are placed correctly. That's why I encourage docs initially ⁓ to have DIBS place the brackets for them. They can do that ongoing if they're going to continue to order the trays from them. But if they want to move tray production in house, then eventually they'll need to take that over. But for your first, let's say, 50 cases, just let them do it. Because that's going to eliminate that as an issue. And the other thing that happens is as they're placing those brackets, if there's anything specific to your brace that needs to be modified or adjusted within the trays, they will actually make those changes for you. So they'll actually be improving your bonding experience. and your tray fit and design while you are just sitting back at your office waiting for those trays to arrive. Once you start taking that over in your practice, you'll need to give that feedback to them. So for instance, like maybe every time you load a max or you left canine bracket, like it seems like it's a little loose or it seems like it's coming off a little bit, or it seems like it's too tight, whatever it might be, if you give that feedback to them, they will actually modify and adjust your specific trays to your specific brackets to get the ideal fit possible. So that's something that's worth looking into. Now as far as the delivery of the trays, your team, if they're not used to it, they're probably going to hate it at first, right? mean everything that we throw at them initially, they don't love change in general, right? And so you're going to have some pushback. You need to keep elevating them to the new standard. Talk to them the way that I'm talking to you today. Talk to them about the future of our profession. Talk to them about the results. Talk to them about the time they're going to save. Not waiting on you to get done with your consult to come bond these brackets. Not all those things that they're dealing with now that they don't really Alison Werner (28:39) Right. Right, yeah. Dr. Jeremy Manuele (29:00) or even issues because they've always done it that way, like paint them the bigger picture. And over time, once they get comfortable with this, then if you were to take it away, it would be like the worst thing ever, right? I mean, because it becomes so easy for them. They can get the brackets on there, they're not wondering like, it in the right spot? Like, is the tray seated down? Did I cure it long enough? Did I bump it when I cured it? Like all these things that come up, those hassles are eliminated. And then you get to the point where you're just, you're basically, ⁓ you're grooving, you're driving. Alison Werner (29:03) Mm-hmm. Right. Dr. Jeremy Manuele (29:30) Things are going well and then your team is going love it. Alison Werner (29:34) Okay, so let's go back to digital indirect bonding save significant share time in the long run. And so you've talked a little bit about there about how that does manifest, but talk to me a little bit more about the share time savings. Dr. Jeremy Manuele (29:47) Absolutely. and so, know, obviously, you know, we'll have to separate this discussion out between the savings that you may get from, you know, your bracket type, know, twin versus ligating, and then the savings that you'll get from a digital indirect bonding system. In my opinion, you know, digital indirect bonding pairs best with some sort of self-ligating bracket, right? Because what you can do is, you you can put these braces on if they're in the right spot and you have an active wire that's not fatiguing, and clips that aren't fatiguing, or doors that aren't open, Alison Werner (29:57) Mm-hmm. Dr. Jeremy Manuele (30:18) Then you can let that additional wire run for you know for three months or so now with remote monitoring as well being able to track the hygiene and being able to track any emergencies that may come up like there's no reason that you can't you know let that patient go Especially one with significant crowding for three plus months while the wires is working So initially you're going to save ⁓ time right off the bat doing it that way Where you save the most time on let's just say for both systems both self-ligating and twin bracket systems I would say is from the Alison Werner (30:35) Mmm. Dr. Jeremy Manuele (30:47) repo appointment on. And the reason for that is that, you know, once you get to that repo appointment, one, you may eliminate an entire appointment, but two, the consequences of your repos are not always ideal. Like sometimes you repo and you get it right, right? But other times you repo and you don't get it right again, right? Then we have like another repo down the road or another detail bend and those things compound. And so from the time you repo onward, the detailing that you will need to do is significantly less. And so that's where, you know, when you see these doctors Alison Werner (31:04) Right. Dr. Jeremy Manuele (31:17) talking about like, I saved X amount of appointments, I saved this much in treatment time. That's where the majority of that value is coming from the indirect bonding system itself, is not replying as many brackets or not replying any brackets at all, and getting through the finishing stages of your treatment to get a good occlusion, to get that final result socked in as quickly as possible. Alison Werner (31:39) curious because you talked about you know that length between appointments are you using any type of remote monitoring with these patients? Dr. Jeremy Manuele (31:47) Yes, so I use Grin for my remote monitoring system. And I think there are multiple on the market now. I for me personally, I chose them primarily for two reasons. One is that there was a face-to-face ⁓ relationship with an actual team member that Grin provided for me. So they made the onboarding very, very easy. And then the other thing is that at the time the cost was significantly less. So pairing those two things together is why I chose them. But yes, we can see ⁓ the progress of the case ⁓ as we go along throughout digital. Alison Werner (31:50) Okay. Yeah. Okay. Dr. Jeremy Manuele (32:16) Now, do I use it on every single one of my braces cases? No, I use it on all of my aligner cases, I use it on all of my MARPE cases. To date, I don't use it on every single one of my braces cases ⁓ because I don't feel like it's necessary and it is an additional expense. But braces cases that I feel like need it for one reason or another, maybe they are severely crowded and I feel like a wire can go four months, well I'm gonna wanna throw them on there just to keep an eye on things in the meantime. Alison Werner (32:30) Okay. Okay. OK. I'm curious, how does bracket positioning precision kind of translate into actual treatment outcomes with these systems? Dr. Jeremy Manuele (32:50) Yeah, so here's another fascinating thing. So when you start using digital indirect bonding of any type, you are going to see, ⁓ let's just call it the deficiencies of your prescription, right? And so as these cases play out, know, case number one, case number 10, case number 20, you're going to start to see these patterns that arise within your cases. And those patterns are going to teach you something if you pay attention to them, right? So for instance, like, you know, with my prescription, I noticed that, hey, you know, like every time Alison Werner (33:02) you Dr. Jeremy Manuele (33:20) I set up these cases like my second premolar Actually is too far inset. It's too far lingual compared to ideal and I always end up stepping it out there So, you know I go back to my prescription and I say hey look like what you know Why is this and I look at the inset and it's like, you know, the inset is larger and like, know Like I'm sure there's a reason that they did that but for my flavor for my treatment for my getting the inclusion the way I want it It wasn't working. So I went ahead and I and I did I switched my bracket I said, okay Well, well the the maxillary left premolar has the same prescription except for its Alison Werner (33:44) Mm. Dr. Jeremy Manuele (33:50) not as offset, so let's put that bracket on the tooth or whatever. And we actually swap that out. And so we do the same kind of things with our detail adjustments within the software. If we're seeing something clinically happening over and over and over and over again, we're going to take that information back to either the prescription and the braces that we're actually using, or at a minimum to how we adjust the final tune of the setup to account for that. Another example would be mandibular canine rotations. like when I was, and again, it takes you time to pick up on these things. Alison Werner (33:53) Okay. Dr. Jeremy Manuele (34:20) every single case I'm detailing lower canines, mesiofacial, lower canines, mesiofacial. And so I realize, hey, I'm going to set this up in the software. I'm going to put that bracket a little bit more mesially on those canines. I'm going to rotate them more on the software. And then lo and behold, it's like, hey, now I'm not doing all these mesiofacial ⁓ bends on these cases. And so another cool thing while we're talking about it, because this is, ⁓ it relates to it, it's not exactly your question, but it relates to it, is if you ever have problems with patients biting off Alison Werner (34:47) Yeah. Dr. Jeremy Manuele (34:50) on the lower incisors. This is something that we constantly struggled with. And we would do the opposite of what I do now. We would place the brackets more incisal and hope that it would push those teeth down so that they wouldn't hit on them. But what we do now is we actually err on the side of placing those lower incisors more gingively. And then we'll typically step the wire down at the two to two when we get into that final wire. And so before we get into that final wire, they're typically disarticulated with some type of turbo or something like that. Alison Werner (34:55) Yeah. Dr. Jeremy Manuele (35:20) and as we get closer to the final wire, we'll step that wire down so the bracket position is lower on the tooth already, but they're also, the lower incisors are stepped down as well so that the vertical level is taken care of, and we almost never have issues with patients ⁓ either biting down or wearing off teeth due to deep bites and lower incisor bracket positions. So that's just a little tip or help for those out there that may be struggling with that, as I did for years. Alison Werner (35:42) You ⁓ okay. Well, it sounds like you have a lot more data around how treatment is progressing, how your positioning is translating into outcomes with this kind of digital system. Dr. Jeremy Manuele (35:59) Yes, yes. Alison Werner (36:00) Okay, so I'm curious. Okay, so what are the upfront costs and kind of the tech tech investments? And I guess overall, as we kind of wrap this up, are they worth it? Dr. Jeremy Manuele (36:11) Yeah, so yeah the question of value comes into play right so and again this is this this is for me Here's the thing like if you want to integrate this into your practice the number one reasons you won't or that you won't stick with it are either problems with integrating it and or cost like long-term costs those are the two biggest reasons why either a you won't start doing it or B you won't keep doing it So let's address those ⁓ one by one. So let's talk about cost. That is a big in my opinion ⁓ guess seller would be the right word for something like DIBS because the barrier point initially is quite a bit lower. You could make the same argument for something like uLab or possibly 3Shape or Archform. All of those costs are somewhat lower. It's just that DIBS has been in this game the longest. And so when you pair that with the experience you'll have in onboarding, you're more likely to have a better result cost-wise, I think, with DIBS. But 100 % you are going to save that money over the course of your career and probably within the first, Alison Werner (37:04) Okay. Dr. Jeremy Manuele (37:10) say year. As you start cutting off those appointments and all of the overhead associated with those appointments, that cost savings is going to be realized very quickly. DIBS, I believe, is around $165-ish per case. ⁓ And everything else is the same. So you know what your exact increase in cost is. So you times that by the number of appointments you have, and you can kind of get an idea of, well how much is this really costing me per appointment? And what does my chair time cost me per appointment? You will save that money back in a Maybe even an inventory depending on how many brackets you repo and if you grab new brackets I mean if you're using an eight dollar bracket and you're replying five on average and put you know with new brackets You know you're gonna save that money probably or a lot of that money right then or some of it at least But I would say the majority of the savings comes in the forms of decreasing your Alison Werner (37:48) All Dr. Jeremy Manuele (37:59) ⁓ your number of appointments needed and finishing the case faster, right? So that you're not having to continually service these patients when they should be already finished if that makes sense. So the other side of it is the onboarding side. And again, that's why, you know, that's why I made the decision that I did to onboard completely with DIBS initially. Now, am I saying I'm going to stay with them forever? No. Like if there's another company that comes around that's doing it better or that offers more value or maybe they're doing it exactly as good but they're half the cost would I switch? Absolutely. Yeah. You know, like I'm not I'm not I'm not beholden to to to any any particular company I'm beholden to the results and what the value that it adds to my practice, right? So when we talk about in integrating this like you have to be you want to have a company that has the training ability the software capability you want to make sure that that your ⁓ integration ⁓ Failure or success is not due to the product Alison Werner (38:32) Yeah. Mm-hmm. Dr. Jeremy Manuele (38:55) or their service, right? And so for me, it's like, you know, even if you want to use another indirect bonding system later, but you're just not sure, I would say, you know, go ahead and integrate, even if you even just do like 10 cases. And again, that may not be a fair shake, but 10 cases will give you some experience. If you get through 10 cases, you're going to see a lot of things. Now I wouldn't stop there because after 10 cases, we still had a lot of problems that we continued to work through. Now I didn't integrate in 2025, so hopefully there's less of the problems that, you know, Alison Werner (38:56) Yeah. Mm. Yeah. Dr. Jeremy Manuele (39:24) I had going through it, but I would say you want to give it longer than that. But even if you just did 10 to get your assistants familiar, or maybe you did like every assistant did three or four cases, that would be a huge jump and would teach you a lot about digital indirect bonding in general. I mean, I would say if you do 30 to 50 cases, you're going to know, let's just say, 85 to 90 percent of what that system offers. And then you can make a more educated decision. Maybe it is worth switching to a KLOwen and or a LightForce for the additional value that they add with the way that your practice is, the way that it runs. We didn't talk about it. LightForce has some aesthetic advantages as well, right? Their brace looks pretty nice. So there's other reasons that you may consider switching to other products. But if you want to integrate this and you really believe in it and you don't want to have your team, you know, know, revile again. Alison Werner (39:57) Mm-hmm. Mm-hmm. Yeah. Yeah. Dr. Jeremy Manuele (40:16) you know, in three months later or whatnot, you want to have the least amount of problems. In my opinion, would say DIBS is the easiest to integrate first. And then once that's established, and you're more familiar with that, you don't have to change your bracket, right? All that stays the same, the mechanics. I would encourage you to change your appointments, especially the repo appointments, or at least consider doing that, based on the conversation we had today. But that's going to be your easiest way to sort of get into it. And then once you're into it, yeah, pick whatever system works best for you. And or if you're like, Alison Werner (40:20) Yeah. Dr. Jeremy Manuele (40:44) I'm an Ormco user, like this looks great, I'm just gonna do it, great, like do it. But commit to those, really commit to 30 to 50 cases, like really, really understand the system. Once you have those 30 to 50 cases, again, you're gonna know the majority of the value that it has to offer, and if it makes long term sense for you to keep it around. But out of all the things in my practice, that would be one of the things that would be the saddest if that got taken away, and I had to go back to either analog indirect bonding or direct bonding every case. I mean, if had to go back to direct bonding, I would have no time. Alison Werner (41:06) haha Yeah. Right. Dr. Jeremy Manuele (41:12) You know what I mean? Because it takes me three times as long. I'm not a nine minute bracket placer. I'm like a 15 minute bracket placer, right? But I can set up a case in less than five minutes. So that would kill my time. If I had to go back to the stone models, I would just cry. So many issues with stone models. Alison Werner (41:17) Okay. You're not the first person to say that to me. ⁓ Okay, so if anybody has some questions for you, I know you also lecture, how can they get in touch with you or learn more about what you've got on tap? Dr. Jeremy Manuele (41:43) Yeah, for sure. I try to keep people updated as much as I can. So I do have a YouTube channel. It's called Vegas OrthoDoc. I've actually posted a number of DIBS setups in there, kind of like teaching some tips and tricks. ⁓ I try to do webinars with any company that I'm using that I think has something cool or worth sharing. I try to do webinars with them. I don't have anything scheduled with DIBS at the moment, but I do tend to talk about all of my systems anywhere that I talk. So I'll be speaking at Wocon. I don't know when this will air, so it might already be over by then, but if it's not, then great. Alison Werner (42:10) Yep. Dr. Jeremy Manuele (42:13) And then doing a course in February with Stu Frost, we'll be talking about MARPEs but also digital indirect bonding to some extent as well. And of course, you can just reach out to me, right? So I mean, I'm on all the social media, so you can send me a message, or you can email me. My best email for stuff like that is info at Vegasortho.com, which is an inbox that I monitor. And so yeah, or just if you have my number, just text or call me. mean, yeah, I'm an open book. I'm not always right about the things that I say, but I do believe what I say at least. ⁓ Alison Werner (42:38) Yeah. ⁓ Dr. Jeremy Manuele (42:43) And I'm gonna give you my opinion and tell you how it is in that moment. as my opinions change, like I say, I try to keep people updated, so yeah. Alison Werner (42:49) Yeah. All right. Well, Dr. Menwell, I thank you again for joining me and you will be back again with us shortly. So thank you. Okay. Thanks. Dr. Jeremy Manuele (42:56) Wonderful, thanks for having me. Glad to be here. Goodbye.