Treatment time: SureSmile vs conventional

Abstract

Aim:
To understand the efficiency of SureSmile treatment vs conventional treatment.

Methods:
First, 12,335 completed patient histories representing different treatment philosophies and geographically diverse practices were collected. Included were 9,390 SureSmile patients and 2,945 conventional patients. Variables in these patient records included: (1) treatment time, months from bonding to debonding; (2) malocclusion class, Angle Class I, II, or III; (3) patient age, adolescents (< 18 years) or adults (≥ 18 years); and (4) patient visits, total number of treatment visits. Nonparametric regression tests were used to analyze the data.

Results:
The median treatment time for the SureSmile patient pool (15 months) was 8 months shorter than that of the conventional patient pool (23 months). The median care cycle length of Class II SureSmile patients (13 months) was 2 months shorter than that of Class I SureSmile patients (15 months) and 3 months shorter than that of Class III SureSmile patients (16 months). SureSmile patients (14 visits) had four fewer median treatment visits than conventional patients (18 visits). All results were significant at P = .001. No significant differences were noted between the median care cycle lengths of adolescents and adults.

Conclusion:
This study found that SureSmile treatment facilitates more timely care than conventional treatment. Further prospective studies are required to elucidate the effectiveness of SureSmile treatment.

Full text

Sientic
Iovati
72 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
1 Cofounder and Chief
Clinical Ofcer, OraMetrix,
Richardson, Texas, USA.
2 Clinical Research Program
Coordinator, OraMetrix,
Richardson, Texas, USA.
3 Senior Vice President,
The Dallas Marketing
Group, Dallas, Texas, USA;
Advisory Board, University
of Texas at Dallas, Dallas,
Texas, USA.
4 President, Market
Research Answers, Dallas,
Texas, USA; Advisory
Board, University of Texas
at Dallas, Dallas, Texas,
USA.
5 Intern, OraMetrix,
Richardson, Texas, USA.
6 Professor, Program
Di rec tor, and Cha ir,
Department of
Orthodontics, University
of Oklahoma Health
Sciences Center,
Oklahoma City,
Oklahoma, USA.
7 Clinical Assistant
Professor, Department of
Orthodontics, University
of Oklahoma Health
Sciences Center,
Oklahoma City,
Oklahoma, USA.
CORRESPONDENCE
Dr Rohit C.L. Sachdeva
OraMetrix
2350 Campbell Creek Blvd
#400
Richardson, TX 75082
Email: rohit.sachdeva@
orametrix.com
Treatment time:
SureSmile vs conventional
Rohit C.L. Sachdeva, BDS, MDentSc1
Sharan L.T. Aranha, BDS, MPA2
Michael E. Egan, PhD3
Harold T. Gross, PhD4
Nikita S. Sachdeva5
G. Frans Currier, DDS, MSD, Med6
Onur Kadioglu, DDS, MS7
Aim: To understand the efciency of SureSmile treatment vs conventional
treatment. Methods: First, 12,335 completed patient histories representing
different treatment philosophies and geographically diverse practices were
collected. Included were 9,390 SureSmile patients and 2,945 conventional patients.
Variables in these patient records included: (1) treatment time, months from
bonding to debonding; (2) malocclusion class, Angle Class I, II, or III; (3) patient
age, adolescents (< 18 years) or adults (≥ 18 years); and (4) patient visits, total
number of treatment visits. Nonparametric regression tests were used to analyze
the data. Results: The median treatment time for the SureSmile patient pool
(15 months) was 8 months shorter than that of the conventional patient pool (23
months). The median care cycle length of Class II SureSmile patients (13 months)
was 2 months shorter than that of Class I SureSmile patients (15 months) and 3
months shorter than that of Class III SureSmile patients (16 months). SureSmile
patients (14 visits) had four fewer median treatment visits than conventional
patients (18 visits). All results were signicant at P = .001. No signicant differences
were noted between the median care cycle lengths of adolescents and adults.
Conclusion: This study found that SureSmile treatment facilitates more timely care
than conventional treatment. Further prospective studies are required to elucidate
the effectiveness of SureSmile treatment. O
rthOdOntic s
(c
hic
) 2012;13:72–85.
Key words: conventional, efciency, SureSmile, treatment time
Patients frequently consider length of treatment as a factor in their deci-
sion to pursue orthodontic care.1–4 Hickory5 evaluated responses from
1,520 orthodontic patients to better understand what they were willing
to pay for a reduced-length care cycle. His study determined that a quarter of
respondents were willing to pay a 40% premium for a 30% reduction in time.
The majority of respondents did not object to paying 10% more for reduced
treatment time. Therefore, it is clear that many patients are willing to cover
greater costs for shorter treatment times. Numerous studies have also dem-
onstrated a positive correlation between shorter orthodontic treatment time
and patient satisfaction.6–9
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

73Volume 13, 2012
Healthcare policymakers have recognized the importance of shorter treat-
ment times. The Institute of Medicine advocates efciency, effectiveness, and
timeliness of care as three of the six dimensions of quality care.10 The British
Orthodontic Society recommends that patients be adequately informed re-
garding the length of care.11 Extended length of care negatively affects pa-
tient compliance and may result in poor quality of care.12–14 Furthermore, an
extended care cycle adversely affects clinical operations, productivity, and rev-
enue generation.15,16 Patients, parents, and practices all benet from a shorter,
more predictable care cycle. Therefore, it is imperative for clinicians to un-
derstand the factors that impact orthodontic treatment duration in hopes of
maximizing patient convenience and practice productivity.
Studies note that treatment time generally ranges from 18.3 to 31.3
months.2,3,17,18 Sameshima19 reported a mean treatment time of 28 months in
North America. The wide range in duration of treatment is probably due to the
varying interactions of factors such as patient sex, age at onset of care, patient
compliance, severity of malocclusion, nature of treatment, type of appliances,
and the experience of the care provider.6,19–21
In the past decade or so, orthodontics has witnessed the development of new
technologies in the xed appliance arena, namely Insignia (Ormco), orthoCAD
(Cadent), iBraces (3M Unitek), and SureSmile (OraMetrix). These technologies
enable clinicians to provide computer-driven customized care solutions at vary-
ing levels. By minimizing the reactive care process, SureSmile has the transforma-
tive potential of affecting the duration of orthodontic care in clinical practice.22–26
SureSmile was designed to provide a completely integrated, clinical solu-
tion to the extended care cycle. Three-dimensional (3D) imaging, clinical de-
cision support, treatment surveillance, and customized therapeutics enable
orthodontists to minimize iterative care processes and potentially reduce the
duration of care without compromising quality.23–33 Saxe et al34 recently stud-
ied the efciency and effectiveness of SureSmile vs conventional treatment.
The authors collected 62 pre- and posttreatment plaster casts of consecutively
treated SureSmile patients and conventionally treated patients from the prac-
tices of three diplomates of the American Board of Orthodontics (ABO). The
mean ABO objective grading system (OGS) score was 26.3 for SureSmile and
30.7 for conventional treatment. This difference of 4.4 points was signicant
at P = .001. The mean treatment time with SureSmile was 14.7 months vs
20 months for conventional treatment (P = .001). SureSmile demonstrated a
25% reduction treatment duration and an improvement of 14.3% in ABO OGS
scores.34 Similarly, Alford et al compared the treatment times of 69 SureSmile
and 63 conventionally treated patients. The mean treatment time with Sure-
Smile was 15.8 months vs 23 months for conventional treatment. SureSmile
demonstrated a 31% reduction treatment duration and an improvement of
11% in ABO cast/radiographic evaluation (CRE) scores.35
The purpose of this study is to understand the efciency of SureSmile using
a larger sample size while considering different variables than previous studies.
Although Saxe et al34 and Alford et al35 provided the initial steps in identifying
the clinical benets of SureSmile, the robust sample size (12,335 patients) and
diversied practitioner base (142 practices) characteristic of this study allows
for a clearer understanding of the clinical impact of SureSmile on the duration
of the care cycle.
“”
Patients frequently consider length of treatment as a factor
in their decision to pursue orthodontic care.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
74 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati
METHODS
In 2003, OraMetrix developed an ongoing system to collect completed treat-
ment records of both SureSmile and conventional patients from volunteer
SureSmile practices. The purpose of the system is to elucidate clinicians’ per-
formance characteristics and provide feedback on better clinical practices. By
2008, this program, Comparative Effectiveness Research Program (CERP), re-
ceived more than 12,000 completed orthodontic patient histories from a di-
verse group of geographical practices, patient types, treatment philosophies,
and clinician experiences. This is the rst extensive study dedicated to investi-
gating SureSmile’s impact on the duration of treatment time as well as factors
that inuence treatment time.
Patient samples
This study used the CERP database from 2003 through 2008, which consisted
of data submitted by 142 SureSmile practices throughout the United States.
At the time of analysis, a total of 12,335 patient records had been submitted,
containing a mix of two treatment types: SureSmile (9,390 patients) and con-
ventional (2,945 patients). Variables in these patient records included: (1) treat-
ment time, months from bonding to debonding; (2) malocclusion class, Angle
Class I, II, or III; (3) patient age, adolescents (< 18 years) or adults (≥ 18 years);
and (4) patient visits, total number of treatment visits (Fig 1).
Some records were incomplete as they lacked information on the distri-
bution of Angle classication of malocclusion and patient age. Hence, these
incomplete records could not be used for the analysis of these variables, re-
sulting in the smaller samples as shown in Fig 1.
This study did not utilize any protected patient medical or dental informa-
tion by the practices. Only selective treatment attributes were used for the
analysis. Therefore, institutional review board approval was not obtained.
Data analysis
The objective of this analysis was to statistically identify and quantify the key de-
terminants of the efciency of SureSmile protocol vs conventional orthodontic
treatment. The parameter for statistical signicance was a P value less than .001.
(n = 12,335)
2,945
9,390 2,796
2,630 2,236
604
(n = 5,426)
(n = 2,840)
Treatment time/visits
(total sample size) Malocclusion class
(Class I, II, and III) Patient age
(adolescent and adult)
Conventional
SureSmile
Fig 1 Sample size and variables studied.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
75
Sientic
Iovati
The CERP data had a signicant degree of skewness and kurtosis and were
not normally distributed, rendering conventional regression analysis inappro-
priate. (Skewness and kurtosis were calculated as the third and fourth mo-
ments of a distribution, respectively. Measures of skewness and kurtosis equal
to or greater than twice their respective standard errors were deemed to show
a signicant departure from normality.) Therefore, nonparametric regression
was used to analyze the data via SPSS (IBM). This methodology requires that
all records contain a complete set of variables; however, as previously noted,
some records were incomplete and could not be used for statistical analysis.
All 12,335 records were used for treatment time analysis, although only sub-
sets of the record pool containing attributes other than treatment time were
used for malocclusion and age analysis.
RESULT S
Treatment months
SureSmile patients experienced shorter treatment times than conventinal pa-
tients. SureSmile patients experienced 15 months of median treatment time,
while conventionally treated patients experienced 23 months of median treat-
ment time (Table 1).
Malocclusion class
The shorter treatment time associated with SureSmile was evident for all class-
es of patients. SureSmile Class I, II, and III patients experienced 15, 13, and 16
months of median treatment time, respectively, while conventionally treated
Class I, II, and III experienced 22, 22, and 24 months of median treatment time,
respectively (Table 2).
Patient age
Where patient age was available, patients were grouped as either adolescents
(younger than 18 years) or adults (ages 18 and older). Median treatment times
for both SureSmile adolescents (16 months) and adults (15 months) were signif-
icantly less than those of conventionally treated adolescents and adults (both
Table 1 Mean and median values for treatment months
Treatment nMedian Mean SD Mean difference Signicance
SureSmile 9,39 0 15 16 6.75 8< .001
Conventional 2,945 23 24 8.24
SD, standard deviation.
Table 2 Mean and median values for treatment months by patient class
Class Treatment nMedian Mean SD Mean difference Signicance
ISureSmile
Conventional
1,478
1,2 02
15
22
16
24
6.92
9.2 3 8< .001
II SureSmile
Conventional
892
773
13
22
14
23
5.68
6.86 9< .001
III SureSmile
Conventional
260
821
16
24
17
25
7.19
8.33 8< .001
SD, standard deviation.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
76 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati
24 months). Patient age appears to exert only a modest inuence on SureSmile
treatment efciency, for the median length of treatment time for adults was just
1 month less than that of adolescents (Table 3).
Treatment visits
With a median treatment time of 8 months less than that of conventional-
ly treated patients, SureSmile patients also experienced four fewer median
treatment visits than conventional patients. SureSmile patients experienced
a median of 14 visits to their orthodontist over the course of treatment, while
conventional patients experienced a median of 18 visits (Table 4).
Frequency distribution of the data
Plots of CERP data distribution also demonstrate treatment time trends. Figure 2
shows the distribution of the median treatment times for both SureSmile and
Table 3 Mean and median values for treatment months by patient age
Treatment Group nMedian Mean SD
Mean
difference Signicance
Adolescents SureSmile
Conventional
1,3 82
479
16
24
16
25
7.18
8.14 8< .001
Adults SureSmile
Conventional
854
125
15
24
17
25
7.14
9.07 9< .001
SD, standard deviation.
Table 4 Mean and median values for treatment visits
Treatment nMedian Mean SD Mean difference Signicance
SureSmile 9,39 0 14 15 6 .16 4< .001
Conventional 2,945 18 19 7.31
SD, standard deviation.
Treatment mo
No. of records
900
800
700
600
500
400
300
200
100
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47
SureSmile
(median, 15 mo)
Conventional
(median, 23 mo)
Fig 2 Frequency distribution of median treatment times for both treatment groups.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
77
Sientic
Iovati
conventional patients. The median value for SureSmile treatment time was
8 months less than that of conventional treatment. Figure 3 shows the per-
centiles of patients treated as a function of time for both treatment groups.
Fifty percent of SureSmile patients experienced a care cycle of 15 months or
less, while 50% of conventionally treated patients experienced a care cycle of
23 months or less (Fig 3).
DISCUSSION
The purpose of this study was to understand the efciency of SureSmile vs con-
ventional treatment. Variables studied were treatment time, number of treat-
ment visits, malocclusion class, and patient age.
Treatment time analysis
Various authors have studied the inuence of factors, such as severity of maloc-
clusion, treatment method, patient age, and type of appliance, on the length
of treatment time. Table 5 summarizes the results of previous studies on the
duration of the care cycle. As shown in Table 5, many of these studies were
limited by sample sizes ranging from 5 to 605 patient records. Depending
upon the variable studied, the average treatment time of conventional meth-
ods ranged from 19.1 to 57 months.
Studies on the efciency of customized digital therapeutics are generally
lacking. However, a number of investigations have been conducted on Sure-
Smile, albeit on limited sample sizes. Saxe et al34 studied 38 SureSmile and
24 conventional patients from three clinicians, and Alford et al35 studied
69 SureSmile and 63 conventional patients from one clinician. Conversely, the
current study was conducted on 9,390 SureSmile and 2,945 conventional pa-
tients from 142 practices.
Treatment mo
Records of patients (%)
100
80
90
70
60
50
40
30
20
10
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47
SureSmile Conventional
Fig 3 Percentiles of patients treated as a function of time for both treatment groups.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
78 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati
Table 5a Studies reviewed and grouped according to their characteristics and ndings:
Type of malocclusion
Article Classication of malocclusion Total sample size Mean treatment time (mo)
Wenger et al36 Class I 605 26 ± 13.4
Vig et al37 Class I 399 24.6 ± 11.6
Skidmore et al2Class I 135 21.9 ± 4.6
Popowich et al38 Class I 77 20.3 ± 6.0
Campbell et al39 Class I 146 38.5 ± 14.3
O’Brien et al40 Class II Division 1 250 28 .1
Wenger et al36 Class II 760 2 9.9 ± 12. 2
Vig et al37 Class II 567 29.0 ± 11.2
Skidmore et al2Class II 226 24.5 ± 4.5
Popowich et al38 Class II Division 1 160 24.4 ± 6.2
Janson et al41 Class II 97 25.8
Janson et al42 Class II 112 28.2
Campbell et al39 Class II Division 1 36 42.6 ± 14.8
Wenger et al36 Class III 52 28.0 ± 17.0
Skidmore et al2Class III 5 23.0 ± 5.3
Cassinelli et al43 Easy
Difcult
Easy (95)
Difcult (84)
Easy (24.8 ± 17.4)
Difcult (33.8 ± 12.8)
Table 5b Studies reviewed and grouped according to their characteristics and ndings:
Type of treatment
Article Treatment method Total sample size Mean treatment time (mo)
Alger44 Nonextraction
Extraction
37
55
19.1
23.7
Vig et al45 Class II Division 1 extraction
Class II Division 1 nonextraction
236
202
31.3 ± 13.2
31.2 ± 14.6
O’Brien et al40 Class II extraction
Class II nonextraction
171
79
30.6 ± 10.4
24.8 ± 9.2
Vig et al37 Class I and II extraction
Class I and II nonextraction
411
583
29.4 ± 11.3
24.0 ± 11.2
Popowich et al38 Class I nonextraction
Class II Division 1 nonextraction
Class II Divison 1 extrac tion
77
81
79
20.3 ± 6.0
25.7 ± 6.8
25.0 ± 5.5
Janson et al41 Class II maxillar y premolar extraction
Class II four premolar extraction
49
48
23.5 ± 5.86
28.1 ± 7.59
Janson et al42 Class II nonextraction
Class II maxillary premolar extraction
43
69
29.7 ± 9.7
26.7 ± 10.5
Campbell et al39 Class II extraction 30 44.0 ± 14.5
Luther et al46 Orthodontic/orthognathic surgery 69 Presurgical (27 [range, 7–47])
Postoperative (8 [range, 5–11])
Hall et al47 Surgical-orthodontic treatment: (extraction
vs nonextraction and leveling of the curve
of Spee before or after operation)
37 26.8
Presurgical (17.5)
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
79
Sientic
Iovati
The current study showed that SureSmile treatment time was signicantly
shorter than conventional treatment time. The median SureSmile treatment time
was 15 months, which is 8 months shorter than the median conventional treat-
ment time of 23 months (P < .001). SureSmile patients also experienced four
fewer median treatment visits than conventionally treated patients (P < .001).
Table 5c Studies reviewed and grouped according to their characteristics and ndings:
Age of patient
Article Age group Total sample size Mean treatment time (mo)
Robb et al18 Adults
Adolescents
32 (mean age, 31.3 y)
40 (mean age, 12.9 y)
30.6 ± 8.0
29.4 ± 8.8
Von Bremen and Pancher z48 Early mixed
Late mixed
Permanent
54
104
46
57
33
21
Hsieh et al49 Early
Late
86 (mean age, 10.5 y)
322 (mean age, 13.4 y)
45.2 ± 15.4
33.3 ± 11.7
Campbell et al39 Adults
Early treatment
45 (mean age, 32.3 y)
134 (mean age 10.8 y)
Adults (41.2 ± 12.61)
Early treatment (49.0 ± 12.61)
Table 5d Studies reviewed and grouped according to their characteristics and ndings:
Type of appliance
Article Type of appliance Total sample size Mean treatment time (mo)
Von Bremen
and Pancherz48
Appliance: functional (with or without preceding expansion
with maxillary plates), combination (functional and xed
appliances in combination), Herbst (in combination with
multibracket appliances), and multibracket
Functional (32)
Combination (91)
Herbst (42)
Multibracket (39)
Functional (38)
Combination (49)
Herbs t (19)
Multibracket (24)
Breuning et al50 Class II (skeletal) treatment groups:
group A (headgear–activator, xed appliances, and
intraoral osteodistraction of the mandible), group B
(xed appliances and intraoral distraction), and
group C (xed appliances and bilateral sagittal
split osteotomy)
Group A (10)
Group B (19)
Group C (13)
Group A
(44.2 [range, 29–63])
Group B
(28.6 [range, 16– 40])
Group C
(34.7 [range, 19–55])
Amditis and
Smith51
Fixed appliances (bracket slots)
0.018- inch
0.022-inch
64
21.0
0.018-inch (20.2)
0.022-inch (21.7)
Eberting et al52 Bracket type:
Damon self-ligating
Steel ligature/elastomeric O ring
Damon (52)
Conventional (48)
Damon (14.4–23.4)
Conventional (22.8–32.6)
Tag awa53 Bracket type:
Damon self-ligating
Conventional self-ligating
Damon (66)
Conventional (66)
Damon (20.3)
Conventional (27.5)
Clark and
Gebbie54
Bracket type:
In-Ovation R
Conventional
In-Ovation R (114)
Conventional (241)
In-Ovation R (19.8)
Conventional (23.7)
Mascarenhas
and Vig55
Comparison of graduate orthodontic clinic
(GOC) and private practice orthodontics
(PPO)—all case types
GOC (165)
PPO (143 )
GOC (33.0)
PPO (27.5)
Christy et al56 GOC—all case types, bracket t ype, and
compliance (2004–2006)
455 29. 0
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
80 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati Malocclusion type and treatment time
Of the records evaluated, 2,630 SureSmile records and 2,796 conventional
records contained information on the type of malocclusion. The results dem-
onstrated that Class I SureSmile patients experienced median care cycle
lengths of 15 vs 22 months for Class I conventional patients; Class II SureSmile
patients, 13 vs 22 months for Class II conventional patients; and Class III
SureSmile patients, 16 vs 24 months for Class III conventional patients. For all
types of malocclusions, SureSmile patients experienced signicantly shorter
care cycles than conventionally treated patients (P < .001). Previous studies
indicate that Class I patients usually experience shorter treatment durations
than Class II and III patients.2,37,38,57,58 Surprisingly, Class II SureSmile patients
experienced a shorter median treatment time than Class I SureSmile patients.
Possible reasons for this nding include the fact that mild dental Class II types
were included in the Class II category and that Class I patients had more severe
crowding than Class II patients.
Patient age and treatment time
Of the records evaluated, 2,236 SureSmile records and 604 conventional re-
cords included information on patient age. The results showed that the me-
dian treatment times for both SureSmile adolescents (16 months) and adults
(15 months) were signicantly less than those of conventionally treated adoles-
cents and adults (both 24 months, P < .001). The current study did not nd any
signicant differences between the treatment times of SureSmile adolescents
and adults and conventionally treated adolescents and adults (P < .001). Simi-
larly, Dyer et al59 found no signicant differences between the treatment times
of conventionally treated adolescents and adults (P < .05).
Other treatment modalities and treatment time
The SureSmile patient records were not classied as extraction and/or surgical
cases; therefore, the inuence of extraction and/or surgery on the length of
treatment time was not analyzed in the current study. Previous studies, however,
have found that extraction does not contribute signicantly to an extended care
cycle.56 Fink and Smith3 concluded that the extraction of a single premolar, two
premolars, and four premolars contributed to 0.9, 1.8, and 3.6 additional months
of treatment, respectively. Based on the aforementioned research, it may be as-
sumed that extraction therapy in SureSmile patients would add no more than
4 months of treatment time (19 months), which would still be considered shorter
than the mean treatment time of extraction therapy in a conventionally treated
patient (28.12 months).3
Attributes of SureSmile technology affecting care cycle
SureSmile provides an integrated digital technology platform that enables cli-
nicians to diagnose, plan, and design a customized therapeutic solution in the
form of a prescription archwire for the patient. The components of SureSmile
technology that may impact the length of the care cycle are discussed below.
3D imaging. SureSmile’s 3D-imaging environment allows for improved spa-
tial visualization, localization, and measurement of the dentition in all three
planes of space. Bouwens et al60 noted a signicant difference between root
angulation measurements from panoramic and 3D cone beam computed to-
mography (CBCT) images. That research found panoramic images to be dis-
torted and therefore unreliable as a means of assessing tooth angulations
and visualizing roots. Similarly, Okumura et al61 and Kattan et al62 determined
that 3D virtual imaging provides a more precise display of morphologic fea-
tures than 2D imaging systems and is potentially useful for routine treatment
diagnosis.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
81
Sientic
Iovati
Decision support system. SureSmile provides a robust, interactive decision
support system driven by simulations. Through simulations, a clinician can vi-
sualize and validate the mental model of a plan with regard to treatment po-
sition.63 Furthermore, the treatment plan can be designed interactively with
the patient. Almog and Sanchez64 demonstrated that computer-imaging simu-
lations provide patients with a better understanding of proposed treatment
plans. Morisky et al65 demonstrated that better-informed patients generally
adhere to treatment protocols more diligently, which favorably impacts the
care cycle. Morisky et al65 randomly assigned patients into two groups, a spe-
cial intervention group composed of well-informed patients and a usual care
control group, and found that the special intervention group experienced sig-
nicantly higher levels of adherence to medical protocols than the usual care
group (68% vs 38%, P < .001).
The SureSmile decision support system also allows for interprofessional col-
laboration since clinicians share their treatment plans with and seek clinical
advice from one another. Both patient-clinician and interprofessional collabo-
ration may minimize the disconnection in treatment objectives.66
Integrated clinical pathway. SureSmile software has built-in workow auto-
mation and standardized checklists that provide a framework for the sequential
management of patient care. Wolff et al67 showed that the incorporation of
checklists in clinical pathways results in improvements in the quality of pa-
tient care and builds reliability. His study also showed a positive correlation
between the clinical pathway program and patient compliance. Furthermore,
Hales and Pronovost68 determined that the use of checklists improves the de-
livery of patient care and controls for error.
Robotic technology. The use of conventional appliances largely requires
iterative changes to bracket position coupled with archwire bends, which
prolongs care.69,70 Studies on the reliability of conventional straight-wire ap-
pliances reveal that bracket slots have relatively poor tolerances, which may
lead to imprecise tooth movement and add to treatment time. Conversely,
a predened plan drives the design of the SureSmile customized prescrip-
tion archwire. The angular and torsional bends of the robotically bent archwire
are precise to ± 1 degree and linear bends are precise to ± 0.1 mm.33 The
coupling of the clinician’s plan and the prescription archwire overcomes the
reactive elements of orthodontic care and enhances the reliability of appliance
design. In turn, the movement of the dentition is more directed, potentially
resulting in a shorter care cycle.
Practitioner experience. This investigation did not study the impact of the
clinician’s skill and the learning curve on the length and quality of treatment.
Numerous studies in the medical arena have demonstrated an association be-
tween cumulative experience and improved performance using new technolo-
gies in health care. This is to be expected with the use of SureSmile technology
as well. SureSmile technology in itself is not a magic bullet. It is only an en-
abling technology. Successful treatment outcomes can only be achieved in a
timely manner when care is driven by an expert who has accumulated experi-
ence through deliberate practice.71–74
Limitations. While the number of records used for this analysis is quite ro-
bust, a substantial number of records lacked information that could have pro-
vided additional value to the current study. Furthermore, the records were
collected from multiple practices that were not calibrated in terms of data
collection, which could impact the accuracy of the provided variables, such
as malocclusion type. A means of addressing the sometimes imprecise and
incomplete nature of records is the establishment of a consistent method of
data classication and entry.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
82 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati Future studies. To further clarify the impact of SureSmile technology on
patients, further studies must be conducted. Variables such as degree of case
difculty, nature of treatment, bracket type, practitioner experience, practice
location, and reliability of appliance systems must be considered as inuences
on treatment time. A randomized, prospective clinical study of SureSmile vs
conventional treatment would be an important second step in understanding
the efciency and effectiveness of SureSmile. Additionally, studies evaluating
the impact of each unique clinical pathway of SureSmile technology as well as
the integrated process itself are necessary.
CONCLUSION
This study determined the efciency of SureSmile vs conventional treatment in
terms of treatment time and additional variables that inuence treatment time.
On the basis of the results of this study of 12,335 patients from 142 SureSmile
orthodontic practices, the following statistically signicant (P < .001) conclu-
sions may be drawn:
• SureSmile patients experienced a median treatment time of 15 months,
which is 8 months less than that of conventional patients (23 months).
• SureSmile patients experienced a median treatment visitation period of 14
visits, which is a period of four fewer visits than that of conventional patients
(18 visits).
• Class I, II, and III SureSmile patients experienced care cycles 8 to 9 months
shorter than those of Class I, II, and III conventional patients.
• Class II SureSmile patients experienced shorter care cycles than Class I
SureSmile patients, and Class III SureSmile patients experienced the longest
care cycles in the SureSmile patient group.
• SureSmile adolescents and adults did not experience statistically signicant
differences in treatment time.
DISCLOSURE
Dr Rohit C.L. Sachdeva has nancial interest in OraMetrix, the company behind the SureSmile
treatment concept. The second and fth authors, Dr Sharan L.T. Aranha and Nikita S. Sachdeva,
are employed by OraMetrix.
ACKNOWLEDGMENT
The authors wish to thank Arjun Sachdeva for his invaluable assistance in preparation of this
manuscript.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
83
Sientic
Iovati
REFERENCES
1. Mavreas D, Athanasiou AE. Factors af fect-
ing the duration of orthodontic treat-
ment: A systematic review. Eur J Or thod
2008;30:386–395.
2. Skidmore K, Brook K, Thomson W, Hard-
ing W. Factors inuencing treatment time
in orthodontic patients. Am J Orthod
Dentofacial Orthop 2006;129:230–238.
3. Fink DF, Smith RJ. The duration of or th-
odontic treatment. Am J Or thod Dentofa-
cial Orthop 1992;102:45–51.
4. White LW. Editor’s corner: Biding our
time. J Clin Orthod 1998;32:281–282.
5. Hickory W. Patients will pay more for less.
Praxis excellence in orthodontic manage-
ment. 2004;2:2–6.
6. Shia G. Treatment overruns. J Clin Orthod
1986;20:602–604.
7. Keim R, Gottlieb E, Nelson A, Vogels D.
JCO orthodontic practice study. Part 4.
Additional breakdowns. J Clin Orthod
2005;40:95–102.
8. Klein A. Informed consent: A practical
approach. Risk Management Report
198 8 ;1:1–3.
9. Cunningham S, Hunt N, Feinmann C.
Perceptions of outcome following orthog-
nathic surgery. Br J Oral Maxillofac Surg
1996;34:210 –213.
10. Corrigan J, Donaldson M, Kohn L. Cross-
ing the quality chasm: A new health
system for the 21st century. Washington,
DC: The Institute of Medicine, 2001.
11. Warren J. A medico-legal review of some
current UK guidelines in or thodontics: A
personal view. J Orthod 1999;26:307.
12. Segal G, Schiffman P, Tuncay O. Meta
analysis of the treatment-related factors
of external apical root resorption. Orthod
Craniofac Res 2004;7:71–78.
13. Fox N. Longer orthodontic treatment
may result in greater external apical root
resorption. Evid Based Dent 2005;6:21.
14. Graber T, Eliades T, Athanasiou A. Risk
Management in Orthodontics: Experts’
Guide to Malpractice: Chicago: Quintes-
sence, 2004.
15. Clark J, Gebbie J. Increasing Practice Ef-
ciency and Protability Using In-Ovation®
Self-Ligating Brackets. http://www.gacintl.
com/UserFiles/File/literature/ WP_Clark1.
pdf. Dentsply GAC, 2007.
16. Phipps G. Seven keys to on-time nishing.
J Clin Orthod 2004;38:155–158.
17. Beckwith FR, Ackerman RJ, Cobb CM, Tira
DE. An evaluation of factors affecting dura-
tion of orthodontic treatment. Am J Orthod
Dentofacial Orthop 1999;115:439–447.
18. Robb SI, Sadowsky C, Schneider BJ,
BeGole EA. Effectiveness and duration
of orthodontic treatment in adults and
adolescents. Am J Orthod Dentofacial
Orthop 1998;114:383–386.
19. Sameshima G. Ask us. Some or thodontists
claim they can complete treatment rela-
tively quickly, and they rarely treat patients
as long as 3 years. How can they do this
and still achieve high-quality results? Am J
Orthod Dentofacial Orthop 2005;127:526.
20. Turbill EA, Richmond S, Wright JL. The
time-factor in orthodontics: What inuenc-
es the duration of treatments in National
Health Service practices? Community
Dent Oral Epidemiol 2001;29:62–72.
21. Mahmoud KA-O, Elham Saleh Abu A.
Factors affecting patient satisfaction after
orthodontic treatment. Angle Orthod
20 0 6;76:422– 431.
22. Sachdeva R, Feinberg MP. Reframing clini-
cal patient management with SureSmile
technology. PSCO NewsWire 2009;2:2–24.
23. Sachdeva RC. SureSmile technology in a
patient-centered orthodontic practice.
J Clin Orthod 2001;35:245–253.
24. Sachdeva RC. SureSmile’s promise:
Digital care solutions for the orthodontic
industry. http:// orthocj.com/2001/06/
digital-care-solutions-for-the-orthodontic-
industry. TheOrthodontic CYBERJournal,
20 01.
25. Sachdeva RC, Fruge JF, Fruge AM, et al.
SureSmile: A report of clinical ndings.
J Clin Orthod 2005;39:297–314.
26. Mah J, Sachdeva R. Computer-assisted
orthodontic treatment: The SureSmile
process. Am J Or thod Dentofacial Orthop
2001;120:85–87.
27. Snyder WC. Or thodontics: The changing
face of or thodontics. Minnesota Edition:
Doctor of Dentistry: A Business and Life-
style Magazine for Dentists 20 07;4:8–13.
28. Lohse J. Redening orthodontic care with
SureSmile. Shared learnings from high
performance practices. Peer2Peer 2007;
1.1:3–11.
29. Moles RC. Transforming to an all-digital
practice with SureSmile. Shared learnings
from high performance practices. Peer-
2Pe er 2007;1.2:3 –11.
30. Whitlock B. SureSmile in a technology-
driven practice. Shared learnings from
high performance practices. Peer2Peer
20 07;1.3:3 –11.
31. Moles R. The SureSmile system in orth-
odontic practice. J Clin Orthod 2009;43:
161–174.
32. Cohen MJR. Taking adult orthodontia to a
new level. Indiana Edition: Doctor of Den-
tistry: A Business and Lifestyle Magazine
for Dentists 2007;2:1–6.
33. Sachdeva R. Integrating digital and
robotic technologies. In: Graber T (ed).
Diagnosis, Treatment Planning, and Ther-
apeutics. Orthodontic Current Principles
and Techniques, ed 5. St Louis: Elsevier,
20 11.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Treatment time: SureSmile vs conventional
84 ORTHODONTICS e Ar n Pace  Dntocia Enancemen
Sientic
Iovati 34. Saxe AK, Louie LJ, Mah J. Efciency and
effec tiveness of SureSmile. World J Or-
thod 2010;11:16–22.
35. Alford TJ, Roberts WE, Hartseld Jr JK,
Eckert GJ, Snyder RJ. Clinical outcomes
for patients nished with the SureSmile
method compared with conventional
xed orthodontic therapy. Angle Orthod
2011;81:383–388.
36. Wenger R, Douangpanya S, Vig K, Beck
M, Vig P. Classes I II and III differences
in severity, duration, and orthodontic
results. J Dent Res 1996;75:437.
37. Vig K, Weyant R, Vayda D, O’Brien K, Ben-
nett E. Orthodontic process and outcome:
Efcacy studies—strategies for develop-
ing process and outcome measures: A
new era in orthodontics. Clin Orthod Res
1998 ;1:147–155 .
38. Popowich K, Flores-Mir C, Nebbe B, Heo
G, Major PW. Comparison of Class I and
Class II treatment duration among three
different orthodontic practices. Semin
Orthod 2006;12:52–59.
39. Campbell CL, Roberts WE, Hartseld JK,
Qi R. Treatment outcomes in a gradu-
ate orthodontic clinic for cases dened
by the American Board of Or thodontics
malocclusion categories. Am J Or thod
Dentofacial Orthop 2007;132:822–829.
40. O’Brien KD, Robbins R, Vig KWL, Vig PS,
Shnorhokian H, Weyant R. The ef fective-
ness of Class II, Division 1 treatment. Am J
Orthod Dentofacial Orthop 1995;107:
329–334.
41. Janson G, Maria FRT, Barros SEC, Freitas
MRd, Henriques JFC. Orthodontic treat-
ment time in 2- and 4-premolar-extraction
protocols. Am J Orthod Dentofacial
Orthop 2006;129(5):666–671.
42. Janson G, Barros SEC, Freitas MRd, Hen-
riques JFC, Pinzan A. Class II treatment
efciency in maxillary premolar extraction
and nonextrac tion protocols. Am J Orthod
Dentofacial Orthop 2007;132:490–498.
43. Cassinelli AG, Firestone AR, Beck FM, Vig
KWL. Factors associated with orthodon-
tists’ assessment of difculty. Am J Orthod
Dentofacial Orthop 2003;123:497–502.
44. Alger DW. Appointment frequency versus
treatment time. Am J Orthod Dentofacial
Orthop 1988;94:436– 439.
45. Vig PS, Orth D, Weintraub JA, Brown C,
Kowalski C J. The duration of orthodontic
treatment with and without extractions:
A pilot study of ve selected practices.
Am J Orthod Dentofacial Orthop 1990;97:
45 – 51.
46. Luther F, Morris DO, Karnezi K. Or th-
odontic treatment following orthognathic
surger y: how long does it take and why?
A retrospective study. J Oral Maxillofac
Surg 2007;65:1969–1976.
47. Hall B, Jamsa T, Soukka T, Peltomaki T. Du-
ration of surgical-orthodontic treatment.
Acta Odont Scand 2008;66:274–277.
48. von Bremen J, Pancherz H. Efciency of
early and late Class II Division 1 treat-
ment. Am J Orthod Dentofacial Or thop
2 0 0 2;1 21 : 31 – 37.
49. Hsieh TJ, Pinskaya Y, Roberts WE. Assess-
ment of orthodontic treatment outcomes:
Early treatment versus late treatment.
Angle Or thod 2005;75:162–170.
50. Breuning KH, Peter JVS, Birte P-A, Tuinz-
ing DB. Duration of or thodontic treatment
and mandibular lengthening by means
of distraction or bilateral sagittal split
osteotomy in patients with Angle Class II
malocclusions. Am J Orthod Dentofacial
Or thop 2 0 0 5;127:2 5 – 2 9.
51. Amditis C, Smith LF. The duration of xed
orthodontic treatment: A comparison
of two groups of patients treated using
Edgewise brackets with 0.018” and 0.022”
slots. Aust Or thod J 2000;16:34–39.
52. Eberting J, Straja S, Tuncay O. Treatment
time, outcome, and patient satisfaction
comparisons of Damon and conventional
brackets. Clin Orthod Res 2001;4:228–234.
53. Tagawa D. From good to great: The Da-
mon system vs conventional appliances: A
comparative study. Clin Imp 2006;15:4.
54. Clark J, Gebbie J. Increasing practice ef-
ciency and protability using In-Ovation
self-ligating Brackets. http://www.gacintl.
com. Dentsply GAC, 2007.
55. Mascarenhas A, Vig K. Comparison of
orthodontic treatment outcomes in edu-
cational and private practice settings.
J Dent Educ 2002;66:94–99.
56. Christy QV, Roberts WE, James KH, Susan
O. Treatment complexity index for assess-
ing the relationship of treatment duration
and outcomes in a graduate or thodontics
clinic. Am J Orthod Dentofacial Orthop
20 0 8 ;13 3:9.e1–9. e13.
57. Popowich K, Nebbe B, Heo G, Glover KE,
Major PW. Predictors for Class II treat-
ment duration. Am J Orthod Dentofacial
Orthop 2005;127:293–300.
58. Callaway C. An investigation relat-
ing treatment duration to qualities of
orthodontic care [thesis]. College Station,
Texas: Texas A&M University, 1999.
59. Dyer GS, Harris EF, Vaden JL. Age effec ts
on orthodontic treatment: Adolescents
contrasted with adults. Am J Orthod
Dentofacial Orthop 1991;100:523–530.
60. Bouwens DG, Cevidanes L, Ludlow JB,
Phillips C. Comparison of mesiodistal root
angulation with posttreatment panoramic
radiographs and cone-beam computed
tomography. Am J Orthod Dentofacial
Or thop 2 011;139:12 6 –132.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 13, 2012
Sachdeva et al
85
Sientic
Iovati
61. Okumura H, Chen LH, Tsutsumi S, Oka
M. Three-dimensional virtual imaging
of facial skeleton and dental morpho-
logic condition for treatment planning
in orthognathic surgery. Am J Or thod
Dentofacial Orthop 1999;116:126–131.
62. Kattan MW, Zelefsky MJ, Kupelian PA,
Scardino PT, Fuks Z, Leibel SA. Pretreat-
ment nomogram for predicting the
outcome of three-dimensional conformal
radiotherapy in prostate cancer. J Clin
Oncol 2000;18:3352–3359.
63. Gaba DM, Howard SK, Fish KJ, Smith BE,
Sowb YA. Simulation-based training in
anesthesia crisis resource management
(ACRM): A decade of experience. Simula-
tion & Gaming 2001;32:175–193.
64. Almog D, Sanchez M. The effect of es-
thetic consultation methods on accep-
tance of diastema-closure treatment plan:
A pilot study. J Am Dent Assoc 2004;
135: 875– 881.
65. Morisky DE, Malotte CK, Choi P, et al. A
patient education program to improve
adherence rates with antituberculosis drug
regimens. Health Educ Q 1990;17:253–267.
66. Gaba DM. The future vision of simula-
tion in health care. Qual Saf Health Care
2004;13(suppl 1):i2–i10.
67. Wolf f AM, Taylor SA, McCabe JF. Using
checklists and reminders in clinical path-
ways to improve hospital inpatient care.
Med J Aust 2004;181:428–431.
68. Hales BM, Pronovost PJ. The checklist—A
tool for error management and perfor-
mance improvement. Journal of critical
care 2006;21(3):231–235.
69. Matasa CG. Bracket angulation as a
function of its length in the canine distal
movement. Am J Orthod Dentofacial
Or t h o p 1996 ;110:178 –18 4 .
70. Raphael E, Sandrik JL, Klapper L. Rotation
of rectangular wire in rectangular molar
tubes: Par t I. Am J Orthod Dentofacial
Or thop 1981;80:13 6 –144 .
71. Edmondson AC, Bohmer RM, Pisano GP.
Disrupted routines: Team learning and
new technology implementation in hos-
pitals. Administrative Science Quarterly
20 01:6 85–716.
72. Edmondson AC, Winslow AB, Bohmer
RMJ, Pisano GP. Learning how and learn-
ing what: Effec ts of tacit and codied
knowledge on performance improvement
following technology adoption. Decision
Sciences 2003;34:197–224.
73. Pisano GP, Bohmer RMJ, Edmondson
AC. Organizational differences in rates of
learning: Evidence from the adoption of
minimally invasive cardiac surgery. Man-
agement Science 2001:752–768.
74. Ramsay CR, Grant AM, Wallace S, Gareth-
waite P, Monk AF, Russell IT. Assessment of
the learning curve in health technologies.
International journal of technology assess-
ment in health care 20 00;16:1095–1108.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.