June 17, 2025
What’s Wrong with Traditional Class II Appliances? Let’s be honest: when a 12-year-old walks into your office with a Herbst and a cheek ulcer,
my name is Neil i’m an orthodontist nice to meet you all virtually and you know I’m I’m uh kind of an odd bird right so
I really didn’t understand what I wanted to do when I was graduating orthodontics but I did know that I wanted to do
cranioacial because I worked here at the cranio I I was resident in orthodontics
which was right next to the cranioacial center so this has a large um influence
on how I developed as a professional if you will and um two of my five board
cases were cranioacial double jaw surgeries and I I was just so struck by how I was able to change someone’s life
that I thought like okay you know I really want to do this for a living unfortunately when I applied for the job
the guy that was here wasn’t really open to uh any help so uh I got denied um but
I was kind of persistent and so the next year I was uh uh lucky enough to get
hired on at the University of Chicago across town to do the cranial facial job there and I was there to 2006
and then at that point they got out of the crane they got out of dentistry just they let the whole dental team go
because they didn’t think that it made sense to mix that with medicine not quite sure
why but um so I was uh still in the cranial facial world because I had all
these cleft kids in my practice and uh one of my kids the mom said to a surgeon
uh when they were at here at the UIC cranial facial center I guess it was a bad day it wasn’t running well and she’s
like “You need my orthodontist to come here and fix this place.” Well one thing
led to another and I’m and I’m still here so so almost uh wow probably 14 15
years here at UIC running the orthodontics but uh more so it’s you know I just have a uh on any given day
I’m doing one of three jobs i’m either in my private practice just doing orthodontics I’m here at the university
in our university practice or I could be out lecturing so uh it’s all good and you know and I’ve been a key opinion
leader on various things so you know but but one of the things that’s really ve very quick to grow right now you know is
clear aligner therapy right and we know that um probably this is an off number
but about 40% of all cases starting right now are clear aligners and you know in 1999 when I was starting up with
Invisalign uh clear aligniners didn’t exist right so in my professional career
uh it has grown into probably the the most aggressively growing thing that I’m
seeing in dentistry right other than maybe implants but implants have kind of stopped this aggressive growth vector
but clear liner therapy is really taking off right now back in COVID the clear
liner industry in the United States was about a billion dollars about a billion three this year it’s between four and
five billion uh it could be anywhere between 15 and 30 billion in 2030 so people are
paying attention to that but you know here’s the facts look at this slide less than or only about half of patients wear
their their appliances for 22 hours a day so I think that’s really a damning thing to say people
aren’t necessarily trustworthy to wear something that’s removable so you know
so if you’re going to really kind of go after a tough case especially a class
two case right do you really want them to have to take stuff on and off i mean
it it it doesn’t make any sense to me at all right now
this year at the show a couple companies launched different versions of twin blocks on clear aligners and uh previous
to that there was the MA appliance and previous to that there was like um like
uh just twin blocks in general the one thing I will say probably picked up and grouped very much in the last 15 to 20
years is the Kier appliance i think it’s pretty clever um I think it’s it’s very unique and it works well but what do you
do if if if you want to fix a fullstep class 2 retronathic pattern i mean like
are you going to let the patient be in charge of the case or are you actually going to try and do something where it’s
working day and night because you know as well as I do growing bone is really hard to do so so I I think the number
one thing that we have to talk about is efficiency right and nothing is more efficient than things that are permanent
so when you think about the class 2 market which is roughly three out of 10
cases it’s it’s somewhere between one in four and one in three you know somewhere
around 30 25 30 34% depending on what number you look at from what study the
cases coming in the door are class 2 so if there’s 10 million new patients a year which there are right you have to
have a different approach for a severe class two right and and I’m not even a convinced that fixing a class two is
something that you can do in a single in a single time in someone’s life because you catch them early it’s it’s going to
relapse because the moment you take your stuff off them if they’re a bad grower they’re still a bad grower so I I think
you have to have just a really different approach for some of these cases so to me this was the thing after finishing
over 30,000 cases that really stood out to me like something something has to be
better here right there’s something missing right so there there has to be a better solution and and this is what
came out of my head right so so I wanted a high-performance class 2 system
meaning something that actually worked and grew bone that could be on the teeth fulltime
and you know it was custom and it would deliver the right amount of force and it
had to be durable because you know anytime you hold something forward it’s very difficult on the appliance the
appliance gets beat up and it has to integrate with whatever mechanics you want to use whether it’s braces or
aligners right so so I I did a lot of you know thinking about this and you know wrote a patent with I had two other
co-inventors that started it with me but you know and they’re really out of it at this point but but the concept here was
that we would make something that was more the the term I like to use and we created two words the first word I’ll
talk about is called biodnamic right this is something that functions like a TMJ
next slide so so so the question was then really like if we had this new idea
we can actually create this concept this appliance right you know like you know what kinds of cases are we
actually able to treat and then you know how low can we go in terms of age can we catch someone early on and do a phase
one with it versus a phase two right you know the difference between sometimes a class two case and a sleep apnea case
sometimes it’s just the age of the patient right like could could you take this concept cept could you even make it
possibly removable so that they can have the effect of it at least while they’re sleeping without having their teeth move
you know so could can you can you take this and apply it to someone who’s just
beyond bad growth someone who’s like genetically altered like a cranioacial issue so so these were the issues that I
was looking at right so so I’m going to show you a series of six cases today and
I want to just state that you’re not going to come out of this webinar and say to yourself I can do this tomorrow
okay because that’s not our goal our our goal is we’re presenting a highlevel
interest webinar here we’re I’m releasing it we’re releasing it because we want feedback right you know I’m not
going to learn by doing this myself and and the worst thing that I I do is I make things look easy when I do it
sometimes and I think I don’t want people to struggle if they ever tried to do this so our goal is to really kind of
show you just cases that didn’t conventionally work and maybe here’s
another approach this is how I would say they would go so our first case comes
from a pediatric practice where they had um treated this girl for airway issues
mostly right and she was in treatment for 52 months so for you for you guys who are not good at math that’s over
four years okay and um she’s class 2 division one so when when she presented
to me you know the mom brought her in and and uh I’ll just say that mom is a
physician and the mom said to me she’s like you know my daughter’s really unhappy you know she’s had braces for a
while and although they’re telling us that you know it’s successful that the airway is much better um that’s not how
my daughter feels she was very upset about her spaces now this kid was going into seventh grade and you know this is
what she looked like when she presented to me she had spaces you know amongst a bunch of teeth she was missing several
teeth some of the teeth weren’t even normally shaped and she had 100% overbite so so you know my first thought
is okay here here’s your your seph taken out of our comb beam you can see teeth
are still erupting that you know the overjet on this case is about eight or nine millimeters which maybe for airway
is okay but not for a seventh grade girl emotionally right next slide here’s the panorax you can
see she’s missing a bunch of teeth too right so so I I look at this and right off the bat I’m thinking okay this is
ultimately an implant case right i got to give this kid self-esteem i have to consolidate my spaces i have to figure
out a way to give her pontics the parents also told me that um she
really just wants the spaces closed so the very first thing I I I did was okay like let’s let’s make her a couple clear
aligners and we can uh at least consolidate the spaces so So we put her through some UAB
and we make some some some uh some correction on the spaces and
then they had talked with a prostadonist because you know they’re going to be doing implants and the prostadonist said
hey you know I can I can make her some Marilyn bridges next slide so so what’s
cool about this case is this is Casper number two this is my second case right
so I made everything wrong on this case i am really really happy to share with
you my failures even though they’re successful but what was important here was
you’re understanding two things that are really highly important here so number one is I’m answering the patient’s need
i made her an aligner we’re going to paint the pontic spaces and she’ll be able to walk around with teeth and then
the other thing is I’m mixing a removable system with a fixed system my class 2 systems never going to come out
the removable system that’s giving her space closure can come in and out next slide
so here she is after we consolidated the spaces the procedonist had put some
Marilyn bridges in the uh teeth were starting to separate a little bit because she stopped wearing her aligners
i’m like “What are you doing you got to wear your aligner still.” I I was sort of surprised to see the gap opening up
even with the Marilyn’s in but that’s that’s what I observed so but this is
also what I observed look at the difference in her profile like it’s strikingly better right so this kid is
walking around now with some self-esteem her gaps are closed her airway for sure
is better okay her profile is better her lower third is longer and you can see
from the top where I met her to the middle where the mirins were placed to
the bottom which was about a month ago which is about 16 months 17 18 months since I’ve met her maybe a year and a
half she is growing up filling out her profile looks phenomenal right but as we
say you can’t see what I’m doing so so one of the reasons why this is called
Casper because I’m an old guy everyone knows Casper’s a friendly ghost right and I was all about you don’t see the
appliance so we every time we do a project in our practice and I don’t you know I’ve been
u incredibly fortunate to do a lot of projects um every project always has a
code name so our code name for our class 2 system is Casper but uh our code name
is going to live in infamy because I think we’re keeping the branding so uh I think this is really a very nice
solution uh uh I have since given her I’ve taken out those baby incizers and
the lower we made her uh kind of like a Krauss um kind of a concept where those
pontics are fixed to Casper’s lower member okay and um now I say this is
Casper number two okay because we’ve learned a lot about how to design and build this over time and keep in mind
when I wrote the patent in 2016 metal printing wasn’t really optional right we
were writing for the future we were talking about theoretically printing
materials that didn’t exist yet but I was so convinced that it was going to come that’s how I built the pattern so
this is kind of where she’s at today uh this is a really nice profile this kid
absolutely likes me like we get along she comes in she’s in a good mood uh the
brother is a patient now the mom is a patient now the physician right the only one I don’t have right now is the dad
and they have a little baby that’s two years old which I’m sure when the baby’s ready they’ll probably trust me with the baby too so so this is how we this is
how we roll right we build confidence next case also a failed orthodontic case
in treatment for 44 months i had the lucky pleasure of them transferring to
my practice so this kid transfers into my practice after almost four years of
orthodontics fully class two okay 100% overbite
severe hygiene issues and the parents are like clueless like they’re they don’t know what’s going on so I had to
sit down with the parents and say to them I’m like I’m really unhappy with where he’s at next slide
this is how he transfers to me you can’t even see his lower teeth so so I went ahead and I’m like let’s take the braces
off let’s give him a chance to brush his teeth okay so here’s here’s the records we took on him
9 millimeters of overjet after 44 months this is what he looks like after we take
off his braces so he’s cleaned up a little bit i explained to him like “Look
I want to try and knock out the overjet first and I don’t know if it’s going to work because he’s 16 years old already
and you know boys the lower jaw is going to grow late but I don’t know if he’s going to respond.” So I said to him I’m
like I may leave this thing in for a while if you can tolerate it and and he’s like yeah it’s okay you know I’m
taking a gap year after I graduate so I’m I’m good with it next slide so here he is when we installed Casper one of
the things I love about this kid is his hair is getting longer and longer and longer and longer in all my photos
because that’s just his personality you know so here he is at six months into
Casper and at that point I said to him I’m like “Okay you know you have this bilateral buckle open bite it’s time for
us to start vertically erupting the teeth.” I said “Would you like braces?” And he’s like “Hell no i had braces for
44 months.” I’m like “Great let’s put you in aligners so
I don’t know that you have to listen to me about whether he thinks this is a good product or not but I think Tom can
share with us a little video from my friend here and why don’t you listen to him uh like
I guess two three weeks two or three weeks right yeah like first day was a tough day right first day was an awesome
day actually really it’s just Yeah this is So it didn’t hurt that much uhhuh it
kind of started hurting for the next week then it kind of slowed down yeah
yeah it was hard to eat early on but everything else was easier so are you
sleeping better yeah I’m sleeping better uh I sing better as well which you
resonate better that’s awesome okay i don’t know this thing is great i love it
this is So here’s a dumb question you and your brother both have this right yeah didn’t you do a couple years of
orthodontics before you met me we did but it was like old orthodontics yeah it
didn’t get much done it did not get much done and um How old are you now 17 17
right yeah can people even see that this is on your teeth no no it’s crazy right
it also improved my jawline I think just It improved your jawline a lot it did yeah a lot yeah that’s the whole thing
right yeah yeah yeah yeah so so it’s kind of weird this the the hidden thing that I think that I tell people about is
they actually breathe better you know it’s kind of a weird thing like you don’t think about it but like you sleep better probably hopefully so you know a
lot of people that when the draws far back they have a hard time sleeping you don’t really think about it but once you get this thing on you’re like “Yeah you
know actually I am sleeping better.” I love the fact that you’re telling me that you like this yeah I love it that’s
amazing that’s so cool okay
so we planned 62 stages of aligners for him okay so here’s here’s an interesting thing with uh the amount of tooth
movement you need to do it’s really not a lot if you figure the AP is being handled by Casper the only thing you’re doing is arch development and vertical
closing um I happen to use uh a brand of a clear liner that uh is kind of special
that they don’t even have to be worn full-time it’s the only one in the country like that but I’m not even I’m
not even plugging that that brand right now i’m just saying like as a rule you can kind of determine how you want to do
your clear liner staging if you think the moves are really small you can have them change the tray weekly you can also
wear the tray every two weeks and just cut the trays in half i just said 62 stages cuz I wanted 62 weeks of wear of
the Casper so here’s what he looks like with the aligners on you can’t even see them on
and it’s just really it’s great you know so so I and I know like so this kid had
9 millimeters of overjet so I I have to tell you something about this case i was afraid I was going to push him too far
so I left him with like two or three millimeters overjet i pushed him forward 6 millimeters we’re just now right now
like last Tuesday we just took we just talked about taking the scans to replace
the lower member to push them forward so one of the things I hated about Herps other than it broke a lot is the screw
strip and like things fall out so with Casper when you want to if you have a
very very large AP change on someone and you’re bringing the jaw forward 8 nine 10 millimeters I suggest you break it
into pieces right and the way I do it is I actually remake and just resee the
second member so the lower member so that’s what we’re going to be doing with him but I I think this is just a
transformative concept right because it just it it can treat problems vertically
so well because I’m establishing vertical from day one right and that is
the hard hard thing to do here in class two cases because they’re class two for
a reason because genetically they just don’t grow well so so we’re psyching the body out is what we’re really doing and
I think it’s pretty evident that the change profile-wise is good the part that uh you’ll hear me say a lot and
I’ll repeat this a lot is that Casper is socks and underpants meaning keep it
clean and don’t think about it because rarely unless you got a wedgie do you think about it so there you go next
slide please second case uh third case is just a standard you know 10-year-old
class two division one that you can see in your office every day severe overbite severe overjet moderate cl crowding on
the lower arch minimal crowding on the upper arch crossbite mixed early you know early uh late mixed
dentition early permanent dentition next slide so here here’s the the sept coming
out of the comb beam about seven and a half millimeters overjet here’s our panorax showing all the teeth
are erupting in nicely so it’s time to get rolling on her and you know it’s like I I went to the University of
Illinois for training like this is clean cervical headgear land but I don’t know
that clean cervical headgear does a great job of improving airway right i
think advancing a mandible does so when so we when we built it can you go back one slide take a look at no overbite you
know the overbite’s 100% no teeth show we install Casper next slide and all of
a sudden all the lower teeth show so right out of the gate I’m changing vertical you should understand that
right and we’re building these cases so that they’re tripoded they’re hitting on their front teeth generally they’re
hitting on the back appliance Casper itself and they are not touching in on
the sides right that open bite on the buckle segment that’s the secret sauce
when you pull those teeth together it locks them into their new class one position next slide here she is at 10
weeks crazy only 10 weeks she looks older
right and that’s because this is what we’re we’re shooting for right this is the development we’re shooting for next
slide you can see the simple expander that I put in these cases now listen
sometimes if you need more arch development you can you can put an accusal rest on the preolar and you can
make it more rigid if you don’t want it rigid you don’t have to have that arm moving forward it’s all up to you it
depends on how fast you’re going to integrate the braces i’m not really excited to put braces on these cases for
the first eight to 10 months sometimes up to a year i think the longer I wait to put the braces on the easier it is
for them to keep clean the less I have in their mouth the longer I can let Casper burn and grow grow jaw next slide
so here she is at four months that’s a pretty reasonable change next slide here
she is at 8 months you can see this is the day I put the braces on and uh
everything looks okay you know and and she’s kind of coming along you’ll you’ll kind of see in the photography the
buckle segments have almost come together already just because that’s what happens when you open those buckle
segments the teeth start to erupt because that’s what teeth know to do they feel that they don’t have the
concept of an opposing tooth and they’ll start erupting again next slide that’s
her face at 8 months right that’s her profile at 8 months
this is the day we took Casper off now she’s still mentally kind of like holding your jaw forward because she
just you know whatever um so uh an interesting story so I had an
orthognathic case in the other day and she was a severe retrogathic case and she had a mandibular advancement and we
took teeth out even in order to advance her she’s a very digital person works in the digital space and she wears a an
Apple uh watch her Apple Watch uh actually basically told her in in metric
form it’s tracking her health care and it said to her that she’s actually her
her gate her posture and her walking is better her comment to me when she said I
know this sounds crazy but since I’ve had my jaw brought forward I look at people more straight in the eye i said
there’s nothing crazy about that at all your TMJ whether you buy this or not i I 100% believe this your your posture your
gate how you hold your head is all related to your TMJ and when your bite is better you look more horizontally out
and it’s just the reality of it so what you’ll see our patients do their posture of their head will change over time next
slide so this is where she was at 16 months when we took Casper off okay and you see
the open bite on the mers because I literally that’s the day I took the appliance off and now we put braces on
her and we start to pull her together and that vertical uh eruption of the mers happens very fast because the other
teeth are now in contact next slide so here she is she’s about 15 months in
she’s in full braces now right and now it’s just a matter of it’s a class one
case close up get all your you know your second merginal ridges do all that stuff
to really get the case nailed down she should be finished by Christmas of this year and uh hopefully in future uh
webinars I’ll show this case its progress as she wraps up but I think that’s great
case number four is a pipsqueak kid she’s about seven years old severe severe class two
this is a genetic case mom’s class two she’s class two her older sister all class two okay and she’s she’s biting on
her pallet so the question is is you know when is it right and when is it
wrong to do Casper you know so I I wanted to to be in there for a while to
grow her but you know at the time I wasn’t able to make Casper and and so I would use a herps but even before I put
you in a herps I still think I want to get my width done because I don’t like putting too much in my herps i’d rather
just have a transpal bar versus an RP because it it just it’s too bulky sometimes with the piston arms and the
kids would complain a lot so So we put her through a just a quick phase one
next slide so this is how she started right next
slide this is how I wrap up her phase one her teeth are now straight and and to me now I can build a herpst on it
because now I can put the front teeth together and you know and I’ll do the rollolo crowns and the piston arms and
the whole nine yards so this is the results of our limited orthodontics but you’ll notice my orthodontics didn’t
address the AP at all so that’s what I saved for the herps so I said to the mom I’m like look my experience is severe
severe severe cases i don’t care how good of a doctor you are the best orthodontist I’ve ever met was nature
and if you’re a bad grower the moment our hardware comes off you become a bad grower again so I said you know I think
this may be over a couple of stages here i don’t think I going to I’m going to be able to fix you in a single shot but I
said let’s put you in a herps and let’s put your daughter in herps and see what happens so I put her her daughter in a
herps and uh herps is on here and she’s she’s
been expanded with a phase one she’s got fixed upper and lower wires she She looks pretty good profile wise she looks
great because the piston arms have her advanced next slide here she is when we took everything off
kid looks great she’s really happy really a nice change and and and I and I’ll say this as a parent of three kids
if you are a parent and you know and you’re honest with yourself and you have
a kid who’s kind of funnyl looking or gawky looking or something’s just not quite right you’ll give your every last
penny to give your kid the opportunity to feel better about themselves so this
isn’t about money or anything else but it is about doing what’s appropriate that’s how I would say this next slide
so So after six months this is what I see on this kid okay do you see the
overjack coming back it’s not that I didn’t do my job right i’m losing ground
right so when I started her and this goes back a while ago when I started her
Casper wasn’t nearly ready yet right as I was going from the phase one into her
Casper wasn’t ready yet i take her out and I give her you know an upper holly
and a lower wire and I’m like let’s see what happens well this is what happened she’s losing ground she’s already at 6
millimeters overjet again so I’m like I’m not excited about this so so now
what can you do theoretically to try and hold what you got so so this is um our
code name is Batman okay and Batman won’t be to market for a while yet but I’m but I’m showing you how creative we
are right now right remember at the end of the day I’m an orthodontist in the trenches working six days a week nine
months out of the year so like this crap just comes out of my head in the middle of the night and I don’t you know when
and I just stay up at night and think and work these things through this is a removable version of Casper built with a
thor a thorough design so it’s cut out around the deciduous uh canine first
mercumar which allows the permanent canine and both preolars to erupt
without physically affecting the actual uh Casper model itself so this is a
clear version of Casper it’s uh 3D printed it’s in um a material called AMP
AM which is active memory polymer um if you go on to Facebook you look for the
AMP uh Facebook group i’m I’m one of the co-chairs of it and you can learn more
about this material this is a super special material but I would tell you that when you look at how she started
and you look at her today you have to say to yourself “Wow that’s that’s impressive right this kid looks really
fantastic.” And I think if you’re the parent your thought as the parent is
yeah yeah this is good my kid feels good about themselves we’re winning right the
next kid I want to show you uh is uh also a failed case he um I’m meeting him
at uh a 18 years old he was in uh uh uh
the uh largest clear liner manufacturer in the world has an AP uh appliance
system called MA and he was in that system
and uh he is being sent to me by the
sleep apnea person at the University of Chicago who’s at his wits end because
kid can’t tolerate a CPAP and he doesn’t want to put him through surgery and he’s got severe apnea and
and sometimes you know apnea has nothing to do with whether you’re heavy or not
if you don’t understand that and he still has about 80% overbite
and he’s leaving for college and he’s like he’s a nice enough guy this is his
uh seph taken out of our comb beam and the the the doctor asked me he’s like
you usually have a couple tricks up to your sleeve do you have any idea you know what you can do to help this kid
now I had never done this before but I’m like I have a trick up my sleeve i can try so so this is his panorex so this is
his airway assessment prior to me touching him so he’s a very
flat airway right around uh the second and third vertical vertebrae in his neck
and you can see it really pinches quite closed so his problem is mostly
anatomical okay so so one answer for the
apnea here potentially could be mechanical if you can just hold him forward maybe he’ll breathe better next
slide so we designed uh the Casper concept
to be put into a full aligner that was printed in AMP which is that active
memory polymer and this is what it looked like in design in theory right next slide this
is what it looks like in the mouth and I think what’s interesting about it I think we have one more slide behind this
right yep so so what’s interesting about this is like
there’s a whole lot of other problems now you have to figure out like how to support the the the member components of
Casper so they won’t break over time because this is going to fatigue now amp is a very specific material if you drop
it in boiling water for three minutes it will rejuvenate the material and it’ll take its original shape again so whereas
60% of all removable sleep apnea appliances cause tooth movement I will
tell you that you won’t necessarily see this with the design that we are working on because not only do we rejuvenate the
material daily before the patient puts it back on but we um have control
fordimensionally meaning of the thickness of the tray not just of the shape of the tray so this is just really
really great stuff and as you can see from his profile again nobody knows what I’m doing he’s only wearing this at
bedtime um he’s been very successful with it we’re almost a year into it now
with him and doing quite well so I I’m really excited to tell you that um it’s
pretty easy for us to nest this stuff and the the part that’s so so so powerful for me is the fact that we can
put this on our print farm within the office and we can knock these things out in an hour earn 15 minutes so when I
tell you there’s about seven bucks worth of material in this appliance and we can probably conceivably can sell it for
about $3,000 uh the ROI is off the scale okay so and
and that’s not why I’m showing you this but I’m just telling you like there’s a there’s a lot of creativity here so the
question really is okay I love this concept right it really is interesting
what are its limits it’s mission impossible my my favorite
kid okay so this is a class 2 division one this is a kid that I actually took braces off during COVID because she she
was born with a condition called hemiacial microsomi she’s um a grade three meaning she does not above the
gonial angle of her right mandible she is nothing she doesn’t have a a coronoid
notch she doesn’t have a coronoid she doesn’t have a condile she has nothing and you know she’s made it to 8th grade
no problem just with a kind of a crooked jaw so I took her braces off because her
uh I started her in sixth grade i had her in braces for about two and a half to three years her teeth were straight
her hygiene was off the hook bad and I looked at her straight in the face i was really mad at her it was during COVID
and I looked at her i’m like “What’s the point of straightening your teeth out if you’re going to bomb them out I’m going to have to pull them out.” And I pulled
the braces off on the fly you know because it just I wasn’t getting anywhere it was a valuable learning
lesson for me which I’ve unfortunately learned a couple times more than once that you know I might have the will and
determination to fix somebody but if I don’t have a willing participant it doesn’t help anybody so
so this is how she presents to us it’s beyond a severe uh overbite she’s biting
on her pallet and she’s rotated completely to the right side because of the lack of the condo so so we designed
an asymmetrical uh Casper which would create the vertical dimension that she needed to be
at and then uh remember I work in a cranioacial center right because I I’m
still here i got my scrubs on right here right and um so I have a very talented surgeon
and the plan was that we would remove a rib from her back and do a rib graft to
establish a condile that she’s never had and it’s not going to really be a condile but it’s something she can
function on so there if you read in the literature about rib grafts you know there’s reasons why they fail sometimes
it’s you know because they have too much pressure put upon them and and this is a concept that um I really believe in and
I was talking it through with her and her mom and my surgeon i’m like “Look I really think this is a good idea because
it’ll give you an opportunity to heal a little bit easier it’s going to be a little tough you know but we’ll get through it and once we’re through the
tough part I think you know it’s I’m I don’t know what to expect but I’m expecting things will will be better
than they are you know so this is really out of the box thinking so this is kind
of establishing the growth that she never had because she’s missing that part of the jaw next slide so uh when
she came in after about this was about eight nine weeks after they did the rib
graft you can see that she had an incredible amount of symmetry in her face that she didn’t have before it’s
not perfect but pretty good symmetry now and the whole bottom third of her face is longer because we established the
vertical component uh that she was missing in the actual Casper appliance itself and then once we
knew that was okay we established it permanently by putting a ribbon in its place to to function like the mandible
so this is a world’s first you know and uh I’ll be talking more about this case at the KF 2025 meeting in Japan if you
happen to come next slide but this is the part that you must pay
attention to okay the volutric airway okay meaning the amount of space in her
airway at the smallest point in the airway was 1 cubic millimeter
the volutric cavity same spot which is around C4 on her
fourth cranial uh fourth vertebrae down the the same spot post-operatively
uh we calculated the through dolphin the volutric airway is approximately 630
cubic millimeters so her airway got established like
period you know and I said to her specifically I’m like you know how are you sleeping now she’s like oh my god
she’s like I sleep great now you know and um next slide
you know so So the picture on the left represents what she looked like when uh
we were talking about doing stuff the picture in the middle has arch bars on because we had to put arch bars on her
in the O in order to confirm that the bite was in the right place the picture
on the right is you can see Casper in the back but the picture on the right is
showing you uh photos from about maybe three weeks ago what I want you to pay
attention to nope stay on this picture for a second look at the image in the middle and find the midline on the two
front teeth and go to your left to look at the upper left canine and now look at
the upper left it’s the upper left canine it’s the upper right canine it’s on the left side of the image and now
look at the the the picture in the on the on the right look at that same canine the upper right canine which is
on the left side of the image look at it’s completely in contact now with the opposing canine so those two teeth
completely erupted together vertically supporting the face so even if the rib
graft fails right even if Casper’s taken out you now have teeth supporting the
structure of what we’re trying to achieve by the way the rib graft isn’t failing the rib graft looks great next
slide so you be the judge look at her smiling today in the blue sweatshirt and look at
her when she started the case wouldn’t you feel good about being the
person that helped her achieve this i mean this is off the hook good this is
something that’s never been achievable before and I’m learning right now i’m not telling you I have any of the
answers i have some but I I have a lot of questions right now and I want to
take this concept and blow it up and change the world because if 30% of the world is class two I think this is
incredibly effective at fixing those 30% so we’ll see how that goes next slide so
this is a concept right it’s not it’s not a single thing it’s incredibly
complex to understand and design but we’ve done it so now the train is on the
track and what we’re releasing right now or we’re about to release is the Chrome
cobalt version of Casper the top picture show shows it integrated with any
bracket you want the middle picture shows it integrated with any clear
aligner you want i’m agnostic i don’t care what brand that you want to use it
with i hope in the future one of the big brands kind of puts their arms around us
and really kind of says like “Hey this is really unbelievable we want to change
the world with you.” Because there is nothing short of this is 100% innovation
okay there’s nothing like this ever been created the bottom image is the part that I’m most excited about because
that’s actually showing you the potential what this can do with clear aligners okay and the clear aligner
world is what’s growing the fastest right now but you and I both know that really the the concept of fixing AP with
clear aligners hasn’t gone very well so far you know and there’s a couple
unicorns out there that maybe know how to do it but the majority of the people that have tried it have bombed out or
you know it’s like you have to do the AP then you kind of take the AP component off and you got to rebuild all your aligners and redo the trays again uh-uh
this this is efficient this is kind of keeping your car in your lane and doing stuff as you need to do it so So I think
as a removable device this is pretty unchallenged it can it can be like its
own thing like there’s never been anything like it you know and by the way we don’t have to print this just in amp
we can also print it in a in a flex night guard resin as well which I’ve done and I wear to bed every night um or
we can even mill it and make it as a retainer just like a twin block you know so there are a lot of ways that this can
be manufactured there are a lot of ways that these can be this can be administered what I’m
excited for is the fact that there’s just an untapped potential here right
which leads us to our next slide what’s next for this project right
we want to hear from you guys i hope everybody weighs in a little bit because the more people that talk to us the the
better we’re going to understand how to respond does this look real is this interesting do you think it would make
sense to come and do a handson threeh hour four hour workshop in the
ODL space with me what kind of auxiliaries can we incorporate into this i mean because
there there’s anything’s possible right you know would
you would you like to see this sold as a whole package you know aligners with the
Casper all in a single box you know what do you need in your offices would you like a typodonant you know would you
like to see a video you know would you like to see more memes of me which I think are absolutely hysterically funny
you know I’ll leave that to the marketing guys but uh I think from here I’m gonna let Tom kind of close it out
and and kind of field your questions um I hope we have some people watching i
have no idea if people are on or not um yes we do yes we do that’s great so
thanks good yeah yeah um we do have some questions that I feel like we have some time to get to um let’s talk we have a
couple questions here about advancement and we’ve talked about this um is it
adjustable to gradually advance the mandible and then um VJ also asked the
same question so what are your thoughts on advancement for this appliance so like I said I I don’t this is not a
herps where you’re pinching a little ring on the on the piston there are no moving parts on this thing there are no
screws to strip anything that’s adjustable says to me it’s breakable okay and
that’s not necessarily comfortable so so because we’re talking about like I just showed you you know correcting 10
millimeters of AP right and like I showed you an 8 millimeter correction that’s going to be done in under 24
months so so what I would say is this i feel it’s faster and easier to really
keep this thing fully custommade so you can order Casper with two lower members
a stage one is stage two and when you hit month six to month eight you just
cut off stage one and you just reseement stage two and that’ll take you that next two to three millimeters so they’re back
edge to edge to me that is going and we’ve tested it several ways that’s the
way that’s been very successful in my hands and it’s been the most predictable i’ve had in three and a half years I’ve
had two members come loose and that’s it and and we’re about at a 100 plus uh
cases right now so it’s it’s not like we have one or two or three of these things i mean I wouldn’t even do the webinar
until I hit the number 100 which was this year so so now that we’re at the point where we have a volume that’s
critical it makes a lot of sense for us to figure out if there’s a better way to
advance it there we we we know how to how to make it adjustable i’m not in
favor of it because anything that’s adjustable can be stripped anything that’s adjustable can be broken i like
the idea of the 3D printed metal because it’s it’s incredibly well finished these guys are incredibly good at at making
sure that things are smooth the other thing I didn’t talk about and you should have maybe thought about is hey I know
when when people do her appliances the lower incizers flare out well when you
when you get down to the nuts and bolts about her about the Casper system what you’re going to see is on the lower
member we have a really special design where Casper sits below the CJ and it’s
less likely to ever force any of the teeth to flare so these are the things that I think
will be kind of borne out as we finish cases and we see the final results nice
greg also asks um you know are there arch wire tubes you probably can’t really see through this camera but yeah
they’re integrated right into the Casper itself so they don’t need to be welded onto the side of it they’re right you
know embedded it goes right it goes right through the the the actual physical appliance yeah so Vivian asks
“If you’re not putting braces on for up to 12 months how do you prevent lower
incizer proclination during mandibular advancement?” Vivian I just answered your question my appliance doesn’t flare
the teeth you’re moving the jaw forward the tongue’s got plenty of room there’s no
pressure on the lower incizer so why would it move forward casper sits below
the lower incizer it’s one of my secrets greg also asked “Can we bond can we bond
brackets uh upper lower five to five um is it good for all types of class two?”
Um yes yes yes okay cool you know by the way I I have probably seven types of
brackets in my practice so I have everything incorporated with this thing
right now and then we’ll we’ll we’ll end with this one here this or maybe we have two more here so Kevin this is a little
bit beyond my head but uh beautiful work you’re doing one question might you
agree with McNamara Bishara and others who claim that a distal step primary second mer relationship in a 3 to
5-year-old will always progress to a full class 2 dental skeletal nl occlusion in the mixes in the mixed
and/or permanent dentition if no intervention is initiated upon earliest recognition it’s a mouthful kevin Void I
love Kevin Void yes I agree with Kevin so this is why there’s different
versions of this appliance right so I think what I’ve learned doing cranioacial for 35 years is tough
problems are tough problems right so we may be I only want to be fixed in metal
at certain points like when someone’s 10 to 13 years old I want to be fixed in
metal as a twin block concept for bed i think Casper for bed makes a ton more
sense than um a twin block because our design
allows for eruption of teeth and for exfoliation of teeth so in this scenario
what I would tell you is uh our code name is Batman batman’s been
doing incredibly well we’ve had uh nothing but success with it
and again you know I think the idea here isn’t bad or good i think the idea is
you have to manage these problems over a very long period of time and it’s not
it’s not a one-stop concept here you may go from a fixed
version of it to a removable version of it the idea that I like about the fixed metal more than anything else is people
for my kids actually forget it’s in and and if you literally talk to some of these kids they will tell you like “Yeah
it doesn’t bother me at all.” You know it bothers them at the beginning and I think the ones that have the most
trouble are the ones that start in braces and I screwed up and like I didn’t really I didn’t really realize
we’re full class two and then all of a sudden you know like we deprogram and then all of a sudden they fall back and
their class 2 just got 3 millimeters four millimeters 5 millimeters worse that’s when I’m like “Oh god I
completely blew it.” you know and it doesn’t happen too often but it’s happened in we have two or three of
those cases in our hundred or so so I think um class two is just genetically
hard to fix right and if someone is genetically class two the moment you take your pressure off they’re going to
fall back because they’re a bad grower so we just switch gears and we just go
from fixed to removable i think um picking when to choose somebody to start
is is a tough spot right we’ll get in early if someone’s having airway issues
100% you know and I’m not opposed to um
discussing you know how early can you get in because I don’t I don’t really have that answer kevin you probably know
more than I do because you do more of this and you have a PhD in anthropology on this but um
I think from our end the only goal I’m telling you here is this is a new
concept it’s incredibly good on airway we’ve got lots and lots
and lots of data to prove that and that’s easy to prove um I the last kid
was cranioacial you know so that’s real i mean like that correction is 100% real
and by the way she’s going into braces having a lfor to tip the maxilla down to level everything so she’s got work ahead
of her um so again this is a tool it’s one tool of many and my hope is that if
uh if we get enough people kind of starting to test this concept use it
appropriately which I don’t say that lightly um I think there’s a lot of
potential learning here for for many of us and I think the goal should be that
we try to make you know our profession better any way we can
for subdivision cases how do you ever place a Casper arm on just one side that’s not an option you can’t place one
arm i don’t know that on a subdivision case it’s the right appliance right
because you might need to distalize
a molar first so that maybe they’re at least parallel right and then you can do
Casper uh but I don’t think on a subdivision case I there’s so many
reasons why it could be subdivision but you know you could have early loss of a tooth you could have asymmetry you could have you know a wonky looking maxilla
you know for whatever but I think you know um that is something I probably wouldn’t go
excited i I I’m only really doing only fullstep class twos uh your second
question thanks Charles is how are patients tolerating the comfort of the buckle portion comparison to herps like
like uh if uh very well all I can say is very well
like I even even the kids that like you know walk out of the office like blareed and crying because you know it’s like
it’s a hard day to put stuff in they’ll come we bring him back with him 14 days like how you doing and like there’s one
kid specifically who will be in our future presentations like he he had a
really really tough time today we put stuff on and you know but he was verbal with me which was great and he was talking to me like the whole first week
i really probably have notes on on this conversation and by day 10 he’s like
“Oh,” he goes “I figured it out i’m good today.” And that was it and he never complained afterwards and um you know I
think that’s what happens we tell people it’s about a twoe period where they’re uncomfortable and after they kind of get
used to the idea of they’re just being held forward it it it’s weird because you have to actually let Casper function
effectively like your TMJ and there’s a there’s a lot of radiuses built into the
the ramps and the curves to make sure that the ball tracks in the bean tracks in a certain manner to uh protect you
from like kind of skipping out but unlike um like a mara where you can kind
of get locked backwards you can’t get locked backwards if this is made right it just it’s impossible and the ramps
aren’t too long so that if you bite you impinge yourself like that that doesn’t happen anymore we’ve we’ve been pretty
sophisticated about how we’ve created a whole checks and balance system of you kind of weighing in you gota you got to
check in on a 3D checker and actually say yes I approve this stage before
Casper goes to the next manufacturing stage so so there’s there’s a lot to this like you have you have to be
incorporated in the building process so that you literally are in charge right
there’s never been anything like this could this be something that could be generically put into a kit format the
answer is yes do I think manufacturers want to do that the answer is I don’t
know let’s ask American let’s ask Ormco let’s ask 3M Unitech let’s ask you know
GC America uh but I think the answer is going to be no because you know I think
most of the fixed appliance market is like they are just fighting for every case they can get right now because now
that you know there’s cases out there that are c custom between dibs and uh
light force and koen you know and and and other kind of for just a little bit more you can get custommade or
semi-customade I think you know the the all all that’s happening is is you know
the doctors are going from one camp to another but I don’t see the the fixed market really growing a lot i will say
this I think the fixed market is finally getting a little traction back from uh
the clear aligner market in the sense that like it took a hit because everybody went to clear aligners and
then I think you know after a while you know all these GPS that are doing clear aligniners you know a lot of them don’t
do a great job and the cases failed and we all know someone or a hundred people where like clear aligner therapy didn’t
work and it’s uh it that that happens you know and a lot of times clear liner therapy fails for lots of reasons and
I’m not going to get into But the truth of the matter is
I built a concept that’s going to work with both and I think that uh if you
have like a class 2 division one case you know that might theoretically be an aligner case with Casper it may not be
fixed metal you just have to open your brain up a little bit because then you can do sequential distalization in an
aligner even though Casper is attached to it so uh there is just a whole lot of
stuff here to talk about the only thing that we’re really focusing on right now that’s ready to go is the chrome cobalt
3D printed metal appliance that can have or not have a TP bar and expander stuff like that and um it integrates very
nicely with aligners from 5 to 5 so if you know you want to do aligners you can still do aligners with it and I’ve got a
bunch of those cases going so I’ll be happy to share those with time but as you know fixing class two takes two to
three years so um just you know this has been an incredibly quick learning curve for us and we’re making great strides
and we’re writing code every week about automating the printing and all that other stuff but there’s just lots and
lots and lots of hurdles and by the way I have a daytime job you know I have three of them actually so um you know
I’ll give it back to these guys you know they’re they’re the lab um I don’t know you know but I I I think it’s been a
it’s been a fun project for all of us oh it’s been amazing yeah just the the change in the patients we were actually
in Chicago the day that the last patient um with had her Casper placed so that
was that was experiential for me and Mike and TJ that was great to see um and
just what a beautiful young girl you know it’s great to see that change so two two closing things yes we will send
um first the number one closing thing is I want to thank you Dr neil for being here with us it’s been a pleasure it’s a
partnership totally and um the this recording so if you know anyone or you
want to show your staff this is going to go out um sometime tomorrow at the latest uh early Friday we’ll have this
uh recording out and then uh if you did want to set up a meeting start talking about this more in depth with either TJ
or set up a meeting with Sarah uh I have that link all the way at the top uh
right here so or you can just go on to our website odlortho.com and you can um go to the get started tab
and figure out how to contact us there so uh call text us thank you everyone
for joining us have a wonderful rest of your evening and uh thanks
thank you bye
