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Episode #555: Surgically Facilitated Orthodontic Therapy (SFOT), with Dr. Drew McDonald

With new technology and advanced procedures, you can give patients better results faster and easier than ever. Dentistry is evolving, and to highlight the importance of 3D imaging and Surgically Facilitated Orthodontic Therapy, Kirk Behrendt brings back Dr. Drew McDonald with advice for maximizing case outcomes and preventing the results that you and your patients don’t want. Stop hiding in the past with 2D! To hear how 3D will help increase your patients’ quality of life, listen to Episode 555 of The Best Practices Show!

Episode Resources:

Links Mentioned in This Episode:

CBS News story about AGGA:

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


Chicago Study Club:

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

Main Takeaways:

Learn from the mistakes of AGGA.

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

Never expand without proper teeth and bone assessments.

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

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


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

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

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

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

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

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

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

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

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

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

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

“In general, I think every orthodontic and every periodontist who are out there understand, in common, that there’s a risk for periodontal issues when you get into ortho. But we’ve always looked at it as, ‘Is there already recession, or is the gum tissue thin?’ What we need to wrap our heads around is, where is the bone? So, back to playing together, this is where the imaging facilitates conversation. Basically, in my world, we do our diagnostics with our CBCT, MRI, whatever else we do. But with that, I put together a whole presentation that shows those levels of bone to the patient. And then, with my referral to the periodontist, it has those same pictures of that CBCT. And then, we send the image so they can scroll through too and see what they need to see.” (18:02—18:58)

“The other thing I do is that I utilize treatment simulation software that allows us to visualize one, the bone. Two, if I move these teeth in this fashion, what does that bone look like around the roots? Did I move the root out of the bone if I try to accomplish that? And there are some softwares that are helpful for visualizing that, one of which . . . there are multiple different types of software that you can simulate tooth movement. One is SureSmile. The newer Invisalign technology also shows you bone levels. And again, we can’t just assume that if we move teeth, the bone will follow.’” (18:58—19:42)

“Just like everywhere else in dentistry, not everybody loves being procedures. So, as an orthodontist, if you’re out there hearing this, you know who your periodontists are in your area of town, and you can say, ‘Hey, if I’m seeing these issues and I’m taking CBCTs, are you comfortable with performing this type of procedure, the surgically facilitated bone grafting or soft tissue grafting, or even some cuts in the bone that help the teeth move faster?’ And so, you can approach your periodontal colleagues and say, ‘Is this something that you feel comfortable doing?’ Because the real thing is that there are publications in terms of the book that Dr. Mandelaris and Dr. Vence are putting out. There’s a ton of research digging back to the ‘80s on all of these procedures. And the techniques get better and better over time, or have gotten better. So, I think it’s a very approachable conversation that an orthodontist and periodontist in your city can all have. And I don’t think that it’s too far above anybody to say, ‘Let’s work together and do this,’ because it’s not that far out of the scope for either ortho or perio. It’s just, how are we going to accomplish this together? And that’s where the imaging, the treatment simulation technology helps to say, what do we really need? And it helps all parties know how to execute.” (20:36—21:55)

“The tide is here. It’s crested in terms of the evidence we have that certain types of orthodontic procedures do help us breathe better, especially through our nose. Maxillary expansion, whether it’s for a three-year-old with a tooth-based expander or something that’s easier to expand because the kiddo is super pliable, and I always use the analogy, they’re like a ball of Playdough. We can mold them so easily at those ages. But as you get older, the patients become harder to expand with tooth-borne expanders. And again, if we’re trying to achieve expansion to open up nasal passages and help give our tongue better space to operate, and all of that, it’s really important that we know what we’re working with with the bone around those teeth, especially as a patient gets older.” (22:42—23:31)

“In my office, we do a lot of MSE or MARPE style of expansion on adults. And I actually cut the arms off so that it’s not pushing on teeth, because I don’t want any chance of tipping those teeth, especially if I saw on their pretreatment images that they had thinner bone. And so, again, if we’re trying to achieve an orthodontic and an airway-directed plan that’s trying to help somebody breathe better, sleep better, all of the above, then it’s really important that we understand what we’re working with.” (23:33—24:05)

“The most important thing that we need to understand no matter what type of expander we have is, what is the foundation of the alveolar bone? Because that’s where people can get in trouble. That’s what happened with this AGGA situation.” 24:41)

“If you go in and just expand everybody without assessing things properly, there can be trouble on the back end of that situation. And that’s exactly what happened with AGGA. If we’re trying to tip those front teeth out or push the anterior part of the maxilla forward and widen at the same time, there are biologic limits to that, especially, obviously, is the bone. And if we don’t see that bone level, we can ask for trouble. Which is what happened where people were tipping teeth out of bone, causing severe recession, causing people to lose teeth and have a much bigger dental problem than what they came into the treatment plan with. So, I can’t stress this enough. Seeing before we get into cases will save our butts on the back end of things.” (25:10—25:55)

“When you come out of residency, you need a job. And when you need a job, sometimes the people who are operating that job might have a practice model that pushes something of what we call in orthodontics same-day starts of treatment. What that means is that, as the orthodontist, the first time you meet that patient, you’re expected to look at photos, usually a 2D X-ray, sometimes a 3D, if you’re lucky, in one of those settings. But essentially, you’re expected to look at a pano, a lateral ceph, and some pictures, and have the entire diagnosis right then, tell that patient, and their parents, the treatment plan that you’re thinking. And then, oh, by the way, they’re supposed to start treatment that day because the business side really likes that model because it’s a start. It’s money in our pockets. It’s booming. We did this many today. And again, not to throw too much shade, but there are Facebook groups where people and offices brag on, ‘We did 28 same-day starts today, and we’re competing with this other office for this.’ And what that means to me is same-day shit.” (27:25—28:31)

“You cannot be expected in that short of a time to analyze airway, bone, have a CBCT that you’ve ran through, seen everything. And most importantly, back to CBCTs or any other imaging, when you have a high-level image that’s showing a lot of stuff, you need a radiologist to read that. And they can’t read those in 30 seconds. They need some time.” (28:50—29:12)

“From the first time you meet that patient to when you’re offering treatment options, to actually be able to offer them options and say what’s under the surface, ‘Is there an airway issue we have to be part of, are there joint issues that are part of this?’ we need time. And I think that what we need to do is feel comfortable stepping back and saying, ‘Hey, at that new patient exam, these are the issues I’m seeing. I need these images and these materials for me to adequately assess and make recommendations.’ And ultimately, what I’ve seen is that patients value that. They love it because they’re like, ‘Okay. That’s not what I heard down the street at that other place where they were trying to get me to go start treatment and take $500 off if I did it right now,’ kind of thing. But that is a model. And so, back to doing quality care, it’s possible. And patients, they’re not going to run away from that. They actually want it.” (29:33—30:30)

“By taking a step back and doing things differently and being higher quality, you can have a more independent style practice where you can charge more, see less patients, and have a better quality of life along with that and, ultimately, do better for your patients. And I can’t tell you how many patients that come in orthodontically with crowding or a bite that’s way off, and we discover an airway issue, especially, or a jaw joint issue, especially, where we go, ‘Okay. Well, we did something bigger for this patient, and their life quality is going to be better because we were able to help those things or get them better.’” (30:43—31:24)

“We, as orthodontists, do not have to only offer our world to other orthodontists when we’re looking at advice.” (31:38—31:45)

“When we have an opportunity to change the standard of care because we know more, because we have new technologies, we have to do it. We can’t hide in the past with our two-dimensional images. So, embrace the new.” (33:27—33:40)

“With orthodontics, we are evolving. And the wave is here on the airway front, on the tongue, front, on the perio side, on the joints. All of the things that we know very well that contribute to malocclusions and why that patient is in our chair, we can’t hide from them anymore. We can’t just hide on a 2D ceph or pano. We have to be better diagnosticians.” (33:43—34:08)


0:00 Introduction.

1:32 Dr. McDonald’s background.

5:14 Surgically Facilitated Orthodontic Therapy, explained.

8:08 What to know about bone conditions before talking to patients.

13:22 Embrace the 3D world.

16:43 Imaging helps ortho and perio work together.

21:56 Understand what you’re working with before starting treatment.

25:55 Slow down.

32:00 Last thoughts on SFOT and the future.

35:38 More about Dr. McDonald, his study club, and how to get in touch.

Dr. Drew McDonald Bio:

Dr. Drew McDonald is a board-certified orthodontic specialist with a strong focus on airway and temporomandibular joint-focused treatment planning, surgically facilitated orthodontic treatment, and providing complex interdisciplinary care for patients. He lectures internationally on these topics and has contributed to literature and textbooks in these areas. He is dedicated to advancing the profession of orthodontics and dentistry as a whole.

Born and raised in Tucson, Arizona, Dr. McDonald’s love of baseball brought him to Albuquerque, New Mexico, where he played as a catcher for the Lobos from 2006 to 2008. While attending the University of New Mexico, he met his wife, Emily, a New Mexico native. He also fell in love with the Sandias, green chile, and the near-perfect weather. He graduated from the University of New Mexico in 2008 with a Bachelor of Science degree in biology and a minor in chemistry.

Dr. McDonald attended dental school at the prestigious Creighton University in Omaha, Nebraska. Known for its rigorous academic curriculum and intense clinical training, he received many academic accolades while at Creighton, including inductions into Omicron Kappa Upsilon (National Dental Honor Society) and Alpha Sigma Nu (Honor Society of Jesuit Universities). He also served in leadership positions as class president and student body president, and on alumni relations committees.

After graduating cum laude from Creighton, Dr. McDonald was accepted as one of only three residents nationwide into the University of Missouri-Kansas City Orthodontics program, a renowned two-and-a-half-year, full-time residency known for its clinical excellence. He graduated in December of 2016 with his certificate in orthodontics and master’s degree in Oral and Craniofacial Sciences.

When away from the office, Dr. McDonald is a “girl-Dad” to two daughters, a self-proclaimed grill master, and minimally talented yet enthusiastic golfer. You can find him taking in a Lobos game and spending time outdoors with his family.


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