Next-generation treatment planning

Clinical , Current Issue
Editor’s intro: Using combination treatment plans allows Dr. Adam Schulhof to approach appliances like menu options — let him whet your appetite for this approach that can result in more predictable results for your patients’ treatment, as well as setting your practice apart.

Dr. Adam Schulhof discusses how combination treatment plans can yield greater efficacy for patients

During their education, orthodontic students are often taught to approach their work using a specific method or philosophy. Orthodontists tend to remain on that track throughout the entirety of their career without crossing over or combining methods.

A newer way of thinking about esthetic orthodontics by creating hybrid treatment plans has potential to impact practices and the effectiveness of treatment for patients. Combining two or more philosophies can prove to be much more successful for patients.

At Columbia University College of Dental Medicine, we weren’t taught one way over the other, so I was able to learn how to use different methods for the individual and mixing when necessary. From a bio-mechanical perspective, hybrid orthodontic treatments allow us to utilize the right tool at the right time. But we are also business owners and have to satisfy our patients with the treatment method that suits them without sacrificing efficiency and effectiveness.

Identifying suitable cases

Knowing when to utilize a hybrid treatment starts by opening a discussion with patients. I have my patients rate factors such as cost, time, looks, comfort, and lifestyle based on which is most important.

As the orthodontist, I rate the appliance options. I conduct treatment planning from a different angle without separating brackets, lingual, or aligners into silos. From this perspective, I can approach appliances like menu options, mixing and matching in a way that will meet the terms the patient cares about most, and what I, as the clinician, consider will be most effective.

A recent combination case I treated was for a patient who had lifestyle and appearance concerns. This particular patient is a teenager and an actress who had an impacted canine, but there was never perfect timing to get her treatment going because of her demanding work schedule. We determined the best method for her by thinking of the appliances chronologically, starting with lingual on top to correct the canine and aligners fitted on the bottom. Once the canine was brought in, we finished with aligners on the top as well. Embracing the advantages of different appliances and using them in conjunction ensured not only great results, but also met the needs of her lifestyle and timing.

Figure 1: Initial photographs — actress on prime-time television with impacted canine on top

Achieving predictable results

Predictable outcomes are all about communication. Patient compliance is one of the big concerns with aligner therapy since they are not stuck to the tooth like fixed appliances. Of course, compliance issues exist with elastic bands and brushing, but compliance is a bigger challenge with aligners. A lot of practices downplay the compliance because they don’t have the backup lingual option for esthetics. When a practice has limited tools that is what they are going to sell. When you have every tool, you can be a better orthodontist and guide the patient to make a more educated decision.

Some patients dislike the idea of attachments, so practices skip attachments altogether. Unfortunately, forgoing aligner attachments can result in extended treatment and less predictable results. In my practice, if the patient is turned off by having attachments, then we do lingual. We can’t bend to a patient’s will to the point where I compromise treatment.

Recently, I treated a patient that came to me after seeking treatment from other orthodontists. She wanted clear aligners but was told that her crowded bottom teeth eliminated her as a candidate for aligners, and that her treatment would take 2 years. Our solution was to use clear brackets on the bottom teeth with clear aligners on top. This method was efficient from the get-go and didn’t stretch out the timeline of treatment. It was a successful case of giving the patient the esthetic look and appliances she desired, while utilizing a method I knew would work and have the outcome I wanted to achieve. No one had given her that option before, and I was thrilled to be able to find the combination that worked for her.

Figure 2: Progress photographs — impacted canine on top treated with Incognito™ system while lower treated with aligners

Practical impacts

Previously, a large drawback to prescribing a hybrid treatment was the cost. A combo case that only needed upper aligners would incur a fee for the full set, and those costs were often a barrier for patients. I use 3M™ Clarity™ Aligners because they have a much different model — you only pay for what you use. This is where the clinical part meets the small business aspect of what we do. With Clarity Aligners, I have lower overhead for the case and don’t pass along inflated fees to the patient.

It’s easy to have tunnel vision for the kind of treatment we are used to and thus categorize patients. Conducting combo treatments is a new way of thinking, but it’s fitting in the new world of orthodontics we have entered. Modern procedures are not bound by brackets on the front of teeth — there are lingual, clear aligners, clear brackets, and more. Exploring the possibility of using each appliance for its strengths simultaneously can delivery greater efficacy for your patients’ treatment, as well as setting your practice apart. Ultimately, any way you can differentiate your business and better serve patients is a great combo.

Figure 3: Final photographs — canine in position, all accomplished completely invisibly with Incognito and Clarity Aligners

Check out Dr. David Alpan’s approach to another type of combination treatment in his CE, “Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time.”