'How did I get into this pickle?'

The challenges of orthodontic case finishing.

Even identical twins can have very different orthodontic needs. (Photo Raul Carabeo / Wikimedia Commons) 

Dr Chris next teaches at the RMO Diagnostics & Early Treatment Seminar in Denver, August 18-19. For more information, call  (303) 592-8268.

Dr Edward H Angle (1855-1930) is considered to be the father of American orthodontics. (Wikimedia Commons image)

Dr Chris Baker's book,  "Your Child's Smile", is the premiere guide for parents who want to learn more about their children's oral health.

Dr Chris is very happy to lead a very happy team at the Advanced American Dental Center in Abu Dhabi, UAE.

Orthodontic treatment challenges the best of us.  What seems easy to many patients, is often a tough job for the orthodontists!  

Those of us who provide orthodontic treatment develop a keen awareness of the difficulties in our work with the constantly-changing human body. And, it’s over a relatively long period of time to accomplish orthodontic results.  

Can you imagine?  — We have learned ways to attach braces to teeth, move the teeth through bone, and remove the braces without harming the teeth? That in itself is almost crazy.  

Even in this day and age of high tech, lasers, 3D printing and other miraculous medical treatments, it is still amazing that we can move teeth through bone into nicer positions.  And more amazing, is that Dr. Edward Angle was doing it in 1900. (Dr. Angle was the inventor of modern orthodontics.)

It is of critical importance that in our performing the miraculous feat of moving teeth through hard bone, we take the health and well-being of the whole patient into consideration.  
Of course, you say.  

BUT that can be very difficult when coupled with the fact that each human body reacts differently to everything. Even identical twins’ teeth and treatment results are different.  

Why is that a problem?  

Because the variation in the human body’s reactions means that you can provide seemingly the exact same orthodontic treatment sequence, wires, brackets, and plan, and the results you see will vary so widely that it scares the bejiminy out of you!  
​
Your patient treatment that you planned to make everything better for your patient puts you in a fret and worry fest.  You start out to help and now you ask, “Why, oh why are the teeth doing THAT?  And what should I do about it now?”

Or, how did I get into this pickle and how do I get out of it?

The inevitable, every-patient variations - the crazy-making happenings that scare you or prolong the patient’s treatment and take much more time than your patient wants, is, in the orthodontics world, called “finishing” the treatment.  

“Finishing” starts before you bond the braces on. You work to identify the areas of likely challenge, the “outliers” in the patient’s presentation.  

Then you work and practice to learn the many strategies to help address and salvage the orthodontic treatment so the problems don’t prolong treatment time and make patients, parents and you frustrated and unhappy.  

In orthodontic treatment we must learn a lot of strategies, so we have a lot of tools in our toolbox, since EACH patient’s teeth will react differently. 

We must choose the appropriate tools, or at least tools that seem as if they will be helpful, employ them and see what happens.  Sometimes the tools we employ are not helpful.  It depends on that human body’s physiology.

Like everything in life, finishing takes learning, practice, and more practice.  As they say, “Why do you think they call it dental practice?”  

An overview of finishing of orthodontic treatment entails a few areas:
​
First, learn to identify when and where the treatment has stopped progressing in the best ways and directions.  Even that can be tough.

Secondly, learn and understand what you can do and what you cannot do.  There are late growth patterns that befuddle you. We must learn what strategies may help, which strategies may intercept or guide growth even a little bit, and which strategies may worsen the situation.  

We must learn what tooth eruption problems will likely not respond to efforts to get the teeth to erupt, and when we must counsel the parents and patient about implant replacement. 

We must understand how difficult asymmetric treatment can be, and what may help.  What to do with the peg lateral you want to maintain as a natural “implant,” and what to do with the missing lateral space?

Third, we gain capability in treatment strategies AND communication strategies to aide in addressing problems encountered mid to late treatment, such as inadequate molar buccal overjet, open bites, inadequate elastic wear, space that doesn’t close, crown and root torque problems, and marginal ridge height discrepancies. 

Most of all, in order to prevent being in a pickle, early identification before you start treatment and consideration of the options of alternative treatment plans that may be better, gives us more awareness.

We can help the patient and parents understand realistic expectations concerning treatment time, pitfalls and possible complications.

Not getting into the “pickle” and also knowing what to do when it is unavoidable, is a powerful, valuable body of knowledge called “finishing.”  
Learning more and more is the key!