Trends in dentistry change and evolve. At one time, each specialty basically did its own thing, but today’s general practice is becoming more comprehensive. This trend can be attributed to several factors. First of all, Americans are becoming dental consumers. With the influx of new orthodontic techniques, there are now new ways to reposition teeth more quickly and more aesthetically than with traditional means.1 The economic factors of running a successful general practice, now more than ever, call for the dentist to incorporate additional revenue generators. The general public has reached an enlightened phase when it comes to aesthetics, and actively seeks out smile improvements. In fact, more than 5 million Americans are in orthodontic treatment each year.2 Balance that knowledge with the fact that only about 20% of general dentists perform orthodontic techniques, but the other 80% have a healthy percentage of their own patients in need of this treatment.3,4
When general practitioners (GPs) add orthodontics to their skill sets, this allows them to produce more beautiful results in the smile zone and, with the right training, will also allow them to treat more complex cases when correcting the occlusion is needed.5 Minor tooth movement and limited orthodontics are becoming more and more popular in the general dental practice where treatment is often limited to the maxillary anterior segment. This seems to be a comfortable place to start integrating orthodontics into a general practice. Nevertheless, spending the additional time to learn straight-wire comprehensive orthodontic techniques adds more value to what can be provided and improves the level of service for the patient. The team should be trained so they can be better informed of the services the practice provides. Then, they will be more prepared to discuss the options available and to motivate patients to consider potential treatments. The team can help your patients understand that not only having a beautiful smile is important, but also that many dental diseases can be avoided with orthodontic treatment. The clinician, by serving patients better, can elevate his/her professional status in the community at large and positively affect referrals. This in turn, should provide an increase in practice income—a truly a win-win situation.
ANALYZING YOUR PRACTICE
If you have been toying with the idea of adding something to your practice that would energize it and create excitement, you should first do an analysis. Run a simple report of how many of your patients are in the age range of 10 to 15 years old. Also, find out how many of your female patients are in the range of 20 to 45 years old.
The report showing the number of preadolescents and adolescents provides a snapshot of potential comprehensive (brackets and wires) orthodontic cases. This is an extremely rewarding and fun group of patients. They generally desire the treatment due to social pressure. Their parents generally recognize the need for orthodontics and, therefore, are very accepting of the treatment.3 This is a group that carries with it a large referral potential within the family unit as well as extending outward to their social group. The average fee for comprehensive orthodontics is around $5,000. Let’s say that you have an average-sized practice and that this group contains 150 patients. With proper training, you should be able to easily treat 80% of these cases, and the rest you refer to a specialist in order to take advantage of their additional training. You now have a group of 120 patients. If every one of these patients accepted your treatment, your increase in production that year would be $600,000. At 50% acceptance, your increase would be $300,000, and at 25% it would be $150,000. To be as realistic as possible, landing somewhere in the 50% range is quite feasible. Don’t forget to figure in the increase in new patient revenue. Although there is no way to quantify this in advance, know that it will occur.
Now look at the group of females in the range of 20 to 45 years old. Traditionally, more females accept orthodontic treatment than males, as these women are more likely to be looking for cosmetic improvements.2 A reasonable share of treatment will be performed on males, but for analysis purposes, let’s just look at groups that can be quickly marketed to. This particular group is more likely to be interested in minor tooth movement in the smile zone.1 If you know how to utilize clear aligners, you will then have some very interested patients eager for treatment. A typical fee for one arch is $1,500 to $2,400, keeping in mind that often times it is necessary to treat both arches at the same time. For demonstration purposes, let’s assume that this group represents 500 patients, and that they only need one arch treated. If every patient in this group accepted treatment, you would generate an additional $750,000 to $1.2 million. To be more realistic, a 50% acceptance rate would provide you an additional $375,000 to $600,000, and a 25% acceptance rate would be an $187,500 to $300,000 increase in production.
Knowing what the financial possibilities are, what are the estimated costs? You must first locate a reputable organization (one that preferably participates in the ADA CERP or AGD PACE continuing education sponsorship programs) that offers comprehensive training for GPs. It should have the following characteristics:
- Provides a sound protocol of diagnosis and treatment that is logical, safe, and repeatable.
- Offers both classroom and hands-on training.
- Provides educational reference material in the form of a technique manual and additional technique DVDs.
- Provides continued mentorship for you as you take on more cases and have questions.
- Provides training in minor tooth movement in the smile zone as well as comprehensive treatment to correct the molar class.
- Gives you the skills to know what cases to accept and what to refer.
The tuition cost for a course that has the above criteria can be as low as $4,000. The start-up supplies can be relatively low if one buys supplies as needed, such as one set of brackets, one set of the necessary pliers, minimal number of elastic ties, etc. However, know that there are usually discounts when you buy multiple sets of brackets, ties, pliers, etc. So, for a small investment, you can produce some serious revenue. There is a very short list of like investments in dentistry that will provide such a large return.
The following cases represent only a snapshot of what a GP will be able to do with the proper training.
MINOR TOOTH MOVEMENT
Minor tooth movement can be accomplished using brackets and wires, and a time frame ranging from 3 months to one year. This case example is a 17-year-old female who had a deep bite and possessed a smile that showed excessive gingiva (Figures 1 and 2). The molars were in dental Class I relationship. She came to the office requesting a consultation to discuss the possibility of having porcelain veneers placed. When she was further questioned, she had asked for the veneers not knowing that other options existed.
The dental cosmetic pyramid, as described by these authors, includes bleaching, orthodontics, cosmetic periodontics, and then restorative as the top tier.1 If we did not have the ability to treat this case with orthodontic means, our cosmetic dental pyramid would lack that level. In this situation, the remaining option would be very aggressive. It would have involved extensive surgical crown lengthening and excessive tooth reduction for the porcelain. After educating her as to the options available, she allowed us to place ceramic brackets on both arches and treat her condition with the traditional straight-wire technique combined with interproximal reduction. The case was debracketed 6 months later, and she was placed in upper and lower bonded retainers. The result shows level arches with a normal anterior overbite and overjet, combined with a normal display of gingiva (Figures 3 and 4).
A 34-year-old female patient presented with lower arch orthodontic relapse and a Class I molar relationship (Figure 5). There was a substantial amount of crowding present (Figure 6). Although there were malpositioned teeth in the upper arch as well, the patient was only concerned with the lower arch. A straight-wire technique, in combination with interproximal reduction, was used to resolve the crowding and align the teeth.
This case was completed in one year, and a lower bonded retainer was placed to prevent future movement of the teeth (Figures 7 and 8).
A 19-year-old female patient presented, seeking orthodontic correction for both arches in the smile zone only. The upper occlusal view shows rotated laterals, while the lower occlusal view shows that all 4 incisors are malaligned (Figures 9 and 10). She was not interested in traditional orthodontics using brackets and wires, but was willing to have her treatment performed using clear aligners.
This case was completed in 5 months using the Essix in-office clear aligner system (DENTSPLY Raintree Essix) combined with interproximal reduction (Figures 11 and 12). Retention was provided using an upper Essix retainer and a lower bonded retainer.
There is an abundance of post-orthodontic relapse cases in every practice. Minor tooth movement can rescue these patients and return their teeth to perfect alignment or at least close to it. This 24-year-old patient presented with concerns that his teeth had moved out of alignment even though he had a bonded retainer. Unfortunately, this older-style bonded retainer would not prevent relapse of the incisors because it was not bonded to all 6 teeth from canine to canine. Figure 13 shows that the lower right central incisor was the chief complaint. The old bonded retainer was removed, and an Essix aligner, fabricated in-office, was used to re-align the teeth. The case was taken to completion in approximately 3 months and a new bonded retainer was placed, bonding to all 6 teeth from canine to canine (Figure 14).
Comprehensive Treatment With Traditional Techniques
Comprehensive orthodontic cases will present as frequently as minor tooth movement cases if you can recognize them. These cases are both fun and profitable. Comprehensive orthodontics allows the clinician to correct arch shape, provide lip and cheek support, address trapped or submerged teeth often without extracting teeth, and correct the molar class. Shortcuts and short-term treatments are better suited for adults, but comprehensive treatment is the responsible approach for preadolescents and adolescents.
A 12-year-old female patient presented with constricted arches, a Class I skeletal relationship, and Class II molar relationship (Figure 15). Her case took 27 months to complete, and involved upper molar distalization, instead of extracting premolars. In most cases, parents will choose a slightly longer treatment over extracting permanent teeth when given the choice. Post-orthodontic retention was provided with an upper Essix retainer and a lower bonded retainer (Figure 16).
A 10-year-old male patient presented with a Class II skeletal relationship, a Class II dental relationship, constricted arches, and 100% overbite (Figure 17). Due to the severity of his case, it was begun in mixed dentition stage and took approximately 30 months to complete. It involved both upper and lower molar distalization, thereby avoiding premolar extractions. The patient was retained with an upper Essix and a lower bonded retainer (Figure 18).
Adult comprehensive orthodontic cases can also be extremely rewarding for clinician and patient alike. These patients have wanted a beautiful and healthy smile their entire lives, but hesitated in pursuing treatment outside of the general practice environment. These treatment successes become wonderful referral sources for your practice.
Why should GPs learn to perform orthodontic procedures in their practice? Because, in doing so, they can re-energize their practice, taking it to the next level. It rekindles a higher level of excitement for dentistry for the clinician and the team. With more revenue coming in, goals are achieved and economic freedom becomes a real possibility. If you are a young dentist who still has educational and construction debts to pay off, this is a wonderful way to reduce those debts faster or to even eliminate them. If you are a seasoned dentist, learning orthodontics often provides an intellectual and professional rebirth. Either way, orthodontics is a great fit for the general practice, and it follows that “if the coat feels good, wear it!”
- Nauman A. Patient-friendly short-term orthodontics. Dent Today. 2013;32:106-109.
- Wędrychowska-Szulc B, Syryńska M. Patient and parent motivation for orthodontic treatment—a questionnaire study. Eur J Orthod. 2010;32:447-452.
- Dimatteo AM. The straight story on orthodontics in the general practice. Inside Dentistry. 2007;3:46-49.
- Schlossberg M. Orthodontics. Where does it fit for the GP? AGD Impact. 2003;31:(3)9-13.
- Morgan J, Presley S. Follow the cosmetic pyramid for optimal aesthetic results. Dent Today. 2012;31:82-87.
Dr. Morgan received her dental degree from the University of Texas Health Science Center at San Antonio. She practices with her husband, Dr. Stan Presley, in Salt Lake City. She has served as a founding member of the South Texas Chapter of the American Academy of Cosmetic Dentistry and has served on the board of directors of the American Orthodontic Society. She lectures internationally on various conservative cosmetic topics, and she teaches an orthodontic continuum for general dentists and pediatric dentists in partnership with Henry Schein Orthodontics Straight Wire Seminars. She can be reached at email@example.com, (801) 561-9999, or via the websites orthodontictraining.net and prestigeseminars.com.
Disclosure: Dr. Morgan reports no disclosures.
Dr. Presley received his dental degree from Baylor College of Dentistry in 1977. He is a general dentist practicing with his wife, Dr. Jaimée Morgan, in Salt Lake City. His training at the L. D. Pankey Institute and Dr. Bob Gerety’s straight wire continuum has provided him with a sound cosmetic treatment philosophy. He was one of the founding members of the South Texas Chapter of the American Academy of Cosmetic Dentistry, where he served as secretary and vice president. He lectures internationally and also teaches an orthodontic continuum for general dentists and pedodontists in partnership with Henry Schein Orthodontics Straight Wire Seminars. He can be reached at (801) 561-9999 or via the websites orthodontictraining.net and prestigeseminars.com.
Disclosure: Dr. Presley reports no disclosures.