The Efficiency Equation by Dr. Mike DePascale

Reducing refinements without sacrificing quality

by Dr. Mike DePascale

My goal for each patient I choose to treat orthodontically is simple: maximum happiness. I know that some of you just read that and rolled your eyes because you think it means sacrificing quality, but that’s not at all where I am headed. I’m here to tell you something that still doesn’t seem to be an accepted thought in orthodontics: You can do it all. You can produce outstanding results in a comfortable, convenient way, without sacrificing quality, and you can do it in fewer appointments than you think. Let me start by telling you the numbers in my own practice, because if you’re going to listen to me, you should care what they are. Here is unaltered objective data over the last six months of consecutive aligner finishes (more than 100 patients):

• Estimated treatment time: 16.3 months

• Actual treatment time: 15.5 months

• Total visits, including scans and delivery: 7.5

• Regular (nonemergency) visits: 6.9

Approximately 70% of my patients tracked over the last 600 finishes complete aligner treatment in one refinement or fewer.

The results are consistent, reproducible, and, most importantly in my opinion, attainable for all. So how do we maximize happiness? Well, everyone has to be happy. That means you, your patient, your patient’s mom or dad, and your team must all feel great. That demands the results be excellent as well.

Let’s start with you. Have you ever thought to yourself, “Man, I’d love to take more time out of my day setting up these cases”? Didn’t think so. You’d rather be golfing, hiking in Portugal, or, if you’re me, running to a new fishing spot with the wind and salty air in your face. That is possible with the right planning and commitment to success.

Step 1: Diagnosis is key. Make sure that you have excellent records, ideally a cone beam computed tomography (CBCT) scan (controversial, I know. Come find me if you want to debate this one), and accurately determine what the patient’s issues are.

Step 2: Define. Your. Goals. If you have a moving target, you’ll never hit it. You do not have to fix every single thing on every single patient, but you certainly have to decide which issues you wish to fix and which you don’t.

Step 3: Treatment plan effectively and efficiently. Start with the end in mind. This is where the power of aligner digital design shines, in particular with Ormco’s Spark StageRx.

Step 4: Trust the system and your protocols. Take the time to dial them in and then let them do the work.

Step 5: Know when to audible on your plan.

I want to elaborate on a few of these that are less self-explanatory and provide some clinical planning and staging tips to help minimize refinements and maintain the quality of your results. StageRx is a planning tool built to streamline and improve aligner design. It uses a series of command blocks to let you build and adjust a design in a much simpler and more detailed way than has been possible before. There is a command block for every single tooth movement you can think of (Fig. 1), and it allows the doctor to build a database of case protocols (read: crowding, spacing, Class II, Division 2 with crowding, and so on). Here is an example of the protocol for a crowded case (Fig. 2). Once you drag and drop this protocol into your plan, each block can be individually adjusted into a patient-specific treatment in a matter of seconds (Fig. 3). The point is to remove communication problems between the doctor and the technician, along with the difficulty of articulating exactly what your goals are. You can also share your protocols with other doctors so you can learn and grow from each other. I believe this tool can transform aligner treatment.

Fig. 1

Fig. 2

Fig. 3

Here is the foundation of what I do for crowded cases, for those who haven’t seen it before: constrict all terminal teeth while expanding the 456s (mesial out on 6s if needed) and adding buccal root torque (BRT); simultaneously, procline all anterior teeth to ideal inclination with relative intrusion; once the procline phase is complete, plan interproximal reduction (IPR), then retract; while retracting, add lingual root torque to the lower incisors, palatal root torque to the upper incisors, and intrude as needed for preservation of smile arc, bite opening, and compensation for the tendency of incisors to retrocline. In a spacing case, the procline phase is eliminated, but the rest stays the same. All other protocols (deep bite, anterior open bite, Class III, and so on) are built from this. As an example, if I am using sequential distalization, I plan all of these movements and add the proper distalizing sequence, which is one tooth every four or five aligners, never moving more than three teeth at a time, and treating the 3-3 as one unit. I typically use 3–4 mm horizontal rectangular attachment (HRA), but vertical rectangular attachment (VRA) can be used as well.

The biggest issue doctors have with planning aligner treatment is one of two things: They do not fully grasp the specifics of the mechanics, or, more frequently, they have no foolproof way of communicating their goals so that the design comes back consistent, repeatable, and predictable. That is what StageRx solves. I believe the technology is headed to a state in which artificial intelligence assists in diagnosis, builds a treatment plan in real time (and adjusts it in real time) from prior data on similar cases and detailed diagnostic input, and makes outcomes substantially better while taking much less doctor time.

If you start with great protocols, your No. 1 job to minimize refinements is make sure your patients are compliant and that you know when things aren’t going well. Confidence in the protocols is key. If you have that and the aligners are not tracking, in most cases you can presume that either (a) the patient is not wearing them as often as he or she says, or (b) you have missed something in your design. So when this happens, if you feel that the patient is being compliant, critically evaluate what you did wrong: Look at every tooth movement in detail, the movement velocity, and any planning steps you took. The answer is always there. Once you consistently find it, you can produce amazing results (Fig. 4).

Fig. 4

Below is a list of some of my other planning tips that will help you reduce appointments consistently, in no particular order:

1. Plan all IPR at the same stage when possible. (Exceptions are periodontally compromised cases that may require you to do it sooner to reduce round-tripping.)

2. Set progress appointments at 12- to 20-week intervals. You do not need to see patients sooner than this.

3. Program four or five passive aligners in all cases so that your patients can keep changing their aligners weekly while you wait for your refinement set.

4. Have the patient wear aligners for 12 hours if tracking is not ideal while you design a new series. More wear than that will continue tooth movement in an unfavorable way.

5. Scan for refinement early if tracking is off. Don’t let this ride. Always make clear retainers to hold in this situation. It’s annoying, but necessary.

6. Do not tell the technician how many aligners to plan until you’ve gotten very good at this and are extremely confident. Until you are there, let the system work. Overriding the design before you learn exactly what you’re doing will often lead to frustration, more aligners, and more refinements.

7. Evaluate the trimline for comfort and fit. When crowns are overcontoured, reduce the trimline so that it doesn’t cover the gingiva. Do not cover too much distal of the 7s when the tooth is not fully erupted. Avoid pontics unless absolutely necessary for aesthetics. Extend the trimline on the anterior if needed to maximize torque expression.

8. Make sure that your attachments placed initially are as close to perfect as possible. The plan means nothing if the execution is off. A lot of people miss on this. Here’s a pro tip: if you have a fit issue that you rescan for, don’t change any attachments, and your patient tells you that the aligners are way more comfortable than the first time they got them, your attachments were not placed ideally initially. You can’t go back, but it’s something to learn from.

9. Avoid pure extrusion and rotation.

10. Create space in severely crowded situations and maintain that space throughout the course of movement. Do not close it until after movement is complete. Aligners love space!

11. There are a few situations where “overplanning” is needed. The most common one is severe deep bites in brachycephalic patients with strong musculature. You will need to set the final position of these teeth in a slight anterior open bite.

12. Study your cases. I always tell people to spend the most time on the outliers. When treatment is going extremely well, figure out exactly why. If it is going very poorly, figure out exactly why. That is where the vast majority of my learning has come from.

In summary, here are some take-home tips to reduce refinements without sacrificing quality: (1) take amazing records, (2) use the treatment planning data and education available to you, (3) use visual planning tools to both save time and increase efficacy, and (4) critically evaluate progress and adjust as needed. 

Dr. Mike DePascale, a New Jersey native, received his orthodontic master’s degree at the University of Maryland in Baltimore. In 2017, he joined the team at Kozlowski Orthodontics, a practice that matched his dedication to high-quality treatment, innovation, efficiency, and education. When DePascale is not in the office, you can find him in his garage gym or coaching CrossFit at a local gym, where he puts to use his passion for personal growth, leadership, and commitment to others. He believes in pushing boundaries, doing what you love, and sharing that with the world.

Disclaimer: Dr. DePascale is an educator for Ormco.