A Voice in the Arena: Adult Orthodontic Rehab Cases by Dr. Chad Foster

A Voice in the Arena: Adult Orthodontic Rehab Cases 

by Chad Foster, DDS, MS, editorial director

I’ve been involved with several different interdisciplinary dental study clubs in the past handful of years. Most have been Spear Study Clubs, but there are quite a few other excellent interdisciplinary dental study clubs out there. It is quite amazing how different dental specialists see the same case!

Seeing teeth through their eyes has forced me to confront and work to improve my own deficient, two-dimensional understandings and assumptions of how restorative dentistry and the other specialties should properly interface with my orthodontia. On the flip side, it has also been eye-opening to realize their misunderstandings of what orthodontics can and can’t do to assist them in their restorative and rehabilitative dental needs.

In almost every case that is dissected, I have been obliged to humbly play the role of both teacher and student. These many discussions with my non-orthodontist colleagues have completely shifted the way I look at adult orthodontic rehabilitation (complex interdisciplinary) cases more than any other learning activities.

Rewarding results—but some hard lessons

Adult rehabilitation cases
Fig. 1
Adult rehabilitation cases
Fig. 2

Adult rehabilitation cases have been some of the most challenging and rewarding of all the orthodontic cases that I treat. For an example I’m sharing the records of a patient I recently finished (Figs. 1 and 2). Both he and his general dentist informed me that no one had wanted to accept his case because of its complexity. A corporate dental office had even suggested the only option was for him to consider extracting his remaining teeth and setting up for an “all-on-4” implant-supported prosthesis!

While there were certain treatment limitations to work around (not a perfect case in many ways), after 36 months of tough sledding, it was enough to make those of us involved feel like we had been able to serve the role of “specialists at the end of the road” for a guy who thought he was out of options.

At the finish line, seeing how much the treatment meant to him is enough to make me want to be that specialist for every orthodontic rehabilitation case that walks through my office door. But, as Lee Corso of ESPN’s College GameDay says: “Not so fast, my friend!” More valuable than me just showing one meaningful case, I’d like to discuss some of the “keeping it real” hard-learned lessons I’ve taken away from treating these types of cases over the past 11 years.

Profitability. It’s prudent to consider price per chair/appointment for our treatments. However, in my experience, if you’re expecting to see anything near your practice averages when you dive into these financial metrics at the end of a rehab case, you’re likely to be disappointed—even if you increased your fee significantly above average. This is not to assume where motivation for profitability should rank on your priority list when you evaluate these types of cases, but for your own sanity, it’s good to consider this realistically and ahead of time.

The restorative dentist’s expectations. I’m much more deliberate about this nowadays. For example, does the referring doctor fully understand how difficult it would be to rehab vertical dimension in a patient who has seven missing posterior teeth, lower incisors impinging on the palate and bite strength that would scare off a brown bear? Or after 30-plus months of attempted orthodontic heroism, would they be complaining that the case took too long, the patient wasn’t happy and the orthodontic work still left something to be desired for a perfect restorative setup?

If proper expectations and potential limitations of orthodontic treatment are not thoroughly outlined before teaming up, the dentist may actually think less of your abilities after all the blood, sweat and tears shed on the case than if you hadn’t taken it on in the first place! When planning with your restorative partners, always highlight the compromises and limitations, undersell the best possible outcome, then try to overdeliver within your ability.

The patient’s personality. Let’s be honest. A large percentage of patients who need complex pre-restorative orthodontic rehabilitation have something in common: They’ve been quite willingly and actively negligent about reasonably caring for their dental health over the years. While some may have had a “come to Jesus” moment that made them ready to now be an excellent patient and partner in the arduous journey you’re about to embark on together, the reality is that many are the exact same people who got themselves into this dire situation to begin with.

My strong advice: Look for any red flags. Do they seem bothered to be meeting with you, the orthodontist, in the first place? “I don’t even understand why I am here at the orthodontist. I just want my dentist to fix my front tooth!” Do they seem like someone who is happy and prepared for a long, and at times unknown, road? Or are they demanding guarantees, balking at cost and time in treatment, or otherwise coming across as grumpy? Or even worse, are they playing the role of victim in their own version of how they came to become an orthodontic rehabilitation patient?

My “musts” for accepting adult orthodontic rehab cases

After finding myself married to a number of the wrong type of patients in these cases over the years, I now have four prerequisites before I’ll accept a case. In the initial exam, I specifically look for:
  • A generally happy person I enjoy having a conversation with.
  • Someone who is willing to realistically accept the severity of their situation and the extent of what will be required to properly remedy it.
  • Someone who is willing to acknowledge their own responsibility in the previous decline of their dental health/condition.
  • Someone who understands that the only guarantee I can offer is my commitment to do my very best to attempt to deliver a good result from a very compromised situation.
If any one of those criteria is missing, I politely inform the patient that I don’t believe I’m the best doctor for their care.

To be totally honest, I must admit that nowadays I’m much more nervous when a person meets all of the criteria and I agree to take on their rehab case! I just hope that I won’t look back a few months into their difficult treatment and realize there was a fifth criteria that I should have seen staring me in the face and waving a red flag in the exam room. …

What are your “musts” when agreeing to treat an adult rehab patient? Verified members of the Orthotown community are free to share their thoughts and opinions in the Comments section under this column below.

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