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Combination Treatment Helps Speed Case Progress by Dr. Eric Wu

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Categories: Orthodontics;
The Right Tool Combination treatment helps speed case progress at the Right Time 

Combination treatment helps speed case progress

by Dr. Eric Wu

When choosing treatment appliances, it is usually braces or clear aligners. However, with combination treatment, it can be braces and clear aligners, taking advantage of what each appliance does best.

For me, combo treatment means starting with braces and transitioning to clear aligners.

Benefits of combo treatment
Based on my experience, braces “kick-start” teeth and bone for orthodontic movement; teeth then move more easily in clear aligners than with a clear aligner cold start. Also, each treatment approach has distinct movements that are either difficult or easy for that particular system. As a result, I handle “aligner difficult” movements such as rotations and extrusions up front with braces. Clear aligners have a “speed limit” imposed by the plastic’s limitations; braces are not hindered by that limitation, so we can rotate quickly while also reducing the number of aligners needed on the back end. Plus, clear aligners express the fine details of the finishing stage better and more precisely than braces, so you get the best of both appliances in one treatment plan.

If you resolve major crowding first with braces, you can reduce or eliminate the need for interproximal reduction, preserving the patients’ natural dentition. Moreover, completing significant movements with braces reduces the need for attachments during clear aligner treatment.

Predictability is another huge benefit. With combo treatment, I can more accurately predict how quickly we can get to our treatment goals because I’m able to use the most efficient tool for the movement desired. And hitting that estimated completion date consistently leads to higher patient satisfaction while increasing profitability.

In my practice, combination treatment also reduces chair time. A typical 18-month braces case can require as many as nine or 10 office visits; by transitioning to clear aligners, I can eliminate two or three appointments.

In addition to the practice benefits I mentioned, my patients tend to prefer combination treatments because we can get treatment done more rapidly and predictably than with aligners alone while preserving many of the aesthetic benefits that aligners enjoy over brackets. Patients who come in requesting aligners will often accept six to 12 months of braces initially to shorten the total treatment.

Pay-as-you-print pricing
For readers wondering how mixing treatment modalities can be affordable with the high lab fees that traditionally accompany clear aligners, I have three words: per-aligner pricing.

Instead of paying a high comprehensive fee of $1,000 or more for an entire series of clear aligner treatment, I pay only for the aligners each case needs. If the pricing tier is $20 per aligner and I need 10 aligners, my cost is $215 (including shipping), so I can still price the treatment affordably and increase the profitability for my practice. It’s a win-win for everyone.

Also, the treatment planning software I use, uDesign, includes a bracket removal tool. With one touch, the braces disappear, making it possible to plan without extensive touch-ups. I can have the aligners waiting at debonding, eliminating an appointment and extra work for the team, as well as avoiding potential relapse.

Because the software captures and uses actual tissue data, the straight trim line meets the gingival margin. Some other systems estimate gingival tissue so they use a scalloped trim line to accommodate any inaccuracies. However, aligners with a straight trim line at the gingival margin or 2 mm beyond provide better aligner retention than aligners with a scalloped edge.1

Another game changer for my practice has been chairside treatment planning. In the past, I’d spend evenings and weekends treatment-planning all my new aligner cases. Now, I plan and order right at the treatment chair and submit before the next patient arrives.

Personally, I prefer outsourcing the aligner manufacturing rather than printing in-office. My staffing changes over the past two years made it clear that having uLab Systems manufacture the aligners would be a better use of my available resources. Plus, I can still handle the one-offs or emergencies with in-office printing if necessary. In-office aligners are more expensive for me to produce than to purchase from uLab, but it can be worth it to replace a lost or broken aligner before the patient’s teeth shift.


 CASE STUDY 1

Diagnosis and treatment plan
This patient (Fig. 1) presented with a deep bite, severe crowding, anterior attrition and a chipped incisor. She also has an implant on the lower right, which challenged how much movement we could get in that quadrant.

We discussed combination treatment: first using braces to handle the rotations and correct the crowding, then finishing up the case with a short series of clear aligners.

 Fig. 1
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case


Treatment progression
We put braces on this patient in January 2021, using Pitts21 to correct the rotations and crowding. She responded beautifully and started clear aligner therapy in August 2021, finishing in just four months. With combo treatment, this case finished in one year.

Case notes
As I mentioned earlier, the patient had a small chip on her top right incisor. Many orthodontists steer clear of restorative work because it can take significant time, but I was able to reconstruct it in about 10 minutes using uLab’s Add/Subtract feature. I 3D-printed the model and used it to thermoform a template; then, using composite, I was able to quickly restore the tooth. By undertaking it myself, I saved the patient money and time coordinating the restorative work with her dentist. The chip was so small she might have just left it, but restoring it definitely improved her final results. (Plus, I had fun finding a new use for the technology.)

Adult deep bites are notoriously tough, and this case is no exception because her right occlusion was particularly challenging for me. The patient was referred to a periodontist for gingival recontouring after treatment to further refine her smile aesthetic (Fig. 2).

Her case would have taken 18–24 months using a single treatment modality. With combination treatment, we completed the case in 12 months, with no delays and a smooth transition between fixed appliances and clear aligners at the three-quarter mark.

 Fig. 2
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case



CASE STUDY 2

Diagnosis and treatment plan
This patient (Fig. 3) presented with a complicated case. He needed a second phase of orthodontics after initial treatment from a different orthodontist; late jaw growth had resulted in a significant underbite. He arrived in my practice with the bonded retainer.

This could have been a surgical case, but I recommended that we undertake combo treatment, starting with braces to address the severe underbite. By avoiding surgery, we would be able to treat his case faster and avoid a painful recovery. Once the difficult movements were completed, we again transitioned to clear aligners for the final stage. I’ve never met a patient who didn’t love having their braces removed sooner and switching to aligners.

Fig. 3
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case

Treatment progression
The patient started in braces in September 2020 and wore them until November 2021, when we removed the appliance and treatment-planned his clear aligners chairside with uDesign. He wore successive clear aligner trays until January 2022. His entire treatment from start to finish (Fig. 4) was around 16 months: 13 in fixed appliances, three in aligners.

Fig. 4
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case
3D Printed Clear Aligners Case

Case notes
With the amount of underbite we encountered on this case, it would not be exaggerating to estimate that the treatment plan might have been 18 months to two years. By addressing the degree of underbite with fixed appliances, we were able to deliver the patient to the endpoint much faster than if we had chosen either braces or aligners alone.


Final thoughts
Combination treatments offer us the best of both worlds. We get the control and heft of braces to get things moving quickly, and the finesse and efficiency of clear aligners to finish the case. I am continually impressed by how technology and innovative approaches to treatment planning and production have facilitated these options. Clinicians can now take advantage of what each treatment modality excels at, which is better for us and our patients.

Reference
1. Cowley, D., Mah, J., and O’Toole, B. “The Effect of Gingival-Margin Design on the Retention of Thermoformed Aligners.” JCO; 2012:702.

Author Bio
Dr. Eric Wu Dr. Eric Wu is an adjunct professor at the University of Nevada, Las Vegas and the postgraduate department of orthodontics at Roseman University in Henderson, Nevada. He also teaches at Foothill College in Los Altos Hills, California.

Wu attended dental school at the University of Pennsylvania and a one-year advanced education general dentistry residency at UCLA before his orthodontic residency at the University of Pittsburgh. He also completed a mini-residency in sleep medicine from UCLA. In addition to his private practice in Palo Alto, California, Wu serves as a key opinion leader and clinical advisor to Orthoclassic and uLab Systems. He enjoys teaching, lecturing and keeping up with the latest developments through study groups, and has been published in several industry publications.
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