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A Voice in the Arena: Noncustom Ninja by Dr. Chad Foster

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Categories: Orthodontics;
A Voice in the Arena: Noncustom Ninja   

The case for mastery of noncustom, nondigital fixed appliances

by Chad Foster, DDS, MS, editorial director

In last month’s column, I discussed the importance of the “person behind the machine.” Regardless of the technological advances we can only imagine coming our way, the skill of the operator will always be a significant differentiator.

One of the big developments in our specialty over the past few years has been the emergence and further development of custom digital appliances, including both fixed and clear aligner options. I’m grateful to personally know some of the talented innovators and top clinicians associated with these companies; they are people who love our specialty and are a driving influence on improving the quality of patient care that our profession delivers.

I don’t believe the opinion I’m about to share will be met with universal agreement, but I feel strongly about it and specifically hope that young orthodontists and those in residency programs consider it. Here is the message: First and foremost in your training, in your personal practice and in your continuing education, aim to be a badass with traditional fixed appliances. Set a goal to master those appliances. When you hear that a new and disruptive appliance will deliver superior accuracy or efficiency, be sure that you possess a very high level of skill in noncustom fixed appliances to compare those claims to. With a novice or even average skill set, it is not nearly as useful of a comparison.

This is a major reason why it makes good business sense for these orthodontic companies to specifically target residents and young orthodontists: If those companies can get them to start using their appliances early on—well before mastery of traditional fixed appliances can develop, which easily takes a few years of purposeful practice in the real world—the comparison is much more heavily weighted in favor of the company’s claims.

The biggest claim of custom digital appliances is their supremacy in efficiently getting the patient to their ideal and unique tooth alignment/prescription position.

Alignment isn’t the major challenge
In my practice, I use a noncustom bracket that Ifind accurate and consistent. I use loupes and treat bracket placement like it’s the most important part of treatment—which it is. I will invert brackets and switch bracket tooth positions to under- or overexpress certain movements as needed. My skill at aiming for ideal aesthetics and efficiency is constantly evolving and is vastly different than it was in my first handful of years in practice.

For the far majority of my patients, chasing ideal alignment/prescription is not at all the most challenging or inefficient part of treatment in my day-today clinical practice. If my noncustom fixed appliances are inferior in regard to their ability to universally express ideal prescription values for each case (which I do not dispute), this is almost without exception not why any of my cases go longer than 12 months.

The reasons my more challenging cases do go beyond 12 months are unrelated to alignment/prescription (tooth position) problems, and include (but are not limited to): waiting on an impacted or late-erupting tooth; purposely staging certain movements after ideal alignment when needed; chasing ideal occlusion; properly timed IPR or other aesthetic detailing; or some other case-specific component of AP, transverse or vertical. Again, these issues are not related to inefficiency in achieving ideal alignment/ prescription with a noncustom digital appliance.

Except for unusual circumstances, pano/repo is completed by the sixmonth mark (typically repositioning zero to two brackets on average immediately while chairside in less than five minutes). By the 12-month mark, the patient has already been in their full-size finishing stainless steel wires for two to four months, and the necessary one to three detail bends (on average) to complete ideal alignment/prescription have already been placed in one appointment (the appointment after the placement of those finishing wires) where I am chairside for less than five minutes.

Ideal alignment/prescription is achieved in four to six appointments in eight to 12 months. For a simple Class I case with alignment problems, this is the treatment duration I expect. Again, even for moderate or complex cases, ideal alignment/prescription is not often something I’m chasing after that amount of time. For me, the benefit of using a custom digital appliance is not as valuable as it might be for orthodontists who find themselves continuing that chase significantly longer than that.

The point of discussing my protocols here is not to propose how everyone should be practicing or to claim mine is a superior way of treating. Without a doubt, there are those reading this who are more ninja-like than I am in their mastery of noncustom fixed appliances. The point I’m trying to make is that for the large majority of your cases, if timed right (don’t start too early), planned correctly and with appliances applied (positioned) accurately, there should be few occurrences of needing to continue to chase ideal alignment/prescription after the one-year mark. High efficiency for me comes from an accurate and intentional initial diagnosis and treatment plan, custom bracket positioning, use of early elastics and use of bite turbos that are unique in their position and shape.

Keep learning and improving
For perspective, I will add that you don’t need to limit yourself to a small boutique practice or spend 20 minutes chairside with each bonding to achieve this level of efficiency. With a mastery of noncustom fixed appliances and efficient systems, I have found this very possible even in a large practice. To be fair, though, I will also add that if you are seeing well over 100 patients per day, the value of any degree of efficiency offered by custom digital appliances likely starts to become more practical.

While my opinions are biased by my own experiences and prejudices, I don’t view myself as a chronic skeptic of technology or late adopter of new advances in our field. Though I still make use of some old-school techniques that remain efficient and effective—for example, I still dust off a set of headgear a handful of times per year—I would submit that much of my view on clinical orthodontics, and particularly aesthetics and efficiency, are pretty progressive.

Again, I practice much differently than I did five years ago. I’ll definitely acknowledge that my opinions on everything I’ve said above could be much different in another five years. I hope they are! I love that about orthodontics. However, I can promise you that whatever revolutionary change comes knocking next, I will make sure I’m a master of the skill set it’s there to disrupt, so I can fairly and more accurately judge its disruptive claims relative to what I can already deliver in a more cost-effective or otherwise better manner for my practice.

Whatever your opinion or path you are on, I hope you’re practicing the best orthodontics of your life with the best still yet to come. Set your navigation toward mastery and always be a student in your practice and learning. Expect neither a guru nor a product to deliver it to you, and keep both curiosity and skepticism as your buddies on the road trip that we’re all so lucky to be on. Cheers!

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