In orthodontics, the chief complaint is sacrosanct. Or at least we talk about it like it is. The reality is that better is better and most patients will be well satisfied with a better-looking smile even if we cannot address their chief complaint or achieve “perfection”. Now I know you’re thinking about the outliers – that 1-2% of patients that will not be satisfied with anything short of what they consider perfection – but don’t forget that making policy based on outliers is wholly illogical. Most people want a better-looking smile and are reasonable (understanding even) when we orthodontists explain what is possible. Especially when that alternative to “perfection” takes less time, involves less pain or costs less money!
Why does this matter?
Well the position we take on how we address unrealistic chief complaints is every bit as important as how we think about ideal. Ideal is dumb and blindly pursuing a layperson’s desires when you know they are not based in reality is as well. To be clear, I am a huge advocate of giving patients what they want and I’m not saying anything to the contrary here. I am saying that the progressive, pragmatic orthodontist can help patients get what they really want (even if they don’t know what that is) through education. Most patients anyway. Again, it is very important to forget the outliers instead of focusing wholly on them as we orthodontists are want to do.
Lets’ look at some specific scenarios:
- The patient could have “perfection” with the removal of 4 premolars and this is what they “want” but they could have a really good looking smile with a few compromises, without tooth removal and get there in much less time. What do you do? Damn the torpedoes and go for “perfection” as we are taught in school or educate the patient? I know we are told to treatment plan like time and money are not relevant BUT THEY ARE.
- The patient has mesially impacted lower second molars and they (and their dentist) want the teeth uprighted. Now, if the teeth are not too mesially angulated this is an easy fix but past a certain point mesially impacted lower 7s are a nightmare. In the latter case I would extract second molars on my own child and I tell the patient so.
- The patient has a crazy impacted canine or three. You know the ones I’m talking about here. There is no space for it but we will extract a premolar or spend the next 5 years making space to get that “keystone tooth” into the arch so it can look terrible with the crappy gingival attachment that so often accompanies these cases. Why? Extract that joker, finish the case in less than 18 months and move on. This is what I would do if it was my family member. Who needs all that pain and suffering? For what?
- The patient is missing upper laterals, is class II molar/canine and they (and their dentist) want you to extract upper 4s to make space for implants. That’s dumb. Tell them so. Close the space and reshape the canines. If you don’t know how to make a canine look good as a lateral, stop Dr. David Sarver when you see him at the AAO Annual Session and ask him. He’s great at it. In fact, in most missing upper lateral cases that are not Class III why not close the space and help the patient avoid an anterior implant that will look like crap at some point in the future and need to be redone at least once? Burning upper anchorage is EASY. What’s that you say? Not ideal? That’s dumb. Ideally, the patient would have all their teeth and said teeth would be straight…
Look, you can do whatever you want, however you want. That’s the beauty of this profession. Also, patients can do whatever they want with their bodies! I’m all for it. I just think we tend to make policy and suggest treatment to patients based on some antiquated, paternalistic, illogical assumptions while focusing on outliers. It’s time to address the reasons we do what we do.
What’s that? You’re not sure how to get people to see what better looks like and most patients have a hard time understanding what their smile will look like at the end? I’m glad you spoke up because there is a very easy solution. Get yourself a scanner that does preliminary setups on the spot! If used properly a scanner is one piece of technology that can make you money rather than cost you. Letting people see what their teeth will look like at the end of treatment is a powerful selling tool and it adds to patient satisfaction. It’s an idea and a technology whose time has arrived. Just remember that you don’t need to do a setup before selling the case for every patient… Don’t waste time (yours and theirs) on the straightforward cases that make up the majority of orthodontic practices!