I know the knee jerk reaction when you aren’t getting results and the patient says they are wearing elastics is to just use a class II corrector because “they don’t require compliance”. That sounds good but I believe that class II correctors are terrible for us individually and as a profession (not to mention patients generally hate them). I’ve done thousands of Herbst appliances, hundreds of the springs you snap on to braces and hundreds of those appliances that are a bar between the canine and first molar (but still require elastics and an LLA) and when they work they are great but when they don’t, nothing is more of a pain. Patients and parents hate the first two as much as I do because of the size and discomfort. The third one makes no sense because you still need elastic wear and it’s no different than wearing Cl II elastics on braces. The good news is all three significantly increase your overhead.
When we decide to use class II correctors, we are taking non-compliant patients and putting all the responsibility for growth and results and long term stability on ourselves. I know vendors and experts love to show the cases that work and they look beautiful but no one tells you about the other 3 or 4 out of 5 of these cases that don’t work or don’t hold up long term (yeah that pesky detail). PLUS if there is an issue with these appliances it’s a real orthodontic emergency and requires that everyone heads up to the office on nights and weekends and patients have better things to do.
In my experience, anything you can do with a class II corrector, you can do with elastics and a compliant patient. Getting kids to comply is at least 50 percent of our job as orthodontists! You gotta learn how to do that and take some responsibility for the overall level of compliance you get in your practice (remember to ignore the outliers, because they are outliers). If you aren’t getting good compliance overall then perhaps it’s time to hone your skills by visiting an office that does this well and learn from a colleague? Knowing that patients have to take responsibility for their treatment and their compliance and knowing when they are being compliant or not is also an important skill you need to learn.
Look, you didn’t make patients the way they are, their genetics and environment and habits did. If a patient is a surgical case then they are a surgical case and everything else is compromise. If they don’t want surgery then we do the best we can. If you prescribe elastics and the patient doesn’t wear them and they don’t want surgery and they don’t want to wear elastics, what are you supposed to do? How are you responsible for this? Does it make sense to put on a class II corrector out of desperation and then get taken to task when that fails? I think not.
Think about this. What if a patient is told they have cancer and the oncologist suggests they take oral chemo but the patient refuses to comply because they don’t like the taste or they lie and say they took the meds. What happens to that noncompliant patient? Something a lot worse than a class II canine or a centric slide I assure you. You can’t force people to do what you suggest and it’s not our responsibility to do so. I know it takes courage to stand your ground and let thing play out when patients refuse to do their part but taking it personally and feeling like their chronic lack of compliance is your burden is bad for everyone involved. This is a tough topic and I expect a good deal of debate.
On Tuesday, I’ll post tips and scripting to help you evaluate compliance so you can be sure of what is going on.
Amen! I’ve never had an emergency from elastics or headgear Ben. Thanks again for preaching the truth. Compliance is such an issue with Class II….but then everyone wear their aligners…..right…
I couldn’t agree more Ben! I’ve always said that my 3 ways to fix a Cl II are elastics, extractions, or surgery. I did Herbst and Mara in residency and HATED them and so did my patients. Forsus – not as much, but when a kid really wears her elastics, I’ve gotten as good a results as I’ve gotten with Forsus.
Totally agree! In my opinion class II correctors are not the answer. As a matter of fact, if your non-compliant patient fails to wear elastics, and you now put them in a forsus or esprit (or whatever) the responsibility is now on you if the bite is not correct. At least that would be the way the parents see it.
So glad you agree James! I am not claiming that I’m right or that this is the only mindset. I am just sharing what I’ve seen over tens of thousands of patients and a lot of failures. I am glad you see it the same way I do but I know most won’t and that is perfectly ok. I will however stand behind the statement that “anything you can do with a class II corrector you can do with a compliant patient and elastics” no matter what is said.
Exactly Richard!! Well stated.
In another group, someone said they use TADs and headgear because they don’t get unwanted side effects. I think he brought another important facet to this convo by doing so. I wanted to share my response.
No adverse side effects with TADs and HG?
That wasn’t my experience. I’ve placed one or two TADs in my time but I don’t do it any more for many of the same reasons I don’t do Cl II correctors. Plus I don’t like to turn pros problems into ortho problems, tooth movement is dependent on bone remodeling not proportional to force or anchorage and kids showing their friends at school that “their orthodontist drilled a screw into their face” is not a practice builder.
I know you will disagree and that is your prerogative but that’s been my experience.
You said it. The trend over the years has been for patients/parents to shift their responsibilities onto the ortho. If we don’t notify a patient/parent of an upcoming appointment (that THEY scheduled) with a reminder, and they miss the appointment, who’s fault is it??? They blame it on us!!! Talk about shift of responsibilities.
This is why I avoid placing fixed retainers, because as soon as I do, I now own it and the responsibility. If they get decay from poor hygiene, who’s fault is it? If the hygienist complains about cleaning around it, etc., who’s the bad guy? If they use their teeth to take off a bottle cap at a frat party and it breaks lose and some relapse occurs, whose fault is it??? You guessed it, in each case (yes all have happened to me at one time or another), according to the patient/parent, it’s my fault.
I love reading your stuff it is just so entertaining. You know this all boils down to how you spin your environment. When you have the staff and patients properly motivated from the beginning I think you see good results. Unfortunately life is a bell curve and their are outliers in everything. Your comment about if you are a surgical case you are a surgical case. What exactly determines that? Genetics? Bad cooperation? No growth? Here it is. It you are a quality act and you provide the environment and the tools and support network for the kid or adult to succeed then, then most of the time if it is a well run environment you succeed. You will not good good results from time to time. In my post case conference or the letter to the dentist I say we did our best, but we did not get as much correction as I would have desired. I make it a positive not a negative. For the same reason Ben, in your hands you get the same results as Class II correctors with elastics. Really all that matters is the people who are around you understand that. Your point is so true you can’t teach people how to talk. Some of us are comfortable talking even in the most tenacious situations, others run from it. You are part professional, part performer, part entertainer, part cheerleader, etc… It’s why you are who you are, multiple offices work for you and yes so do class II elastics.
My 2 cents, elastics have a little rebound and have limits on none growing adults. I make a living fixing cases that already attempted to treat. I don’t always use the same mechanics. Ok believe each person gets individualized mechanics specific to their desires and needs. It is the only true way I know to treat. On any given day I can suck. It’s just the truth. It may even involve the patients cooperation. But I don’t make blanket statements that class II elastics can fix everything.I think the truth is you need to use you skill set and think outbof the box sometimes, and I don’t necessarily mean it orthognathic surgery. You are incredibly successful because you love every aspect of what you are doing. I am just a.humble guy working every day. I hope my kids understand my work ethic and learn that I believe I make a difference every day. But understand i truly believe some cases will fail. It is just statistics. It’s not your fault though so no sense hanging your head low or running from it. Figure out how to get these outliers corrected, well that I believe is the holy grail.
Hi Ben
You must have been reading my mind. I was waiting for you to take the conversation here. I am hoping everyone else jumps in with more comments-as it would be great to reach an honest experienced based consensus.
I have 2 quick questions for you regarding your comment: “In my experience, anything you can do with a class II corrector, you can do with elastics and a compliant patient. ”
1. So are you saying you are getting good results EVEN WITH your compliant full cusp class II div 1’s with just cl II elastics (meaning-non extraction, non surgical treatment and no ancillary or anchorage appliances?
2. Are we speaking of both growing and non growing cl II patients?
Thanks again for sharing
Steve
Good questions.
1) No way. If a patient is not compliant we will not get a good result. That’s their choice and as I described in the post I don’t think it’s smart for us to try and take responsibility for the result when the patient is noncompliant.
2) Yes. My point of view is the same for adults and kids when it comes to this stuff.
Thanks Ben
Let me re-phrase question 1
I meant to say: assuming there is good patient cooperation with elastics, do you see your full cusp class II division 1 patients getting just as good results as the easier to fix end-on Class II div 2 patients?
Also would love it if everyone else following this thread would throw in their 2 cents-think I am on the verge of an epiphony!
Thanks again!
Steve
When I was a kid I once missed a dental appt .—-my Dad made me go to the office and personally apologise ! When I was told to wear my ortho .appliance or do my physio ,excercises and complained ,my Dad said stop whining ,take it on the chin and suck it up!
There again he was ex-military!
I dont think society ,for better or worse ,operates like that anymore—-essentially pts. chose their own level of care with prompting from us and help from us .
Having said this ,we can only do so much—I love dentistry and ortho. but I am not having a heart attack over someone elses teeth !
Well said.