Recently a member of Ortho101 asked about how to handle an imperfect finish. It is a great question and one we all deal with almost daily whether or not we want to admit it out loud. Here are some of the specifics the doc wanted to discuss:

• Do you keep patients in braces when they want them off and have the patient/parent upset?
• Do you make them happy and debond?
• I feel like when I talk to the parent, they want it perfect but they’re mad at me because they are still in braces?
• Am I just picking out small stuff that the parent doesn’t care about anyway?
• Do you send a letter to DDS for small stuff or is it just a letter pointing out flaws that they probably wouldn’t notice; making them think, “they always have an excuse”?

These are great questions and present an excellent opportunity to discuss a very common occurrence. I applaud this Young-Doc for asking and wish I had asked way back when instead of learning how to deal with this stuff the hard way.

I wanted to share a few thoughts about the questions based on hard experience:

1) There is no such thing as a perfect case – show me any case you think is perfect and I’ll find something wrong, I promise. Teeth and faces are not symmetrical by and large so it’s almost impossible to get a perfect result. In that same vein it is also dumb to talk in terms of ideal with patients and with PCDs because if the patient was ideal they wouldn’t need us and there is almost always some sort of compromise when dentists evoke the term “ideal”.

2) The patient’s head and teeth belong to the patient, not to the orthodontist. We are like waiters at a very nice restaurant – we tell people what we can do for them and how much it costs and then they tell us what they want and we do our best to accommodate them within reason. We shouldn’t allow the patient to ask for something we cannot deliver. We don’t force the patient to take what we want to give them – we simply advise and give reasons why we think what we think.

3) If a patient says to me, “When can I get my braces off?” my answer is always the same. “Today”, I tell them every time. Then they will say, “But I want such and such fixed before I get my braces off” and so I say, “No problem, it will take x months with good cooperation to do that” and then they say, “But I want my braces off” and I say, “No problem we can do it today” and round and round we go. I will always give patients what they want. I want to help them but I’m not going to force anyone to do anything and I’m damn sure not going to keep someone in braces who wants them off. I will always show the patient what I see and why I suggest what I suggest but the decision is theirs.

4) I will take the braces off early for lack of compliance or lack of hygiene with zero remorse. My job is to look out for the patient’s best interest and having braces on with chronic poor hygiene is not good for the patient. Also, if a patient is not going to cooperate then I do not want to waste the patient/parent’s time or money coming to see us. I am very good at talking to the patient and parent and documenting all along so that by the time we get to the point of, “It’s time to remove because we all have better things to do and Johnny just isn’t wearing his elastics” or “I know you remind Johnny to brush all the time mom, but he just refuses to do so and we need to remove the braces” that no one is upset and it works out just fine.

5) I always document in the chart when there is something undone that I think could have been accomplished given good hygiene or cooperation or more time. I also point this stuff out to the parents and patient when we are removing braces in a less than perfect case. It’s all you can do.

6) I tell patients all the time, “Look I’m a tooth nerd and I want your teeth as perfect as possible and I’m going to keep going until we get there or until you want the braces off. I want you to be happy but this is your head and these are your teeth so you’re in charge!” The patient/ parent IS in charge. They are paying you for a service. The paternal model of healthcare delivery is dead.

7) Dentists of a certain type will find something wrong with every case you do with no regard for where the case started, the inherent limitations, cooperation level or anything because they have no context. Our Miami and Las Vegas “trained” primary care dentist friends tend to be the worst about this kind of thing. They think they know what they are talking about after a few weekend courses but by and large they don’t. I have watched dozens of these expert PCDs criticize the hell out of me for .25 mm discrepancies and then start doing braces themselves – and apparently the same standards don’t apply to their orthodontic cases. You don’t want these kinds of dentists as “referral partners” and you don’t want to treat “their” patients unless the patient finds you outside of a referral. And this is not just for egotistical reasons – having the patient caught between two healthcare providers who differ in opinion is very unpleasant for all involved and especially so for the patient. Working with unreasonable PCDs is bad for business, bad for the patient and bad for your wellbeing. You are the expert when it comes to orthodontics. Period.

Long story short, there is no such thing as a perfect case! Treat every patient as you would treat your own family and things work out just fine the vast majority of the time – even when there are complications.