Clinical Advice for Young Docs (Part 1)

I rarely give clinical advice or talk about technique, treatment planning or philosophy for lots of reasons. Mostly because everyone thinks we are good drivers just like everyone thinks we are the best at orthodontics. Well there are many ways to treat any given case and with that in mind I’m going to share a few things I’ve discussed lately with some young doctors that I advise on cases from time to time. These are off the top of my head and in no particular order. I’m sure I will think of more later thus the part 1 in the title. FWIW

Start each case with the fact that it’s very difficult to maintain upper anchorage and very difficult to burn lower anchorage in the front of your mind. The converse is true as well. You can always burn upper anchorage and you can always retract lower anterior teeth if there is space. This is super important when trying to correct a class II in any extraction case or case with space and leads us to point 2.
Never extract in the lower arch for anything other than severe crowding that will utilize the extraction space during alignment. Well almost never – there are a few instances where the skeletal or profile considerations make it a good idea. The point being never extract upper 4s and lower 5s just to try and correct a class II. I’ll say it… that’s just dumb for lots of reasons. You end up chasing the class II because of point 1 above and rarely succeed in achieving a class I bite and this only happens with exceptional compliance which is rare these days. If crowding is not an issue then you are far better off extracting upper 4s and doing a nance button to reduce OJ while conserving anchorage. You’ll end up with a class II molar but a class I canine. If there is a little too much crowding on the lower then upper 4s and a lower incisor are a great option. I’ve done tons of cases and done it a lot of ways and visited hundreds of offices and seen tens of thousands of cases. I’m not saying I’m right or this is the only way to do it – I’m telling you that experience has taught me this and I’m just sharing with you.
There is no proof that a class I bite is better than a class II or class III bite. None. I’ve asked for decades for someone to show me on scientific article that says so. There isn’t one unless it’s brand new and I haven’t seen it. Look for yourself before you scoff.
In the medical literature it is well documented that the one factor most associated with a higher likelihood of a positive outcome in any given procedure is the number of procedures the doctor has performed… so the idea that the less patients an orthodontist see the better the orthodontist/patient care is complete BS.
If something is too complicated for you then consider referring it to another orthodontist with more experience. Orthodontist howl with protest when I suggest such a thing and say silly things like, “as a specialist you cannot refer out those cases”. Oh no? Ever heard of the Mayo Clinic, Cleveland Clinic, etc where cardiologists and cardiothoracic surgeons routinely refer the most complicated cases? Do what is best for the patient in front of you not for your pocket book or ego.
Use a nance if in doubt about being able to maintain upper anchorage. Once anchorage is gone you ain’t getting it back.
Distalization is a pipe dream.
If the molar is class I and there is no Bolton discrepancy then the bite, the class I canine and the overjet should all work out. Think about it. Remember this when looking at crazy looking cases with lots of crowding or ectopic teeth.
If you can’t figure out what’s going on, count the teeth! Dr Buford Suffridge taught me this in residency and it’s always at the front of my mind.
The main job of braces is to make teeth mobile. If teeth didn’t get mobile they wouldn’t move. Get over that fact and stop freaking out when teeth are a bit mobile during treatment. Never start a case with active perio and insist on good hygiene and regular checkups during ortho treatment and know that teeth will get mobile with braces on – some more than others.
Speaking of variability – it’s almost always the case when retracting canines or closing space that one side will move significantly faster than the other. I don’t know why.
Short appointment intervals are dumb unless you have a very good reason for it – like an open coil spring or something aggressive. The science backs up light jiggling forces applied over a long time and people have better things to do than come see you all the time. Plus, aren’t you worried about mobility??? Use small wires and let them cook for a while. We try to average 10 weeks. Think about what happens when a patient in 014 or 018 niti wire run off for 6 months – what do they look like when they sho up again. Usually they look great!
If someone else has already done it, it’s probably possible.
Don’t believe the one off or handful of cases bracket hockers show at meetings are the norm. If you want to see what they are really doing then show up at their office unannounced and hang out for a day. Judge orthodontists by their median case not their best or their worst.
Take responsibility for ALL your cases. We orthodontists are taught to blame bad and claim good. Think about it. If someone has a bad result what do we say? Bad grower, bad compliance, bad brushing, etc? We never say bad treatment plan, bad diagnosis, bad mechanics, bad motivation, bad training. only 2 year olds and orthodontists act this way. It’s not useful.
Learn to read radiographs. I think this skill and the necessary knowledge has suffered of late. Most recently it has suffered due to COVID craziness at the dental schools but it’s been going on a long time. Things like vertical bony defects can ruin your day if you don’t know what they are or why they are so scary. There are other things you need to recognize too.
There isn’t always a right answer. Many times you just have to do the best you can for the patient given the limitations. Work hard to be realistic.
You cannot practice error free. No one can. To think we do is folly.
TAKE THE DAMN BRACES OFF – when the patient wants them off, when they prove they won’t wear elastics, when they prove they won’t brush, when you aren’t making progress, etc… if the bite isn’t “fixed” after 30 months it ain’t gonna happen.
Your staff can help you catch errors but they will almost never correct or advise or even inform the doctor unless they feel safe and comfortable. If they don’t feel that way then you’re the reason. Work on it.
There is very little liability in practicing orthodontics. That’s why our insurance is so cheap. Don’t be afraid. You got this!
There is very little liability in taking on a transfer case. Take photos, diagnose and treatment plan as per normal. You aren’t on the hook for what was done before just what you do as long as you have good documentation. Plus from a moral and ethical standpoint it is really important that transfer cases are taken care of.
Orthodontics is mostly psychology. Learning to communicate well, listen well, understand the patient and find a way to motivate them is most of what we do. They don’t care why you want them to do something – figure out how to explain why they want to do something.
ASK THE PATIENT WHAT THEY WANT TO ACHIEVE!! Most young doctors discount the chief complaint and focus just on teeth. That’s a big mistake. The same case can be hard or easy depending on the chief complaint.
Symmetry is important when managing baby teeth. If you ext a primary canine on one side the take out the other side too. Otherwise the incisors will migrate toward the side with the missing C and the midline will be off big time.
Speaking of midline – don’t mention this in the NP exam. Don’t make a huge deal about it and should a patient mention it in the NP exam in their chief complaint then explain that usually they align and we will do our best but it’s not always possible because we are not symmetrical beings and teeth are not exact replicas on the right and left side.
The job of baby teeth is to maintain space for adult teeth. That’s it. Try to think in terms of how to get the adult teeth in the mouth as straight as possible – the goal being that the patient wont need braces if you do a great job – when you are managing someone in mixed dentition. It’s not often that happens but it’s a good way to think about early treatment. Don’t be shy about recommending extraction of primary teeth if needed.
Don’t treat patients early unless you have a very, very good reason for it. Getting paid is not a good reason. If you do early treatment then clearly define your goals and timeline and you quit when that is done. Don’t fall into the trap of “just adding on a few more brackets” and treat them for years as it’s no fun for anyone and not good for the patient.
There is nothing scientific about the saying “the canine is the keystone of the mouth”. If it’s crazy ectopic extract it and move on. Attempt herodontics at your peril. David Sarver has a lot of great resources about how to reshape teeth in substitution cases.
Doing implants for anterior teeth should be avoided at almost all cost. Especially missing upper laterals. Dentists want to get paid to do implants. It’s not their decision. Sometimes the bite is such that you must do some kind of pros replacement but that’s not usual.
Don’t turn a pros problem into an orthodontic one! This may seem to contradict the previous point and maybe it does but what I mean is in the posterior or in a case where pros replacement js required then don’t try to close the space orthodontically. It will cause you headaches.
Uprighting molars that have tipped into an edentulous space is almost always a bad idea if the tipping or super eruption is substantial. If you are going to do that then be prepared to use some serious intrusion mechanics (absolute intrusion like TADs or something not relative intrusion tactics) or be prepared to get an open bite.
Bonding 7s that are not far out of line is usually a bad idea for lots of reasons. This goes double for adults.
Trying to upright mesially impacted lower 7s that are below the height of contour of the 6 or tipped more than 45 degrees is usually a bad idea unless you and the patient are masochists.

That it for now. I’ll check with the young docs I know and see what I missed. Not saying I’m right or this is absolute just giving some insight I’ve picked up over the years. Be well!