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!

4 thoughts on “Don’t Be Constrained by the Chief Complaint

  1. It is quite interesting how our own biases enter into what we recommend patients. As far as substitution of canines for laterals is concerned, think you should make up your own mind, but this excerpt from my upcoming book (not yet published) may shed some light on these topics for you.
    Prior to the advent of sophisticated implant therapy, substitution of the canines for missing laterals was a very common, if not the most common, choice for treating cases in which the patient was congenitally missing lateral incisors. In the first half of the 20th century, orthodontic texts stated no other arrangement was aesthetically acceptable, since the restorative techniques were fairly crude by today’s standards. In the 1950s, it became more common to recommend cuspid substitution (Hotz, 1974. Shaw 1994) because of the relatively poor aesthetics of restoration at the time, and that patients with canine substitution had better periodontal health.
    When I present the option of substituting canines for missing laterals to many of my restorative colleagues, I generally receive the comment, “I can’t stand cuspids in the lateral slot!” When asked why they dislike them so much, the responses are generally “they always look bad,” “it causes temporomandibular joint dysfunction,” “it can cause loss of periodontal attachment on the maxillary premolars,” it can cause undue wear of the incisors”. Let’s address each one of these complaints, and look at what the literature says. First, the question “It looks bad.” Does it look bad to the dentist, or does it look bad to the patient? My first response to “it looks bad” is this: that is probably because you have not seen one that has been “lateralized” properly. There are a number of variables that affect the final appearance of a canine taking the place of a lateral incisor, but the most significant factor, in my opinion, is the skill in which the clinician reshapes the canine to resemble a lateral. I have seen a number of approaches, the least invasive involving simple addition of composite bonding to the corners of the incisal tip of the canine (figure), resulting in an extremely wide substitution for the lateral incisor, generally wider than the central incisor. The next step up is for the clinician to knock off the tip of the canine, resulting in a better appearance but a tooth that is still quite a bit wider than the central incisor. In 1970, a detailed methodology was introduced by Tuverson (Tuverson D L, Orthodontic treatment using canines in place of missing maxillary lateral incisors August 1970Volume 58, Issue 2, Pages 109–127). Later in this chapter we will demonstrate my approach to canine lateralization.
    In 2000, Robertsson and Mohlin (Robertsson S, Mohlin be; the congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Eur J Orthodon; (22) 697-710, 2000) compared patient opinions of the esthetic results of cuspid substitution versus7restoration of the missing lateral to that of the dentist’s opinions. In addition, they also looked at the questions of function and periodontal health. In this study the patient had to be missing one or both laterals, and implant restored restorations were excluded. The follow-up time averaged 7.1 years, which left time for soft-tissue reaction and adaptation to have occurred.
    As far as esthetic outcome, patients were asked what they thought about tooth shape, tooth color, anterior space distribution, and dental symmetry. Interestingly, 95% of patients who had canine substitution were satisfied with their appearance, but expressed high dissatisfaction with the color difference. Only 65% of patients were satisfied with the appearance of their teeth in the prosthodontically restored population.
    In 2005, Armbruster et al. (Armbruster PC, Gardiner DM, Whitley JB Jr, Flerra J. The congenitally missing maxillary lateral incisor. Part 1: esthetic judgement of treatment options. World J Orthod 2005; 6: 369-75.) (Armbruster PC, Gardiner DM, Whitley JB Jr, Flerra J. The congenitally missing maxillary lateral incisor. Part 2: assessing dentists’ preferences for treatment. World J Orthod 2005; 6:376-81) conducted studies to determine how dentists, orthodontists, other dental specialists, and laypeople judge the relative attractiveness of missing lateral cases treated with canine substitution as compared to both Maryland bridges and implant restoration. Patients with no missing teeth were used as controls. Orthodontists rated each category from best to worst in the following order, no missing teeth, canines as lateral incisors, Maryland bridges, and finally implants. General dentists rated no missing teeth and canines substituted for lateral incisors most attractive (with no significant difference between them). This was followed by Maryland bridges and finally by implants. Orthodontists rated each category as being statistically significant in the following order from best to worst: no missing teeth, canines substituted for lateral incisors, Maryland bridges, and finally implants. As far as laypeople were concerned, rated the canine substituted as lateral incisors as the best, followed by the no missing teeth images, then Maryland bridges, and finally the implants. Among dental professionals, there is wide variation of what is considered the “best” option for replacement of congenitally missing lateral incisors.
    There’s no doubt that restorative technology has improved significantly since the year 2000. So how has that changed how patients perceive canine substitution as compared to contemporary implant-restored missing laterals? In the most contemporary study, Schneider (Esthetic evaluation of implants vs canine substitution in patients with congenitally missing maxillary lateral incisors: Are there any new insights? Schneider U, Moser L , Fornasetti M, Piattella M, Sicilianid G. Am J Orthod Dentofacial Orthop 2016;150:416-24) gathered a panel of orthodontists, dentists, and layperson who rated the esthetic appeal of dentitions after orthodontic space closure by canine substitution compared with space opening to replacement of missing maxillary lateral incisors by implant-borne crowns. The results were compared to the outcome with the results the Armbruster studies conducted in the United States in 2005. In this the Armbruster study, a panel of orthodontists, general dentists, combined dental specialists, and the lay population were shown a variety of cases in which images 1) smiles with no missing teeth (the natural dentition), 2) lateral incisors restored with implant and crown, 3) lateral incisors are placed with Maryland bridges, and 4) canine substitution. Orthodontists, in order, from best to worst, cited the natural dentition, canine substitution, Maryland bridges, and finally implants. General dentists ranked in the following order: the natural dentition, canine substitution (not statistically significant between each other), Maryland bridges, and implants. The lay population rated first canine substitution, followed by the natural dentition, Maryland bridges, and the implant category interestingly, there is no statistical difference between the natural dentition and the Maryland Bridge population and the Maryland Bridge but there was a significant difference between the natural dentition and implants. There are lots of ways to interpret this, but it does raise the question as to whether implants are the only option to consider in replacing a missing lateral.

    Just as a shameless commercial plug, this is one of the topics taught in our office course, our next one coming in May. You may access registration through

  2. Could not agree more. Many orthodontists, especially new minted ones, are taught by “teachers ” with experience but “wrong experiences” I would argue. Do no harm, treat in most conservative way, consider social economic status of the patients – these are some of the most important things many forget, or do not pay attention to. That is the reasons, we see 4, 5, or 6 years cases in active treatment and many of us blame patients for “poor compliance” as an excuse. As far as missing lateral substitution goes, I have treated hundreds cases with space closure and substitution or space opening and prosthetic work, and guess what, I have not seen a perfect prosthetic work yet. It is always something. If it is not a Class III, I agree, it is much better, safer, less expensive for the patient and faster just to close the space and substitute and let the patient avoid “a perfect implant”

  3. well said! when are you going to write and article for OrthoPundit or TheProOrtho Magazine! Your peers need to hear from you!

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