The kind of bracket you use has very little impact on your “clinical efficiency”.

Now before you totally freak out, please allow me to elaborate on the reasons I hold this to be true. If you’ll listen, I promise I can save you a lot of money and aggravation.

  1. Precision manufacturing and very low tolerance are useless bracket qualities.
    • Almost no one uses a full-size wire (for lots of reasons – patient comfort being a big one) so we never fill the slot and thus there is always significant slop.
    • The emergence angle and curvature of teeth in both M-D and O-G directions are widely variable, negating the consistency of most of the tip and torque built into the bracket.
    • Bracket placement is customized by each practitioner – changing greatly and improving greatly with experience. We put braces on, see what happens and adjust how we put braces on… then repeat. We should be learning from our mistakes and constantly improving!
  2. There is very little difference among self-ligating, steel ties and o-ties when it comes to keeping the wire in place and allowing the wire to do its job. While it is easier to train assistants to open/close the gates on SL brackets than training them to place o-ties and teaching o-ties is easier than steel ties, there is no real difference among these methods of ligating when it comes to tooth movement since most of that is wire driven and there is the aforementioned ever present slop. Given time and practice, any of these techniques for ligation can be mastered by both orthodontists and assistants resulting in negligible time differences among techniques so why not use the one that is most cost effective and most desired by the patients? The colors and comfort provided by using o-ties provide efficacy, speed and customer satisfaction as well as being very cost effective. If there are any of you thinking steel ties are better then please ask your patients what they think about getting tied in…
  3. The size of the bracket matters little in terms of clinical efficiency but customer satisfaction tends to push us towards smaller. Perhaps interbracket distance in the lower incisors will help unravel crowding but you don’t need to use a fancy system to have a narrow bracket.
  4. Curvature and fit of the bracket base would seem vital but given the variability of tooth surfaces and placement preference this is probably not the case. Some seem to work better than others for individual practitioners but all of what we do is learned behavior and there is glue between the bracket and the teeth so, again, base design and adaptation matters little. You can learn to use just about anything so why not learn to use a less expensive option.
  5. Design of the wings and availability of attachments, hooks, etc. are not good reasons to buy expensive, precision engineered, low tolerance brackets as you can get just about anything you want in a more reasonably priced bracket. If you have complex needs for your brackets then you probably have complex treatment protocols and neither are good for clinical efficiency. As discussed many times on OrthoPundit, simplification is the key if you want to be efficient.
  6. Design of the mesh pad, the glue interface design or any other precision engineered elements of the tooth facing side of the bracket base are not terribly important as long as the bracket passes the litmus test of staying on the tooth. No bracket is perfect in this regard in my experience – and I’ve tried more than a few. As much as it pains me to admit that an expensive bracket may be worth the money, I’d be remiss to omit the fact that 3M’s APC brackets basically just don’t come off. Like almost never. I bought a practice a couple years ago that used these and I was impressed. Let me clarify why I mention this and why it is important. If you have significant bond failure issues – like to the point that it’s causing customer dissatisfaction and negatively impacting your business – then you need to fix that and do so now. First, check the obvious and most common issues that cause problems:
    • Make sure your bonding supplies are not expired
    • Check your curing lights with a tester
    • Insure your team members and you are following proper bond technique
    • Make sure there is no sunlight hitting your bonding chairs
    • Make sure there is no water in your air lines
    • Track your issues as described in this article
    • Reduce the number of teeth you prep and bond at a time
    • One outlier that is possible but unlikely is that a manufacturing defect is causing your bond failure problems (like the one Ormco had with the D2 bracket back in 2004 – guess how I know about this!). If, after checking all this you still have a bond failure issue that you cannot resolve then, for the sake of your business, consider paying the price for the APC brackets to put an end to your issues. I’ve recommended this to peers in dire straits with their bond failure in the past and switching to APC resolved these issues. I don’t like to admit that our experience, training and skill as orthodontists comes secondary to a manufacturer’s prowess but I’ve seen instances with bond failure where this can be the case.
  7. Made in ‘Murica is not a good rationale for paying big bucks for brackets. Patients don’t care and unless you’re willing to apply this policy across your entire lifestyle it really doesn’t make sense in the modern, global economy. But like any of these other reasons, owning your own business gives you the privilege of doing whatever you like for whatever reason you choose.

So what does matter and why am I talking about this now?

Well, I’ve received several questions of late about how I plan to be efficient enough in the clinic to make money at a 3000 dollar fee. This is well and good but most of the doctors asking the question assume my efficiency will have a great deal to do with my bracket choice. Nothing could be further from the truth. Brackets and/or bracket systems will not make you an efficient clinician but what you pay for the brackets you use can and will impact your practice overhead. This is true for any orthodontist out there. It’s the experience and skill and knowledge that you possess that makes you efficient or not. It’s your willingness to be open minded, visit others who are succeeding, change and implement that will determine your level of success. Think about it. You have to learn to use ANY bracket system and while it may be convenient to buy one that comes with a “system” when you’re fresh out of school, once you have some experience you can learn to work with any bracket that meets the minimum criteria of having a reasonably consistent slot size and the ability to stay on the tooth 97 percent of the time** So why wouldn’t you learn to use the least expensive, acceptable brackets?

Is it really worth hundreds of thousands of dollars a year to be an insider or a big client or get to speak in a vendor booth or to be a VIP at corporate ortho events?

Think of all the stuff you could do with that money if you used an inexpensive bracket. Do you really like your rep well enough to give him money out of your pocket? That’s basically what you’re doing!

And if you’re reading this while thinking that there’s not much money to be saved by switching to a very inexpensive bracket then I assume you:

  • are already came to the realization that brackets don’t matter that much
  • don’t realize how inexpensively you can buy a set of brackets these days or
  • don’t do much volume so the price you pay for brackets doesn’t matter much

If your reason for believing such is #3 then there are lots of ways to work on that problem free for your consumption/implementation here on OrthoPundit. Or you can just come visit my new office in Orlando so we can hang out and talk about it. I have doctors stopping by the next two weeks in a row and several more scheduled in the future but there is always room for one more.

** There is one big factor about brackets that can contribute to your clinical efficiency but it’s not what you think. I won’t buy brackets that are not already on the card and ready for use in the mouth. Spending the hours it takes and dealing with the mistakes that arise from having to place brackets in sets on a card from bulk packages is just crazy in this day and age.

*** I really hope you’re not reading this and thinking custom bracket/wire systems are the solution. Both are overkill and a complete surrender of your professional abilities, not to mention overhead killers.

8 thoughts on “NEWS FLASH!!

  1. Ben, You are correct. There is no “magic” in any brace or brace system so choose whatever you like at the price you are willing to pay. And, there is some validity(in my office) to fewer bond failures with APC’s because it decreases some operator error. I used a variety of basic brackets for 20 years with no real difference in speed or results only in price. The consumer and GP’s don’t appreciate any differences. In an attempt to lower my hassle factor, as I get older, I have used APC brackets for a few years and have seen fewer “emergencies” from broken brackets. Is it worth the extra cost??? I don’t know yet. I’m tracking my broken brackets + emergencies and weighing the cost of repairs (= extra visits that make the team and parents unhappy) vs the high cost of the APC’s.

    1. It’s a matter of preference. My biggest point here is making sure orthodontists know that they are choosing to spend more money – they don’t have to in order to get good results. If you’re very profitable then do what you wish. If you’re scraping by the pinch those pennies! It sounds like you have you’re head up and are on the right track.

  2. Great post! Ben, what is your view on the patient management software? There are tons out there. Some are cloud, some are local server based…. after all these are the brains of our practice. Do more expensive ones (with all the bells and whistles) perform better?

    1. We have been orthotrac users for several years now. PM software is vital as you point out so choose carefully. If you’re very low volume you may not need anything but a simple scheduling software and some paper charts but if you’re doing any volume the cost of PM software more than makes your money back.

  3. Great post. Also, I would to ask you about robotic wire bending and totally robotic ortho approach of Sure Smile – Orametrix. Have you ever tested this system ?

    1. I have not but know several who have. Few did it long term and most stopped after 3-5 years. I am not opposed to the concept or the accuracy but in an era when orthodontists have excess time and capacity why would we spend money to save time?

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