"To begin with the end in mind means to start with a clear understanding of your destination. It means to know where you’re going so that you better understand where you are now and so that the steps you take are always in the right direction."
- Steven Covey from "The 7 Habits of Highly Effective People"
It's an adage that is very apt when it comes to dentistry and in particular orthodontics. We all know that as soon as patients start aligner treatment, they will do the maths of how many aligner sets they have been given and identify that wonderful day when they expect to finish with the final aligner! Equally, as clinicians, we need to look ahead to that day so that we know what truly happens next so that we don't fail to meet our patients' expectations. So, let's break it down and see what paths can follow from the "final" aligner!
Restoration
Refinement
Retention
Many aligner cases are done to facilitate some degree of restorative work such as edge bonding or replacing old anterior restorations. Getting the timing right on this is key for the best results, especially with the time and effort your patient will have already put in.
Often you may have planned for some tooth whitening prior to restorative work. Although some whitening gels can be used with aligners, in most cases there are composite attachments present on the teeth and it tends to be best to wait until completion of the orthodontic phase when these have been removed. Once whitening has finished it's advised that you wait two weeks before any adhesive work, not only to allow the shade to settle but also to ensure a good bond. The weeks quickly add up and can begin to seem like an eternity to a patient who may have been expecting things to happen as soon as they reached the last aligners.
After the restorative work has been completed the patient will then need long term retainers to be made that accommodate the new dimensions of the teeth. It's so important to explain all of this at the outset, so that patients have the right timeline in mind and can also appreciate the quality of the care that you are providing for them.
There will be some cases where, be it due to challenging tooth movements or poor patient compliance, you or the patient are not satisfied with the position of the teeth at the end of the final aligner set. If a patient doesn't know about the option of refinement aligners then this can be very disappointing for them. They can take the view that something "went wrong" or that the aligners "didn't work". If talk of a refinement is new to them at this stage, they may think you are making excuses and trying to dig yourself out of a hole.
This situation can be negated by giving all patients a reasonable expectation before they start treatment that they may benefit from a short refinement stage at the end to put the finishing touches to their smile and bite. This lets them know you really care about the outcome and are willing to put in the extra time to get things just right. If no refinements are needed, then they are delighted that treatment has gone so well and finished earlier than expected!
You might think that if all is well at completion of the final aligner set then it will be plain sailing. However, retention is an area that can be fraught with difficulty, as patients will often have their own expectations regarding retainers. The first hurdle to tackle is to make sure patients know that their teeth will always want to move back towards where they came from, and retainers are the only way to keep them in place. That means wearing retainers for as long as they want their teeth to stay straight i.e. for life!
It's also essential to discuss the types of retainers at the beginning, so that patients don't expect a "permanent" retainer at the end of treatment to prevent any relapse. Let the patient know that bonded retainers are not permanent and require repair or replacement in the long term, and that their role is really to act as an insurance policy for when removable retainers are lost or broken. Whilst bonded retainers are a reasonable option for most patients, removable retainers are mandatory as this is what will hold all the teeth in position, rather than just the front six.
There are some patients, such as those with deep bites, for whom bonded retainers will not be an option. Tackling the issue of retention prior to starting treatment is an essential component of informed consent to orthodontic treatment and definitely makes your life easier down the line.
The key to ensuring you've got a happy patient at the end of aligner treatment centres around looking to the end of the treatment journey and advising the patient at the outset what to expect. Practicing good communication in this way will help to prevent an array of problems towards the end of treatment and allow you and your patient to concentrate on getting the best outcomes and enjoying the process!
Make sure that patients know that reaching the last aligner in a sequence does not mean the job is done.
Advise patients at the outset of the timeline from final aligner, through whitening to completion of restorative treatment and final retainer provision.
Impress upon patients that you have high standards and sometimes you may suggest some additional aligners to get the finishing touches just right for them.
It is essential that patients know all about retention before they commit to starting treatment.
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