Personalised Learning

Hidden complexity- why can't you have a quick look?

It is a really common request from dentists to ask specialists to ‘have a quick look’ to assess for suitability. This is usually because your patient is putting you under pressure for a quick diagnosis and price.

Subtle complicating factors can change the whole diagnosis and approach to treatment. You want to avoid giving information which later turns out to be incorrect:

- Giving an opinion on whether a case is suitable or not

- Estimating how long it will take and the approach

- Estimating cost

- What reasonable outcomes could be expected

Can you have a quick look at this photo?

Sometimes a quick look at an intra oral photograph will be enough to give an idea of complexity and timelines.

This is great! It means you can give the patient a decent diagnosis and estimate of duration before doing the full assessment.

For example, an adult mild relapse case in a patient whose oral health you’ve looked after for is unlikely to throw up any curveballs – or is it?

To assess suitability we need a written orthodontic assessment and a nice intraoral photo series

We’ll describe three situations where things may look simple, but just one intraoral photograph doesn't tell the full story.

Patient expectations change depending on your questions

This patient (25) wanted simple alignment only using clear aligners. He didn’t want any corrections to the bite, just whitening afterwards.

" Once I’ve stabilised his oral health, can this be done, accepting the compromised edge to edge bite? "

On first glance this sounds like a sensible question and this is a decent photo. If that patient is happy with simple alignment, this could really change this patient’s smile. The specialist requested more information

“ With the 23 missing, is the patient happy with the significant midline shift? Correcting this would not be possible with clear aligners ”

The GDP went back to the patient and discussed whether the midline was important or not. On reflection, the patient was bothered by the asymmetry, and did not want to compromise on this aspect of treatment.

This made him unsuitable for clear aligners.

While the photographs clearly show a deviated midline, by not going through the full orthodontic assessment, and just focusing on the edge-edge bite, the dentist wasn’t able to fully uncover the patient’s expectations.

Is there displacement?

Displacement can have a major impact on the treatment design, and is not always easy to assess!

Here is an adult patient looking for simple alignment of the anterior teeth. She’s highly motivated and her oral health is tip top. Surely a simple treatment plan?

The specialist was specifically interested in whether there was displacement at UR2/LR3? The GDP thought there was, but was most interested in why this mattered, would this affect the plan?

The specialist confirmed that displacement would significantly change the treatment approach and therefore duration:

" If there is displacement: if the CL is correct in RCP then eliminating the crossbite with displacement would correct the CL. If there is no displacement: we need to plan to correct the CL. "

Another great example why a quick look at intraoral photographs without a full assessment might have given the patient the wrong information.

(PS there is an Advanced Topic on Displacement on the learning pathway – look out for it!)

Knock on consequences?

A quick look at some intraoral photographs shows that this isn’t a simple case; a lot of movement is required to align these anterior teeth. But- with some attachments and a longer course of treatment- is this suitable for clear aligners?

You may have seen other moderate to severe crowding cases which worked with clear aligners – so it might be doable?

The specialist wanted a bit more information. The dentist took some time to complete the full intraoral photo series which provided much more information.

The existing overjet with the significant space requirement would make this an extraction case. Without extractions the overjet would be between 7-10mm, and would potentially result in lip incompetence.

Without a comprehensive workup you might have missed this complexity.

Explaining this to patients – stick to your guns

Patients don’t always understand how nuanced orthodontics can be. They want a quick quote, no fuss.

Explain that orthodontics is serious, it can be deceptively tricky, but that carefully planned cases will produce stable results which last a lifetime.

By putting the time into a great workup and getting a specialist to assess for suitability you’ll be able to give them accurate and honest timelines.

Less scrupulous parties who don’t  respect the complexity of clear aligners may just ‘crack on’ and ‘see what the simulation comes back as’- with promises of free consultations/whitening and more.

That approach may work to start, but the headaches will come later..

Don’t forget, if your patient isn’t suitable for clear aligners your specialist will write a report explaining why, describe appropriate alternative treatments and the charge will only be 40 GBP. And for your first case, you don't pay anything.

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