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Orthodontic referrals expand treatment options for patients

Aug. 12, 2009
The new age of orthodontics is upon us. A good relationship with your orthodontist can bolster case acceptance and allow for expanded treatment options for patients.
By Adam Schulhof, DMDIt’s the topic of conversation at any gathering of our peers. “How’s your practice in this economy?” A lot of us are in fact feeling the downturn, and suddenly we are looking for ways to weather the storm. Cutting overhead is not always a viable solution. Ideally, we can find ways to increase case acceptance without the purchase of expensive, new equipment.It’s time to get to know your orthodontist!The new age of orthodontics is upon us. Today’s technology is allowing orthodontists to literally perform “miracles.” Movements previously nonviable can now be accomplished even without traditional “braces.” Familiarizing oneself with all that today’s orthodontists can accomplish will allow for expanded treatment options for all our patients.Orthodontic referrals need not be a one-way street. A good relationship with your orthodontist can bolster case acceptance and allow for treatment never thought possible.Adult orthodonticsIn my own office, we tend to treat a good number of adult patients. We offer Invisalign®, ceramic braces, and iBraces, which is a lingual orthodontic appliance entirely hidden behind the teeth. Many of my referring general dentists have commented that the adult patients treated orthodontically in our office tend to return asking for cosmetic treatments such as bleaching and porcelain restorations. They put a higher value on their smile and dental health, and quickly become the patients we all wish we had.
Figure 1 — 23-year-old male: “I know my teeth are a mess, but I won’t wear braces that show.”

Figure 2 — Same patient 10 months into treatmentMany adult orthodontic treatment plans include interdisciplinary treatment such as implants and veneers. Patients who would never consider orthodontics due to the stigma associated with traditional orthodontics can now be treated “invisibly” and, in many cases, much quicker than ever before.Increased recallsPatients in active orthodontic care are told to return to their general dentists on a three-month recall program to better monitor their hygiene during this critical period. This adds four visits to the dentist over the course of 24 months of orthodontic treatment.New technologiesThe most talked about breakthrough in orthodontics is skeletal anchorage. Traditionally, orthodontists have struggled to attain anchorage in many situations. Temporary anchorage devices, known as TADs or miniscrews, have provided an absolute anchorage solution.In order to move an object, one needs a counter support to push or pull against. In orthodontics we pit the mass of a tooth or group of teeth against another tooth or group of teeth. Certain clinical situations, however, call for a point of anchorage that is beyond the dentition, or that will not cause any unintended movement of the anchor teeth.Miniscrews allow the orthodontist to attain absolute anchorage without affecting any other teeth. This allows movements that would have been impossible, or very difficult, with traditional means. It also allows for an appliance and treatment design specific to the target area without a full mouth of orthodontics.The following cases illustrate only one example of how skeletal anchorage is changing the face of not just orthodontics, but general and prosthetic dentistry as well.Case oneA 45-year-old patient presented to her general dentist requesting an implant to replace her lower left second molar. The dentist noted supereruption of the maxillary second molar and referred the patient to our office for full orthodontic appliances to intrude the maxillary left second molar, to avoid RCT and crown of No. 15.

Figure 3 — Supereruption of No. 15The patient was adamantly opposed to braces and asked if she had any other options short of prophylactic root canal and crown on tooth No. 15. I recommended intrusion of No. 15 using skeletal anchorage.
Figure 4 — Palatal and buccal TAD with buttons bonded to No. 15 for attachmentAfter five months of treatment, intrusion was achieved and the patient had an implant placed with plenty of clearance.
Figure 5 — Post intrusion
This is a perfect example of how skeletal anchorage benefits general dentists as well as orthodontists.Case twoA 67-year-old female was being treated by her dentist for years but was extremely unhappy with her left posterior occlusion. She desperately wanted implants on the lower left. She had zero clearance due to supereruptions of her maxillary posterior. She was told that nothing could be done short of extraction and implants on the maxillary left, in addition to the implants on the mandibular left. She, therefore, decided to do nothing as that plan was too excessive.

Figure 6 — Supererupted posteriorAfter her dentist retired, the patient found herself in the office of a colleague who offered a new solution. He referred her to our office for posterior intrusion with miniscrew anchorage. Over the course of six months, we used one buccal and two palatal miniscrews to intrude the patient’s supererupted teeth.

Figure 7 — Palatal TADs with composite added for comfortWe intruded the patient’s teeth to give the restoring dentist as much clearance as needed. Once final restorations are placed, we discontinue intrusion and the teeth erupt to the level of the new restoration.
Figure 8 — Month four of orthodontic intrusion. We are overcorrecting to allow as much clearance as possible.The referring dentist was then able to place three implants and restorations, and the patient was ecstatic.
Figure 9 — Final restorations complete with overcorrection relapsing and settling (Restorative dentistry courtesy of Dr. Jason Suss)This is just one example of what orthodontists are doing with skeletal anchorage to allow general dentists to practice their craft with fewer limitations. Molar uprighting and many other movements can also be achieved with very limited appliances that patients will readily accept.During this economic downturn, one way for general dentists to increase revenues is to work hand in hand with their orthodontist and other specialists to open up as many avenues of treatment for their patients as possible.

Board-certified co-founder of KinderSmiles, a pediatric dentistry and orthodontic practice located in Oradell, N.J., Adam Schulhof, DMD, specializes in cosmetic solutions to orthodontics, such as Invisalign, iBraces, and other orthodontic treatment options. Dr. Schulhof is certified as a premier provider of iBraces. After receiving his DMD at the University of Medicine & Dentistry, where he graduated at the top of his class, Dr. Schulhof was inducted into the Omicron Kappa Upsilon Dental Honors Society. He was then accepted to the prestigious orthodontic program at Columbia University. Dr. Schulhof volunteers as a clinical instructor at the University and lectures for 3M. When not fixing smiles, Dr. Schulhof can be found snowboarding, riding his motorcycle, or at home in Bergen County with his wife, three children, and two dogs.