Real World Orthodon.cs

Transcription

1 Real World Orthodon.cs Trials, Tribula.ons and Triumphs Desmond Ong

2 Clinical Orthodon.c Prac.ce Standard Adolescent Orthodon.c Cases Standard Adult Cases Ortho-Perio Ortho-Pros Orthognathic Sugery

3 Where Do We Start?? The founda.on of quality comprehensive treatment is accurate diagnosis and appropriate treatment planning There is no subs.tute for excellent diagnos.cs

4 Big Picture! You have to know what the problem is before you can find the solu.on! If you don't know where you are going, any road will take you there Lewis Carol

5 Notable Quote Never treat a stranger. Knowing the pa.ent s chief complaint and obtaining a complete pa.ent history (medical, dental and social) is essen.al Laurance Jerrold

6 History and Pa.ent Examina.on Presen.ng Complaint Medical History Dental History Lifestyle Assessment Social History Facial Features Dental Features So[ Tissue Features

7 Presen.ng Complaints Must be recorded and addressed throughout treatment Could be a source of pa.ent complaints a[er orthodon.c treatment Is there a difference between your treatment plan and your pa.ent s expecta.ons?

8 The pa.ent s chief complaint may be very different from the objec.ve problem list envisioned by the clinician Can you just fix this crooked tooth?

9 For some pa.ents, the chief complaint may represent the.p of the iceberg

10 Front Teeth Patient s Concerns Clinician s Concerns Periodontal Disease Uneven Tooth Wear Endodontic Compromises Overbite Posterior Interdigitation Other Pathology Overjet Skeletal Discrepancies

11 Hierarchy of Scien.fic Evidence High Quality Meta-analysis Prospec.ve Randomised Clinical Trial Prospec.ve Study (non-randomised) Retrospec.ve Study (pre-tx selec.on criteria) Retrospec.ve Study (post-tx selec.on criteria) Case Report Opinion of an Expert

12 Notable Quote Opinion has a place somewhere between knowledge and ignorance Plato

13 Evidence Based Den.stry An unbiased approach to oral health care that follows a process of systema.cally collec.ng and analysing scien.fic evidence The objec.ve is to gain useful decision-making evidence with minimal bias (Ismail and Bader, 2004)

14 Evidence Based Clinical Prac.ce Best Research Evidence Clinical Exper.se Pa.ent Values (Forest and Miller, 2008)

15 Growing with and Respec.ng the Evidence

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17 Extrac.on of C s Effec.ve? Evidence-Based? Is there sufficient evidence to recommend extrac.on of C s to intercept palatally impac.ng canines? What are the chances of success?

18 (Ericson and Kurol, 1988)

19 10 Years Old Note the anomalous 12,22

20 11 Years Old Extract the 53,63

21 12 Years Old

22 NO Control Group (Ericson and Kurol, 1988)

23 On Closer Inspec.on The o[en quoted Ericson and Kurol study did NOT have a control group!! How many canines would have self-corrected without extrac.on of the C s??

24 10 years 11 years

25 9 years 11 years

26 (Parkin et al, 2008)

27 (Parkin et al, 2008)

28 Orthodon*sts Don t Do Good Research! (Parkin et al, 2008)

29 (Parkin et al, 2008)

30 þ Control Group þ Randomised

31 (Naoumova et al, 2014)

32 Clinical Relevance for Ectopic Maxillary Canines NO treatment will result in self-correc.on and successful erup.on of 1 in 3 canines Extrac.on of C s can successfully intercept 2 in 3 cases of ectopic canines for adolescent pa.ents (if the ectopic posi.on is not too severe) Therefore extrac.on of C s effec.vely doubles the chances of the ectopic canine erup.ng

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35 23 months

36 38 months

37 38 months

38 38 months

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40 Curing Class II Malocclusions

41 (O Brien and Sandler, 2010)

42 The Importance of Diagnos.cs Are these two Class II division 1 malocclusions the same??

43 2 Jaw Orthognathic Surgery

44 Orthodon.c Treatment Alone 7 months into treatment

45 (Harrison et al, 2008)

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47 (Harrison et al, 2008)

48 (Harrison et al, 2008)

49 What They Don t Tell You!

50 What They Don t Tell You!

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52 (Brierley et al, 2017)

53 (Brierley et al, 2017)

54 (Brierley et al, 2017)

55 Hierarchy of Scien.fic Evidence High Quality Meta-analysis Prospec.ve Randomised Clinical Trial Prospec.ve Study (non-randomised) Retrospec.ve Study (pre-tx selec.on criteria) Retrospec.ve Study (post-tx selec.on criteria) Case Report Opinion of an Expert

56 What Does the Best Evidence Indicate? Pre-adolescent Class II malocclusion treatment is NO more effec.ve than later treatment, and in addi.on to this, is LESS efficient The early results were impressive, however, these ini.al growth effects may be short-lived. A[er a few years the gains tend to evaporate, with NO measurable long-term benefits

57 Therefore func.onal appliance therapy CANNOT be viewed as a clinical equivalent or subs.tute for mandibular advancement surgery (even if it is ins.tuted at a preadolescent age)

58 Worth the Read!!

59 Another Good Blog Evidence Based

60 Curing Class III Malocclusions

61 Cochrane Review 2013

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65 The Latest Evidence - January 2017

66 (Woon and Thiruvenkatachari, 2017)

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68 (Fleming, 2017)

69 Hierarchy of Scien.fic Evidence High Quality Meta-analysis Prospec.ve Randomised Clinical Trial Prospec.ve Study (non-randomised) Retrospec.ve Study (pre-tx selec.on criteria) Retrospec.ve Study (post-tx selec.on criteria) Case Report Opinion of an Expert

70 Unique Twin Study The ONLY way you can truly treat the same patient TWICE with 2 different methods!

71 (Sugawara et al, 2012)

72 Ques.ons to Ask Yourself Why are there so many Class II correctors and func.onal appliances available? Many seem to claim that their appliance is what causes the correc.on Normal facial growth drives the Class II correc.on!! (proponents of these appliances are taking the credit for the good growth that accompanies their use!)

73 16 Different Designs for a Class II Func.onal Appliance!!

74 Why then are there not so many Class III func.onal appliances available? (ONLY widely accepted design is the Reverse-Pull Headgear) Why are they not so successful? The growth panern dominates over the treatment procedure!!

75 So many prac..oners are willing to take the credit for good growth in Class II cases AND so willing to blame the growth panern for the unfavourable results in Class III cases you cannot have your cake and eat it too!! growth can either help you or hinder you

76 Be Realis.c Do not promise what you cannot deliver AND do not take credit for things that you did not do! A healthy dose of cynicism is needed when analysing treatment results (especially case reports and wisdom from so-called gurus or experts) A healthy dose of pessimism can be useful when discussing poten.al outcomes of cases with significant skeletal discrepancies (especially Class IIIs)

77 As clinicians, our experiences can become biased by our observa.ons of what works in our hands (ie observa.onal bias) Especially regarding treatment of Class II malocclusion with func.onal appliances (growth is helping all the way during treatment) Recognising the extent to which dental and/or skeletal factors are involved in a Class III malocclusion is cri.cally important (as it will determine the recommended treatment op.on and is integral to the informed consent process)

78 (Turpin, 2005)

79 (Lagravere and Flores-Mir, 2005)

80 (Lagravere and Flores-Mir, 2005)

81 The majority of informa.on about the Invisalign technique consists of case reports, commentaries, surveys and descrip.ve technical ar.cles (Turpin, 2005)

82 Hierarchy of Scien.fic Evidence High Quality Meta-analysis Prospec.ve Randomised Clinical Trial Prospec.ve Study (non-randomised) Retrospec.ve Study (pre-tx selec.on criteria) Retrospec.ve Study (post-tx selec.on criteria) Case Report Opinion of an Expert

83 (Kravitz et al, 2009)

84 (Kravitz et al, 2009)

85 (Kravitz et al, 2009)

86 Cost-Effec.ve? The efficiency and effec.veness of any technique certainly depends upon the proficiency of the prac..oner

87 Cost-Effec.ve? Mid-course correc.ons and/or revisions inevitably increase costs! Materials Clinical Time Opportunity Costs Overheads

88 Important Point If your prac.ce runs on 50% overheads and you take twice as many appointments or.me to successfully treat the case Effec.vely you have treated the pa.ent for free (ie zero profit!)

89 Marke.ng vs Reality! Sheridan (2004) found that 70-80% of pa.ents treated with Invisalign required mid-course correc.on, case refinement or even conversion to fixed appliances before the end of treatment

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91 Djeu et al, 2005

92 Djeu et al, 2005

93 Djeu et al, 2005

94 Djeu et al, 2005

95 Hierarchy of Scien.fic Evidence High Quality Meta-analysis Prospec.ve Randomised Clinical Trial Prospec.ve Study (non-randomised) Retrospec.ve Study (pre-tx selec.on criteria) Retrospec.ve Study (post-tx selec.on criteria) Case Report Opinion of an Expert

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97 Kuncio et al, 2007

98 Clinical Reality Increased relapse can be expected if non-ideal root posi.ons (ie lack of root.p and torque control) persist at the comple.on of treatment It is universally acknowledged that fixed appliances provide the greatest control over root posi.ons

99 Significant Root Torque Required

100 The Gold Standard

101 Completed Root Torque Correc.on

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103 (Weir, 2017)

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105 (Rossini et al, 2015)

106 (Rossini et al, 2015)

107 (Rossini et al, 2015)

108 (Weir, 2017)

109 (Weir, 2017)

110 (Weir, 2017)

111 Predictable Cases in My Hands þ Class I or mild Class II molar rela.onship (will tend to improve a Class II malocclusion) þ Mild-moderate spacing of up to 5mm þ Mild crowding up to 4mm per arch þ Mild OJ with up to 5mm of space þ Normal or shallow anterior OB (will tend to deepen the OB) þ NO extrusion required to correct tooth alignment þ NO Class III or Class III tendency

112 UNPREDICTABLE Cases in My Hands ý Significant crowding or spacing (over 5mm) ý Significant anteroposterior discrepancies ý Severely rotated teeth (greater than 20 degrees) especially canines and premolars ý Deep anterior overbite ý Class III cases (will tend to worsen a Class III malocclusion) ý Pa.ents with poor compliance

113 Significant Crowding

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115 Significant Anteroposterior Discrepancy

116 Severely Displaced Canines

117 Deep Anterior Overbite

118 Class III Cases

119 The Case Killers! Poor Case Selec*on Poor PVS Impressions Inappropriate ClinCheck TM Poor Compliance

120 Addi.onal Limita.ons Short clinical crown heights (less surface area for the aligner to push on the teeth) Naughty teeth: upper laterals, lower canines Your pa.ent will scru.nise the teeth up close throughout the en.re treatment Tends to anract high maintenance, difficult-toplease, detail-oriented pa.ents

121 Advice Effec.vely, you have ONE chance to plan the tooth movements required (ie ClinCheck or equivalent digital planning) If this is NOT sa.sfactory or does NOT track as planned (for whatever reason), more digital planning is required (ie mid-course correc.on or refinement) This automa.cally increases costs (financial, opportunity, clinical), decreases efficiency and importantly a loss in pa.ent confidence (in the clinician and the appliance)

122 Advice Conven.onal fixed appliance therapy remains the GOLD STANDARD for the orthodon.c correc.on of malocclusion (also becomes your get out of jail technique) Clinicians who prescribe sequen.al plas.c aligner treatment should be fully aware of the limita.ons of this treatment technique and inform pa.ents accordingly

123 Advice Treatment of unsuitable cases with Invisalign is likely to result in poor efficiency and effec.veness This will inevitably lead to unsa.sfactory treatment outcomes and pa*ent dissa*sfac*on especially if they have paid you $ AND it took twice as long as conven.onal braces and never quite got there!

124 (Djeu et al, 2005)

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127 EVEN WHEN YOU THINK YOU HAVE DONE EVERYTHING RIGHT.

128 Dissa.sfied Pa.ent!!

129 Is it Possible? Everyone, including the orthodon.st, wants faster treatment, with less.me wearing braces For certain pa.ents, treatment can be completed in only a few months This is very possible if straightening of the front teeth is the only treatment objec.ve

130 However, not every case can be accelerated to finish in 6 months to a good and stable result Pa.ents with bite problems (eg protruding front teeth, very deep bite) or severe crowding will naturally take longer to treat

131 Orthodon.c Treatment Stages Over a course of braces treatment, there are 3 treatment phases, which generally occur in this order: Alignment/ straightening phase (6 months) Bite correc.on phase (can start immediately in some cases) Finishing and detailing/ perfec.ng phase

132 What Can Be Rou.nely Corrected in 6 Months??

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142 Obtaining the Right Ingredients = Correct Diagnosis Following the Recipe = Appropriate Treatment Plan Cooking it Well = Treatment Progress Final Presenta.on = Finishing and Detailing

143 Another Analogy Similar to a baking a cake, removing the braces prematurely (ie not baking the cake for long enough) will produce a result that on the surface may appear sa.sfactory

144 However, other parts will not be complete or under-cooked eg incomplete bite correc.on with resul.ng stability issues and/or the front teeth will look straighter yet not perfect

145 The Facts Will it align my crooked teeth? Will it correct my bite? Is it a new and revolu.onary technique? Is it suitable for everyone? Maybe

146 (O Brien, 2013)

147 (O Brien, 2013)

148 (O Brien, 2013)

149 (O Brien, 2013)

150 Points to Consider If something is worth doing. You get what you pay for What are you willing to accept.. If it sounds too good to be true. What may feel/taste good now, will you regret later?

151 hnps:// insights/fast-tracked-orthodon.c-treatmentsgive-rise-informed-consent-scope-prac.ceissues-2/

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157 The Basic Equa.on RISK REWARD Clinical Risks Legal Risks Reputa.on Sanity Professional Fulfilment Financial

158 Important to Remember Cosme.c treatment can be very rewarding for both the pa.ent and the clinician However, it is o[en becomes a high stakes scenario

159 Preparing Yourself for a High Stakes Game Good Records Competency Communica*on Informed Consent Know Your Limits Priori*se the Pa*ent

160 X-Factor = Pa.ent The treatment may be predictable however, pa.ents can be notoriously unpredictable!

161 Unfortunately Den.stry Can Be Very Confron.ng and Humbling What Keeps Us Going? Our Pa.ents

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163 Final Thoughts Incorpora.ng orthodon.c treatment into the comprehensive treatment plan has the poten.al to significantly improve the aesthe.c and func.onal outcomes for challenging cases There is no subs*tute for comprehensive diagnosis and appropriate treatment planning

164 Conclusions We are very privileged to work in an area of healthcare where we can significantly improve all of the following for our pa.ents: Aesthe.cs Func.on Quality of Life Self-Esteem

165 QUESTIONS Thank you