Don’t be fooled by the name, there is a sound method to the madness! This article reviews the benefits of limited-objective orthodontics in meeting aesthetic demands and as an additional skill to improve the quality of cosmetic dentistry offered by dentists. It draws on personal experience and recommendations. Two simple cases demonstrate the types of results that can be achieved.
History and Terminology
Compromise orthodontic treatment plans are not a new phenomenon. This concept, which Profit describes in his book “Contemporary Orthodontics” as limited outcome orthodontics for adult patients, has recently been rebranded and commonly referred to as short-term orthodontics or STO. The name is a misnomer and is disliked by some, as it implies this treatment claims to be quicker on a like-for-like basis, than conventional (or comprehensive) orthodontics. Other acronyms for this type of treatment are; cosmetically-focussed orthodontics, anterior alignment orthodontics and simple anterior orthodontics. Despite this it is an appealing term to patients, hence the increasing number of companies offering this type of treatment. It is up to dentists to inform patients what this treatment can actually achieve and for specialists and generalists to understand how patients may benefit.
It is important to stress that STO is definitely not a substitute for full (or comprehensive) orthodontics. Rather, it is an extension of cosmetic dentistry and an aesthetic alternative to veneers and crowns. There is a paradigm shift occurring in dentistry. Many patients desire an improvement in anterior dental aesthetics rather than a change to their skeletal, dental or soft tissue factors relating to malocclusion. We need our specialists more than ever to address those concerns and we will make them busier by sending them these patients. The tide, thankfully, is turning with specialist orthodontists who are early-adopters benefitting from an increased number of referrals to them from clinicians such as myself. Everyone is busier because there is a heightened awareness of orthodontics.
In my practising career and postgraduate training I always took an interest in orthodontics. I favoured orthodontic training courses over more popular restorative courses that advocated destructive removal of healthy tooth tissue to improve the smile.
Like most general practitioners that preferred to move teeth rather than brandish a handpiece, I started with removable aligners as there was only one orthodontic company providing training to GDPs in the early 2000s. It was a system that allowed GDPs to improve patients’ smiles. However it was slow, inaccurate, frustrating and the overheads for the practitioner were astronomical.
It is rewarding to create great aesthetic results and save patients from having heavily prepped teeth restored with porcelain crowns or veneers and the resulting problems that such treatment entails. However, the limitation of removable aligners is frustrating and can lead to disenchantment with the process and results.
Around this time I planned to investigate the concept of STO which was increasing rapidly in popularity in the US and UK. I signed up to a course in Sydney, sceptical but interested. During the course I realised the concepts being delivered were exactly those I had been prescribing my patients, yet the issues I had with aligners were also resolved using fixed appliances.
Since then, I have attended just about every STO course available to ascertain the differences. The variation in training and scope of recommended practice varies widely. I have found most courses definitely lack training in and appropriate emphasis on the importance of full orthodontic assessment and diagnosis, meticulous record keeping and safe treatment planning for the general dentist. These aspects are imperative, as are the limitations of this treatment and knowing when to refer to a specialist.
So what are the essential requirements of a training course to get started with STO? Well, there are very few courses that offer robust specialist-led training with a thorough hands-on component and demonstrate the process of assessment, record taking, diagnosis and treatment planning. Such training would require a support network allowing you to upload photographs and discuss cases with clinical supervisors. Like general dentistry, your real learning will occur when managing your own patients but it helps to have a place to turn to for sound advice where your cases can be discussed and where you can learn from other colleagues.
Once you have undertaken suitable training you will see this treatment as stimulating, challenging and rewarding. GDPs could be accused of being “unconsciously competent” in routine dental care and for some this no longer poses a mental challenge, making the working day tiresome and repetitive. With QST, you will look forward to seeing your patients. It is enjoyable to see how treatment unfolds, critically appraise cases and decide on your next course of action to bring your treatment plan to fruition.
As your patients approach the finishing line, you will notice the tremendous improvement made to their smile. All this with removal of only a minimal amount of enamel interdentally, whereas the alternative would have been major tissue reduction and restoration with porcelain to achieve a compromised aesthetic result, as the teeth where in the wrong place to begin with.
STO has been a fantastic addition to my skill set, enabling me to produce huge improvements to patients’ smiles and self-confidence. It is the most rewarding aspect of my career to date. I look forward to a working day when I have an orthodontic appliance review.
Case 1: Duration 6 months
The patients’ main complaint was that she hated the “snaggle” tooth sticking out on the upper left and wanted an improvement in less than one year. In summary, she had a class II division 2 incisor relationship on a skeletal II base, with an increased and complete overbite. There was a narrow upper anterior dental archform, hyperactivity of the mentalis muscle and a lower lip causing retroclination of the upper and lower anterior teeth. The upper left lateral incisor, falling outside of lower lip control had a normal angulation clinically.
The cosmetically-focussed treatment plan was to align the upper anterior teeth by proclination and use IPR to minimise any potential increase in overjet, which was to be expected in such a case. This would be followed by cosmetic contouring of the upper canines and indefinite (lifelong) retention with fixed and removable retainers.
This case demonstrates the simplicity that lies at the heart of an aesthetic orthodontic case. The patient was unhappy with her smile due to the retroclined incisors and relatively prominent upper left lateral incisor and this was addressed easily with a fixed appliance within her desired timeframe. Although comprehensive orthodontics was offered, she declined this in favour of a simpler approach.
Case 2: Duration 6.5 months
This patient’s main complaint was that she hated her smile due to the crooked front teeth. In summary, she had a class II div 1 incisor relationship on a skeletal II base with increased overjet and overbite, narrow upper mid-arch, mild crowding and incisal flaring. There was increased gingival display on smiling and tooth width discrepancy of anterior teeth.
- Mild lateral expansion of the constrained mid arch
- IPR to help resolve crowding and reduce the incisal flare
- Intrusion of the upper incisors to reduce the overbite, reduce the gummy smile and hide the gingival margins (under the upper lip) to achieve relative improvement in crown height ratios on smiling
- Intrusion of UR2 and superior repositioning of the gingival margin followed by composite buildup of the incisal third post-alignment in order to obtain symmetry
Treating this case without orthodontic alignment would be more difficult, more invasive and more expensive for the patient. This would require significant reduction of sound tooth tissue and crown preparation of the anterior teeth. This would most likely devitalise, or condemn her to future root canal treatment. Periodontal surgery would also have been required to achieve improvement in gingival aesthetics on smiling. Achieving this result with STO, interproximal tooth tissue was removed, with IPR in acceptable limits, but nowhere near the amount that would be required with a restorative-only approach.
After experiencing first hand many of the popular STO, anterior alignment and cosmetically-focussed orthodontic systems I have been most impressed with the package offered by QST for the following reasons:
Quality of the training
Access to and quality of the training and Quick Straight Teeth training courses is probably the first and most important decision you will have to make. The QST package is the most economic overall and there is no reduction in quality of training. It shows commitment to advocating the benefits of STO to the wider demographic of GDPs. QST aim to keep the general dental practitioner safe and within their scope of practice. They encourage the GDP to undertake simple, predictable cases and to learn progressively and continually. There is emphasis on proper case selection and working closely with specialist colleagues and understanding when it is better to refer. A large proportion of the initial day focuses on this, together with proper orthodontic assessment, record taking and diagnosis.
Quality of the product
This is paramount to the success of treatment. With a number of inferior systems I have used, the quality of the product has caused me numerous headaches, loss of income and slowed down treatment time. In these instances the brackets were of poor quality composite or plastic. Restorative-grade bonding components were advocated instead of the appropriate orthodontic-grade products (remember you have to get the appliances off!). The inferior products resulted in numerous bracket failures, to the extent that I was seeing patients every two weeks for emergency repairs, rather than 4 weekly routine adjustments. This doubled surgery time and therefore halved profit margins. This also meant I had to keep a large supply of expensive spare brackets that were quickly used up.
QST on the other hand, only use top quality 3M Gemini ceramic brackets and 3M orthodontic bonding agent and composite. The aesthetic tooth coloured wire also tends not to delaminate as much as other systems, exposing unsightly bare metal underneath. This is crucial when offering aesthetic appliance systems to patients. The indirect bonding trays are clean, polished and delivered on 3D printed models. They don’t have remnants of lab-used residue on the bonding surfaces and they don’t fall out of the trays, a common issue I have had from other suppliers. The products are reliable and bonding is proven and efficient. You will not need to rebond individual brackets.
QST offers a comprehensive online support platform where your cases can be uploaded and specialist advice can be obtained at any point in treatment. This is a wonderful safety net at first, meaning you don’t stray too far out of your comfort zone, but it also allows you to gauge your own treatment planning skills. Eventually you may find that you don’t need the safety net as much but even then it is reassuring to have another set of eyes on a case. The QST mentors, drawing on their experience, often spot issues that you may not.
QST offer indirect bonding trays with top quality 3M ceramic brackets, aesthetic wires and bonding components at a very competitive price compared to other systems. This alone is reason enough to choose them. In addition they also offer beautifully crafted bonded retainers, removable vacuum-formed retainers and hydrogen peroxide whitening gel. You also get as much support and advice, from specialists, as you need and whenever you need and within 24 hours! This is all included in a value package. It just doesn’t make clinical or economic sense to go elsewhere.
Treatment costs $6000
Reviews 20-30mins x6/7
Circa $700-800 p/h
Dr Neil Lutton
Proffit W, Fields Jr HW, Sarver DM. Contemporary Orthodontics. St Louis: Mosby, 2006: 282