A digital workflow creates efficiencies—but only if you ensure that treatment itself is efficient.

by Greg Thompson

This article is sponsored by 3M. Dr. Groth is a consultant and speaker for 3M.

A digital workflow creates efficiencies. But if the actual treatment workflow isn’t efficient, it’s going to be hard to capitalize on those efficiencies.

In working with clear aligners, orthodontists have the ability to control appointments and reduce and/or eliminate the need for emergency visits. On its own, it’s an efficient model; but all too often practitioners fail to avoid efficiency killers.

“Clear aligners offer an efficient mode of treating patients, especially in this COVID world,” says Christian G. Groth, DDS, MS, a partner at TDR Orthodontics in Birmingham, Mich. “My team and I have kept track of what succeeds on the workflow side of aligners, ultimately distilling it down to 13 tips.”

#13: Maximize treatment efficiency by having the same number of trays on the top and bottom. “Always have the upper and the lower tray start and stop at the same stage,” Groth says. “For example, I may have a lot more work to do on the bottom than I do on the top. When that happens, you may finish the top and simply continue on the bottom. We make sure that we have the exact same number of trays for top and bottom, so the patient has something to wear during the whole treatment—top and bottom.”

#12: Do procedures at your interval. Groth likes to see patients roughly every 12 weeks for aligner checks. If there is a need for an interproximal reduction that may normally take place at 5 weeks, Groth will find a clinically appropriate way to combine procedures. “I’ll either do that procedure at the start at number one,” he says, “or I’ll push it back to number 12, but I want to make sure they are bundled together. We want to batch these small procedures together.”

#11: Use passive trays at the end of the series. If there are 30 sets of trays that are actively moving teeth, Groth will actually have 33 trays. “The reason for this is that once I do a reset at the end of 30 trays, I’m not done,” he says. “Usually I want to have some clean trays for patients to wear, because when you wear these all the time they get kind of funky and patients really appreciate getting into a clean set of trays after you see them for the redesign scan.”

#10: Be ready to discourage aligners if compliance is a problem. Clear aligner treatment amounts to what Groth calls a personality choice. He puts it this way: “If you’ve got a person who is forgetting things all the time, it’s probably not the right decision to use an appliance that takes a lot of discipline. In that case, it makes sense to recommend traditional braces.”

#9: Manage expectations. Even success can seem like failure if patients are expecting one outcome but get another. I make sure patients understand what we can and can’t do,” Groth says. “It is key to success, and gauging time is almost as important as gauging results.”

#8: Embrace the virtual visit. Orthodontists spend time, effort, and money cultivating the office experience, but Groth contends that most people do not want to visit the office given the choice. “The COVID situation has taught us that we can absolutely deliver excellent care virtually, and aligners are a perfect way to do it,” Groth says. “Whether it’s photographs or Facetime videos or Skype calls, you can keep in touch. Give patients their trays and see them every 8, 10, or 12 weeks.”

#7: Give multiple trays. Orthodontists frequently hold all but the set of trays that will be worn in the short term, but Groth and his team give all of the trays. He may see patients in 12-week intervals, but they will have 30 to 40 trays at home. The move eliminates the need for storage in the office and streamlines care. As for the fear that patients will simply stop paying, it has not been a concern. “There will be the occasional person who doesn’t do what they’re supposed to do, and they don’t come back, or they stop paying,” Groth says, “but 99% are going to be responsible.”

#6: Be systematic with treatment reviews. Viewing plans on the computer screen is fine, but good clinicians have a system to make sure they don’t miss things. Develop a set of best practices and stick with them. “Do it the same way every single time,” Groth recommends.

#5: Add bite ramps to all deep bites. Treating deep bites with aligners can be difficult but adding bite ramps to the anterior teeth will aid deep bite correction.

#4: Overjet is your friend. Running on the assumption that you always end up with less than you planned, Groth’s team wants to make sure that the front teeth “are not hitting too much when we’re finished with our aligner treatment.” He recommends: “Plan to have a little more space between the top and bottom teeth to make sure that your back bite is where you want it to be.”

#3: When in doubt, add attachments to the upper lateral incisors. Lateral incisors are notoriously tough to deal with. If there’s any thought that they might need an attachment, “Put it on,” Groth advises.

#2: Collisions are movement killers. Create mesial and distal spaces for big movements, especially rotations.

#1: Be smart and treat the hard and unpredictable movements with brackets first. “Every patient should be considered a hybrid patient,” Groth says. “Sometimes you want to start with some braces just to take care of the boulders and get down to the pebbles. Be smart if it’s going to take too long. Start with some brackets and then switch after a few months once you’ve gotten out of the woods.”

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