by William R. Hyman, DDS, MS, and Nancy Hyman
A healthy combination of clinical excellence and post-debonding practice-growth strategies turn former patients into walking testimonials for your practice. William Hyman, DDS, MS, shares his tips on the clinical side of debonding, and his wife and Ortho Referral Systems founder Nancy Hyman gives her insight on the marketing side.
When you think the time to debond has come, take a deep breath. If you can, remove the wires and take a good look at all the teeth from all perspectives. Take a look at the patient’s chart, and do a quick review of the treatment objectives. Confirm your choice of retention options. Review your deband checklist to be sure that you have not missed something. Very few moments in your day are worse than informing a crying teenager that the braces have to stay on for a little longer while her mother scowls at you. Take a good look now before you open your mouth to tell your patient that the next appointment will be “the day.”
When the day comes, the operatory needs to be prepped. This is the messiest procedure on our schedule. Be sure that the patient gets glasses and a bib, protective barriers are on all necessary surfaces, and operators have protective glasses and masks.
Most of our patients have bonded metal braces. The easiest way to remove them is to leave the archwire in place and go around the arch with a bracket-remover plier. Crimping the bracket wings together generally breaks the bond. Sometimes the distal brackets can slide off the end of the archwire. To prevent this, powerchain the brackets together. If some of the teeth are banded, use a band-removing plier. A band-splitter plier may be necessary, especially if you have multiple bands and want to remove them while they are still attached to the archwire.
Lingual attachments (such as buttons and tongue directors) can be difficult to get off. A high-speed handpiece with a metal-cutting bur should take care of them quickly.
Ceramic brackets present a special concern. We have come a long way from the early ’90s when I held my breath every time I debonded a ceramic bracket and then looked to be sure that all the enamel was still on the tooth. If you are using a ceramic bracket for which the manufacturer has specified a recommended debonding method, use that method. If something goes badly, you want to be able to say you were following the best protocol available.
For most ceramic brackets, I begin by removing the archwire. Take a high-speed handpiece with a multifluted tapered carbide burr and remove the flash from around the bracket. I try to remove each bracket with a bracket-remover plier. Place the talons of the plier at the mesial and distal of the bracket, just where it comes into contact with the tooth. Squeeze gently at first, then increase to moderate force. Most brackets will come off immediately. If not, look for any discrepancies between the bracket base and the tooth surface. Try to angle the plier to get underneath that spot. Apply force there. If that is not enough, apply heat from your tooth dryer to the bracket for 20 seconds before applying force. This should take care of the vast majority of the brackets.
There will be a few really difficult brackets. These may be partially broken or have bases that perfectly match the surface of the tooth (most often maxillary central incisors). Take a football diamond burr in a high-speed handpiece and, using water spray, grind the bracket off. Realize that the ceramic bracket will degrade the diamond coating on the burr.
Removing brackets from sensitive teeth can be a problem. These are usually going to be incisors or periodontally compromised teeth. During debonding, support the tooth with your off hand by placing a moderate intrusive force on the incisal edge. An alternative is to use a wax bite wafer to help support the teeth. With some sensitive teeth, especially with ceramic brackets, you may need to grind the bracket off.
Once the braces are off, the composite needs to be cleaned off the teeth. The fastest way is to use a high-speed handpiece with a new multifluted carbide burr, followed by a polishing point. Use a new burr, if possible. An old burr will be slower and leave chatter marks on the enamel. A slow-speed handpiece with a carbide burr followed by a polishing point also works well, and may be a better choice if you are delegating this work to an assistant. Flex discs also work well. Whatever system you use, be meticulous about the end result. Referring dentists can get very upset about excess composite left from orthodontic treatment. Be especially aware of porcelain and composite restorations and any decalcification. I use Restore Diamond Polishing Paste from Reliance. Composite restorations can be gently refinished with some discs. For patients with decalcification, I gently work around that area, make an immediate Essix retainer, and give the patient MI Paste with instructions to wear the Essix retainer with the MI Paste every night for a week.
Post-Debonding Practice-Growth Strategies
The debond experience is a terrific opportunity to confirm your patient’s satisfaction with the quality of your services. I often find that orthodontic practices ask for a referral at the close of treatment and presume that the patient’s excellent result will produce a volume of referrals, but this is not always the case. Once a parent/patient departs your practice, it is easy to forget the wonderful experience you provided. Even “raving fans” forget that friends and family members will benefit from your services.
I recommend developing a debond referral committee within your team and a checklist to ensure implementation of your plan. Here are some categories to consider:
E-blast Strategies: Create a database of your debonded patients to use for an ongoing marketing campaign. Consider two separate e-blast lists: 1) patients and 2) parents of patients who are minors. Patients of any age may receive birthday and debond anniversary cards, newsletters, and bimonthly Internet-only drawings. Parents may receive newsletters, a separate bimonthly drawing geared toward adults, and possibly an offer of special pricing for treatment.
It is extremely important that your e-mail list be current. I recommend asking for an e-mail address during the initial patient phone call, confirming the address when the patient arrives for the first appointment, holding an annual drawing that confirms patients’ and parents’ cell number and e-mail address, and finally, confirming again at the debond appointment.
The goal is to keep debonded patients engaged with your practice so that you are top of mind if someone ask where they got their beautiful smile!
Ask Debonded Patients/Parents for Referrals: Arm the debonded patients with a printed collateral piece such as a referral card. Mike Shoun, president of Affordable Image, the branding and marketing company that creates our referral materials, recommends creating a patient-to-patient referral card specifically for the debonded patient, with a designated phone number that corresponds to a tracking service. The tracking information will clearly relay the success of the card. Shoun says, “Doctors are not sure if referral cards are effective, when, in fact, the potential patient is calling and the initial call is not handled as a sales opportunity. I worked with a practice that received 30 calls from a promotional mailing, and 17 calls received during normal business hours were not answered!”
Who should hand the debonded patient/parent a referral card? The answer is dependent on the personality of the orthodontist. If the orthodontist is comfortable with this step, this is an excellent opportunity to confirm the patient’s satisfaction and ask for referrals as you pass along the referral card. The dental assistant or receptionist can also pass along the card. The key is to find a staff member who enjoys this task and conducts it with genuine enthusiasm.
For all strategies, confirm the details with your full team and be prepared with a protocol for each type of inquiry. Your team can be updated on all promotional initiatives via weekly marketing meetings. In these meetings, the person in charge of practice growth can explain each current growth builder and get a detailed look at tracking results. A monthly review of the tracking of new patient phone calls will tell you if your strategies are working. Of course, it is key to determine if unsuccessful strategies have been properly implemented before eliminating them.
Patient/Parent “Thank You”: Parents appreciate a “thank you” letter from their child following treatment. Provide cards personalized with your practice logo, and mail them to the parent on behalf of the child. In addition, the orthodontist may send a “thank you” letter to the patient and parent a week after the debond appointment. Include a photo of the orthodontist and the patient.
A post-debonding call from the dental assistant, confirming retainer instructions, is also effective. Or you could arrange a formal portrait at a photography studio, covering the fee and including one photo for the patient as a parting gift. The photos may also be displayed at your practice and posted on practice and patient Facebook pages (as long as the subject signs a release).
Debond Survey: Conduct a survey of the patient and parent during the debond appointment. Obviously, you will get a much higher return rate from a survey completed in the office than one that you mail.
A survey used in our office includes prompts such as: “The main reason I chose Dr Hyman is …” and “My one suggestion to improve patient care is …” Review the surveys monthly, and divide the suggestions into three categories: feasible, not feasible, and feasible in the future. As an example, in reviewing a survey we noted that many patients were dissatisfied with our waiting area. The team encouraged the patients to use the “on-deck” area and eliminated the problem.
When you survey patients and parents, give them the option of including their name, and if they do, respond with a follow-up letter or e-mail to let them know that their compliments and suggestions for improvement have been heard. Compliments may be recorded as video testimonials for your Web site, Facebook page, or YouTube channel.
A successful debonding experience and the resulting referrals are a reflection of your clinical excellence as well as your awareness of each team member’s role in a dynamic practice.
William R. Hyman, DDS, MS, is in private practice in Montebello, Calif.
Nancy Hyman developed the training program for Practice Builders’ orthodontic division and established marketing plans for its clients from 2003 to 2009. She is the founder of Ortho Referral Systems.