What if you could simplify your orthodontic cases before a patient begins braces or aligners—while also cutting overall treatment time, improving compliance, and increasing your ability to offer same-day starts? The Sagittal First philosophy, promoted by Henry Schein Orthodontics (HSO), aims to do that. Sagittal First is premised on the idea of reclassifying Class II and III cases into Class I cases at the beginning of treatment. Once the Class I environment is achieved, patients can then be finished with braces or aligners with shorter treatment times overall.

Orthodontic Products spoke to Dave Paquette, DDS, MS, MSD, and Jep Paschal, DMD, MS, who recently lectured on the Sagittal First philosophy, at the HSO Orthodontic Excellence & Technology Symposium, to get their take on why this approach is a game changer for orthodontic treatment at a time when patients are demanding shorter treatment times and when same-day starts are more important than ever for the orthodontic practice. In addition, we asked Dave Ternan, CEO of OrthoFi, to weigh in why same-day starts are so important in the current competitive landscape and why you shouldn’t worry about shortened treatment times leading to increased payment delinquency.

Orthodontic Products: Dr Paschal, you have described the Sagittal First philosophy as a “very different treatment for our profession.” Why is this?

Paschal: Sagittal First is different in a few ways. First it utilizes a segmental approach to treatment, and second you are utilizing elastics on day one of treatment. Individually, neither of these approaches is all that new, but used together in this fashion, they are highly unusual within the optics of traditional orthodontic therapies. Another way in which Sagittal First is different is that it solves the A-P problem first, then utilizes whatever technique you want to apply to establish arch form and treat any transverse problems. Hence, Sagittal First.

The Sagittal First approach utilizes the Carriere® Motion 3D appliance [from HSO] that is exquisitely simple to apply and utilize. Correcting the A-P first creates an opportunity to apply other treatment options like simplified mechanics and even clear aligners. In addition, we are seeing vastly shorter overall treatment times.

Finally, another difference is that Sagittal First is not limited to only solving Class II cases. It is easily applied to Class III treatment plans as well. For the first time, we have a philosophy and technique that can be applied to all A-P corrections—Class IIs and IIIs.

OP: Dr Paquette, by addressing the chief complaint early on, what does this accomplish?

Paquette: Many times patients run over estimated treatment time because orthodontists have requested additional compliance with elastics late in treatment, when the patient is already burned out. By utilizing Sagittal First, we can address the most frequent chief complaint, “my front teeth stick out,” right out of the gate—at the point when the patient is most excited and most willing to be compliant. A beneficial side effect is that the subsequent treatment is then less complicated for the both the patient and the orthodontic team.

OP: In your opinion, what are the key tools/products that play into successfully implementing the Sagittal First philosophy?

Paquette: The Carriere Motion is the key to successful implementation of the Sagittal First philosophy. Although segmental mechanics have been discussed for decades, it was not until the Carriere Motion was introduced that implementation of segmental mechanics and Sagittal First became straightforward enough to become routine. In addition to the Motion itself, using the correct elastic protocol is essential for success.

Paschal: The Motion 3D Class II or Class III Appliances, the new Motion 3D Sidekick Bondable Hooks, a clear stint, and finally the Force 1 and 2 Elastics [all from HSO] are the primary tools I utilize to apply Sagittal First treatment and establish a Class I platform.

OP: What is the average treatment time you are seeing with the Sagittal First approach in your practices?

Paquette: I typically see a 3 to 6 month time frame for bite correction and then 8 to 12 months of fixed or aligner treatment to finish.

Paschal: In my practice, the average time in the Motion appliance is 3 to 5 months. Total total treatment times for full treatment with the Motion appliance average from 14 to 18 months.

OP: Why is a shortened treatment time so important in today’s competitive landscape? 

Paquette: Most adolescents today have an expectation of around a year in treatment. By utilizing Sagittal First, we can generally meet or exceed those expectations. Another benefit is that by having appliances on for a shorter duration, we reduce the likelihood of white spot lesions when treatment is completed.

Paschal: Simply because patients want it! And if you don’t provide shorter, more efficient treatment approaches, someone or some corporation is going to provide them. Sure you can say, “But my longer approach is better!” Better how? Today’s consumers are describing better in different ways. These may not be the way we want them to describe it, but that becomes our burden to “sell.”

OP: Looking beyond the clinical impact of this treatment protocol, how does implementation of the Sagittal First philosophy impact the rest of the orthodontic office?

Paschal: It improves the efficiency of patient on boarding or starting. Traditional bondings take about an hour of chair time and in most practices this needs to be scheduled. Starting a patient with Sagittal First only takes about 15 minutes to bond the Motion 3D and scan (or impress) for the lower stint. Doctor time is only about 3 minutes using this technique. This has minimal impact on even a busy schedule and enables the practice to routinely have the capacity to start patients on the same day as their examination.

OP: Dave Ternan, from a data perspective, why are same-day starts important for an orthodontic practice?

Ternan: With increasing competition and more people doing multiple consultations, it is critical for offices to become more customer centric. We have found that patients expect to start treatment and select financial arrangements the day of their exam. Across all of our practices, there is a linear correlation of same-day starts with higher conversion rates. Obviously 100% of same-day start patients convert since appliances were placed. We also see a 98.6% conversion rate for same-day contract patients. For patients that don’t start but schedule follow-up visits, the conversion rate falls to 80.4%. What is even more shocking is that for patients that walk out of the door with no commitment, their conversion rate drops to 49.4%. With no commitment from the patient, it is basically a coin toss if that patient is going to start treatment with you. Orchestrating a same-day contract is not easy—it takes commitment from the team and having the right processes in place. We’ve found that giving the patient what they want, including same-day starts, will be rewarded with a higher conversion rate.

OP: Many orthodontists worry that shortened treatment times will lead to more delinquent patients. Why isn’t extended financing a bad thing?

Ternan: The majority of Americans shop based on monthly affordability. Few people know how much their car costs, but they definitely know their monthly payment. With faster treatment times and increasing competition, there is no choice but to be flexible with down payments and extend payment plans beyond treatment length. We have stimulated tremendous growth for our OrthoFi clients by giving patients open choice on down payments and monthly payments, all while maintaining or even raising their fees. The good news is, across our 250+ practices we’ve delivered delinquency rates and ultimately write-offs that exceed industry standards even with some plans out to 36 months. With a good collection protocol in place, the data proves that extending payment plans past treatment length is not as risky as doctors have been led to believe.

OP: Drs Paquette and Paschal, what has your experience been with shortened treatment times and extended financing? 

Paquette: One of the initial concerns with shortened treatment times was that patients would have an increased default rate on payments. In fact, we have found no difference in default rate. In fact, with simplified same-day starts using the Motion appliance, any defaults are far and away offset by increased revenues generated by increased starts.

Paschal: Very favorable. Orthodontists traditionally have made the assumption that if they finished treatment prior to collecting the balance, they wouldn’t get paid. This is not the case. If a patient or account holder is not going to pay you for treatment, they usually have trouble meeting the financial terms in the beginning months. Over 95% of all patients will pay regardless of when they finish treatment. The few that stop paying after their treatment is completed usually have paid more than enough to make the case profitable.   

OP: You are several years past implementation of the Sagittal First philosophy into your practices. Knowing what you know now, what advice would you give to anyone hesitating to implement this approach into their practice? 

Paquette: We are all creatures of habit and change is disruptive. In this case, the biggest disruption is that we found patients finishing so much quicker than before that after 12 months we needed to increase the number of debond appointments available. Knowing what I do now, and the benefits for the patients, I would not hesitate to make the changes needed to implement Sagittal First.

Paschal: Start 20 cases using Sagittal First and Motion 3D. Starting out choose cases that are mild to moderate Class IIs or IIIs. Gain some experience applying the treatment plan and Motion 3D appliance on straightforward cases. Once you see how straightforward and predictable the treatment approach is, then start to expand your envelope of care to full Class II and III cases. After awhile, you will find yourself utilizing Sagittal First for all A-P corrections.

Also, come to an HSO event and see how we have implemented these techniques into our practices, or attend an in-office course where you can learn how we apply the technique live. OP

Photo courtesy of Henry Schein Orthodontics.