Complex orthodontic treatment

«Doctor, I have a difficult case! » — Our team often hears this phrase in consultations, because we are the orthodontists who come to us for high competence in the hope of solving problems that seem very difficult for patients to treat.

In this article we want to understand the concept of «treatment complexity» from different angles: from the patient's side, from the doctor's side and from clinical situations. And to convince you that there are no unsolvable cases, and the key to solving any difficulties — is to choose your doctor.

How do patients define complexity of orthodontic treatment for themselves?

Patients typically infer complexity in the following cases:

1. The patient was denied treatment.
   Sometimes doctors, may not be willing to treat a patient on the particular appliance the patient has chosen, or may simply not see the indications for orthodontic treatment.

2. The patient was given a long treatment time frame.
   The treatment time frame — does not equal the degree of difficulty because some tooth movements take longer, but it will be completely predictable and with a guaranteed result.

3. The patient was quoted a high cost.
   Cost — it is not always an indicator of complexity, it is made up of many factors. Sometimes additional equipment in terms of treatment, on the contrary, simplifies and speeds up treatment. For example, treatment with mini-screws, will cost more, but will give a more predictable result.

4. The patient has a long unproductive dental history.
   If the patient tries to deal with point problems for several years in order to save money and time, instead of a one-time comprehensive approach, the oral situation worsens and trust in doctors decreases.

5. The patient has had a bad experience with orthodontic treatment.
   It may have been completed before optimal results were achieved, or a relapse may have occurred.

6. The patient attempts to define complexity visually.
   In our experience, patients consider the following situations to be complex:

   • A lot of missing teeth, more than 3-4,
   • Pronounced crowding when individual teeth stand outside the dentition (dystopian),
   • Very pronounced and noticeable jaw growth disorders. When it is visually visible that one jaw is much larger or smaller (already) than the other. Usually, patients notice this by facial features: an inharmonious profile, where the lower jaw protrudes strongly forward or sideways, so pushed back that there is no clear shape of the chin.

It is not always the case that a clinical case that a patient considers to be difficult is actually difficult for the orthodontist. For this reason, we recommend not to worry too much, but to visit an orthodontic consultation and get the orthodontist's point of view on your situation.

What clinical situations can be described as complex?"

The complexity of orthodontic treatment — is a subjective assessment. But there are situations in which treatment will take longer, require the use of allied specialists or additional appliances. They don't have to be complicated: the orthodontist knows how to solve them and what the end result will be.

The orthodontist knows how to solve them.

We have categorized clinical situations into objective groups:

• duration,
• the need for additional equipment,
• the need to involve other specialists.

Prolonged treatment

• Treatment with the closure of large gaps from 5 mm. For example, when closing the site from the removed teeth, if orthodontic treatment is chosen as an alternative to implantation.
• Treatment of retarded (non-sobering) teeth. Sometimes lost teeth do not erupt even in adult patients, because there is not enough space in the dentition or there are obstacles to teething. The treatment of such cases takes longer, because first you need to create a place or remove an obstacle. And then pull out the retented tooth and put it in the dentition.
• Treatment of skeletal bite when the patient refuses orthognathic surgery. The orthodontist needs to make large enough movements of the teeth to create the correct closure.

Requires the involvement of additional specialists

• Treatment of skeletal malocclusion. Skeletal occlusion is an irregular closure that is formed by the disproportionate size or position of the jaws. When the discrepancy is excessive, this type of bite requires surgical correction. Therefore, a maxillofacial surgeon is involved in orthodontic treatment. The success of treatment with surgery depends on the communication between the orthodontist and the surgeon.
• TMJ dysfunction. If the patient has joint dysfunction and there are risks of deterioration due to orthodontic treatment, then we connect a gnatologist to the treatment.
• There are a lot of missing teeth or there are implants installed. Such treatment requires the active involvement of a surgeon and orthopedist at the planning stage. The orthopedist performs diagnostics and gives recommendations to the orthodontist: where and how much space to create for further implantation and prosthetics. The surgeon evaluates the condition of the bone tissue and the possibility of implantation.
• The presence of recessions or the risk of their occurrence. Patients who are prone to recessions need to be monitored by a paradontologist and, possibly, surgery to close recessions before or after treatment.

Requires additional equipment

• Orthodontic treatment with mini-screws. Mini screws — are an absolute support to move the tooth in the right direction. Some patients believe that if their treatment requires the placement of miniscrews, then their case is — difficult. But in fact, the use of mini screws greatly simplifies the work of the orthodontist and facilitates movement.
• Treatment with correctors of the second class. Proofreaders of the second class — The Herbst device or Powerscope is used in the treatment of distal occlusion in adolescents and stimulates jaw growth. An additional device allows you to achieve a more harmonious result.
• Treatment with a MARPE expander. The device is used in cases of narrowing of the upper jaw in addition to braces or aligners. Allows you to get a faster result.

Complex orthodontic treatment from an orthodontic perspective

Often for any clinical situation, an orthodontist has a treatment plan by which he or she solves the problems at hand. And if all manipulations go according to plan and work correctly, then any diagnosis for the orthodontist will be easy and predictable to treat.

And if all manipulations go according to plan and work correctly, then any diagnosis for the orthodontist will be easy and predictable to treat.

Orthodontists generally consider 2 types of situations as complex cases:

Complicated by predictability

Every body is unique, and it happens that protocols that have been tried and tested over the years do not work as planned. Then orthodontic treatment becomes a challenge for the orthodontist: every appointment you must not just do routine manipulations, but carefully analyze every action and check the result at the next appointment.

Difficult to cooperate

Orthodontic treatment — is a teamwork between the patient and the doctor. The patient must follow the doctor's recommendations, which directly affect the course of treatment. The most common example — wearing elastics — intermandibular rubber bands that must be worn 12 – 24 hours a day, removed before meals and put on new ones immediately after. This can be tedious, but is necessary to correct the bite. And unfortunately, the doctor can only affect this situation indirectly: motivate the patient. But he cannot wear elastics for the patient. If there is no mutual understanding and cooperation between the doctor and the patient, the treatment is delayed and loses effectiveness.