Hybrid thinking and the custom-fit approach to appliance therapy

Labial. Lingual. Aligners. If clinically appropriate, these remain most patients’ — and doctors’ — choices, with traditional labial appliance therapy still the most common option, though losing ground to aligners. However you feel about aligner therapy, it is a reality and will continue to cut into the fixed-appliance portion of the orthodontic market. In our practice, we have found a way to give our patients what they want (aligners) and still achieve the standard of care we owe the patient. Digital treatment planning, in particular, gives us the ability to custom-fit appliance therapy to suit each patient’s unique malocclusion as well as his/her treatment preferences.

Here is a case in point. A prospective patient is getting married in 8 months (or, perhaps more commonly, in 3 or 4) and wants to “fix her smile.” Upon the initial exam, you determine that aligners alone won’t do the trick in the allotted time. In this case, the patient has an overbite of 60% and several teeth that have significant rotations in the maxillary and mandibular anterior segment. There is contact on the lingual of the maxillary incisors. In cases like this, digital case planning can save the day, not to mention the marriage. We treated this patient with labial appliances for 6 months to correct the anterior rotations and open the bite, and then continued treatment with aligners up until a week before her wedding. To the untrained eye, her smile was perfect; to the professional eye, it was vastly improved and required only some modest modifications to complete the case to our standards.

Marriage saved! Well, at least for now — schedule a recall in a few years, and hope that their happiness is operating at the same level as her retention.

Digital technology gives us a more sophisticated approach to case planning, an especially valuable benefit as patients’ increasing awareness of aligner therapy often shapes unrealistic expectations of treatment times and quality of results. Fixed appliances allow us to correct rotations quickly and level the arches to reduce our needs in the aligner phase of treatment to smaller, first-order movements. Vertical movements in the anterior occlusal plane are controlled by the fixed-appliance therapy. No need to do that with aligners. It also initiates the biological cellular activity needed to move teeth and, thus, makes it possible to plan larger first-order movements in our aligners. This reduces the number of aligners the patient must wear. In our practice, at least 30% of our cases now involve some combination of fixed appliances and aligners. I’m able to plan the initial movements in 4-8 months and finish regularly in 10-14 months with aligner therapy, the significant difference being that our job shifts from wire adjustments to tracking the movements of teeth with aligners. We are still driving the treatment to the desired finish, but we are using a different appliance to do so. The teeth do not care what force system is being used; however, the patient does.

Taking a hybrid approach requires more planning on our part, a process supported by suresmile®, our digital treatment system of choice, and supervision of patient compliance supervision in later phases of treatment. Nevertheless, using new technology  allows us not only to meet our patients’ demands, but also to achieve consistently superior results that satisfy our professional requirements in an efficient manner. It’s a win-win approach for the doctor and the patient.


J. Peter Kierl, DDS, MS, graduated from the University of Oklahoma College of Dentistry, completed his orthodontic residency at the University of Iowa, and received his master’s degree in Orthodontic Sciences. He has been in private practice for more than 33 years in Edmond, Oklahoma. He has been a clinical professor in the Graduate Clinic in the Department of Orthodontics at the University of Oklahoma College of Dentistry since 1982. He achieved his certification with the American Board of Orthodontics in 1993.  Dr. Kierl has been a 100% suresmile® practice since July 2006. He has completed more than 3,000 suresmile cases and more than 250 lingual cases using the suresmile system.

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