The power of choice

Dr. Manika Agarwal says to “begin with the end in mind” when deciding on orthodontic treatment with clear aligners or braces.

Dr. Manika Agarwal discusses relying on our strengths to develop a versatile approach

The choice

The prevalence of social media, advertising, and in turn, consumer awareness has seemingly encompassed all areas of our lives and our patients’ lives. The ability to harness the digital world’s efficacy in attracting new patients and communicating with existing patients, while simultaneously navigating through the world of information overload, has never been more important. The educational resources now available to our patients have created a population of prospective and existing patients we have never seen before. Patients are now well-informed of their orthodontic treatment options and will request, or at times demand, to be treated via a certain modality. At the same time, as orthodontists, we have the ability to offer different treatment options to satisfy those patients’ requests. Now more than ever, we must be versatile and offer braces and clear aligners, irrespective of what we may have preferred in the past, all in an effort to continue meeting the needs of our patients and remain relevant. We must rely on our strengths to develop that versatile approach, and at times, it may be necessary to change one’s perspective in order to achieve that result.

The approach

“Begin with the end in mind.” I vividly remember this statement echoing in my mind as I tried to navigate my very first clear aligner case. In 7 Habits of Highly Effective People, author Stephen Covey uses these words to encourage his readers to first establish and focus on the end goal, and then to create a path forward toward that destination. A lack of clarity or trouble envisioning an end goal can create unnecessary challenges and roadblocks, which can be difficult to overcome and navigate. You may be wondering, why is this relevant? How does this apply to us as orthodontists? “Begin with the end in mind” continues to resonate with me and manifests itself in how I approach all of my clear aligner and braces cases. As practitioners, we need the confidence to treat all cases to the same level of exceptional care and use any treatment method as a means to get there. By beginning with the end in mind, I can work toward creating a roadmap to facilitate achieving the smile I have envisioned for my patients. But as you can imagine, I did not always start with the end in mind early in my practice.

One of my biggest obstacles when starting in private practice was not to approach my cases differently, depending on whether I was going to use braces, specifically passive self-ligation (PSL), or clear aligners. Instead of focusing on the technical components of what defines a beautiful smile, I tried to navigate my clear aligner cases differently. I wasn’t relying on my orthodontic principles or working with an established destination, something that came naturally with my PSL cases. For some reason, treating a patient with clear aligners elicited a degree of uncertainty and anxiety that led to a lack of focus on the basics and not having an end goal in mind. I didn’t know where or how to start, and then when I did start, depending on how the treatment was progressing, it became difficult to pivot if needed. When I was able to make the necessary adjustments in the treatment, there were times I felt unsure as to when a patient had successfully completed their treatment. By not envisioning the end result and not establishing a path toward that end result, I was unsure where I should be and when I would reach my destination.

As I continued to work through the obstacles I faced in my initial approach to clear aligner cases, I tried to listen to that voice in my head and draw on my experiences treating PSL cases. I began to envision what I viewed as my perfect result: an esthetic smile with an ideal occlusion rooted in the fundamentals of transverse development and natural archform. This was different from what I had been doing initially, which was to define that perfect smile, depending on the treatment modality. By switching my approach from “how do I treat this patient with clear aligners or braces?” to “what are my esthetic and functional goals for this patient?” I have allowed myself to lean on my orthodontic foundation and begin with the end in mind. This has given me the confidence in providing the best care to my patients without differentiating the care based on the treatment method. By detailing and defining the most important aspects of a beautiful smile and a functional occlusion, I have been able to create a clear roadmap to facilitate reaching that end goal, step-by-step, in a predictable manner. By focusing on the fundamentals of orthodontics that I learned in my training and advice I garnered while working with my mentors and colleagues, I have been able to envision the smile my patients deserve. I have defined my end. Now all I have to do is start there.

The destination

Now you may be asking, how did you come to define this destination, this smile you want all of your patients to have? For me, it all comes from my experience successfully treating PSL cases, where I consistently saw that destination, and in a predictable step-by-step process, created a path there. In a very orthodontic fashion, the destination or smile I envisioned for my patients is defined by the esthetic and functional goals I have established for that patient. When evaluating the esthetic goals, I focus on the three components that Dr. David Sarver established: macroesthetics, miniesthetics, and microesthetics. This approach has allowed me to focus my esthetic goals by prioritizing facially driven treatment planning. And when evaluating the functional goal, I focus on the keys to normal occlusion, a goal defined by Dr. Larry Andrews. In adopting this methodology, I am able to treat my patients knowing that I am achieving my goals and ultimately the smile I envisioned.

As we continue to develop our treatments, incorporate new ideas, and learn from our experiences, it is important to keep the basics in mind and to listen to that voice, to begin with the end in mind. This is even more important as we have patients who are well-informed and aware of their treatment options, in turn, demand a specific treatment modality, and are hyperfocused on esthetics. Patients know what they are looking for, and it is up to us to help them achieve those goals. Whether we use braces or clear aligners, it is important to realize that the approach is the same — that the end result is the same. An efficient and organized way to achieve those results is to begin with the end in mind.

Case examples

Transverse development is the start to achieving excellent clinical results. The power of the transverse dimension is what we are always evaluating and treating to in our PSL cases, and is the fundamental principle on which beautiful results are achieved. As alluded to earlier, these principles are based on what Dr. Larry Andrews described as the keys to establishing optimal occlusions and balanced faces in all individuals, irrespective of treatment method. Thus, when diagnosing and treatment planning the following two cases, I focused on those fundamentals to determine how my esthetic and functional treatment goals created my destination.

The following two cases are also a great example of how we, as orthodontists, give our patients the opportunity to choose their treatment modality while maintaining confidence in our abilities to achieve and deliver the same results. As you will see, both cases had a similar initial diagnosis, but one was treated with clear aligners and the other with PSL.

Figure 1: Case 1–Patient SJ was treated in 12 months with 48 aligners and 1 refinement
Case 1: Patient SJ

Diagnosis: A 19-year-old female presented with Class I malocclusion with moderate maxillary and mandibular crowding. The constricted maxillary arch resulted in a unilateral right posterior crossbite and lower midline deviation to the right. She presented with a straight soft tissue profile, normal vertical dimensions, and normal lip structures. The tapered arches resulted in poor smile width and excessive buccal corridors, with slightly protruded incisors.

Objectives: The objectives of this case were to upright and develop the buccal/posterior segments for an improved smile width. This would allow for correction of the posterior right crossbite and increase in arch length to allow for alignment of the anterior teeth and prevent any further protrusion of the incisors. In addition to these functional objectives, an increased incisor display and improved smile arc was our primary esthetic goal.

Treatment plan: This patient preferred to be treated with clear aligners. The key to setting up this case was to ensure that the objectives were addressed by appropriately staging the movements. I used the fundamental principles outlined in the objectives to ensure the step-by-step process would achieve predictable results. In order to do so, I dictated how the teeth would move through the use of the software, eliminating any deviation from the plan.

I started staging this case by uprighting the buccal segments with simultaneous expansion and rotation of the molars to create a natural archform. Crossbite elastics were worn on the right to establish a stable transverse dimension while filling the dark buccal corridors. The transverse development helps create space to align the anterior teeth. Focusing on esthetic treatment goals of improving the smile arc through eruption of incisors allows for a consonant smile arc with appropriate incisor-show.

Figure 2: Case 2–Patient MA was treated in 14 months
Case 2: Patient MA

Diagnosis: A 14-year-old male presented with a Class I malocclusion with moderate maxillary and mandibular crowding. A constricted maxillary arch resulted in a unilateral left posterior crossbite with a mandibular midline deviation. He presented with normal soft tissue contours and vertical proportions. The posterior constriction resulted in tipped in buccal segments, poor smile width, and excessive buccal corridors. Upright incisors resulted in poor anterior smile esthetics and decreased incisor display on smiling.

Objectives: Since the initial diagnosis was largely similar to Case 1, my destination, and in turn, approach and objectives, were similar as well. My primary goals were to upright the buccal/posterior segments to create space for the anterior teeth and achieve a natural archform. This would allow for correction of the crossbite and improvement of smile width. Increase of both anterior torque and incisor display was also necessary to improve smile esthetics.

Treatment plan: This patient preferred to be treated with braces, so I used the Damon Ultima™ System for his treatment.

Due to his severe posterior constriction and upright incisors, I chose proclined torque brackets for the U1s to ensure no further torque loss during posterior development and to provide additional torque in the anterior. He wore crossbite elastics on the left to improve the posterior left occlusion. The elastics, coupled with posterior development through passive self-ligation, allowed for an increase in smile width while the bracket placement in the anterior was chosen to improve the smile arc.

The wire progression was as follows: 0.014 CuNiti for 4 weeks, 0.018 CuNiti for 4 weeks, 0.014×0.0275 CuNiti for 20 weeks (due to COVID), 0.018×0.0275 CuNiti for 8 weeks, 0.018×0.025SS U / 0.016×0.025SS L for 8 weeks, 0.019×0.025SS U / 0.016×0.025SS L for 8 weeks.


As patients become more aware of their options, their power of choice is becoming the driving force behind how we practice. Part of providing exceptional care is listening to and understanding our patients’ desires. If that means using a particular treatment modality, we must have the perspective, mindset, and confidence to be able to achieve the same results, irrespective of whether we use braces or clear aligners. By shifting our focus to the goals we have established and achieved for our patients in previously completed cases, we can draw on those experiences and distinguish ourselves as versatile clinical orthodontists. We can position ourselves to be able to provide our patients with two reliable choices and be confident in delivering exceptional results.

Dr. David Alpan discusses the efficacy of treatment with clear aligners or braces in his CE, “A comparison of efficacy and efficiency of clear aligners versus braces post-COVID-19.” Subscribers can take the quiz and receive 2 CE credits!

Dr. Manika Agarwal, a Diplomate of the American Board of Orthodontics, earned her certificate in orthodontics as well as her MS in oral biology from the University of Illinois at Chicago. Prior to residency, she completed her dental training at the University of Pennsylvania. Now in private practice in the western suburbs of Chicago, she maintains active memberships in both state and national organizations in order to stay up to date with the latest innovations in the field. She believes in treating all her patients with compassion and kindness and strives to provide them with the highest level of care. As a key educator, she is passionate about education and enjoys sharing her ideas with others, while learning from her mentors in order to continue elevating her skills.


Disclosure: Dr. Agarwal is a paid consultant for Ormco™. Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment when treating patients. The opinions expressed are those of Dr. Agarwal. Images are of actual patients and have not been altered.

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