The Impression

Ask An Orthodontist: How Is A Treatment Plan Designed?

There's a whole lot to think about when you're straightening someone's teeth.

Tracy Middleton
Contributing Writer

If you had braces as a kid, the process probably seemed pretty straightforward: Your orthodontist stuck brackets and wires on your teeth, and your parents dragged you in every few weeks to get them tightened. (And to pick out some sweet new rubber band colors, because something fun had to happen.)

But what you probably didn’t realize then — or may not know now, if you’re considering orthodontic treatment as an adult — is that a serious amount of thought, care, and expertise goes into teeth straightening. The process is highly personal. Treating an overbite and closing a gap are very different things, after all. And even two people with the same class of malocclusion (Latin for “bad bite”) can be treated differently. “It really depends on each patient,” Dr. Billie Zoldan, an orthodontist in New York City, tells The Impression.

That’s why expert treatment planning is so critical. Before treating a patient, an orthodontist creates an individual treatment plan based on a multitude of factors: the eruption pattern and position of the teeth, the shape of the face and jaw, the patient’s goals, and much more. In other words, it can be complicated. So we asked Dr. Zoldan to break it down.

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Tracy Middleton: I actually just had my daughter at the orthodontist this morning. So I’m curious: When you see a new patient for the first time, where do you start? What’s your first point of assessment?

Dr. Zoldan: The first thing I do is ask, “What brought you in?” Was it the parent, was it a dentist, was it the patient? Because that’s the point you go from. For example, did the patient’s dentist see something that didn't look right? If the patient is a child, sometimes the parent can think something looks funny, but it's developmentally normal. So I always like to say, “What triggered you to come in?” And then I'll go from there. You look at the age of the patient. Do they have all their teeth? Do they not have all their grown-up teeth yet? Then I'll take a look at their mouth. If I need to then, I'll take a panoramic x-ray to give me a better look inside the bone.

Is it a similar approach when you have adult patients come in?

I would say pretty similar, besides what stage of dentition you're in. Obviously, if it's an adult, they have all their teeth, right? But with adults, you see other issues, like, is their bone level good for moving teeth, are their teeth healthy? Those are things that I don't see with kids. What kind of restorations do they have? Are these crowns old? Are they new? Do they have an implant? Those are things I'm going to see with adults that I'm not going to see with kids. So, both of them have different considerations to take in.

And that's important because if an adult has a bridge or things like that, those are going to-

When they come in, right away, I ask, “When was the last time you saw a dentist?” And if the person said that, “Oh, the dentist sent me here,” then obviously they saw a dentist recently. But if it's an adult, and they just didn't like the look of their teeth, but they haven't even been to the dentist, that's their starting point. Seeing a dentist needs to be their foundation.

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How do you define what the treatment plan is going to be?

It depends. If it's a child, the treatment plan is going to multi-stages. If it's a child that's half primary teeth, half permanent teeth, then you would start with a phase one, using braces or expanders to create space for the permanent teeth. And then phase two would be when you align the permanent teeth that come in.

For an adult, it could be multi-faceted. The plan might be to make space for bonding that they want and decreasing their overjet and aligning their teeth. You see what their issue is, there are different things you could add in. Let's say they have some kind of bite issue, you would add in elastics. Or if they have an implant you can't move, that's something else you have to consider. So it really depends on each patient.

What other factors do you take into consideration? 

If the patient is still growing or not. Can you manipulate their growth or can't you? If the patient is 12 or 13, you can. Once I see a girl that's 16, not any more. if the patient is growing, the bone is almost like, you could put it where you want it to go. Not 100%, but there's different growth modification methods that you could use. You can't do that on an adult anymore. Their bones are fully developed. You could still use things like rubber bands to change the position of the teeth, but you can’t change their growth. They're done growing.

It sounds like sometimes the things that you see when you look at a patient are different from what led them to consider treatment.

Yeah. There are a lot of times when someone says, "I just want to fix this lower tooth that's out of place," right? But they're not realizing that their whole occlusion is off, and fixing that lower tooth is not actually going to help them. It's not always ideal to change things if you're not going to go the whole way. It's not ideal to fix one tooth, because other things will be affected and not in a positive way.

Is there ever a tension between aesthetic and functional considerations? Are there times when someone wants something that just doesn’t make sense?

Let's say the patient wants to significantly push back a tooth. They may not realize that if I do that, it will mean that tooth won’t be aligned correctly, and it won’t be functional with the opposite arch. But once I explain that, we’re usually pretty much on the same page about treatment.

Are there objective measurements you use to see if the bite is “normal” when you're putting together a treatment plan?

There are, but the truth is that, at certain points, those measurements are kind of gray. Every person is different. You can’t really go by a number. For example, a patient might look like they need surgery to create room for all of their teeth to come in. But maybe you’ve treated other people in the family, so you know that you can probably move the teeth without surgery.

At what point do you determine what kind of technology should be used for treatment?

Right from the beginning. Some patients know they want aligners, and clear aligners are so advanced now that you can fix almost everything with them. It’s very uncommon to come across something that I can't treat with clear aligners. But age is a big factor. With younger patients, parents worry that they’re going to lose the aligners, so braces are more common. 

Tell me about the virtual model, the 3D imagery of the treatment plan. Is that to help patients understand the process?

Once I determine the treatment plan, we use a software program to create the model from either a digital scan of the teeth or a scan of impressions they make. It shows the patient what the end result will be like, but it’s for me as a doctor also. I need to see where the teeth are going to end up, and it helps me see that. Are they where I want them to be? Are there other movements I need to add to the treatment plan?

Are people ever surprised when I see that? Like, “Oh, I didn’t know that’s what it was going to be like.”

Sometimes they’re surprised at how their teeth look, because with the model, you can see everything. But you really can’t see your mouth like that normally. So when they see the model, they’re like, “Whoa. That’s really bad.” That’s usually what I get. And I go, “That’s your mouth.”

Is there anything you wish people considering aligners or braces knew about the treatment planning process?

So, I’ll tell you. Let's say at the end of treatment with clear aligners, the patient says, “The position of my teeth is not exactly the same as it was in the virtual model." So I say to them, “This is a computer and you are a person. The computer is really great at guessing, but you're still a person, right?” The computer can't determine, 100% of the time, how every person’s teeth will move. I'm not going to move the same as the person next to me. My teeth, my body, don’t work exactly the same as yours do. Not everything is going to be exactly what a computer determines. ✧

Let’s get things straight.

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Ackerman, J et al. Communication in orthodontic treatment planning: Bioethical and informed consent issues. Angle Orthod. 1995;65(4):253-61.
Dental Anatomy and Development, Merck Manual, accessed 20 June 2019.
Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics. American Association of Orthodontists, 1996. Last reviewed 2017.
Cunningham, S et al. “ABC of oral health: Improving occlusion and orofacial aesthetics: orthodontics.” BMJ (Clinical research ed.) vol. 321,7256 (2000): 288-90. doi:10.1136/bmj.321.7256.288
Malocclusion, Merck Manual, accessed 20 June 2019.
Zoldan, Billie, DDS. Personal interview. 17 June 2019.

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