Dr. Eric Wu is an adjunct professor at the University of Nevada, Las Vegas and the postgraduate department of orthodontics at Roseman University in Henderson, Nevada, and also teaches at Foothill College in Los Altos Hills, California.
Wu attended dental school at the University of Pennsylvania and a one-year advanced education general dentistry residency at UCLA before his orthodontic residency at the University of Pittsburgh. He also completed a mini-residency in sleep medicine from UCLA. In addition to his private practice in Palo Alto, California, Wu serves as a key opinion leader and clinical advisor to Orthoclassic and uLab Systems. He enjoys teaching, lecturing and keeping up with the latest developments through study groups, and has been published in several industry publications.
When choosing treatment appliances, it is usually braces or clear aligners. However, with combination treatment, it can be braces and clear aligners, taking advantage of what each appliance does best.
For me, combo treatment means starting with braces and transitioning to clear aligners.
Benefits of combo treatment
Based on my experience, braces “kick-start” teeth and bone for orthodontic movement; teeth then move more easily in clear aligners than with a clear aligner cold start. Also, each treatment approach has distinct movements that are either difficult or easy for that particular system. As a result, I handle “aligner difficult” movements such as rotations and extrusions up front with braces. Clear aligners have a “speed limit” imposed by the plastic’s limitations; braces are not hindered by that limitation, so we can rotate quickly while also reducing the number of aligners needed on the back end. Plus, clear aligners express the fine details of the finishing stage better and more precisely than braces, so you get the best of both appliances in one treatment plan.
If you resolve major crowding first with braces, you can reduce or eliminate the need for interproximal reduction, preserving the patients’ natural dentition. Moreover, completing significant movements with braces reduces the need for attachments during clear aligner treatment.
Predictability is another huge benefit. With combo treatment, I can more accurately predict how quickly we can get to our treatment goals because I’m able to use the most efficient tool for the movement desired. And hitting that estimated completion date consistently leads to higher patient satisfaction while increasing profitability.
In my practice, combination treatment also reduces chair time. A typical 18-month braces case can require as many as nine or 10 office visits; by transitioning to clear aligners, I can eliminate two or three appointments.
In addition to the practice benefits I mentioned, my patients tend to prefer combination treatments because we can get treatment done more rapidly and predictably than with aligners alone while preserving many of the aesthetic benefits that aligners enjoy over
brackets. Patients who come in requesting aligners will often accept six to 12 months of braces initially to shorten the total treatment.
Pay-as-you-print pricing
For readers wondering how mixing treatment modalities can be affordable with the high lab fees that traditionally accompany clear aligners, I have three words: per-aligner pricing.
Instead of paying a high comprehensive fee of $1,000 or more for an entire series of clear aligner treatment, I pay only for the aligners each case needs. If the pricing tier is $20 per aligner and I need 10 aligners, my cost is $215 (including shipping), so I can still price the treatment affordably and increase the profitability for my practice. It’s a win-win for everyone.
Also, the treatment planning software I use, uDesign, includes a bracket removal tool. With one touch, the braces disappear, making it possible to plan without extensive touch-ups. I can have the aligners waiting at debonding, eliminating an appointment and extra work for the team, as well as avoiding potential relapse. Because the software captures and uses actual tissue data, the straight trim line meets the gingival margin. Some other systems estimate gingival tissue so they use a scalloped trim line to accom- modate any inaccuracies. However, aligners with a straight trim line at the gingival margin or 2 mm beyond provide better aligner retention than aligners with a scalloped edge.
Another game changer for my practice has been chairside treatment planning. In the past, I’d spend evenings and weekends treatment-planning all my new aligner cases. Now, I plan and order right at the treatment chair and submit before the next patient arrives.
Personally, I prefer outsourcing the aligner manufacturing rather than printing in-office. My staffing changes over the past two years made it clear that having uLab Systems manufacture the aligners would be a better use of my available resources. Plus, I still can still handle the one-offs or emergencies with in-office printing, if necessary. In-office aligners are more expensive for me to produce than to purchase from uLab, but it can be worth it to replace a lost or broken aligner before the patient’s teeth shift.