For orthodontists when bitten by damaged clear braces in the mid 1980s, the concept of a second foray is an intimidating possibility. Patrice Pellerin, DDS, understands the reluctance. He has actually dealt with the yellowed brackets and nicked enamel triggered by spying off old quartz braces. "When the very first generation of clear braces showed up, there was a great deal of trial and error, and they got a bad track record," confesses Pellerin, that goings a solo exclusive method in Lachine, Quebec, Canada. "However do the very same issues exist containing today's technology? No, they do not.".
Before he could convince others of the merits of clear ceramic braces, Pellerin first had to convince himself. A decade after switching to an all--aesthetic practice, his doubts are gone. Now, he says the key to convincing referring dentists is to cultivate satisfied patients.
"Ahead of the Parade"
If you want to go all aesthetic, Pellerin also recommends sending those dentists a preemptive strike in the form of a comprehensive letter. Acknowledge the earlier problems in writing, and give a full explanation of the benefits of new technology. Whether your letter works partly depends on factors you can't always control. "It depends on the age of the referring dentist," says Pellerin, who received his dental degree in 1985 and his postgraduate orthodontics certificate in 1991 from the University of Montreal. "Younger ones tend to not be scared at all of ceramic braces. If you have guys like me, who graduated 20 to 30 years ago and may have been burned with the first use of the clear braces--they will be more difficult to convince."
One way to combat this skepticism is to clearly outline your reasons for making the aesthetic switch. Make it clear that your standard of care will not be changing, and treatment time will be the same or shorter.
"Whatever you say before is information, and whatever you say after is an excuse," Pellerin says. "Make sure all your referral dentists hear it from you and not from a jealous colleague. Spread the word and get ahead of the parade. You don't know who graduated when and what they know about clear braces."
Eye of the Beholder
Like many orthodontists, Pellerin initially decided to use metal braces for children and ceramic for adults. In an effort to differentiate himself, he went the clear route in 1998 for all patients. Averaging almost 600 starts per year, he chose Clarity(tm) Ceramic Braces on 99% of all new cases. Adults and most children quickly embraced the concept, but Pellerin soon discovered that a subset of young patients had no interest in being inconspicuous.
When these color-conscious kids laid eyes on Pellerin's original colorless typodonts, they mistakenly thought metal braces were the only route to colorful smiles. "If your typodonts feature colorful elastics on ceramic braces, kids are going to know they can have color with clear braces--and they are usually going to select that," Pellerin says. "You must have a typodont on the table that shows the clear braces with the colorful elastics. We used to take it for granted that the patients knew that, but they did not."
Now all the typodonts in Pellerin's practice have half the mouth in color and half in clear, so there is no misunderstanding. With the showy elastics option, 99% of 10- to 13-year-olds select the ceramics. For the remaining 1% who still want metal, Pellerin will gladly put them on.
The key to convincing reluctant parents is Pellerin's assurance that the use of clear braces does not mean that results are being compromised. "I am selling results," Pellerin says. "Aesthetic appliances must give you the same result as other systems. If not, you will have problems with your referral dentists. The most important thing is customer satisfaction. I will not compromise on the standard of our treatment--and that means time and results. Yes, we want to be different and aesthetic, but we will not compromise."
Not surprisingly, virtually all adults opt for the clear braces and have no interest in color. However, Pellerin was surprised that his personal preference for gold wire was not the unanimous choice. Putting silver wire into the mix is one example of how orthodontists must never forget to listen closely to patients. "People say you are a good orthodontist if your patients listen to you, but you're a great orthodontist if you listen to your patients," Pellerin says.
"I thought that clear braces with gold wire were the nicest and coolest thing--not realizing that some patients just did not like gold. I was not listening."
Color is a big concern for adults, but the gripe is usually too much color in the form of yellowish elastics stained by coffee or cigarette smoke. With the advent of self-ligating (SL) braces that require no elastics, even this complaint has largely disappeared. "Prior to self-ligation, adults who chose clear elastics would have to come back due to stained elastics," Pellerin says. "If it was a smoker or a heavy coffee drinker, it was even worse. With self-ligation, we got rid of the elastics and got rid of the yellowing. Less yellowing means fewer visits, and I can see more patients. If I can see more patients, that means more growth. For patients, self-ligation means fewer visits, less yellowing, and fewer diet restrictions."
Pellerin uses two self-ligating systems: the 3M Unitek SmartClip[TM], which uses metal brackets, and Clarity[TM] SL for ceramic cases. Both systems incorporate a nickel titanium clip that secures the wire in the bracket without the need for elastic ligatures. Pellerin still uses traditional ceramic braces on a limited basis, depending on the needs of the patient, but uses the Clarity SL appliances on the majority of his patients.
While Pellerin acknowledges that self-ligating brackets have helped the practice to fulfill its 100% aesthetic niche, he believes that success involves many factors. Communication, satisfaction, quality appliances, and good results can never be neglected. Since so many of these factors depend on listening to patients, he expects nothing less from the manufacturers he works with. "If you want consistent good results, you need good appliances," Pellerin says. "My reason for going with 3M is their superior quality. It is a proactive company that supports its products and listens to what you have to say."
Inevitably, many parents--and adult patients--assume that less visible equals more expensive. When they learn that there is no price difference between metal and ceramic, the attitude toward treatment changes. Knowing that results are virtually identical to metal often seals the deal.
Practice Makes Perfect
Enduring the "bad old days" of troublesome aesthetic braces has given Pellerin a unique perspective on what it takes to successfully use today's technology. After all, he remembers what he deems the "silly" practice of using a thermal debonder to get a particularly pesky adhesive to melt. All of it makes the new equipment a comparative breeze to work with.
Pellerin's staff members are unique in that 99% of the braces they work with are ceramic. Most practices he knows offer 80% metal with a mere 20% devoted to clear. There is a bit of a learning curve for ceramics, a curve that gets quickly mastered if you see nothing but clear braces. "The staff in my office is probably faster at working with clear braces than those that use them only 20% of the time," Pellerin says. "Since it is ceramic, the corners of the brackets are rounder, and the way you work has to be a little bit different--such as what you use to tie the wire in the bracket. Because it is ceramic, it is a little bit more fragile than metal. We have to be careful, but it is not special training."
Eating restrictions are the same, Pellerin says, since those precautions are mostly derived from bond strength. Since most studies show little difference in bond strength between metal and ceramic, no unique instructions are necessary.
Clinically speaking, there are definite precautions that all aesthetic-minded orthodontists should be keenly aware of. For example, since ceramic is harder than tooth enamel, it can be a problem if the top teeth can touch the lower braces. "If you have clear braces on the outside of your top teeth, that is not a problem because nothing except your lips will touch there," Pellerin cautions. "But if you put those braces on the lower teeth, when you bite your teeth together--the top teeth can touch the lower braces. Since the braces are harder than the enamel, you can wear or do damage to the upper teeth."
The solution is to delay bonding the lower braces until the proper correction can be made to the upper teeth. "Or we build a different system to change the bite so that the top teeth don't reach the lower braces," Pellerin says. "That is the only limitation on ceramic braces--the deep bite. That is, we must open the bite if there is going to be contact with the lower braces."
When it comes to lingual braces, Pellerin had to cut his teeth on early technology, which he called "horrible." During his residency in 1989, he remembers a whole series of cases that had to be salvaged with regular braces due to continual problems with the lingual technology.
Despite his earlier troubles, a year ago he started using iBraces[TM] lingual braces from 3M Unitek on a limited basis. Just as he did back in 1998 when he went all ceramic, Pellerin sent letters to referring dentists explaining the new technology and the reasons for the change. For patients who believe that clear braces are still too conspicuous, lingual can represent a nice niche.
Word of Mouth
A decade after beginning his all-aesthetic odyssey, Pellerin has no regrets. His 4,500-square-foot office is part of a 10,000-square-foot stand-alone building that he owns. The remaining space he rents to an oral surgeon and a periodontist. His busy practice in the largely French-speaking province of Quebec (Pellerin speaks fluent French and English) continues to grow. "The impetus to start an aesthetic practice was to be different, to find myself a niche--because we all do orthodontics," Pellerin muses. "So why would someone seek my services? Because I only treat with clear or aesthetic appliances. And for some people, it is a good reason to come in and see me. Once they are in, it is your job to keep them in--but first give them a good reason to seek your advice."
Word of mouth now accounts for 95% of Pellerin's 550 to 600 annual starts. Since clear braces are still a relatively unusual sight, conversations are sparked by soccer moms and even strangers at grocery stores. "I had a patient who met one of my patients on the train," Pellerin says. "This person saw the braces, thought they were nice, and inquired as to who may have done that. We ask all the people coming in who referred them, and we get all kinds of interesting stories. We do not do television, radio, or newspaper--and my name is in the smallest section of the Yellow Pages."
Pellerin's one marketing indulgence comes in the form of sponsorships for sports teams and graduation yearbooks. If any patient he treats asks for his support, the answer is always yes. When those same patients finish their treatment, they always fill out a comprehensive survey. Roughly 10% of patients routinely say that if clear braces were not an option, they would not have visited his practice. When you consider that 10% of Pellerin's starts translates to a hefty 60 patients, it all adds up. In the most recent survey, almost 60% of respondents said they would have likely been less satisfied with metal braces.
Pellerin reiterates that it all boils down to listening to patients, focusing on results, and firmly believing in the efficacy of aesthetic braces. "Do you really believe it will make a difference? If you don't, it won't work," Pellerin says. "If you are convinced, then you will be more convincing. Switching to an--all aesthetic model made a huge positive change in my practice. Patients were happy, and after a while, the word spread."
