The Value of Patience in Orthodontics

by Shadi Samawi

“There is more to life than increasing its speed.”– Gandhi

Patience is a rare commodity these days. A lost art. Everything has become an unnecessarily hasty venture, with little time to stop and think about what we are doing before we actually do it!

In Orthodontics, as in life, patience is a great virtue. We, as orthodontists, have always prided ourselves on our vision,  foresight and “long-term thinking”. After all, these are  important  skills  in our profession. However, many of us may often fail to live by our own “assumptions”. I, for one, have been guilty of this myself on many occasions. But the fact of the matter is that there is no substitute for patience if we want to perform at our very best and provide the best results for our patients. This actually starts from the very first consultation visit, through actual active treatment and all the way to post-treatment follow-ups. Patience and just “slowing down” provides us with the time necessary to focus, think, plan, and reiterate, until we can produce better results with maximum efficiency. After all, “If not Excellence, What? If not excellence Now, When?” as Tom Peters states in his interesting book “The Little Big Things: 163 Ways to Pursue Excellence.”

Taking the time and effort to talk to our patient during their consultation visit, to listen to their complaint and provide explanations is a highly vital first step. Taking the time and effort to take complete and proper orthodontic records for all patients (Study models (or Scans), Clinical photographs and required Xray views) is an undoubtedly essential step for a successful treatment. Taking the time to study and fully analyze those records and brainstorming a thorough treatment planning session is even more essential. All of these steps are such an essential part of a successful practice and may seem to some as “Standard” procedure but unfortunately they are often neglected by many for the sake of “speed” or another reasoning! Contrary to what one may think, disregarding these steps does not produce “faster” or better treatments, but rather the exact opposite, as most discover over the course of the treatment.

The Bond-up appointment is probably THE single most important appointment in the course of orthodontic treatment. One of the most obvious examples of lack of patience is the “boasting” of shorter and shorter bond-up appointments. Although we all strive towards improved efficiency and reduction of chair side time through every legitimate and scientific means possible, nothing substitutes patience during a bond-up session. Taking the time for proper bonding of all available teeth is a critical step especially for the all-important initial alignment phase of treatment. Incorrect, hasty bond-ups can result in many issues during leveling and alignment that could prove to be a nightmare to correct later, or that may complicate an already complex case even further by causing unwanted tooth movements at this critical early stage of treatment. In addition, it is also worth taking the time mid-treatment to slow down and recheck bracket positioning and adjust as necessary.

Excellence is in the details.

Another glaring example of our haste in going through orthodontic treatment is our tendency to change archwires almost every visit, regardless of the archwire’s remaining potential for further “work”, and with no regard for ample scientific evidence and the golden rule that we have been taught during our residency programs and read in textbooks; which states that an archwire should be left to work for as long as possible until the bracket slots are completely leveled and the archwire is – more or less – completely passive. I personally believe this latter issue to be one of the main causes of improper control of teeth during space closure as well as loss of anchorage due to unnecessary archwire binding, which hinders tooth movement especially during space closure mechanics.

For example, my own modest experience – largely based on the MBT treatment philosophy – has led me to follow a certain broad archwire guideline throughout the course of most treatments where I rely on up to 3 main archwires only, with possible intermediaries as the case dictates, if needed. My initial archwire is almost always a 0.012” NiTi archwire which usually remains in place for – at least – the first 3-4 visits. A Heat-activated Rectangular NiTi archwire usually follows and again, left in place for another 3-4 visits. I have learnt to resist the urge to replace the archwire until I’m confidant its is almost entirely passive and can easily be removed by gently nudging it outwards using a probe or tucker at the midline. If it slides effortlessly out of all the brackets AND molar tubes , then I know it is time for the next  archwire. This simple tip alone has had a considerable effect on the smooth progression of my cases throughout various treatment stages, minimizing round-tripping and slow (or unwanted) tooth movement, and ultimately maximizing my treatment efficiency.

As a final note, I leave you with this excerpt from the fantastic book FOCUS by Leo Babauta, the blogger behind the famous blog Zen Habits.

“.. The world most of us live in is hectic, fast-paced, fractured, hurried. What’s more, most of us are conditioned to think this is the way life should be. Life should be lived at break-neck speed, we believe. We risk our lives in cars and we break the speed limit, rushing from one place to another. We do one thing after another, multitasking and switching between tasks as fast as we can blink. All in the name of productivity, of having more, of appearing busy, to ourselves and to others. But life doesn’t have to be this way. In fact, I’d argue that it’s counterproductive. If our goal is to create, to produce amazing things, to go for quality over quantity, then rushing is not the most effective way to work. Slowing down and focusing is always more effective. Rushing produces errors. It’s distracting to flit from one thing to the next, with our attention never on one thing long enough to give it any thought or create anything of worth. Hurrying produces too much noise to be able to find the quiet the mind needs for true creativity and profound thinking. So yes, moving quickly will get more done. But it won’t get the right things done.”