The Case for Ortho: An Interview with Dr. Brock Rondeau

There are a few people who have changed the way I look at how a patient's multiple dental problems may share a common origin. The first time I took Brock Rondeau’s course I had a hard time believing what he taught me; it was so far from what I learned in dental school. I took the course a second time when I was ready to begin some ortho cases and never looked back after that. Almost 20 years later, I see everything Brock taught me is accurate, effective, and that mothers love two-phase treatment as much as he said they would.

Enjoy this interview, and I hope you will consider taking Brock's course. Even if you don't want to treat these cases, you owe it to your patients to learn how to diagnose them.

Michael DiTolla: Tell us a little about your background and how it ended up that you decided to treat only ortho patients.

Brock Rondeau: Billionaire Napoleon Hill said in his book "Think and Grow Rich," " If you want to be rich and successful, find out what people want and give it to them." In my practice, mothers were coming in asking me what we I could do with their kids’ crooked teeth. And then I would refer them out to the orthodontists in my area.

You know, 30 years ago they were not treating kids early. And the orthodontist was telling the mother, "Let's wait until all their permanent teeth have grown in." The mothers would say, "Well, that doesn't sound sensible. You just told me we've got to treat cavities when they're small, and pockets in the gums when they're small. And now you're telling me you're going to wait until my child is 13 to begin treating these problems"

Then I took a course in orthodontics. It seemed like something I'd be interested in doing. The part that really interested me in those days was the fact the staff did all the work! I thought, I can do my general dentistry in one room, have a hygienist doing perio in another room, and have another hygienist in the other room doing orthodontics - and all I have to do is go in and tell her what to do. In most orthodontic offices, the staff really does do a large part of the work. The orthodontist or the general dentist does the thinking and the diagnosis, and the staff actually does most the work.

Then I got into it and I really did like it. I really liked helping the kids, particularly with the functional issues. These kids come in with narrow jaws, and I knew that if I didn't extract or develop the arches that the cuspids were going to come in like fangs. And then if I sent that case to some orthodontist, they would recommend bicuspid extractions. But from the courses I took from Dr. [James A.] McNamara and Dr. [Donald] Woodside, I realized if you expand or develop those arches you can prevent extractions. So, the mothers were very receptive to that. Then Dr. John Witzig showed the use of functional appliances to bring the jaws forward. Kids would come in with their nose coming through the door five minutes before their chin, and then you put these functional appliances in and the jaw comes forward and the kids look great.

I didn't realize in those days that functional appliances would have such a significant influence on the TMJ. We really didn't even discuss TMJ very much back then. A mother once said to me, "You know, my little girl had headaches before you put that appliance in, and that appliance stopped the headaches. Could you put one in for me?" All the literature said they were for growing children. But again, I had taken courses from Dr. Brendan Stack who had shown some cases using adults. So I said, Brendan did it so maybe I'll do it. I remember telling the mother, "I'm not even going to charge you," which you never should do, and I said, "I'm going to put this appliance in and see what happens." And lo and behold it worked! It brought the jaw forward, the condyle came down and forward, it decompressed the joint, and she got rid of her pain. Then I said, "Gee, this really is something," because what I was taught to do in dental school was push the jaw up and back, and that didn't work. I was also taught in dental school to use flat plane splints. Well, flat plane splints make the jaw go distally and that's not good if the jaw is already back too far. So functional appliances seemed to be the answer. I first started doing children with functional appliances, and then gradually built a practice where I now do adult TMD/ortho cases. It's been quite an evolution.

Anybody getting into this, Mike, I would advise them to gradually add this to their general practice. Don't try to switch over immediately. Learn your skills. See if you like it. Most of these patients are in your practice already; most of those kids are in your practice already because 70 percent of all children have some form of malocclusion. And, you and I have talked about this previously, mothers really want their kids to be treated and will pay to have their kids treated.

MD: So, the orthodontist says, "Well, let's not do anything until she's 13 or 14" Mom would be upset because her main concern is her child’s self-esteem.

BR: Of course. Self-esteem is a big thing. The minute you fix that malocclusion and you put a functional appliance in and get that jaw forward, they look like all the other kids and their whole personality changes. It's just remarkable. Plus, if they did have headaches or earaches or any other TM dysfunction, it brings the jaw forward and you relieve all that. Plus you open up the airway. So the kid is breathing better and sleeping better.

It's interesting - a lot of kids have sleep apnea because of large tonsils and adenoids. You and I talked about that when you took my course 15 years ago. And getting those tonsils and adenoids out has a significant improvement on the child's ability to learn because the pituitary gland secretes a growth hormone. And if children don't get to the deep stage of sleep, which they don't when they have sleep apnea or when they're snoring, they don't grow properly. So these kids' growth is stunted, they wet the bed, and many of them develop ADHD - attention deficit hyperactivity disorder. And again, the medical profession will prescribe medication for that - Ritalin - to try and calm them down. But that's just treating the symptom while the cause of the problem is a blocked airway, which is due to the tonsils and adenoids. Get those out and these kids do beautifully.

MD: One of the eye-opening things I learned in your class 15 years ago is that when a child swallows 2,000 times a day - when that tongue presses up against that anterior portion of the palate - it helps to expand the maxilla to the ideal shape and size?

BR: Absolutely, it's key. The proper size to the maxillary arch is the key to patients being able to breathe through their nose. Because when you expand the maxilla, you enlarge the nasal cavity transversely. When you expand the maxilla, the palate drops. That makes the nasal cavity larger vertically. When you just expand the maxilla, you are providing the best service possible for any patient. If I could do one thing for every patient, that's what I would do. And that's usually my first step. Expanding the maxilla creates enough room for all the permanent teeth to fit. It makes more room for the tongue so the patient can speak properly. Having a proper size maxilla allows the mandible, sometimes on its own, to come forward and help correct the Class II malocclusion. It will certainly correct the Class II Division II malocclusion if you expand the maxilla and torque those anteriors out. And many times, the mandible comes forward on its own. A lot of these kids, the malocclusions can really be corrected long before their permanent teeth have even erupted. It's so easy to work with kids with fixed removable functional appliances when they're actively growing. The mothers will happily bring them in, the mothers will pay your fee, and everybody appreciates what you do. You see the kids get healthier and better looking, and it's very rewarding for doctor and staff. In fact, I'll tell you one thing: you'll never get any of my hygienists to go back to perio. They are orthodontic hygienists who I have trained, and they would never go back to perio - they love what they do.

MD: When I think back on my ortho education in dental school, it seems like it was about 14 minutes long. I remember we had some ridiculously difficult wire-bending task to complete. And basically, the take home message was: " Don't even think about doing ortho. Refer." My point always was, if we that poor of an education in endo or perio or anything else, there would be a class-action lawsuit by the American people because you'd have to go to another country to have a root canal since none of us were taught how to do endo. I could easily make an argument that learning how to do functional orthodontics is just as important as learning how to do dentures!

BR: That's right. Well, my course is eight days long. At the end of those eight days - obviously there are four manuals that go with it and some lab work - but at the end of those eight days I've got dentists doing simple cases. They're graduating and they're coming out doing simple cases. You know, if you added eight days to any orthodontic curriculum, which you could easily do, you could reduce some of the information on other courses and get general dentists to have a basic understanding of what they're doing to help patients. Seventy percent of kids have some type of malocclusion. That's a huge number of children in your practice that could benefit. And you don't have to do any external marketing - they're right there and they trust you.

MD: Most dentists don't seem to enjoy working on kids. Most GPs want to have an all-adult practice that they can do crown and bridge on. They don't like doing fillings on the kids because that doesn't bring in a lot of money. It's really pleasing when you get to work on kids without a needle, without a handpiece, and the same parents who couldn't afford two crowns on themselves can suddenly afford the same $2,000 for their kids. Have you noticed that, that parents are much more willing to spend money on their kids than themselves?

BR: Yes, from one room to the other. I remember one time I suggested a crown, it was $1,000 and the mother said, "I can't afford that." Her little girl was in the next room having a prophy and a cleaning and fluoride treatment, and I walked in and said, "She’s got a narrow jaw and a cross bite in the back. That’s going to be about $1,500. Plus the orthodontic records, that's going to be around $2,000." And the mother said, "Well, when do we take the records?" And, of course, I said, "Do you mind telling me why you just couldn't afford the crown for $1,000?" She said, "Children are different. My child gets whatever she needs. We will find the money, and we'll pay it on time." I said, "Of course. We'll set up a payment plan for you. You pay so much a month." And she said, "Well, we're going to get that done. There's no question."

Even during this recession, my practice is averaging about six new patients a day in ortho, TMD and sleep apnea. And each one of those patients could be a significant amount. If you do just functional appliances, it is about $2,000. But if you do the entire ortho case, it's about $6,000 in my office. There's a lot of demand for health. There's a lot of demand for someone who can do a case without extracting permanent teeth. And there's a lot of patient demand to use functional appliances in order to avoid orthognathic surgery, in cases where it's appropriate.

MD: Give me a typical timeline for a two-phase ortho case. Let's say an 8-year-old patient comes in with a Class II malocclusion.

BR: I’d put in an appliance to widen the upper arch--about four months. Then a Twin Block to move the lower jaw forward--about seven months. And then I would probably modify the Twin Block into a Twin Block 2, and hold her there until she's maybe 10 years old. She just wears the appliance for another six months. So treatment time so far would be 17 months. And the appliance works almost by itself, so I'd see her every two months. And the mother would pay me about $200 a month and I'd check her for about five minutes just to check the appliance, make sure it's not hurting, and adjust accordingly.

Then, I would just wait until all the rest of the permanent teeth erupted. And many times when I do that, you deal with 80 percent of the malocclusion. Then when the permanent teeth erupt, the patient might only be in fixed braces for nine months.

MD: And isn't it surprising how if you personalize the appliances for the kids, with a flower or a team logo, they are more apt to wear them?

BR: Oh yes, absolutely. And I tell them, "Make sure you take this and show it to everybody else in your class and see if anybody else has one - because I think you're the only person in the world who's got it." So then they're showing the appliance off.

My office is very upbeat, and I've got to do a lot of consultations all day. And You just hear kids laughing and their parents laughing and everybody's having a good time up there, which is different from some dental offices. And quite frankly, I'm not tired. We see 60 patients a day but it's not tiring because I'm doing sleep apnea and some TMD cases. I'm also getting some very difficult patients referred to me by some general dentists who take my courses - they send me all the tough ones and they do the easy ones - so it takes me a little longer to do some of those cases. So we can really only do about 50 a day, but it's just a pleasant way to practice. I'm so happy I got into ortho; I really feel I'm helping lots of patients and it's very rewarding.

When I look back, I think I was thinking of the money. I was thinking I can get a room going in ortho and I don't have to be in there that much. We can generate some income there that's nice and helps the bottom line and helps me feed my family. But eventually, when I sat back down to think about it, it's more about the personal satisfaction. After a while, you have enough money and you really want to feel that you're doing something good for your patients. And I feel I'm significantly improving the health of my patients. I believe that most dentists went into the profession to help people, I really do. And I'm not saying that when you put on 10 veneers that you aren't improving their smile and their self-esteem, but I am improving their health as well. Especially when I treat snoring or sleep apnea. We really don't have time to talk about that today, but maybe someday we can talk a little bit about snoring and sleep apnea because that's another huge area of growth for any practice.