Wednesday, April 18, 2018

Braces ... For more than just a Smile.

Braces … for more than just a smile.
 
 
 
Advertisers and some dentists will have the public believe that Orthodontics is just about a petty smile; line up the front teeth and all is well.  No mention of function, long-term stability, relapse, future wear, ability to chew, etc.  So it should be no surprise that clear aligners have become all the rage in today’s dental market.  Are we allowing advertising to make false claims?
 
But is that all Orthodontics is?  Line up the front six and send them out the door?
 
Shouldn’t we be concerned with the back teeth?  Shouldn’t we care how the upper and lower teeth function together?  Shouldn’t we know why the crowding and rotations occurred before lining up the front teeth (just to fail for the same reasons)?  Should we expect to wear retainers for a lifetime?


 
What about health of the gums?  Does it matter if the teeth don’t actually fit in the bone; can’t we just keep pushing them outward until there is room to line then up?  After all, if the circumference is made large enough, any size or number of teeth will fit.  Doesn’t the bone get larger?

These are all important questions that seem to be brushed under the rug in many Invisalign dental offices today as well as the mail-order aligners advertised on late-night TV between the ads for the Foreman grill and the knife that can cut through cement.
 
Common sense should remind people that Orthodontists have to attend two to three years of additional residency after becoming doctors.  Does it make sense that a dentist can attend a weekend course in Vegas then offer the same quality and same outcomes?  Or a U-Tube tutorial (I would laugh out loud but I actually had a local dentist call and ask to borrow some braces from me after watching a U-Tube video!)?
 
“We use to call this practicing without a license and throw people in jail.”
  
Clear aligners are now essentially removing the doctor from the treatment.  Even when offered in the office, the doctor cedes his/her control to a computer and technician (usually in Costa Rica, India, China or Mexico).  There is no consideration of biology, no advanced learning of development or bone physiology by these technicians; no understanding of the computer technology by the doctors and little to no control of forces in the mouth.  We use to call this practicing without a license and throw people in jail.
 
 
Your Future Orthodontist?
 
 
Can a computer technician simply 3-D print a tooth and stick it in the mouth now?  Do you want the geek squad from Home Depot making you dental appliances/aligners to move your teeth?  How about some tech guy from Facebook making decision on what your teeth should look like with no consideration of chewing or function and no checking on the result by a professional; maybe we just need a robot instead of a human altogether?
 
 
 
We used to have greater standards and regulation; for instance a dentist would never consider placing a crown without contact to opposing teeth so why should we allow a company to do the same with our entire dentition?  Why would that same dentist think it is ok to leave the teeth out of function from aligner “treatment” just to line up the front teeth?  Is it just to sell the public a product? What is the standard of care?  What is the evidence in the research?
 
What does the Research on Clear Aligners REALLY show?
 
 “Our results suggested that about 1.5 mm of overbite improvement can be expected when the Invisalign appliance is used in deepbite patients. A previous systematic review on the stability of deepbite correction reported an average of 3 mm overbite correction with fixed appliances [50% more effective with traditional braces]” 
Khosravi, R. Management of overbite with the Invisalign appliances AJO-DO April 2017
 
Invisalign [treatment results] only 41% mean accuracy of tooth movement with a range from 18% to 47.1% (j.ajodo.2007.05.018;www.ajodo.org)
 
Mean percentage of single tooth movement goal of only 57% (j.ajodo.2013.10.022). 
 
When results from Invisalign were compared to traditional braces using American Board of Orthodontic standards, the Passing rate of cases treated with Invisalign were 27% lower (j.ajodo.2005.06.002). 
Another more complete study (j.ajodo.2004.07.016) actually concluded that there was a “minimal improvement in occlusal score based on Board standards from 47 to 36.4 [0 being ideal] and there was a negative change (2.5x worse AFTER treatment) in posterior occlusion contacts with Invisalign.” 
 
This last investigator summarized Invisalign treatment by stating “According to the OGS [Objective Grading System used for the American Board of Orthodontics], Invisalign did not treat malocclusions as well as braces … Invisalign was especially deficient in its ability to correct large anteroposterior discrepancies [overjet] and occlusal contacts.”
 
Another article published April of 2017 in the AJO-DO (Journal of the American Association of Orthodontics) was published that confirmed previous findings (j.ajodo.2016.09.022) showing Inivisalign only 50% effective as braces in opening a deepbite and considering there is already an average relapse of @50%, the net change from Invisalign after treatment is zero.
 
 

The public has been brainwashed by for-profit companies (via social media, Internet advertising and TV ads) that moving teeth is harmless and simple; that going to the Orthodontist is no different than a trip to the nail salon or barber shop.  They have been so successful in dumbing down a very complex process that the public is now being told no doctor at all is needed (after all the dentists providing aligners have no real Orthodontic training either).
 
Does this mean braces are dead?  Not if the public wants full corrections and good function.  Aligners may correct minor rotations and make the teeth look straight-ish, but they are extremely limited in their ability to correct significant problems, the kind of problems that are obvious like excessive overjet, deepbite, openbites, underbites, severe crowding, severe spacing, asymmetries, functional jaw shifts among other common problems.
 
It does mean that good Orthodontists capable of truly treating moderate to severe cases will be harder to find and fees will most certainly go up.  Without milder cases to even out the moderate to severe cases, the cost to treat each case will have to reflect the average amount of time and work in correcting each patient.
 
It also means there will be many un-finished cases of aligners, relapsed aligner cases, mistreated cases or even aligner-caused malocclusions that require correction by real Orthodontics.  There may be loss of gum tissue, loss of teeth or chronic pain from poor treatment; sometimes there is such poor treatment that the damage cannot be undone even with braces and sometimes Orthodontists simply will effuse to get involved.
 
So when you are trying to decide how to treat your family, remember that there are few shortcuts in medicine and dentistry.  Just like investing your hard-earned money in the market; if something sounds too good to be true, perhaps you are not seeing the whole story.  Invest wisely in your family and you will not only get a beautiful and lasting smile, but you will get better function, stability and peace of mind.  Let a trained professional provide your family members with beautiful and truly functional occlusions that will serve them the rest of their lives.
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
 
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 
 
 
 

Tuesday, April 17, 2018

Braces are Better! (and here's why)


Braces are better!  And here’s why.



As a practicing, Board certified Orthodontist who was around when Invisalign first hit the market, I have seen changes with public perception of braces as if they are being “replaced” by aligners.  With so much misinformation and fake/fabricated/paid-for news on social media and television, I feel I must reiterate what I believe everyone already knows despite the sometimes overwhelming presence of salesmen/advertisers/ exaggerators out there saying otherwise.  Braces are simply better than Aligners. And not just a little better; Braces are far more effective, faster and able to move teeth in ways aligners cannot.

 

The only positive of aligners is that they are clear.  The ineffectiveness of aligners versus braces was common knowledge by those of us that were using it when it first was introduced; so much so that there really was no need to publically debunk them since we as specialists were the ones tasked to educate the public.  We saw the ads and propaganda but ultimately we would be able to educate the patients as they came to us and limit aligner use to mild cases of crowding/rotations/relapse.  However with social media and general dentists selling them like candy today, we have realized that we have not kept up with research to prove what we already knew; like so many fields unversed in modern tech media, we failed the public and allowed the advertisers and those who profited from them to drive public perception and ultimately to reduce the standards of Orthodontics so that a mere alignment of front teeth is the only goal (and accepted by the public).

 

And although we have clear braces made of sapphire crystal, still we have dentists that refuse to refer patients to specialists because they want to offer inferior aligners for profit.  Do they know braces are better? If they care to read the studies, yes.  Do they tell the public such?  Rarely.  Once a doctor starts offering aligners it seems they forget ethics.  Believe me no dentist would place a crown out of contact or in an interference with other teeth; they would not leave a filling high or leave space around a restoration.  But they do it regularly if they regularly offer aligners.  Why?  Because aligners have limitations, far more limitations than braces. 

 

Bite opened up following Aligner treatment, patient cannot chew on back teeth.


Dental protrusion after Invisalign treatment.


Recession following Aligner expansion of the lower arch for alignment with no thought to how the teeth would fit once expanded.


Ever wonder why the aligner commercials never talk about function of the teeth?  And do you believe everything you hear on commercials and social media? 
 
 
 
 



Also, ever wonder why you only hear about one company; Invisalign?  That’s because Invisalign is a tech company, not a medical company.  And we all know what tech companies do when there is competition ….
 




Deep down everyone knows Aligners are a short-cut to a partial correction of minor alignment only. No matter what companies are trying to tell you, common sense tells you that a weekend course to learn how to profit from selling aligners is no substitute for a 2 to 3 year residency. And removable plastic is no substitution for fixed/attached braces that work 24h a day using different force wires.  Braces are difficult though which is why it takes additional years to become an orthodontist. 



So do aligners ever work?  Yes, on minor cases of simple rotations or simple space closure.  The problem is, dentists are not trained in what is simple and what is more complex and once they start offering aligners, they either think the aligners will work every time or they turn a blind eye toward the more extensive problems and focus on basic alignment of front teeth.  Sometimes even that is fine for adults but other times partial corrections can lead to fracture/wear of teeth, instability, recession and early loss of teeth, and even TMD/chronic jaw pain.  There is a reason an orthodontic residency is long and difficult following dental school.  There is a lot to consider when moving teeth and changing a person’s bite.

 


 

“… partial corrections can lead to fracture/wear of teeth, instability, recession and early loss of teeth, and even TMD/chronic jaw pain.”

 


Due to patients not even making it to Orthodontists, we now have a new generation of “starving Orthodontists” that feel they also must also offer clear aligners to every patient so they can compete with dentists and profit from the billions of dollars of advertising and patients referred directly from company websites and social media ads.  Why not join them?  Take a digital scan, email it away, get trays in the mail, hand them out and collect the fee. Little staff required, can even work out of a series of kiosks.  If it is what the public wants, right?






And who cares if patients don’t wear them and treatment fails; we all know trying to get teens to wear (and not lose) clear aligners is one of the hardest tasks with aligners.  I would wager a full third to a half of the aligner patients never completely finish their treatment (I have yet to see a study on this but this is the experience I have seen with myself and other doctors); they just get tired of wearing the aligners and they (or their parents) give up.  This includes adults.  I also see dentists blaming failure on lack of compliance when the patient actually did follow instructions.  Now we have a generation of patients out with failed cases making us all look bad.

 

 

Let’s just look at the TRUE research on Clear Aligners:




Mean accuracy of tooth movement: 41%
Range of accuracy from 18% to 47.1%
Accuracy in extruding teeth: 18.3% to 29.6%
Accuracy of Mesial-distal tipping of canines: 26.9% (j.ajodo.2007.05.018)
 

Passing Rate of cases treated Invisalign v. Braces: 27% lower
“Deficient in its ability to correct overjet & occlusal contacts” (j.ajodo.2005.06.002)
 

Mean percentage of simple tooth movement goal (30 patients moving one incisor a single 1mm) only 57% (j.ajodo.2103.10.022)


Minimal Improvement in occlusal score based on Board standards from 47 to 36.4 (0 is ideal)

“Negative change (2.5x worse after treatment) in posterior occlusal contacts with Invisalign”

“Treatment with Invisalign aligners had adverse effects on posterior occlusal contacts” (j.ajodo.2004.07.016)

 According to the OGS, Invisalign did not treat malocclusions as well as braces … Invisalign was especially deficient in its ability to correct large anteroposterior discrepancies and occlusal contacts.” (j.ajodo.2004.05.002)

Another article published April of 2017 in the AJO-DO (Journal of the American Association of Orthodontics) was published that confirmed previous findings (j.ajodo.2016.09.022) showing Invisalign only 50% effective as braces in opening a deepbite and considering there is already an average relapse of @50%, the net change from Invisalign after treatment is zero.
 

Most recently in the February 2018 issue of the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), Orthodontists studied advertising claims that that clear aligners provided for better oral hygiene and healthier teeth during and after treatment.  The study, a prospective and randomized clinical trial, compared not only clear aligners with traditional braces, but also traditional braces with self-ligating braces (another advertiser that has claimed better oral hygiene). Their findings:

 
“No evidence of differences in oral hygiene levels among clear aligners, self-ligating brackets, and traditional elastomeric ligated brackets after 18 months of active orthodontic treatment.”

 

The observations made in this study contradict popular beliefs that removable appliances have a minimal effect on periodontal health

 

Even with such damning results, tech companies and corporate advertising has bulldozed over our standards by telling the public what they want to hear.

Past generations of Orthodontists would have a different take on surrender:
 
I believe Orthodontics (and Orthodontists) sits at a crossroads.  We know what is best but we can’t get it to the patients through all of the advertising from companies and those that profit from those companies.  We are the doctors trained to identify problems and we know how to fix the problems but we know the public wants an inferior product even if can only line up the front teeth.  Personally, I believe in evidence based medicine; I would never allow a tech company to drive treatment in my office but I do want to balance patient desires with patient needs as is best stated below:
 

“It is not possible to practice patient-centered orthodontics not based on evidence, nor is it possible to practice evidence-based orthodontics without considering the individual patient. The approaches complement each other; thus, both are necessary.”  

(Chauca, Florian Benicio, American Journal of Orthodontics and Dentofacial Orthopedics , Volume 153 , Issue 3 , 324)
However this is not the feeling of every dentist or even every trained Orthodontist.  Consider the excerpts from the following editorial that was recently published in the February 2018 issue of the AJO-DO comparing medicine to shopping for a cheap airline ticket on websites:
“Air travel used to be a product and a service. It was highly regulated, required an intermediary to purchase a ticket (travel agent), had well-demarcated differences in class seating and amenities that were identical across all competitors, and was an “experience.” Consumers were expected to act in a certain way even though they were the customers (remember dressing for travel?). Then came deregulation of fares and rate transparency combined with instant communication via the Internet. It took a while, but travel agents became irrelevant even though they railed against the dangers of “do it yourself travel.” The claims the American Society of Travel Agents made about the risks of not using a travel professional were not enough to overcome a shift in consumer preferences, direct access to purchase, and low fares.”
The way it was, the way it ought to be, the way it is, and the way it will be.
Ackerman, Marc et al. American Journal of Orthodontics and Dentofacial Orthopedics , Volume 153 , Issue 2 , 165 - 166

This is what some “leaders” in our profession think of the future of Orthodontics, as if a travel agent is equivalent to an uneducated person selling air tickets.  Might as well tell the public we are no different than a spa or retail store.  The authors go further to justify:
“The current attitude and operational model in orthodontics does not mesh with the way it is and the way it will be with regard to the market for our services. It is mission critical that we create a sustainable market position for the 10,000-odd orthodontists in the United States and the hundreds of residents who graduate annually. We can't be successful in achieving this by colluding with regulatory bodies against purveyors of doctor-directed at-home aligner treatment or by trying to convince the consumer of the perils of do-it-yourself orthodontics …”
In other words, the authors believe we can’t fight public perception with facts and research so if we do not give them what they want, then there will be no place for future Orthodontists.  Again this is summarized in their closing statement:
“If we are truly interested in creating a new vision for orthodontics, we need to appreciate and to a large degree accept what the American consumer wants and expects from us. The sky's the limit!”
 
There is a time not so long ago when this kind of talk could get you sanctioned from the profession and to be honest I was somewhat in disbelief to see such an editorial actually accepted in our Journal. 
 

 

But it reveals the real fears and exhaustion felt by practicing Orthodontists.  Despite 95% of our research with studies focusing on braces and true medicine in Orthodontics, Orthodontists are starting to separate the profession away from the product and, I fear, are waving the white flag to corporate tech company advertising for the sole purpose of profit over quality and/or health of the patients.  There appears to be no sheriff in our profession to regulate advertising or salesmen/companies.
 

 
When do we as doctors make the distinction between what someone wants and someone needs?  How are we going to balance this in the future?  Some have given up, others try to educate patients and fewer of us are still holding onto our promise to do no harm (even the patient wants to take the risk).
 
 
 
I don’t have a crystal ball and I can’t tell the public where my profession may be in the next 5 to 25 years.  But the fact remains proven and solid: if a patient or parent wants the best treatment, the fastest results, the most stable results with the least risks and best outcome with esthetics AND function, then traditional Braces are the clear choice!


 

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 

 

Wednesday, April 11, 2018

How Facebook is Dumbing Down Orthodontics


Dumbing down the Specialty of Orthodontics; How profit-based companies are using Facebook and Google to mislead patients and reduce the quality of modern Orthodontics.


Currently on “the Hill” the founder and head of Facebook is giving testimony on false news and propaganda that his platform has allowed to insinuate are truths.  By combing through the tens of millions of Facebook accounts, algorithms (data processing) and Artificial Intelligent produced by Facebook mined public accounts privately to screen and direct the public to specific companies (or propaganda) based on payment from advertises and not based on facts or truth and without ethical standards or oversight.  The unsuspecting public just followed the ads and ended up being directed to companies who paid Facebook for customers and were allowed to say and claim anything while directing patients to their own biased doctors.  This would have been unethical and illegal in traditional advertising but social media escapes all scrutiny (until recently due to election advertising and bots).

 

I admit I do have a business Facebook page though I am not very keen in social media and there are long times when it goes untouched.  But I was truly horrified to hear that a full 60% of Americans get their news from Facebook.  For years now I have been getting solicitors offering to advertise with Facebook and social media; to use formulas and trade secrets to target my ads and focus prospective patients to my doors.  I even remember when I was setting up my latest website that the hosting company was having ads for Invisalign (pointing patients to my very competitors!) run alongside my site in exchange for some animation aps that I added.

 



“… 60% of Americans get their news from Facebook”
 
I guess it is just a shock that people would take ads on Facebook as absolute fact but I am learning that I just see things different then the public in total.  This is clearly a problem in many fields and subjects/sectors or young Mr. Zuckerberg would not be worth some 33 Billion dollars (all from advertisers paying Facebook to spread their “word”) based on a “free” website platform he provides.

 

A Quick History of Previous Public Knowledge

 
A little over 20 years ago the practice of Orthodontics was a very specialized and advanced field of dentistry having developed from 100 years of research and trials.  Certification required two to three years of advanced post-doctorate training at an accredited Dental School where Orthodontists studied all of the past research and history as they were tutored by highly experienced, expert Orthodontists treating upwards of a 100 patients under the guidance of their mentors.  Orthodontists learned that function of the dentition is paramount for the health of the joint, future wear of teeth and stability of alignment. 
 
In fact, Orthodontists learned that function and occlusion of teeth were more important than esthetics (we were of course taught to create beautiful smiles along with the function).  Lining up teeth for a pretty smile is the simple part, it is the first step with braces and usually takes only 6 to 12mo; it is the movement of the roots and the coordination and fitting all of the teeth within the individual arches (in a moving jaw) that introduced the real difficulties with tooth movement. 
 
Understanding the inflammatory process as well as bone physiology and growth of the face and jaw also required much more education than typical dental school could provide.  An understanding of Physics and differential forces was required to control not just the movements but also maintain the anchorage on other teeth. 
 

“the public used to be educated directly by the Specialists and their professional organizations under strict ethical and moral standards”

 
In short, Orthodontists were highly trained and the public used to be educated directly by the Specialists and their professional organizations under strict ethical and moral standards.  There were no companies allowed to advertise directly to the public, this would have been considered unethical and biased (which it still is).  Likewise, General dentists acknowledged that although they were experts in restoration of teeth and replacement of teeth, they were nowhere near the competency of a specialist and they referred their patients to colleagues they knew could do a better job (in other words the needs of the patient outweighed the potential for profit).

 

 

So what has changed in the last 20 years?

 
About 20 years ago, a new product was being developed from the digital revolution; not from an Orthodontist or dentist, but from a tech person, a business entrepreneur.  They had no education or license to practice dentistry and were not bound by any ethical standards or licensing but they realized that they could use a laser to scan models of teeth and digitize a person’s dentition.  They formed a company and modified a method used by Orthodontists to correct mild rotations and relapse using a series of stone casts.  Instead of taking impressions and pouring stone models, they would capture a digital rendition of teeth which they could move incrementally on a computer.  For each incremental digital movement, they would produce a cast and then a clear plastic “aligner” tray that would incrementally move teeth to the positon altered in each cast.  This product was pioneered by Align Technologies and became known as Invisalign though now there are more than half a dozen different companies that provide the same clear trays.   It was an expensive process for minimal results but at least it avoided a new impression after each incremental movement and ultimately avoided braces in mild cases.

 
Initially only marketed to Specialists for  correction of mild rotations (for which they work well), it didn’t take long before these companies started marketing to the larger pool of doctors (General Dentists) who had little to no Orthodontic training mainly due to floundering from high overhead and inferior product.  General dentists in competitive markets that did not have enough restorative work to keep them busy jumped on the new aligners and it wasn’t long before they were pushing treatment previously considered inferior.  Once the public accepted the idea of straight-ish front teeth over a comprehensive functional correction, dentists (and some specialists) were more than happy to offer this “simple” solution that did not require expert education/certification or fixed braces.      

 
The next 10 years …

 

 
Over the next 10 years, Align Technologies evolved and managed a campaign to dumb down Orthodontics.   Being more of a tech business than a medical company, Align Technologies likely realized they did not want to have to comply to FDA testing and standards or regulations.  They instead turned to social media to get their product directly to patients.  With no regulation or oversight, Facebook was more than happy to push traffic to this new advertiser; same with Google.

 
General dentists (and even un-suspecting Orthodontists) then played right into their hands by selling the aligners to more patients which Align Technology rewarded with sending even moe patients.  Soon they were openly (but privately) claiming that they could provide equivalent treatment to traditional braces.  Responsible Orthodontists would offer InvisAlign to limited cases they knew could be treated and to adults who would not use braces but may accept clear aligners (even if the results were not as good as braces).

 
Many of us would use this opportunity to educate patients and hopefully get them to go for the full correction with braces (we are after all doctors and we should be trying to provide what is best).  But as specialists, good Orthodontists realized that partial movement is sometimes worse than leaving the original crowding so some patients were refused aligner treatment; these patients soon learned that many general dentists were not so selective and were more willing to provide a lesser correction (many out of ignorance, many others simply for profit) especially those recommended by Align technologies via Facebook and Google.  As more Orthodontists started offering aligners on a limited basis, the dentists would point to them and imply they could do the same for less (insinuating all cases and all doctors are the same).  These same dentists stopped referring even difficult cases to Orthodontists.  The joke with most Orthodontists is hearing a general dentist today tell people “I only treat limited cases” when we know not a single patient has been referred out since offering clear aligners.

 
“As specialists, many of us realized that partial movement is sometimes worse than the original crowding so we refused to treat; these patients soon learned that many general dentists were not so selective”

 

 
After several more years of this, Orthodontists began seeing their referral sources drying up; they were no longer able to educate these patients because companies were coming between the patients and the doctors; bombardment and targeting of ads on Facebook, Google, TV and other social media was shifting patients that just wanted straight teeth and assumed braces to “want” Invisalign or other aligners with false expectations.  Many were patients that were never told aligners were inferior and unable to perform the same as traditional braces (see my previous posts on Does Invisalign work as advertised?) and many unethical dentists quietly acted like specialists to sell the product.  Many patients were actually treatment planned into Invisalign and other companies without any guidance from independent dentists or Orthodontists. 

Advertisers became emboldened realizing there was no regulation (as did some general dentists) and they began openly claiming Invisalign and other aligners were just “Invisible Braces” and would provide the same correction as traditional braces.  These aligner companies started creating levels of “expertise” in aligners and began pushing comparisons to the “old” and “outdated” traditional braces even to the point of drawing lawsuits from the American Association of Orthodontists.  Facebook is a prime example of a platform pushing misinformation.  Of course doctors already providing aligners could not speak up or they would look unethical.

 

 
Worse than that, out of fear of losing their patients altogether, many Orthodontists have panicked and just accepted offering aligners; it was the old “can’t beat ‘em so join them” mentality.  This is visible in many Orthodontists’ advertising today as they now compete with relatively untrained general dentists on social media sites for aligner patients.   Of course human nature then demands that these Orthodontists providing aligners must ardently defend and justify the aligners or they would face a backlash from their own aligner patients.  Actually quite brilliant use of Facebook and Google in an age with no regulation and directed onto a public that clearly is swayed by social media.
 

Does it matter that Orthodontics is seen as simple?
So why is this important?  Can we not just move forward into the 21st Century of dentistry with aligners for all and a beautiful-ish smile with no thought of function?  Do we even need a specialty anymore?  Who cares about function? Kids certainly won’t, they just want straight front teeth and isn’t it all about what teenagers want anyway? And besides, braces are unsightly so why not give the patient what they want?
 
As simplistic and benign as this may sound, it is creating a real problem in modern dentistry.  Companies have now been allowed to advertise and throw propaganda at the public with no real oversight or moderation.  And they are thriving thanks to Facebook and Google; squashing real research and drowning out 100 years of education and truth with half-truths/purposeful omission and sometimes just plain lies.  Claims are made and supported with “company sponsored research” even after being disproved by real research; articles that criticize or challenge these companies in any way are pushed to page 25 on google through the billions of dollars of advertising from Invisalign and any dentist that offers such. And if even a mention of dentistry, tooth alignment, smiles or braces crosses Facebook, Invisalign ads pop up immediately to claim they are the only answer and, by the way, here is where you can get it. 
 

So what are Risks of poor treatment?
When teeth are moved (no matter the appliance), there are risks of pushing teeth out of the bone causing recession or loss of bone and early loss of teeth.  These effects are not immediate however and may not show for many years, being later wrongly attributed to genetics or some other unknown when in fact it can be from poorly placed teeth. 


Note the recession of gums as the teeth have been pushed out of the bone to correct rotations.


Traditional braces allow more control in all three dimensions to prevent this and specialists are trained on what movements are good and which are detrimental.  Forces have been controlled and can be modified to suit the movement with specific wires, segmented wires, and good knowledge of physics.  Trays cannot control the force like wires, they have one thickness and all movement is based on distance or degree of rotation, not force.  They do not take into account bone density, physiology, individual morphology or differential root sizes/resistance in the bone.

 

 

Patient K.B. previously treated with Invisalign, fontal view.
 
 

Patient K.B. from the side showing protrusion of font teeth, pushed out by the aligners to correct rotations.  This patient still has a fixed lower retainer revealing that this is how the dentist left this patient as "completed".



 
Patient K.B. being re-treated with traditional braces to re-align teeth while pulling front teeth back/upright over the bone to prevent recession; permanent teeth were removed to allow full correction.



Patient K.B. during braces from the side.




Patient K.B. after traditional braces to collect the dental protrusion from previous Invisalign failure.
Patient K.B. after traditional braces were employed to upright the front teeth and center them over the bone to prevent recession. 
Compare these teeth now versus the initial protrusive teeth.  This treatment required removal of teeth which could not be performed with Invisalign so the dentist simply kept pushing the teeth out with the aligners until they lined up.
Function when chewing is very precise; placing teeth in “alignment” but not fitting them to the opposing teeth when the jaw is in function can absolutely lead to excessive wear on teeth, fracture of teeth, poor chewing efficacy and of course, chronic joint pain.  In fact, I have seen many cases that have interferences in the bite and poor function actually introduced by aligners and research confirms this (see the research study above).  Some patients present with new joint pain due to poor occlusion that was never there before their “alignment”.  This would never be accepted in restorative dentistry; would anyone go to a dentist that gave you a “pretty” crown that didn’t fit or had no contact for chewing?  Because that’s exactly what they sell you with aligner treatment.
 


 

All of these cases reveal bites that remain open with no contact on molars.  This has been shown to be a common problem with Invisalign (see research below).
 

Relapse can be rampant in aligner cases due to expansion of the dental arches to gain space by increasing the length of the arch.  For 100 years we have known not to expand the width of lower canines as they ALWAYS relapse but aligner providers just turn their eyes to this fact.  This is why aligner providers now offer many years of trays in case of relapse. But is this good for the teeth?  Constantly re-treating the teeth? Research continually shows increasing the time teeth are moved or are in treatment can lead to root resorption and loss of teeth.

 
Shortened roots from long-term tooth movement and re-treatment

In children we can expand the actual upper jaw bone (see my previous blog on expansion) however during our middle teens, these upper bones fuse and cannot be expanded without surgery.  That also does not stop unscrupulous dentists from “expanding” the teeth to gain space for aligners; unfortunately for the patient this only pushes the teeth out of the bone which will lead to either recession or immediate relapse after treatment.  If held indefinitely with a retainer, the patient may actually lose bone and eventually teeth from this procedure.  There are many cases that have been “treated” with Aligners that are being held with permanent retainers where recession is inevitable and the patient is ignorant of the ticking time bomb in their mouths.  Time will tell if the damage done on these patients is correctly attributed to previous poor treatment.



Just as in Patient K.B. shown previous, fixed bars are placed in these patients actually holding the teeth outward and over-expanded which is literally causing the recession right in front of the dentists' eyes.



In many adults with long-term crowding, the teeth have determined where the jaw bites down.  This normally includes a shift to one side or the other, front or back or even vertically.  Essentially, the jaw shifted around to a “best fit” and the patient learned to function there.  If the shift is too great, we get excessive wear and chronic jaw problems such as TMD.  Aligners cannot take this into consideration as the trays are made from the beginning.  Even with a modification of trays later in treatment, the jaw can continue to shift throughout the entirety of tooth movements as different teeth begin to hit and others no longer hit. 


 
As the jaw shifts, the relationship of every tooth changes but the aligners cannot accommodate this; you get upper teeth aligned (somewhat), lower teeth aligned the same, but then they do not fit together.  As the jaw now has to shift again to find a best fit after treatment, you introduce wear and tear on the teeth and joints and can create TMD where there was a balance prior to aligners.  Traditional braces are adjusted regularly and good Orthodontists look for these inevitable shifts throughout treatment.   Even with traditional braces, corrections can be very difficult causing changes or refinement in treatment many times along the way.
 
Of course compliance is a great concern as we see Invisalign advertised to kids even 12 to 13 years old (before 2nd some teeth are even fully erupted).  Nothing works if it is not kept in the mouth.  Brace are absolute; they work 24h and they show where any shifts in the bite occur; removing trays in and out can leave a memory of a poor bite throughout treatment which then is never corrected.  Also, teeth that do not move (and aligns simply cannot move all teeth), may be blamed on a lack of compliance putting the blame on the consumers when it is really the product or a combination of product and patient.  Roots can be difficult to shift though the bone making space closure more of a “tipping closed” with aligners instead of the whole root moving.  Theoretically they could move roots more but it would take four times as long and 100 more trays!  The most recent fake ads I have seen suggest Invisalign treatment leads to less plaque and better oral hygiene.  Studies now refute this false claim as well.
 
 
Compliance with removable aligners is not absolute; many cases simply do not finish and the patients simply stop pursuing the correction.

 
What does the Research on Clear Aligners REALLY show?

 
“Our results suggested that about 1.5 mm of overbite improvement can be expected when the Invisalign appliance is used in deepbite patients. A previous systematic review on the stability of deepbite correction reported an average of 3 mm overbite correction with fixed appliances [50% more effective with traditional braces]” 

Khosravi, R. Management of overbite with the Invisalign appliances AJO-DO April 2017

 
Invisalign [treatment results] only 41% mean accuracy of tooth movement with a range from 18% to 47.1% (j.ajodo.2007.05.018;www.ajodo.org)
 
Mean percentage of single tooth movement goal of only 57% (j.ajodo.2013.10.022). 

 
When results from Invisalign were compared to traditional braces using American Board of Orthodontic standards, the Passing rate of cases treated with Invisalign were 27% lower (j.ajodo.2005.06.002). 

 
Another more complete study (j.ajodo.2004.07.016) actually concluded that there was a “minimal improvement in occlusal score based on Board standards from 47 to 36.4 [0 being ideal] and there was a negative change (2.5x worse AFTER treatment) in posterior occlusion contacts with Invisalign.” 

 
This last investigator summarized Invisalign treatment by stating “According to the OGS [Objective Grading System used for the American Board of Orthodontics], Invisalign did not treat malocclusions as well as braces … Invisalign was especially deficient in its ability to correct large anteroposterior discrepancies [overjet] and occlusal contacts.”

 
Another article published April of 2017 in the AJO-DO (Journal of the American Association of Orthodontics) was published that confirmed previous findings (j.ajodo.2016.09.022) showing Inivisalign only 50% effective as braces in opening a deepbite and considering there is already an average relapse of @50%, the net change from Invisalign after treatment is zero.

 

So what’s next from these companies?
The next logical step is for these aligner companies, which have been storing information from years of cases treated by dentists and Orthodontists, to cut the dentists themselves out.  I am tempted to argue these doctors deserve as much but it is the public who will be left with a perception that Orthodontics is like bleaching your teeth or getting a manicure; as if you can do the same as a Specialty trained, Board Certified Orthodontist directly from a commercial on tv, a kiosk in the Mall or a mail order box of supplies. 

 
Facebook has already essentially convinced the public through Social Media and advertising on TV that only the front teeth matter; that Orthodontics is just about straightening front teeth with no need to mention function. They have used the general dentists to trick Orthodontists to offer and accept aligners despite the many shortcomings and high overhead; they have worked quietly to equate Inivisalign with “Invisible braces” and create a pseudo-specialty of providers that they refer directly.  Now that these advertisers have the patients directed to them through Facebook and Google searches, they are offering aligners with no dental supervision or an “off-sight dentist” to review or oversee the case which of course is nonsense as most of these products are made out of the Country in Mexico, China or Cosa Rica.

 

So is this the future, is Orthodontics dead?  Will we see the end of traditional braces?

 
It is a proven fact that traditional braces are far superior to aligners in many aspects of Orthodontics (see research below).  Of course you would never know this since billions of dollars in advertising are spent to bury actual scientific studies comparing Aligners to braces on every search engine and spent to direct anyone thinking about braces directly to aligner companies such as Invisalign or Smile Club (now partially owned by Invisalign); just try and google information about Invisalign and all you will find are ads for providers and efforts to “dispel myths” claiming Invisalign is just as good if not superior to traditional braces (information provided over and over by aligner companies, the largest being Align Technologies). And who do you ask if your dentist provides Invisalign?  Will they be objective and honest; will they know the research or even tell you they aren’t specialists?  Will they claim it is equal to braces?  Will they rely on fake news and fake information on Facebook?  Will they go to page 25 on Google? 

 
The future of Orthodontics & Dentofacial Orthopedics is really in the hands of the public.  If the public chooses to ignore function, ignore the way teeth hit and ignore the damage from poorly positioned teeth such as openbites or TMD Jaw Pain, then we may see the end of the specialty as it has been known. 

 
From the Orthodontists’ view, why go three more years into debt after four years in dental school and four years of college just to work through a very difficult post-doctoral program when you will just to go out and scan teeth for mail-order aligner trays?  Can we make the public want what’s best?  Can we counter a billion dollars a year in advertising against us?   Even in our own Journal thee was a letter to the editor from an Orthodontist chastising his colleagues for not giving in to what patients want, for resisting the inevitable and suggesting we are snobs for demanding a higher standard than what the public wants.  

 
He stated that we should not do things that hurt our profession financially and that it is far better to use aligners than lose the business to dentists.  I almost think it was a plant from an aligner company as the logical next step is to bypass doctors altogether. 

 
Companies know that from the patients’ standpoint, there is no reason to pay a doctor when they are just going to scan the teeth and send it away to Costa Rica or Mexico; why not just go to a kiosk in the mall and pay the company directly for the trays (yes this is already a thing)?  And Facebook is their vehicle to spread this propaganda.

 
Ultimately Orthodontists have done a poor job protecting the public from predatory advertisers representing these unregulated companies and even the American Dental Association has turned a blind eye so that general dentists do not lose a stream of revenue (after all, the ADA is made up of those dentists who don’t want to bite the hands that are feeding them). Orthodontists have been scared to speak out against their general dentists colleagues out of risking losing referrers; they instead just joined them in providing aligners which has now lent a false credibility to the companies’ advertisements and propaganda in the public’s eyes and lowered the standards of those specialists.  Facebook and advertisers in Google are winning and it has led to a predictable fall in standards.

 

Food for thought …

 
So will we see the death of true Orthodontics?  Will Orthodontists have to give up the cases that are simple and only treat the most severe or those that failed from aligners (expect $10k/case for real braces in the future if this is the case).  Will dentists even seek to become specialized if mail-order aligners is what the public demands?  Would a dentist put a crown in without proper function? These are serious questions as we witness for the probably the first time ever, a once respected profession turn into cheap salespeople and a respective branch of dentistry actually go backward after so many years of advancements. 

 
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com.