Tuesday, October 23, 2018

Braces v. Fake-Orthodontics; Public left to educate themselves about Orthodontics


Public left to educate themselves about Orthodontics;

Braces v. Fake-Orthodontics

I have written about the public’s perception of Orthodontics (see my Blog article entitled “Public Perception of Orthodontics”) as well as advertising/propaganda by social media and even by various companies and other non-Orthodontists offering lesser forms of Orthodontics or what I would term “fake-Orthodontics” such as Invisalign, etc. for many years.  However I feel I must re-visit this subject with a focus on Public self-education.



To understand what changes have occurred in marketing and advertising, we must first go back to a time when Braces were only used by experts.  As recent as 5 to 10 years ago, General Dentists performed routine dental care, root canals, fillings, restorative work (crowns, bridges, partials) and hygiene care.  And they did these very well.  At the same time, almost every General Dentist would follow the American Dental Association and American Association of Orthodontists guidelines to have every child see an accredited Orthodontist by age 6 to see if there were any early developing problems.  Teens and adults with crowding would be referred to the Orthodontist for alignment with braces. 

 

Why General Dentists referred patients to Orthodontists:

 

1.     They knew their education was limited on Orthodontics and that only the experts would be able to identify some problems early; they knew diagnosis was perhaps as important as the treatment.

2.     They cared about the long-term health of their family of patients; they knew they would be responsible in the future if something was missed early; they knew crowded teeth led to more cavities and could cause low esteem in kids and they trusted the Orthodontist to fix any problems.

3.     They wanted to offer complete service with the best options for all patients as a practice builder; they worked in a dental “community”; within a circle of professionals that were all masters of their field.

4.     There was a defined and established “Standard of care” from the ADA, AAO and every other governing boards of Orthodontics that mandated a specific proficiency and accredited education level to perform Orthodontics and General Dentists respected this ethical obligation.

5.     They knew a “Jack of all Trades” was a Master of None.  The whole idea for specialists was that there is too much information to be an expert in every field, this is why specialists also do not perform General Dentist procedures because in becoming an expert in Orthodontists, they could not also be an expert General Dentist.  Good dentists work as a team with their colleagues.

 

 

So what has changed, why are untrained General Dentists pushing “fake Orthodontics” or Invisalign/Clear aligners?

 

First of all, every point made above should be absolutely valid today.  Unfortunately, professional ethics in advertising and practice are not the same they used to be and there is so little oversight that the public is really left to the mercy of the dentist they happen to end up with (location, insurances accepted, costs, personal ethics).

 

I would argue one large problem in more populated areas has been a flood of General Dentists with a lack of restorative work to keep them busy and the rapid turn-over of practices, doctors and patients causing a move away from comprehensive general dentistry.  The trend today is to treat everything as fast as possible, do it all “in-house”, and then dismiss the patient.    

 

Insurance also has been a factor. Consider that a good, quality family dentist has to pay more for better staff, pay for an independent building or lease, buy his/her own equipment and maintain a pool of many patients over long periods of time for routine cleanings and monitoring.  A good family dentist is going to be around for many years; he/she will have to answer for any problems that may show years after treatments.   A dental company that employs dentists can share equipment, rent, and have limited to no long-term responsibility to patients.  Dentists come and go almost yearly and they have no personal responsibility for long-term dental care; companies can change dentists at an alarming rate and the company owns the records, not the employee dentist or Orthodontist. 

 

Companies can provide cheap service with less quality and can therefor accept lower reimbursement from insurances.  The more of these “dental factories” in a community, the harder it is for an independent dentist to succeed and the worse off patients are for comprehensive care. 

 

A new report last month in Dental Economics revealed an average overhead of 78% for sole dental practitioners.  Therefore, profit is only 22%.  Insurances ROUTINELY will offer HMO or PPO plans where the dentist must agree to accept lower fees in exchange for being an “exclusive provider”.  What is the discounted fee? Usually they require a full 20% discount of usual fees.  That’s right, nearly all of the profit of an independent office. 

 

 

“to accept this insurance [HMO’s and PPO’s], a dentist or Orthodontist is essentially only working to pay his/her overhead, staff and keep around 2% for profit”

 

In this environment, General Dentists start looking to increase profits by offering other services, even when they are not proficient or qualified.  They become “in-house” labs and “we do everything” clinics.  Little by little, as they introduce “fake Orthodontics” into their practice, they erode the standards of care and the entire field of Orthodontics suffers.



“General Dentists [offering Orthodontic treatment] erode the standards of care and the entire specialty of Orthodontics suffers.”

 

 

I had always been told by older Orthodontists in the previous generation that great quality will always beat out mediocre treatment but I am afraid this just is not the case in general; for one, the public goes for the cheaper route first (including insurance plans).  Secondly, it is very difficult for a patient to know what quality really is when they are bombarded by misleading advertising from Social Media, paid false testimonials, un-ethical General Dentists, Dental Factories and even Dental supply companies that present aligner trays (Invisalign, Clear Correct, Smile Club, etc., etc.) as equal to traditional braces.  It is equally difficult for an Orthodontist to advertise his/her quality to a public drowning in propaganda and social media hyperbole.  And it is uncertain whether a dentist providing “fake Orthodontics” will critique their own work if it is limited at best and more often quite deficient.  You can bet that no dentist would place restorations with the same poor occlusion they leave many times after Invisalign. 

 

 

“… no dentist would place restorations with the same poor occlusion they leave many times after Invisalign”

 

Advertisers, marketers and dental companies know every bit what patients want to hear and they exploit that routinely.  They also know they can bury the truth behind five pages of junk marketing and false claims on Google.  Just search braces or Orthodontists or even Invisalign directly and look at all of the paid advertisements; it’s impossible to find a real article about the efficacy or (in)effectiveness of Invisalign.  And don’t forget about the “art of omission” which is when a provider just says “I can straighten those teeth, let’s get an impression for Invisalign” with no mention of anything else or specialty care/standards.

 

“ …the “art of omission”… is when providers [general dentists] just says “I can straighten those teeth, let’s get an impression for Invisalign” with no mention of anything else or specialty care/standards.”

 

 

Unfortunately, as more General Dentists have been pushing the “fake Orthodontics” or Invisalign over the last 5 to 10 years, more real Orthodontists are seeing their referrals dry up and their practices losing patients unless they also provide Invisalign which is exactly the strategy of these companies; to give the other providers credibility once the specialists are also using their product.  It has become a giant game of dominos.

 




 
Something also more common in the last 10 years is that there are many more adults realizing the benefits of Orthodontics but they are more likely to resist braces; this has led to more patients treating but with inferior products such as Invisalign.  At first many of us figured some treatment was better than nothing for adults that would refuse braces.  But in the long run this has proven to create a monster of a problem as more teen are now being offered “fake Orthodontics” with aligners to try and attract them to one office over another (to tell them what THEY want to hear so they choose an office over another). This is all too common in Austin currently and is leading to rather poor treatments with low overall standards of care and many re-treats.
 
“At first many of us [Orthodontists] figured some treatment [clear aligner therapy] was better than nothing for adults that would refuse braces.  But in the long run this has proven to create a monster of a problem as more teens are now being offered fake Orthodontics with aligners to try and attract them to one office over another”
 
 
As a side note, there is also a population of dentists that will sell very large and expensive “instant correction” schemes to people instead of offering alignment by Braces.  Why? Because porcelain, ceramic, and now zirconia look better than previous generations and can cover small defects and discolorations as well as change the shape of teeth to make them appear straighter in some cases.  In the past, this would be frowned on by the dental profession as providing unnecessary dental work that damaged teeth (see the teeth being prepped for typical crowns below) and created a life-long dependence on replacement and future restorations (of otherwise healthy teeth).




I once even heard the president of the Capital Area Dental Society in Austin speak about his “Pearls of Wisdom” in a meeting with over 200 dental professionals; his “Pearl”? Shave crooked upper front teeth down and place porcelain crowns/veneers with straight front surfaces so the teeth would now be straight instantly.  Cost? $8,000 for the front six teeth.  Result? Six bulky front teeth that looked like Chiclets (yes that square, white chewing gum); opaque and monochromatic, with excessive overjet (buck teeth) due to the still-crowded inside surfaces contacting lower teeth.  Even if the front of the top teeth are made to look good (see below) the gums get squeezed out in areas and remain inflamed in many cases which can lead to periodontitis, recession and eventual replacement; opposing teeth will become severely worn and more dental problems will be created for the future.  Lower teeth can no longer be aligned because they would not fit the back of the upper teeth.

 

 
So what should the Public know?
 
“Orthodontics” is the science and practice of correcting malocclusions, not just making teeth pretty in the front.  It is a fallacy to call Invisalign a form of Orthodontics and certainly “Invisible braces” (I am sure they would disagree as would dentists that are heavily invested in Invisalign).  The facts show in almost every research study not paid for by Invisalign, and even some that are funded by Align technologies (their parent company), that traditional braces are far superior in every aspect of movement (refer to evidence presented in my Blog entitled “New 2017 Study shows Invisalign only 50% effective v. Braces” and “Does Invisalign work? (And should I believe all the Advertising)” with evidence and studies taken directly from clinical research studies published in the Journal of the American Association of Orthodontics & Dentofacial Orthopedics which sets the standards for modern orthodontics).  
 
 
“Orthodontics” is the science and practice of correcting malocclusions, not just making teeth pretty in the front.
 
In every AJODO study comparing Braces to Invisalign that I have read (and I believe I have read them all), Traditional (real) Braces are faster, more efficient, can move teeth farther with true root movements; they can be adjusted month to month as jaws shift changing the relationship and function of the occlusion and they are not compliance based.  In short, Traditional Braces provide Orthodontic corrections (ideal esthetics with ideal function and stability) while Invisalign and other clear aligners tip teeth to appear straighter without the ability to fully move teeth in all dimensions and leaves the occlusion worse off in many cases (again refer to articles presented in my Blog directly from the AJODO) and almost never equivalent to traditional braces.
 
“Braces are faster, more efficient, can move teeth farther with true root movement and can be adjusted month to month as jaws shift changing the relationship and function of the occlusion [v. Invisalign].”
 
So why doesn’t the public know this?
 
Unfortunately, technology has out-pacing regulations and dentistry.  Social media advertising has become the driving force in many direct-to-the-public campaigns and there have been no regulations and no oversight on social media, no rules or penalties for false advertising, no proof required to pass on propaganda (just look at recent elections). Companies learned this was a path for selling directly to the public instead of having to sell their product to a dental professional who then would “use” their product when it seemed appropriate or as the AJODO defined.  As a public company (no different than Coca-Cola or Hershey’s), Invisalign was run by business people, not doctors. 
 

 
They tested the public and learned exactly what the public wanted to hear, these companies then incorporated this into their social media campaign.  They also went directly to General Dentists to sell their product as a replacement for braces because Orthodontists were not accepting Invisalign as a good product for most patients.  Companies instead pushed General Dentists to provide Invisalign themselves and to profit from them without referring patients out to a specialist.  After enough years of this, and especially due to new generation of dentists that were “trained” by Invisalign marketers, almost every dentist now offers this “fake-Orthodontics” and most never refer a case out to the specialist.  Either through omission, ignorance, false claims or maybe just purely profit, it seems rare that patients are even informed of better treatment by these dentists that offer “fake Orthodontics” or Invisalign. (Refer to the Blog entitles “How Facebook is Dumbing Down Orthodontics” and “Orthodontics and Social Media”)
 
This has led to a reduced standard of care and an altogether attitude of “give the patients what they [think] they want.  As more orthodontists just give up, the future of true Orthodontics is quite literally in jeopardy.  That means true Orthodontic care to restore function, protect against TMD (jaw pain/joint disorders), provide a life-long functional occlusion and preserve natural teeth will be harder to find and more expensive.  It also means, as I have seen over and over, many cases will have been incorrectly, incompletely or poorly treated and require now require re-treatment altogether (you can see some of these cases in my other blogs titled  Braces ,,, For than just a smile” and “Braces are Better ! (and here’s why)”.
 
 
So how can patients wade through the propaganda and marketing to make sure they are paying for true Orthodontics and not a sub-par treatment?
 
First, find a good General Dentist that doesn’t try to do everything “in house”; look for someone that works his specialist colleagues to provide the very best for his patients and look for someone who is going to take time to formulate short-term and long-term treatment goals.  Talk to friends and neighbors to find a dentist that continues to follow up with patients and talk to the hygienist about the office you are seeing.
 
When it comes to any Orthodontic questions, get a consult with a true Orthodontist, preferably a Board certified Orthodontist if there is one nearby.  These are generally free of charge and very informative.  Once you are in the consult and if treatment is recommended, ask the Orthodontist for the best treatment option and have him/her provide benefits v. disadvantages of braces v. Clear Aligners if aligners are immediately recommended (I would ask them if they feel braces are faster & more reliable and can aligners move the teeth the same as braces).
 
Next, ask for similar cases already treated to see that this Orthodontist can do what they say with other cases.  All certified Orthodontists will take a full set of records on every patient (models, X-Rays and Photographs) and should have plenty of these cases to share with you.   
 
Finally, be sure and tell the Orthodontist you are expecting a successful and stable outcome; if the treatment with aligners fails, do you still have to pay for braces to finish (and who decides the results are failing)?
 
If you have a treatment with a General Dentist, you really have to have a certified Orthodontist check the results to see if your occlusion is acceptable after treatment; I have found it highly unlikely for dentists using “fake Orthodontics” to actually critique their work when complete and fewer accept issue with the bite thereafter.  If back teeth are not in contact after treatment, then you should demand this be corrected.  See my Blog “Does Invisalign work? (And should I believe all the Advertising)” to see some of the more common and obvious problems seen with Invisalign treatments.
 
Should you completely avoid clear aligners?
 
Even though Braces are superior in every way except esthetics during treatment (obviously the clear aligners are the least visible), that doesn’t mean you shouldn’t consider clear aligners for simple cases in adults.  Most people will not be able to distinguish a perfect bite from braces versus a good bite with aligners.  The problem for the public is that unless your doctor is an Orthodontist and offers both braces and aligners, you are probably not going to get an honest answer for the best treatment without some probing (and even then you may not). 
 
Orthodontists are held to a higher standard and will be more knowledgeable on when not to recommend aligners or when their inherent limitations are going to affect function after treatment. 
 
 
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, July 18, 2018

Orchestrate 3D v. Invisalign; which is better?


Why is Orchestrate 3D a better Aligner System than Invisalign?



Some 20 years ago, digital technology advanced to the point that lasers could scan your teeth and create a digital image to be manipulated by computer software and Invisalign was born. 
 
 
A patient being scanned with a laser scanning wand; note the digital image of the dental arch on the monitor.  Scanners like this can capture an entire dentition in a matter of minutes.
  
Certainly the pioneer of the clear aligner process, today Invisalign (Align Technologies) is not the only game in town (though they certainly would have the pubic believe this and they have purchased other start-ups to stomp out competition).  In fact there more than two dozen companies and labs now offering clear aligners and more join the field every year due to lax standards and essentially no regulation.
 
The question for prospective patients today is which system is the best for you and your family?
 
 
Set of Clear Aligners formed from 3D models following laser scan of teeth.
To answer this question, one must understand the process of traditional Orthodontics a bit more in detail. 
 
 
When you discuss braces, I bet you never ask “What brand of bracket do you use?” to your Orthodontist.  Why? Because you are paying for the Orthodontist and his/her expertise, not the brand of material that is used.  How the Orthodontist gets the job done is up to them and their training/experience.  Just like if you have a crown made, you don’t ask “What brand crown?” or “which lab will you be using?” 
 
As you would expect, there are many different brands of every dental supply we use as Orthodontists; different slot sizes, different metals, different wires, etc.  Some may even be better for one patient over another for whatever reason and based on experience.  A good Orthodontist would never handicap themselves as disciples of only one technique or one system.

 
 

And a good Orthodontist bases treatment on their understanding of bio-physics, not on the materials alone.  If one system is incapable or less efficient of movements needed, they will choose another system or appliance.  For instance, forces are being generated using some teeth as anchorage so that other teeth can be moved.  Some movements require tipping, others rotations or moments; opposing forces must be recognized and either countered or harnessed.  It becomes a very complex system as every force will have an equal and opposite force.  This is true whether we use aligners, braces or simple rubber bands.  
 
 
Newton’s 3rd Law
 
The old adage is that a good Orthodontist (using traditional braces) can fix teeth with a paper-clip which might be over-simplified but points out that it is the doctor, and not the material, that corrects the malocclusion and restores the function and the overall smile. 
 
“[with traditional braces] it is the doctor, and not the material, that corrects the malocclusion and restores the function and the overall smile.”
 
 
When aligner trays are used instead of traditional braces, the ability of the doctor to make changes to aligners mid-treatment and throughout the course of treatment is very important since all trays are pre-fabricated in almost all systems including Invisalign; in other words when certain trays fail to move a particular tooth or there is an unexpected force that opens the bite, future trays will be unable to make the correction.  The more failures along the way, the poorer the correction and the higher risk of leaving new malocclusions such as openbites, interferences, crossbites and incomplete uprighting of teeth.  In MANY cases, poor aligner performance from Invisalign introduces malocclusions previously not present at the initiation of treatment (see my blogs listing recent studies on Invisalign).
 
This is even more troubling when Invisalign “doctors” leave oversight to relatively under-educated assistants.  Invisalign would have you concentrate on their materials and technology but they neglect to educate the public on the role of the doctor (or lack of) as if the doctor has no role.  In fact they would prefer no doctor involvement which is why they have invested in aligners being marketed direct through TV commercials and kiosks in some malls.  In some sense there really is NO reason to go to a doctor for such incomplete care. 
 
But Invisalign cannot ignore biology.  Treatment without considering bone physiology, the inflammatory process or developmental processes is treatment in the dark.  Moving teeth though irregular bone in a functioning, living system that undergoes modification and changes throughout treatment (and thereafter depending on how we leave the bite or occlusion) takes a complete knowledge of that system and an ability to make changes along the way.  This is absolutely ignored by many who sell “aligner alignments”.

 
 

It is also clear in the literature (and confirmed regularly from my own 22 years of experience) that the jaw shifts as the teeth are moved throughout treatment (almost always in adults); some shifts will be predictable but some can be a surprise.  The relationship between upper and lower teeth can and will change significantly from the start to the end of treatment requiring modifications of the treatment plan along the way (continuous re-scanning if aligners are used).  Consider a perfectly good doorway after its foundation settles or moves.  After the shift, the door is identical, the jamb is the same.  But the door no longer opens.  It doesn’t fit because of the shift. 
 
Note the settled foundation and now off-set door.  No damage was done to the door but it no longer functions due to the shifting of the foundation.
 
 
The same thing happens to differing degrees when the jaw shifts during orthodontic treatment and a good Orthodontist will identify the shift, adjust his/her course of treatment and modify the force systems and even appliances being used to counter the shift.  Invisalign limits the Orthodontist’s ability to adjust for these changes.
 

What is Orchestrate 3D?  How is it better than Invisalign?
 
Orchestrate 3D is an aligner system used only by certified Orthodontists; it uses clear aligner trays the same as Invisalign and the other higher-end products but changes to the teeth (the angles and movements) can be performed completely by the treating Orthodontist.  Cases can also be reviewed by other certified Orthodontists at the beginning of treatment to gain from experience of other specialists. 
 
With Orchestrate 3D, teeth are scanned the same way as Invisalign but the raw image (.stl file) is sent to the Orthodontist directly and he/she makes all of the actual movements and attachments in-house on high power proprietary software owned by the Orthodontist and not a 3rd party.  Then models based on those changes can either be made in-house with a 3D printer or sent to a lab for printing based on the Orthodontist’s changes made in the software.
 
Another great difference between Orchestrate 3D and other aligner systems like Invisalign is that with Orchestrate 3D, the Orthodontist uses the models he/she created to make the aligner trays in-house; that means he/she can use different strength materials based on the movement of the teeth/compliance/fit of the teeth.  If rotations are too great, more pliable material can be used.  If there is a stubborn tooth, a thicker material can be used just for that movement or a new tray can be fabricated until the tooth moves. 
 
 
Finally, a huge advantage that I like about Orchestrate3D is that as the Orthodontist, I own the file start to finish; I don’t have to pay a third party company every time new trays are made or when changes in the dentition/jaw relationship warrant a new scan.  For very Orthodontist, this makes more difficult cases less costly and the Orthodontist more likely to re-scan as needed instead of just leaving some teeth unmoved.  I can limit myself to printing 5 to 6 trays in advance so that I can easily make digital changes for future trays in more severely rotated cases including placement of buttons on stubborn teeth mid-treatment.  This prevents the temptation of moving forward based on a previous jaw position or a previous scan when surfaces of teeth may have been initially hidden from rotations. 
 
In other words, Orchestrate3D is much closer to regular braces than Invisalign when used by a competent and experienced Orthodontist.  Most importantly, this assures you are paying more for the Orthodontist and not just for the material and lab techs to move the teeth.
 
“Orchestrate3D … assures you are paying more for the Orthodontist and not just for material and lab techs to move the teeth”
 
With other aligners like Invisalign, most of the time, you are paying for a technician to scan your teeth (the laser actually does the scanning), advertising for a corporate product independent of any doctor, royalties on the software that interprets the data and builds a digital image of your teeth (something a high school kid can do these days), and an unknown and likely uneducated third-world Country “technician”  to digitally re-set the teeth with a mouse into what they think looks and fits good.  Then to top it off, a relatively un-educated dental assistant approves the digital bite with a yes/no, and sets of trays are fabricated somewhere (again, usually in a third-world Country) and packaged in a clever container to present to you (again many times by the assistants) when it arrives back via UPS. 
 
 
You may ask (like I used to before speaking with so many colleagues) why a Dentist or even a real Orthodontist would leave there profession up to private companies, lab techs and third world technicians?  The answer is simple and I will be direct: Profit and ease of treatment (for the doctor).  The following are real responses I have gotten from dentists and Orthodontists and consultants/sponsored speakers at dental conferences:
 
“Why refer to a specialist when I can just send it to a lab like a crown?”
 
“Why go two to three years (after you are already a dentist) to learn about Orthodontics when you can just send the patient to have a scan and your completely done?” 
 
“Why place braces and take the time to see the patient every month and why worry about repairs and emergencies when they can give something that can simply be removed if it hurts?”
 
“Why figure out the physics and continue to evaluate each patient at each visit when you can receive all of the mail-order trays at one time and just give them all out or 4 at a time?”
 
“Why provide excellent care if the patient does not demand it?” (This was actually alluded by the head of Orthodontics in a New York Dental School!)
 
If you think there are higher motives than these, you are mistaken.

 
 

So can Orchestrate3D clear aligners be used with success?
 
The answer is yes in certain cases.  The following are general guidelines for proper Aligner Treatment:
 
  1. Proper examination and records.  No treatment should be planned without first obtaining a standard set of orthodontic records including photos (face, teeth and smile), a panograph X-ray and a side view or Cephalometric X-Ray.  There should be an in-person examination of the teeth and jaw BY THE DOCTOR so that function and joints may be assessed and the overall health of the gums and teeth are evaluated.  If there is bone loss or any other concerns/disease, then further records/consultation with other doctors may be needed.
  2. Proper Case Selection. Aligners are able to make certain movements on teeth but unable to move others; for instance a canine cannot be uprighted by aligners and teeth cannot be pushed into the bone adequately with aligners.  Also, some mal-occlusions are more due to discrepancies in jaw size, shifting of the jaws or more severe interferences; aligners are not able to correct significant overjet, deepbites or openbites with any stability. 
  3. Realize and acknowledge that there is almost no case that cannot be treated faster and to a better result with traditional braces.  Aligners are great only because they are relatively un-noticeable.  But aligners CANNOT move teeth as predictably, as far, as precise or as fast as braces.  If someone tells you otherwise, they are misleading you and you should question their motives.  There is nothing wrong with using aligners as long as you are informed and willing to accept the results.  Aligners will align front teeth and give you a better smile but be realistic in your expectations. 
  4. If aligners are prescribed without an option of braces, ask if it is the best treatment.  Ask if there are certain aspects that may not treat as well as braces.  If a dentist or Orthodontist flat out tells you it is a bad idea, you should heed that warning.  I personally won’t treat cases with aligners if they cannot make enough improvement in the smile, if they will risk significant malocclusions, if they will lead to certain relapse or if compliance is predictably going to be poor.  It is malpractice to offer something that we know will do harm.  That is not to say someone won’t sell you what you are asking for somewhere (usually down the street in my case), but don’t expect less risks from the same products especially from something like Invisalign that is made the same for everyone (less doctor-specific).
  5. Follow all instructions and DEMAND you see the doctor at every visit.  Ask questions as to the progress and if something doesn’t feel correct, make sure you bring it up with the Orthodontist before the end of treatment.   You ae indeed paying for the doctor, not the plastic or the assistant.
  6. Finish your prescribed course of treatment.  After speaking with dentists and Orthodontists over the last 20 years it has become clear that a significant portion of patients simply fade away and discontinue treatment on their own, I would wager it is @25%.  That is an amazing number but I assure readers that if they ask around they will see this is not inaccurate or exaggerated.
  7. Demand at least some occlusion on all back teeth at the end.  There may be less of a correction but the front teeth should look good and the back teeth should at least touch after treatment.  If not, YOU ARE NOT DONE!  Don’t allow any office to dismiss you without contact on your back teeth.
  8. Wear retainers.  Aligners relapse more often (much of this is due to poor treatment and/or poor case selection).  Aligner cases should expect to wear nighttime retainers indefinitely.
 
What are potential problems with poor Aligner treatment?
 
First of all, you can damage the roots of teeth and leave a bite that damages the edges of your teeth.  Over time this can lead to chronic jaw pain, multiple restorations and even loss of teeth.  You can EASILY leave teeth worse off than when you began even if they look straight.  I repeat, EASILY.  Pushing teeth outside of their natural arch form will lead to recession (gums falling away from the teeth and exposing the roots), relapse and/or sensitivity.
 
Will the dentist tell you if the treatment was a failure?  Some will I know because I see patients referred after failure of aligners, but many (especially those who are treating without adequate knowledge or morals) will not and patients are left with chronic problems and sometimes chronic pain that Orthodontists now won’t touch.  If you question your correction and bite after treatment, see another Orthodontist and ask for an evaluation; these are generally free and can either give you peace of mind or inform you if there is indeed a problem.
 
It is up to patients to ask the right questions, interview prospective doctors and filter through the direct advertising that bombards the public regularly in search of more dollars.  Remember Orthodontics is about your smile but equally about your function and dental health for the future.  And remember what you are paying for and what questions to ask BEFORE entering into treatment with anyone.
 
 


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, July 11, 2018

(In)Accuracy of Invisalign spotlighted in recent study.

New Study Continues to Confirm Invisalign Inferior despite Claims by Advertisers and Dentists
 

 
 
Once again, the most recent study published in the American Journal of Orthodontics & Dentofacial Orthopedics (https://doi.org/10.1016/j.ajodo.2017.11.028) confirms Invisalign along with the other clear aligner systems are inferior to braces and lead to insufficient movements, inability to correct teeth, inaccurate predictions and excessive relapse after the partial corrections (see excerpts of the article below).
 
In recent years, researchers have used several methods including the American Board of Orthodontics objective grading system, Peer Assessment Rating scores, and other objective occlusal criteria to assess the quality of Invisalign treatment.1-12  The most notable conclusions were that Invisalign is not as effective as fixed appliances [Braces] for expansion,6 it seems to cause more relapse,5 and it is not very effective in controlling buccolingual inclination,4,10,11 occlusal contacts,4,10,11 occlusal relationships,4,11 overjet,4 and overbite.7
 
It should also be noted that results of this study are based on hand-picked cases that were deemed successful but still had to be refined due to failures in movement and inability to achieve predicted results.  In other words, these were patients that wore aligners, were compliant with wearing the aligners AND were chosen as good candidates with minimal movements by expert Orthodontists and they still failed.
 “All achieved rotations were significantly smaller than the predicted ones by different amounts.”
“ …the achieved rotations and vertical movements were significantly different than predicted.”
 
 
In fact, many studies published in the dental Journals have repeated similar results from different samples rating the success of aligners v. braces and all have found that aligners are simply inferior to braces (see the list of references at the end of this blog).  The real question is when can aligners be used for acceptable outcomes even if they cannot perform as well as braces.
 
Unfortunately due to advertising, poor public education (if not outright being misled by so-called professionals) and patients’ overall preference to clear aligners over braces, many patients are being offered a treatment that simply will not work.  There will always be improvements in alignment that are noticeable, but when do we as doctors draw the line on what is success versus what is improved but ultimately a failure?
 

 
And who is the public going to go to for advice when the professionals have simply given up trying to overcome the false advertising and just give in to offer what the patients demand?
 
Recently the head of Orthodontics at a prominent New York Dental School outright suggested in a letter to the American Journal of Orthodontics that Orthodontists need to just lower their standards and give the patients what they want even though we know the failure rate and relapse rate are high and the predictability is poor even with mild cases!  His reasoning was that we will be out of business if we do not just give them what they want.  This is an educator that has given up on educating.  No different than a principal at a school telling teachers not to teach algebra, chemistry or physics because parents feel they will never use them (and they are hard subjects for the kids) and kids/parents have been complaining.  Is that the school you want your kids enrolled; or the principal you want running it?
 
 
So I ask the same questions I have every time a study confirms the inferiority of Invisalign (and ever since I stopped using Invisalign 15 years ago when it was clear results were poor); What is the future of Orthodontics?  Are we only about the front six teeth or are we there to improve the function and the bite?  What responsibility do we have as dental specialists to provide care that improves function of the teeth and jaw and what liability do we have for providing a “service” that actually does harm to the bite even if the front six teeth look straight-ish?

Does the public in whole really just want a short-cut even though it may harm their teeth/jaw/ability to chew?
 
 


The public seems to have forgotten that Orthodontics is a specialty in the first place; why it takes two to three years AFTER becoming a dentist to be proficient enough to actually practice as an Orthodontist.  From experience over the last 22 years in practice, I can say there are far too many un-ethical professionals out selling a product they KNOW is inferior under false pretenses and solely for profit without concern of “do no harm”.  I worry about doctors that will push an inferior product on patients, products that can harm patients over time, instead of offering what they KNOW is best (and usually FAR superior); makes me wonder what else they will do for profit.

  

“I worry about doctors that will push an inferior product on patients, products that can harm patients over time, instead of offering what they KNOW is best (and usually FAR superior); makes me wonder what else they will do for profit.”

 
There is far too much money in advertising pumped into social media and TV by Invisalign to counter with a simple blog by this humble practitioner.  For now, it is up to the public to wade through the noise and seek out good advice.  If you are looking for a good Orthodontist you can trust, I suggest reading my earlier blog on selecting a family orthodontist.

 
A full view of the article may be seen at : https://doi.org/10.1016/j.ajodo.2017.11.028
Accuracy of clear aligners: A retrospective study of patients who needed refinement
Orfeas Charalampakis,a Anna Iliadi,b Hiroshi Ueno,a Donald R. Oliver,a and Ki Beom Kima
St Louis, Mo, and Athens, Greece
(ajodo, July 2018)

 

Further information and studies concerning Invisalign can be found listed in several of my other Blogs including, “Braces are Better … and here’s why.” and “Does Invisalign really work as advertised?”.

  

1 Bollen, A.M., Huang, G., King, G., Hujoel, P., Ma, T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 1: ability to complete treatment. Am J Orthod Dentofacial Orthop. 2003;124:496–501.Google Scholar
2 Clements, K.M., Bollen, A.M., Huang, G., King, G., Hujoel, P., Ma, T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 2: dental improvements. Am J Orthod Dentofacial Orthop. 2003;124:502–508.
3 Baldwin, D.K., King, G., Ramsay, D.S., Huang, G., Bollen, A.M. Activation time and material stiffness of sequential removable orthodontic appliances. Part 3: premolar extraction patients. Am J Orthod Dentofacial Orthop. 2008;133:837–845.
4 Djeu, G., Shelton, C., Maganzini, A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop. 2005;128:292–298.
5 Kuncio, D., Maganzini, A., Shelton, C., Freeman, K. Invisalign and traditional orthodontic treatment postretention outcomes compared using the American Board of Orthodontics objective grading system. Angle Orthod. 2007;77:864–869.
6 Pavoni, C., Lione, R., Lagana, G., Cozza, P. Self-ligating versus Invisalign: analysis of dento-alveolar effects. Ann Stomatol (Roma). 2011;2:23–27.
7 Krieger, E., Seiferth, J., Marinello, I., Jung, B.A., Wriedt, S., Jacobs, C. et al, Invisalign® treatment in the anterior region: were the predicted tooth movements achieved?. J Orofac Orthop. 2012;73:365–376.
8 Krieger, E., Seiferth, J., Saric, I., Jung, B.A., Wehrbein, H. Accuracy of Invisalign® treatments in the anterior tooth region. First results. J Orofac Orthop. 2011;72:141–149.
9 Kassas, W., Al-Jewair, T., Preston, C.B., Tabbaa, S. Assessment of Invisalign treatment outcomes using the ABO Model Grading System. J World Fed Orthod. 2013;2:e61–e64.
10 Li, W., Wang, S., Zhang, Y. The effectiveness of the Invisalign appliance in extraction cases using the ABO model grading system: a multicenter randomized controlled trial. Int J Clin Exp Med. 2015;8:8276–8282.
11 Buschang, P.H., Ross, M., Shaw, S.G., Crosby, D., Campbell, P.M. Predicted and actual end-of-treatment occlusion produced with aligner therapy. Angle Orthod. 2015;85:723–727.
12 Grunheid, T., Gaalaas, S., Hamdan, H., Larson, B.E. Effect of clear aligner therapy on the buccolingual inclination of mandibular canines and the intercanine distance. Angle Orthod. 2016;86:10–16.
13 Chisari, J.R., McGorray, S.P., Nair, M., Wheeler, T.T. Variables affecting orthodontic tooth movement with clear aligners. Am J Orthod Dentofacial Orthop. 2014;145:S82–S91.
14 Drake, C.T., McGorray, S.P., Dolce, C., Nair, M., Wheeler, T.T. Orthodontic tooth movement with clear aligners. ISRN Dent. 2012;2012:657973.
15 Kravitz, N.D., Kusnoto, B., Agran, B., Viana, G. Influence of attachments and interproximal reduction on the accuracy of canine rotation with Invisalign. a prospective clinical study. Angle Orthod. 2008;78:682–687.
16 Kravitz, N.D., Kusnoto, B., BeGole, E., Obrez, A., Agran, B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135:27–35.
17 Simon, M., Keilig, L., Schwarze, J., Jung, B.A., Bourauel, C. Treatment outcome and efficacy of an aligner technique—regarding incisor torque, premolar derotation and molar distalization. BMC Oral Health. 2014;14:68.
18 Rossini, G., Parrini, S., Castroflorio, T., Deregibus, A., Debernardi, C.L. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85:881–889.
19 Simon, M., Keilig, L., Schwarze, J., Jung, B.A., Bourauel, C. Forces and moments generated by removable thermoplastic aligners: incisor torque, premolar derotation, and molar distalization. Am J Orthod Dentofacial Orthop. 2014;145:728–736.
 

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. Waters with his family on vacation in Oregon.
 

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 and member of the College of Diplomates of the ABO.  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. 
 
 
Contemporary Orthodontics of Austin, Central Austin, TX
 
 
Steiner Ranch Orthodontics, Steiner Ranch (West Austin)