Thursday, June 14, 2018

Closing space between upper teeth (and keeping it closed)


Why does space between top front teeth keep opening up after orthodontic treatment?



Probably one of the most noticeable malocclusions in people with otherwise straight teeth is that of spacing between upper incisors.  In fact, there usually is fairly good alignment of the upper teeth in these cases so many times patients and parents think this is an easy fix.  Many may even try to close space with an upper clear aligner or upper braces alone only to find the space(s) return soon after closure. 

Space in the upper front teeth as an adolescent (after the upper cuspids have erupted) when there is no space in the lower can be a sign of heavy occlusion of the front teeth which in turn holds or pushed the upper front teeth outward; as the arch circumference increases (but the tooth sizes remain constant), the patient experiences gaps, usually between upper central incisors and lateral incisors.  It can be gradual or even develop as the patient transitions from baby teeth to permanent teeth.  If the patient is waiting on upper canines to erupt, the space may close when these canines fully erupt.  If the space is present after canines erupt, then there is usually a problem.  Over time, heavy contact can lead to excessive wear of the teeth, mobility or even recession.
 

Over time, the heavy contact on font teeth caused the enamel to wear down as the lower teeth continued to drive upward into the wearing teeth more and more; once into the softer inner dentin, the wear accelerated.
 

This heavy contact can be from excessive growth of the lower jaw forward (which brings lower teeth forward essentially “jamming” them into the back of upper incisors), upper front teeth leaning backward (termed “Division II”) or can from smaller than average upper teeth.  In rare occasions there can be an extra tooth under the gums which must be removed.  The sequence of eruptions and the timing of the lower jaw growth can also lead to a deepbite (early over-eruption of lower incisors) which also can cause heavy contact and spacing.


Extra tooth in the upper midline (termed a “mesiodens”) not allowing upper central incisors to move together.  These extra teeth must be removed (I prefer to remove them before treatment if there is already space for access).
 
Deepbite with premature contact on upper incisors.  This patient also presents with congenitally small lateral incisors making the space even larger between from teeth.
 




Following treatment with braces, spaces between front teeth are closed, the deepbite is corrected and the small lateral incisors have been built up with white “composite” material.

Sometimes the upper front teeth grow in and lean away from each other making the appearance of a large gap (see patient below); there may be contact but is hidden under the gumline.  In these cases, the teeth must be uprighted so that they lean back toward each other, this brings the contact point from below the neckline (below the gums) up to the top 1/3 of each tooth which can completely close the space.  This is something I see left in cases after treatment as patients come in with retainers “that won’t close the space” from other offices.  I have to explain to these patients that the teeth ARE in contact but it is below the gumline; to “close” the visible space we have to attach brackets to the teeth and tip them back toward each other as we shift the roots away from each other.  No retainer can close space when the teeth are leaning away from each other and already in contact below the gumline.

 

Patient previously treated with relapse due to divergent upper incisors; corrected by tipping the crowns of the teeth toward the midline while moving roots away from the midline. There was no treatment in the lower arch in this case as most of the upper space was secondary to poor root position.

 
So how can we fix the spacing and keep it closed?


If upper incisors are leaning backward then these upper front teeth must be uprighted first; this is a different type of case and is covered in other articles due to the unique complications of that malocclusion.



 

Upper front teeth leaning backward with lower front teeth over-erupted.  To close this space, the upper teeth must be “pushed” back up and the lower incisors “pushed” down as we also pivot the upper front teeth forward (see below).



Same patient after correcting front teeth, notice the space closes easily once the occlusion allows the teeth to bite normally.

 
 

Cephalometric Radiograph to asses tipping of front teeth (Division II)
 

But if the front teeth are not leaning backward (Orthodontists use a cephalometric or side-view X-Ray to determine and quantify this angle) then the answer is we must focus on the lower teeth first.  In almost EVERY case of heavy incisor contact and spacing in the upper arch, the first step is to pull lower front teeth back, away from the upper front teeth.  Once pulled back and there is room for upper teeth to also be brought back, then the upper space between incisors can be closed and held.  Patients should be given a couple of months at the end (before removing appliances) to allow the lower jaw to shift or “settle” because it may have been pushed back and held back by the patient subconsciously so that once it gains the freedom to move, it may come forward bringing the lower teeth forward back into contact; this requires more retraction of the lower teeth or the space will return. 

 
If lower jaw growth is significant enough, and the patient young enough, we may consider bringing the upper jaw forward (see my article on when to treat underbites). 


This 7 year old patient presented with an early developing underbite; correction required pulling the entire upper jaw forward with protraction headgear (see blog on when to fix underbites).
 

At 12 years old, following correction of the underbite from age 7 to 8, the patient no longer has space or heavy contact on front teeth.  In fact, no further treatment was needed or recommended.
 
Growth later in life can increase space that used to be minimal; the patient below is an example of exceptional lower jaw growth that was not corrected early as in the above patient.


This patient’s lower jaw has grown forward beyond the ability to simply reposition teeth; here, as an adult patient, we must either remove teeth and close space or even shift the entire lower jaw back with surgery before being able to close space in the upper arch.

Finally, once the lower teeth are pulled back (and aligned) and upper space closed and held to allow time for the lower jaw to shift, then retainers must be placed and monitored closely for the next 6 to 12mo to check for any heavy contact returning on individual teeth.  If a single tooth is still mobile 3mo following braces, you can safely assume heavy contact and relapse of space; this tooth should be marked with articulating paper (typewriter ribbon for us older folks) and adjusted with judicial polishing of the enamel in the offending spot(s).


If the patient can tap/bite on their back teeth and feel no movement in the upper front teeth, they are safe to go back to regular retainer wear.  But this should be checked regularly over the first year (and even further depending on the patient’s age and growth pattern) if you expect to keep the spaces closed.


“I have heard that the gums between front teeth must be cut to close the space,” what about this?

 
In the past, cutting the gum tissue between teeth with large space in the midline (frenectomy) was sometimes performed if the attachment of the lip was high and between the teeth (similar to being tongue-tied in the lower arch).  When this attachment is the problem, it is very deep and will require an oral surgeon to separate the tissue all the way to the bone (See picture below).  Unfortunately this is almost never done completely during “typical” frenectomies.  In truth, the tissue between two front teeth that have a gap is usually just filling the space because the space is already there; it is not normally the cause of the space.
 

These pictures illustrate a before and after frenectomy due to attachment of the frenum directly between the front central incisors.

Does that mean patients never need a frenectomy?

No. Sometimes the gap has been present so long that when the teeth are brought together, the tissue “bunches up” and becomes chronically inflamed.  In these cases, the excess soft tissue can be removed following space closure using a laser with minimal discomfort and quick healing.

 

My doctor wants everyone to have a laser frenectomy, is that wrong?
 
 

A good case from relieving the tissue that connect the lip to the gums (frenum or frenulum); if left to during development, this thick tissue will hold front teeth apart.
 

I believe there is a trend in offices that get lasers to be more aggressive in prescribing laser frenectomies.  There is some logic in reducing this tissue in some cases (see above) but until lasers, we just rarely sent out frenectomies for anything less than the most significant space.  I have seen no evidence that routine laser frenectomies are effective in most cases of spacing but I will continue to monitor the journals for a juried study to come out.  I will say that the sales people that market these soft-tissue lasers certainly stress the profitability based on X percentage of patients getting laser frenectomies every week which makes me a little wary if not somewhat nauseous.

This photo (borrowed from the Internet) shows a “successful” frenectomy that has healed nicely but you can see there is no effect on the initial spacing from removal of the frenum.
I do like the lasers for more surface-based frenectomies, they are faster than the scalpel and have less side effects/bleeding/discomfort, but I have seen early recession in one case so for now and as I mentioned previously, true cases of frenum attachment goes to the bone which requires actual surgery and not just a surface release of soft tissue.  So I am personally reserving referrals of my patients to really obvious and significant cases only.  And I rarely refer until the space is closed to prevent scar tissue from building which may actually make space closure more difficult.  
Laser fenectomy.  As you can imagine, this really should not be a routine service if not necessary.




What about just placing a permanent or “fixed” retainer on the upper teeth?

 
Sometimes you will hear of a friend or Internet buddy telling you a wire was bonded behind front teeth to hold space closed.  This is NOT the accurate way to keep space closed; although a wire may keep space closed, it may also leave the front teeth in heavy contact and cause sever wear, long-term mobility of teeth, enhanced periodontal bone loss or even lead to mild TMD (jaw pain).  It is a band aid and not a fix.  Now if a wire is bonded AND the bite monitored and adjusted for any heavy contact than that can be acceptable BUT in a good bite, there really usually is no room to bond a wire behind the upper teeth without causing heavy contact with lower teeth.  Also, bonded retainers hold plaque and can lead to decay and enhanced periodontal disease if not taken care of with ideal oral hygiene.

 


 
A bonded upper “retainer” behind front teeth; this makes cleaning very difficult and can cause heavy/premature occlusion with the lower teeth which can push the entire segment of upper teeth forward or lead to excessive wear in the lower teeth.  It can even push the lower jaw back.
 
 
 
 

 This retainer is in contact which is causing lower teeth to push the entire segment held by the wire forward.
 

A similar case where the fixed “retainer” held space closed at the midline but allowed lower teeth to push the entire segment forward (note the space on the left side).  You can also see the gingival margin inflamed.

 
 
Best advice?
Seek out a competent and establish Orthodontist that offers traditional braces and can show you before and after pictures years after treatment.  Space in the upper front teeth can only be properly closed (and held closed afterward) if the reason for the space is identified and corrected.   Just like any other field, there are doctors and there are really good doctors, it is up to you to find good advice and not just find someone who will tell you what they think you want to hear.  In this particular scenario, there is usually one right way and lots of wrong ways to close space; many will lead to relapse but good treatment with good retention will give you a life-long smile.  The most expensive orthodontics is that which has to be done twice (or more). 
 
 
Case previously shown before treatment; braces were used to pull lower teeth back THEN space was closed in the upper arch
 
 
Same patient 2 ½ years AFTER removal of braces showing good stability.  Retainers were discontinued at 18mo after 6mo of full time wear and 12months of nighttime wear.
 
 
 
 

 
Adult with spacing her entire life which led to fracture of a front tooth.  Correction with braces included retraction of the lower teeth followed by space closure in the upper arch.  After space closure a new crown was fabricated for esthetics.
 
 

This photo was taken a full 3 years after removal of braces and the space has remained closed; regular visits were used to monitor for any heavy contact on front teeth.
 
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 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 pretty 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?  Are advertisers and direct-to-customer companies lying by omission?

 
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.  Does the bone get larger as we push teeth outward?


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 aluminum cans.

 

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 used 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 used 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.