Contemporary Orthodontics & Dentofacial Orthopedics
James
R. Waters,
DDS, MSD, PA
Board Certified Treatment for Children, Teens and
Adults
Outsourcing your Orthodontics; the
Invisalign Generation
Consumers today have been bombarded by advertising efforts
to align their teeth with “invisible trays” or “invisible aligner trays”, first
by corporate advertising but later by their own general dentists and friends. In fact now, even the specialists have been
squeezed to the point that many have just given in to consumers’ desires and
now offer extensive treatment with clear aligners knowing that the overall
occlusion cannot be fully corrected.
As a practitioner for 19 years and a Board certified
Specialist who was training when Invisalign was first introduced, I have been
witness to the evolving marketing from correcting minor alignment, to partially
correcting the front teeth to now correcting adolescent crowding and severe
malocclusions. The initial introduction
was created for specialists to correct minor relapse or alignment when the
roots were already in good position with the idea that the Orthodontist is
trained well enough to know the limitations and to realize when function would
be compromised.
Within a short time, the General dentists sued the
manufacturer and the settlement allowed the General dentists to begin using
Invisalign without the extensive base of knowledge or experience that a
specialist has earned. Within the next
10 years, every dental office that needed to supplement their income began
offering these trays until the specialist realized that if they did not
“embrace” these trays, then the majority of adult patients would pursue
treatment elsewhere even if the education and experience level was very low.
Today, I would argue due widespread failures and relapse
seen with clear aligners, dentists are trying to increase their profit base by
offering trays to teens. Of course with
compliance paramount for any movement and with patients still growing (altering
the relationship of the teeth during treatment), we can only expect more
failures. I am particular amused (and
disappointed) to see recent graduates with only a couple of years experience, yet
to finish even 100 cases, claim they can do anything with aligners from teens
up to adults; then leaving the care of the patients up to whatever the
technicians in India provided and whatever forces the trays from Mexico can
exhibit. When it doesn’t work, they
either blame the patient for a lack of compliance, or they claim “that has
never happened” and then place real braces to “finish”.
And if the consumer attempts an honest research of the
systems, they again get bombarded by a deluge of self-described experts and company-provided/biased
“articles” blocking any real critique on search engines. These companies spend millions to keep their
products in favorable light online where there is no standard of truth and no
ethics. I would wager that Invisalign
alone or it’s “top providers” own at least the first 5 pages of Google at any
one time.
“These companies spend millions to keep their products in favorable
light online where there is no standard of truth and no ethics …. Invisalign
alone or it’s “top providers” own at least the first 5 pages of Google at any
one time.”
So what exactly is the process for aligner trays and how can
so many non-specialist dentists offer it if they don’t have extensive knowledge
in orthodontics? Simple, clear aligner
providers exist by outsourcing the treatment from the digitizing of the
impressions and teeth to the movement of the teeth digitally, to the
fabrication of the treatment models and finally the fabrication of the trays.
Then, to add to the mix, most have their limited trained assistants with little
to no formal training, place and monitor the trays from appointment to
appointment. It has become common to
even hand out months of trays to the patient with instruction to just change them
out to tighter trays every 2 to 3 weeks without any supervision.
“clear aligner providers exist by outsourcing the treatment from
digitalizing of the impressions and teeth to the movement of the teeth
digitally, to the fabrication of the treatment models and finally the
fabrication of the trays ….. most have
their limited trained assistants with little to no formal training, place and
monitor the trays from appointment to appointment”
How long will it be before there are scanning kiosks in the
malls and mail-order treatment with more outrageous claims? Probably not long. So is this a service to the public? Is this what to expect for the future? I would say no to both and so would most true
Board Certified Specialists. Do I
compete with dentists and other orthodontists that provide and even push
aligners looking to pad their bottom line?
Yes, but I maintain that as a specialist, I should only treat to the
highest standard. It is not my place or
the philosophy of any specialist to offer less than the best functional and
esthetic correction and it is malpractice to knowingly introduce functional
problems at the expense of lining up the “front six”. I have seen many of the parents of some of my
patients with atrocious and iatrogenic (doctor introduced) malocclusions that
are only missed because the dentist who provided the “correction” did not
critique his own work and no one else sees the patient’s teeth unless they
change to a new dentist. I would wager
that if every patient “treated” with aligners switched to a good dentist and
asked about their bite, a large majority of them would be shocked at the
assessments.
“It is malpractice to knowingly introduce functional problems at the
expense of lining up the “front six … I would wager that if every patient
“treated” with aligners switched to a good dentist and asked about their bite,
a large majority of them would be shocked at the assessment.”
So is it wrong to only partially correct alignment if there
is no functional malocclusion present or introduced? Not necessarily and many
adults are just looking for a little alignment but they should receive
realistic expectations including limitations and possible problems after a
partial or incomplete alignment such as a shift in the occlusion, premature
contacts, an openbite due to incomplete alignment and settling, and even
possible joint discomfort. Aligners are
simply unable to move the teeth the same as fixed braces and perspective
patients need to know when limited treatment is acceptable and when it is
contraindicated (this is of course where it becomes more important to seek
advice of a certified and ethical Orthodontic specialist).
“Is there an alternative that isn’t made in
India or Mexico, leaving control to the orthodontist at every level?”
There is (although there is still limitations even with a
better aligner system since the trays have to be loose enough to be removed and
changed out by the patient); Orchestrate is the only clear
aligner system made by and for Specialists only. It has the same technology where the teeth
are scanned with a 3-D laser and digitized.
But instead of sending the file to India and having the trays fabricated
in Mexico, Orchestrate allows the Orthodontist himself/herself to move the
teeth digitally in all dimensions, fabricate models with a 3-D printer and make
clear trays as they are needed, all on-site under the control of the Specialist. Tray materials can be changed based on the
needs (more flexible trays v. stiffer trays), and even partial trays can be
used in conjunction with fixed braces where more force is needed (once the more
difficult movement is made, the bracket can be removed and the remaining
treatment completed with trays. It is
fully customizable and controlled on-site by your well trained specialist.
“Orchestrate is the only clear aligner system made by and for
Specialists only …. Orchestrate allows the Orthodontist himself/herself to move
the teeth digitally in all dimensions, fabricate models with a 3-D printer and
make clear trays as they are needed, all on-site under the control of the
Specialist”
In my practice, I offer Orchestrate but I educate the
patients before offering such and I do not recommend removable aligner trays
for a growing adolescent. I also offer
the same treatment with clear braces which is usually half the fee and half the
time estimate so the patient knows all the facts. In the long run, I would rather lose patients
to aligner providers than treat patients with sub-par outcomes that are bound
to relapse or create functional problems following alignment. Unfortunately this may not be the common
philosophy and once treated poorly, many cases cannot be recovered once damage
is done (at least without significant effort and cost).
So when looking for treatment, consumers must consider the
education and reputation of the provider, they need to understand the
difference between a general dentist and a specialist Orthodontist, and they
need to be able to discern between what they may want to hear and what they may
actually need. Consumers should ask
questions about education levels, they should be wary of marketing materials
not endorsed by the American Association of Orthodontists or the American Board
of Orthodontics and they should ask for the limitations and risks of aligner
treatment versus fixed braces. Finally, consumers should use common sense
when considering treatment with removable aligners; clearly if they really
worked in most cases, we simply would not still use braces and specialists
would not need 3 years of advanced, post-doctorate residencies to move 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.
Dr. Waters and his wife of 19 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.
Central Austin
1814 W. 35th
Street
Austin, TX 78703
(512) 451-6457
Steiner Ranch
4302 N. Quinlan Park
Austin, TX 78732
(512) 266-8585
Bracesaustin.com
