Friday, December 2, 2016

Is there more to Orthodontics & Dentistry than just Technology?



 
Is there more to Orthodontics & Dentistry than just Technology?
 
I have practiced Dentistry for 20 years; I have worked as a hospital dentist, a sole practitioner general dentist, an orthodontic resident and now, for the last 15 years, as a sole practitioner Orthodontist in arguably one of the most progressive and tech-savvy cities in America.  In this time I have seen the introduction of computers, the use of software to organize schedules and billing, the advent of electronic claims for insurance, the development of the Internet and the introduction of the digital age.  Lasers were introduced first for soft tissue incising and then for hard tissue preparation.  I have seen film-based radiography morph into computer imaging and have watched as digital images were created from three-dimensional laser-scans; digital files that were then used with new milling machines that could transfer the digital world back into porcelain crowns and prostheses.  In Orthodontics, this digital age introduced the advent of clear aligners made from sequentially altered digital scans of entire dental arches allowing incremental changes (tooth movements) to correct mild crowding.
 
    
    
 
With all of these wonderful technological advances, it may be prudent to stand back and balance the new shiny tools and machines with the older and well-tested dentistry of the recent past.  Today, technology is pushed by large dental supply companies to young dentists and specialists as almost a status symbol of modern dentistry; a kind of litmus test of how modern and up-scale a dentist may be perceived.  But is this really a good way to judge a dentist or Orthodontist?  Is there some point of diminishing returns where technology is just more expensive?

 
 
In addition to all of the “wonderful” technological advances, I have seen overhead climb from 50% up to 75% or more in “modern” dental offices.  Radiograph machines are now $80K to $150K up from $10K in the past and since they are digital, they come with expensive software and regular updates that challenge existing hardware and may lead to obsolete machines within just 5 years.  It used to be a dentist could count on 20 years for almost every item in their office but now computers must be all replaced to keep up with new operating systems and added hardware such as printers and scanners.  Software programs will cost a new office $25K to $40K initially with a “forever” maintenance fee of $2K to $4K yearly even if you have your own server however we now can expect higher Internet fees ($200/mo or more) as we move to cloud-based systems and un-ending revolving charges to keep the system working seamlessly. 
 
 
           
 
On the treatment side, the digital age brings more automated systems that reduce doctor time (and sometimes patient time) driven by a need to produce more (to pay for the new overhead) in less time.  Crowns can be made in a single visit as teeth are digitally scanned and porcelain is milled in special machines (another $50K to $75K) and aligner trays can be made to move teeth (at 10x the cost of braces) albeit with less accuracy and many more limitations.
         
                                                        
      
 
This has driven up costs and made the sole practitioner less common than larger multiple doctor offices and companies that can share these expenses.  This trend has also lined many pockets along the way from software companies to computer companies, from third-party labs to local and regional dental supply companies and of course companies that have learned to employ dentists that cannot afford to keep up with the Dr. Jones’ of the world.
 
But is there something inferior to lab-built porcelain crowns?  Is the new material better than the old?  Is the technology actually better than the doctor’s own hands and skills?  Perhaps in some cases, maybe in many cases but the truth is that there are still many things the doctor can do better without the newest technologies.
Laser scanning a tooth prior to preparation of a milled crown 
“Is the technology actually better than the doctor's own hands and skill?Perhaps in some cases, maybe in many cases but the truth is that there are still many things the doctor can do better without the newest technologies.”

Milled single-day "advanced" crown (dull, monochromatic and bulbous)
 
Hand-stacked laboratory fabricated crown; beautiful and natural with blended color to match teeth
 
 
Hand-made, Lab-fabricated crowns can be very beautiful by matching color variations and translucencies of adjacent teeth and matching the sizes of existing teeth more exactly while milled crowns have a tendency to be more opaque and mono-chromatic even to the point of looking like “chiclets” (referring to the white rectangular chewing gum).  Lab crowns may take 2 weeks to return from a good lab, and yes there is a lab bill for $100 or so per tooth, but there is no scan or milling machine necessary that must be paid for before it becomes obsolete.
 
 
Milled single-day crowns, opaque and "Chiclet gum" appearance
 


    
Beautiful laboratory hand-stacked fabricated crowns with natural translucency and color


Lab-created aligner trays are heavily advertised to the public as “Invisible Braces” in attempt to equate them to braces; these trays are made from laser scans sent to third-party companies (Invisalign, Clear Correct, etc.) and they appear to move teeth like braces but in fact, research from the Journal of the American Association of Orthodontics & Dentofacial Orthopedics (as well as any good orthodontist’s own experience) has repeatedly shown accuracy of movement to be on average, a dismal 18% to 57%.  These aligners will many times leave patients with poor or even no posterior occlusion which can then lead to excessive incisal wear and possible TMJ over time (see my blog Does Invisalign Work as Advertised?) 
 
Digital radiographs are convenient and fast (I certainly do enjoy the positive aspects of my digital machines) but they are not necessary to treat patients v. the older standard film based radiographs and in some ways are inferior.  Once an office goes digital, you can add another 10% to the overhead and therefore to the costs of treatment.  If you choose 3-dimensional radiography, expect anther 5% overhead for pretty pictures that are simply not necessary for the majority of cases and will introduce significantly more radiation.


Modern Cone-Beam Radiographic Machine

 

In short, dentists and dental specialists (Orthodontists in particular) must weigh the advantages of new technology v. the added overhead, the shortfalls and the maintenance of such advances.  As doctors, it is our responsibility to offer the best treatment, even if it is not the newest or most trendy available (i.e. braces v. Invisalign) and we should strive to keep patient costs down by keeping our own overhead reasonable.  If we continue to equate quality with technology, we will most certainly end up with automated dental care and faceless companies treating patients (usually to some average parameter instead of providing specific and unique quality care to each individual patient) and will lose the ability to develop a real doctor-patient relationship. 



3-D Image of the skull with Cone Beam Radiography
“dentists and dental specialists Orthodontics in particular) must weigh advantages of new technology v. the added overhead, the shortfalls and the maintenance of such advances.  As doctors, it is our responsibility to offer the best treatment, even if it is not the newest or most trendy available ..”


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 20 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 www.BracesAustin.com. 



Steiner Ranch Orthodontics
4302 N. Quinlan Park
Austin, TX 78732
512-266-8585



Contemporary Orthodontics & Dentofacial Orthopedics
1814 W. 35th St.
Austin, TX 78703
512-451-6457



 
 
 
 

 

Thursday, August 18, 2016

Does Invisalign work? (And should I believe all the Advertising?) Evidence Based Conclusions

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults  ______________________________________

Does Invisalign work?
(And should I believe all the Advertising?)

Evidence Based Conclusions

Modern technology has been assisting medical and dental care for many years; orthodontic treatment is no exception.  From bonding materials contrived by modern chemistry to alloys used in modern wires which arose from the recent space age, we all benefit from advances in science.  The most recent technological change has been the advent of digital imaging and digital scanning with three dimensional lasers.  Creating a digital copy of our teeth has allowed computers to reproduce our teeth and manipulate angles/position of teeth in the digital world which then led to producing three dimensional printings of the teeth with incremental “movements”.  Clear aligner trays can then be made with a vacuum machine over the digitally printed models with the intention of moving the teeth as trays are worn.  Each tray would have a slightly increased movement until a tooth (or teeth) moved to a new/corrected position. This is the idea and mechanism of all aligner systems such as Invisalign, Orchestrate, Clear Correct, and others.

As this new technology became commercially available and the companies (Invisalign in particular) went public (Align Technologies), treatment shifted from a doctor-planned and driven treatment to a patient/corporate driven treatment.  Now, companies like Invisalign advertise directly to the public referring patients to “trained” experts in their product (training that takes just a single day), even when most of the providers are not even orthodontists.  Over the last few years, this advertising has taken a toll on the traditional standards of Orthodontics stressing esthetics of the smile over the function of the occlusion.  Research has been slow to catch up with or verify claims from these companies.  Even worse, due to the power of advertising and the money put forward into promoting their product, it is becoming increasingly difficult to find un-biased studies which can show the true efficacy of the products.  Even now, when Invisalign is googled, you get pages of sponsored (and usually biased) links with heavy salesmanship and Invisalign-sponsored or authored efforts to combat the hidden limitations (what they refer to as the “Myths of Invisalign”) of the product. 

“Over the last few years, this advertising has taken a toll on the traditional standards of Orthodontics stressing esthetics of the smile over the function of the occlusion.”

Unfortunately it is quite difficult to combat something that the public has been told they want and told that it works as if it IS “Orthodontics”, the same as traditional braces; I even see it advertised as “Invisible Braces” which it certainly is not.  Because dentists can take an afternoon course for certification, and because dentists have generally seen patients before they are referred to Orthodontists, Invisalign and other companies are changing (I would argue negatively) the dynamics and the very standards of modern dental treatment.  General dentists that provide aligners do not have near the education in growth and development to properly diagnose an orthodontic case which in turn leads to many treatments that are incomplete, incorrect or even detrimental (see the studies on efficacy of movements in the studies below).  Now with Invisalign for teens, you have general dentists holding off on referring children for orthodontic evaluation/treatment because they want to offer Invisalign themselves later; this can easily lead to poor outcomes due to changes in growth which cannot be accounted for in aligners without multiple scans throughout treatment (and costly remaking of future trays over and over) and incomplete corrections due to waiting too late for optimal correction which may require treatment before all of the permanent teeth are erupted; in some of these cases, waiting to treat will also lead to a significant risk of surgery (underbites, openbites and crossbites).


So does Invisalign “work”? Well in some cases (and in some degree), yes.  Unfortunately it continues to fall short of complete correction on average with success of tooth movements ranging from a dismal 20% to 57% (in school we call this an F) and can cause significant malocclusion in patients by leaving the posterior teeth out of occlusion (see research below) thereby placing front teeth into hyper-occlusion.  Some studies have concluded that cases treated by Invisalign simply could not be completed without additional treatment including traditional braces.  Personally, I have found that in minor cases (those of which Invisalign or other clear aligner systems are best suited), braces could have treated the same teeth more reliably, cheaper and with less time versus starting with aligner trays only to have to finish in braces to fully upright cuspids or reduce overjet (but some people still will want the clear aligners for esthetics, seeing them worth the extra time and cost).  Dentists usually won’t have this option since they are not trained at all with braces so patients will just get what they get.

As an Orthodontist, I see many parents of kids I have in treatment that have chosen Invisalign or other aligner systems recommended by their general dentists because they were told it could fix their bite; many come in after their treatment with complete lack of contact on back teeth and multiple teeth that are leaning one direction or the other.  This is not to say aligners aren’t a great option for correcting mild crowding or closing spaces where the bite allows for closure and esthetics are of great concern during treatment however Invisalign (Align Technologies) has expanded their reach farther and farther into the public’s and general dentists’ imaginations and I am seeing more and more incomplete corrections.

So what exactly does non-biased, professional and juried research show when it is performed and published by non-Invisalign experts in the field?  To answer this, I will be referencing (and including) summaries of actual research published over the last several years by some of the top academic Orthodontic researchers across the Country, research appearing in the prestigious Journal of the American Association of Orthodontics & Dentofacial Orthopedics; the governing literature for certified Orthodontists.

Early in the introduction of Invisalign, the American Journal of Orthodontics & Dentofacial Orthopedics (AJODO, http://dx.doi.org/10.1016/j.ajodo.2004.05.002 ) published a report criticizing the advertising practices of the newly public company stating:
 Despite Align Technology's claims, orthodontic treatment and Invisalign therapy are not the same thing. The misrepresentation of orthodontic treatment in the marketing of Invisalign is a disservice to our patients. It is also at odds with the mission of the AAO, the ABO, and other well-respected orthodontic professional organizations. By emphasizing Invisalign's ability to achieve straight teeth, without mentioning the importance of a functional occlusion, ideal overbite and overjet, aligned marginal ridges, and long-term stability, Align Technology has effectively reduced the role of the orthodontist from that of a “knowledgeable dental specialist and professional” to that of an “esthetician.”
This article continued to reports that “Align Technology has blurred the distinction between general dentists and orthodontists about expertise in dental movement. By equating the experience of doctors using Invisalign to the return search list of recommended doctors found on Align Technology's website, orthodontic specialty training has been rendered inconsequential to the prospective Invisalign patient.”
As Invisalign became more widespread with general dentists, the specialty of Orthodontics began to study treatment with aligners and in 2007 the AJODO published a paper detailing exactly how effective Invisalign was at moving teeth; the summary is below.

How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign

Introduction
The purpose of this prospective clinical study was to evaluate the efficacy of tooth movement with removable polyurethane aligners (Invisalign, Align Technology, Santa Clara, Calif).
Methods
The study sample included 37 patients treated with Anterior Invisalign. Four hundred one anterior teeth (198 maxillary and 203 mandibular) were measured on the virtual Treat models. The virtual model of the predicted tooth position was superimposed over the virtual model of the achieved tooth position, created from the posttreatment impression, and the 2 models were superimposed over their stationary posterior teeth by using ToothMeasure, Invisalign's proprietary superimposition software. The amount of tooth movement predicted was compared with the amount achieved after treatment. The types of movements studied were expansion, constriction, intrusion, extrusion, mesiodistal tip, labiolingual tip, and rotation. 

Results
The mean accuracy of tooth movement with Invisalign was 41%. The most accurate movement was lingual constriction (47.1%), and the least accurate movement was extrusion (29.6%)— specifically, extrusion of the maxillary (18.3%) and mandibular (24.5%) central incisors, followed by mesiodistal tipping of the mandibular canines (26.9%). The accuracy of canine rotation was significantly lower than that of all other teeth, with the exception of the maxillary lateral incisors. At rotational movements greater than 15°, the accuracy of rotation for the maxillary canines fell significantly. Lingual crown tip was significantly more accurate than labial crown tip, particularly for the maxillary incisors. There was no statistical difference in accuracy between maxillary and mandibular teeth of the same tooth type for any movements studied.
The mean accuracy of tooth movement with Invisalign was 41%. The most accurate movement was lingual constriction (47.1%), and the least accurate movement was extrusion (29.6%)— specifically, extrusion of the maxillary (18.3%) and mandibular (24.5%) central incisors, followed by mesiodistal tipping of the mandibular canines (26.9%).”
Conclusions
We still have much to learn regarding the biomechanics and efficacy of the Invisalign system. A better understanding of Invisalign's ability to move teeth might help the clinician select suitable patients for treatment, guide the proper sequencing of movement, and reduce the need for case refinement.
From this article it is very clear that Invisalign cannot completely move teeth as planned.  Much of the movements were so poor that if you predict even a mild amount of relapse, there would essentially be no significant correction at all.  The research revealed that pulling teeth inward was most successful but still only 47.1% accurate.  Closing the bite through extrusion was particularly ineffective with only an 18.3% upper and 24.5% lower correction; since this movement typically will relapse to some degree no matter how you move the teeth, it is logical to assume there will be little correction of any openbite through Invisalign.  And since movement of posterior teeth in any other dimension will, according to the Laws of Physics, have a tendency to extrude (opening the bite), many cases will open and the aligners will be unable to accurately close the bites back.
Other studies continue to confirm these findings with only slight improvement (41% average in 2007 up to 57% in 2013) of Invisalign:
Variables affecting orthodontic tooth movement with clear aligners
Introduction
In this study, we examined the impacts of age, sex, root length, bone levels, and bone quality on orthodontic tooth movement.
Methods
Clear aligners were programmed to move 1 central incisor 1 mm over the course of 8 weeks. Thirty subjects, ages 19 to 64, were enrolled, and measurements were made on digital models (percentage of tooth movement goal achieved). Morphometric features and bone quality were assessed with cone-beam computed tomography. Data from this study were combined with data from 2 similar studies to increase the power for some analyses.


Results
The mean percentage of tooth movement goal achieved was 57% overall. Linear regression modeling indicated a cubic relationship between age and tooth movement, with a decreasing rate of movement from ages 18 to 35 years, a slightly increasing rate from ages 35 to 50, and a decreasing rate from ages 50 to 70. The final decreasing trend was not apparent for women. As would be expected, the correlation was significant between the percentage of the goal achieved and the cone-beam computed tomography superimposed linear measures of tooth movement. A significant negative correlation was found between tooth movement and the measurement apex to the center of rotation, but bone quality, as measured by fractal dimension, was not correlated with movement.
“The mean percentage of tooth movement goal achieved was 57% overall”
Conclusions
The relationship between age and tooth movement is complex and might differ for male and female patients. Limited correlations with cone-beam computed tomography morphology and rate of tooth movement were detected.
This is similar to my own experiences with aligner trays and the reason I use a system that gives me more control between each aligner (Orchestrate; https://www.orchestrate3d.com).  Other researchers actually compared Invisalign to traditional braces, publishing findings again in the AJODO:
Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system
Introduction: This treatment-outcome assessment objectively compares Invisalign (Align Technology, Santa Clara, Calif) treatment with braces.
Methods: This study, a retrospective cohort analysis, was conducted in New York, NY, in 2004. Records from 2 groups of 48 patients (Invisalign and braces groups) were evaluated by using methods from the American Board of Orthodontics Phase III examination. The discrepancy index was used to analyze pretreatment records to control for initial severity of malocclusion. The objective grading system (OGS) was used to systematically grade posttreatment records. Statistical analyses evaluated treatment outcome, duration, and strengths and weaknesses of Invisalign compared with braces.

Results: The Invisalign group lost 13 OGS points more than the braces group on average, and the OGS passing rate for Invisalign was 27% lower than that for braces. Invisalign scores were consistently lower than braces scores for buccolingual inclination, occlusal contacts, occlusal relationships, and overjet. Invisalign’s OGS scores were negatively correlated to initial overjet, occlusion, and buccal posterior crossbite. Invisalign patients finished 4 months sooner than those with fixed appliances on average. P < .05 was used to determine statistically significant differences.
Conclusions: According to the OGS, Invisalign did not treat malocclusions as well as braces in this sample. Invisalign was especially deficient in its ability to correct large anteroposterior discrepancies and occlusal contacts. The strengths of Invisalign were its ability to close spaces and correct anterior rotations and marginal ridge heights. This study might help clinicians to determine which patients are best suited for Invisalign treatment.
“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.”
Again, in a study which looked at results of Invisalign cases to determine success:
Evaluation of Invisalign treatment utilizing the American Board of Orthodontics Objective Grading System for dental casts

The purpose of this study was to evaluate the treatment outcome of patients treated with Invisalign aligners by using the American Board of Orthodontics Objective Grading System (OGS) for dental casts. The dental cast component of the OGS scores 7 categories for discrepancies from ideal related to tooth alignment and occlusion. Depending on the magnitude of the discrepancy, up to 2 points can be scored in each category; thus the fewer the points scored, the more ideal the result. A total of 135 patients treated with the Invisalign system and having pretreatment and posttreatment records were identified from 7 orthodontic private practices. If patients met the selection criteria, the dental cast component of the OGS was performed on the pretreatment and posttreatment casts. The selection criteria were (1) no missing teeth (other than previous premolar extractions), (2) Invisalign treatment exclusively, and (3) available pretreatment and posttreatment models of diagnostic quality. Pretreatment and posttreatment OGS scores were compared, and the differences were analyzed by using paired t tests.
Results showed that, of the 135 subjects, 65 (48%) met the inclusion criteria. These were evaluated with the OGS. For those not included in the OGS analysis, 33 (24% of the 135) required fixed appliances or spring aligners to finish the treatment, 25 (19%) had poor or missing records, and 12 (9%) had missing teeth. For the 65 subjects analyzed, the mean age was 31.1 (± SD 12.5) years, the duration of treatment was 12.5 (± 4.1) months, and the patients wore 17.9 (± 7.3) maxillary and 17.7 (±6.9) mandibular Invisalign aligners. The pretreatment total OGS score (dental component only) was 47.0 (± 16.5), and the posttreatment OGS score was 36.4 (± 16.0; P ≤ .001). Comparison of the categories in the OGS showed that significant improvements occurred in tooth alignment (pretreatment mean: 21.5 points vs posttreatment: 7.0 points (P ≤ .001), buccolingual inclination (4.7 vs 4.1 points, P = .001), and interproximal spaces (1.3 vs 0.0 points; P ≤ .05). On the other hand, there was a negative change in posterior occlusal contacts (4.0 vs 10.3 points; P ≤ .001). The remaining categories, including marginal ridge relationships, occlusal relationships (eg, posterior interdigitation), and overjet (anterior and posterior), showed no significant change. Thus, for this sample treated with the Invisalign system, the greatest positive change as measured by the OGS point system was in the alignment of teeth, followed by closure of interproximal space. An undesirable change was found with a decline in posterior occlusal contacts. The score for the latter category had a negative impact on the overall changes as measured with the OGS method. The results of the OGS show that treatment with Invisalign aligners had adverse effects on posterior occlusal contacts and positive effects on tooth alignment, buccolingual inclination, and interproximal spaces.
there was a negative change in posterior occlusal contacts (4.0 vs 10.3 points; P ≤ .001). The remaining categories, including marginal ridge relationships, occlusal relationships (eg, posterior interdigitation), and overjet (anterior and posterior), showed no significant change….”

“The results of the OGS show that treatment with Invisalign aligners had adverse effects on posterior occlusal contacts”

The public has been led to believe through aggressive advertising (not unlike many drugs that are mega-advertised) that a pretty smile is just simple alignment of the front teeth when in fact alignment at the expense of function is actually a net-negative which can lead to extensive problems down the road.  What may seem like only partial failures of Invisalign and other aligner systems (with “acceptable” limitations in some dimensions of movement) is can actually cause an inability to restore posterior occlusion which can lead to TMD (Chronic muscle and jaw pain), relapse of tooth alignment/spacing, and excessive wear of teeth as well as other issues detrimental to the overall oral health.  In the opinion of most Board Certified Orthodontists, it would be malpractice to align teeth for esthetics but knowingly place them in poor occlusion that will lead to significant risks in the future.  In fact, a doctor could easily and successfully be sued if he or she creates a malocclusion that leads to damage to the dentition/supporting tissues; this goes for traditional braces, restorative crowns or Invisalign clear aligners.
So is Invisalign right for you?  Can you trust your doctor?  Will it work?
I believe today the best way to evaluate whether Invisalign is right for you is:
1. Find a specialist that is fully trained in Orthodontics (a true Orthodontist, member of the American Association of Orthodontists (AAO) and if possible, a diplomate of the American Board of Orthodontics (ABO) as there are no other true specialty organizations for Orthodontists).
2.  Make sure the Orthodontist isn’t exclusively using Invisalign; they should be able to make a calculated and realistic appraisal of treatment and be literate to the research showing the limitations of Invisalign; anyone treating exclusively with aligner trays is not providing or offering the best (and sometimes not even an adequate option) that Orthodontics has to offer and if they are not admitting just that, then you should seek another opinion.
3. Ask the right questions; don’t try to lead your doctor with answers you may WANT to hear; listen to what you NEED to hear.  Realize that poor treatment is the most expensive treatment as it may fail, cause more problems/damage to the dentition or simply have to be re-performed later.
4.  Realize that Invisalign is a publicly traded business, they are not your doctor and not governed by the rules and ethical obligations of a certified doctor; to them you are a potential profit.  Realize that dentists and Orthodontists are not beauticians; we are highly trained doctors; medical professionals that are responsible and obliged to provide the highest standard of care even if it is not the product you want. 
5.  Hold your doctor accountable: If they promise success with aligners equal to traditional braces, and they cannot provide what they promised, report it to your State’s Dental Board.  If your bite is poor or you have problems following aligner treatment, seek a second opinion from a Board Certified Specialist.  Aligners can be a valuable armament in the treatments available to you by your orthodontist but only if we, as patients and doctors, hold anyone who abuses the technology responsible for their actions.

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 20 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







Wednesday, June 15, 2016

DIY Orthodontics?

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults  

 DIY Orthodontics?

It seems the new buzz in the dental community is the notion of “do it yourself” orthodontics with various techniques passed around on YouTube.  I even have had a dentist calling me asking for supplies because she had seen someone moving a tooth on YouTube and she wanted to set up a tooth for a crown in a better position. 

To be honest, I never really took the notion seriously until the American Association of Orthodontics issued reports to us in private practice (and went national with advertising against such efforts) following the posting of a DIY case by a student who claimed a correction for $60 of materials. 


The idea of permanently moving teeth which must fit in all three dimensions with opposing and adjacent teeth (during rest and function), without planning/records and without a care of how the final bite will fit … I mean it seems common sense would tell even the most simple or value-minded people that there would be unforeseen risks and problems.  After all, scalpels can be purchased privately but you don’t see people performing surgery at home, right?  Does the public really see Orthodontics so simple as if any un-trained individual can move the teeth successfully and without repercussions; and what has led to this erroneous and dangerous perception?  I think sadly the answer is “maybe”.


…scalpels can be purchased privately but you don’t see people performing surgery at home”

First of all I must state clearly and unequivocally: Orthodontics is the most complex specialty in dentistry, hands-down.  It requires significant knowledge of biology, bone physiology, physics, anatomy and no small amount of artistic perceptional ability.  Moving teeth to a functional and esthetic relationship requires experience and a knowledge based on 100+ years of research and development; and it requires constant continued education of new technologies, new techniques and new research.  In short, it requires a trained specialist with years of specialty training beyond Dental School.  Orthodontics is not quick, it is not cheap and it many times requires fixed braces for a full correction; if there was a short/cheap/dependable shortcut, your Orthodontist would be using it!

“Orthodontics is not quick, it is not cheap and it sometimes requires fixed braces; if there was a short/cheap/dependable shortcut, your Orthodontist would be using it!”





Some of the force diagramming used when planning orthodontic movements illustrating the physics employed by Orthodontic specialists in every case.  The diagram on the lower right illustrates the different properties/stored energy potential for various wires regularly used (clear aligner trays only come in one size for every movement) v. the elasticity of healthy bone.  Note these don’t even take into consideration the fit between upper and lower teeth OR the fit when the jaw is moving side to side.

So from where is this simplified view of tooth movement emanating?

First, there has been a rising trend of Clear Aligner treatment pushed by general dentists that can now leave your tooth movements (I don’t consider this Orthodontics) up to a lab; in essence it allows a general dentist with little to no orthodontic training to take impressions/scans and send them off to a lab for clear aligners to deliver similar to a mouth-guard, bite splint or retainer.  I leave the efficacy of these aligner systems for another day but will say these aligners are aimed at esthetics over function and they remain VERY limited in any ability to move roots.  Aligner trays end up pushing teeth outward and can tip teeth completely out of the bone leading to relapse and recession that can be difficult or impossible to fix.

 Relapse with recession following dental arch expansion.
In conjunction with this, we have public companies funded by share-holders (and millions of dollars) which advertise directly to the public through television and magazines, pushing clear aligners that magically do all the work (simplifying tooth movement to a lab procedure) as equivalent to traditional braces.  General dentists push it because it is all they can do and they want the money/patients unfortunately this can lead to a dentist placing profit above the needs and well-being of the patients).  In fact, any Orthodontist will tell you that once a General Dentist starts providing Invisalign, all referrals stop including the most complex cases that would be difficult even for the specialist; even the younger kids that require early interceptive treatment are not referred because the Dentist wants to offer teen-Invisalign later and it cannot be performed until all molars are erupted (after growth and after many problems are set and un-correctible).  In turn, many Orthodontists feel the pressure and have begun offering Invisalign rather than lose patients to their general dental colleagues (they feel at least they will be able to fix problems with braces at the end which they usually have to do) but the effect is a watering down of the quality and a false equivocation of Invisalign to true Orthodontics. 



Second, technology used by clear aligner labs is partially available to the public; people with some tech-knowledge can scan their teeth and produce models with 3D printers.  In Austin where I live, I have seen middle school kids using 3D printers in their science projects!  Although crude to dental standards, it can appear similar to the trays used by doctors and some have placed videos online suggesting they “fixed” their own teeth enticing others with a cheap short-cut. 



Finally, the push to find discount alternatives (over quality) and a habit of googling our own common sense away has allowed ignorance to persist as knowledge; consider people placing rubber-bands around two adjacent teeth with the simplified idea of closing a gap (only to open another on the back side, tipping one or both teeth and having the rubber-band slide up the root and destroy the supporting bone). I even see patients following online advice and travelling to 3rd world countries to “save” a few dollars only to learn they have condemned their teeth and now require implants or worse.  We now see foreign sources advertising do-it-yourself impressions to send in and receive do-it-yourself aligners online.

Rubber band placed over front two teeth.

Damage from rubber band sliding up the teeth

This is really what our medical and dental system is evolving toward; a google/Internet based pseudo-knowledge driving patient treatments over the advice and recommendations of highly trained specialists.  As a specialty, we have failed the public we serve by keeping our heads in the sand as these false treatments have grown into the storm we see now.  Unfortunately we do not have the time or money to combat both the Internet and national advertising by big corporate entities such as Invisalign so we work within our regions to offer what we know is good treatment and, as long as we have patients enough to keep afloat, we just ignore the growing malignancy outside our door.

Orthodontists may eventually have to take a more active role against this DIY value/ignorance-based mentality for their own sakes but for now all I can say is “if it sounds too good to be true”, or if you are being told what you want to hear at your urging, buyer beware.  The  most expensive Orthodontic correction is the one requiring re-treatment or even restoration due to damaged/lost teeth.  If it were as easy as a scan or impression to fix the teeth, no dentist would spend another 2 to 3 years in specialized Orthodontic training (and dig into another $200K debt).  Until a sharp Lawyer brings a class action suit or two against these aligner companies for false advertising and against some of the dentists for poor treatment, we will continue to see a devolving of this highly specialized field known as Orthodontics and an increase in DIY gimmicks.     

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 20 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