Wednesday, February 24, 2016

Why am I (or why is my child) still in braces?

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults

Why am I (or why is my child) still in braces?

Probably the most frequently asked question in any orthodontic practice is “how much longer?” If I dared to count how many times this is asked on a daily basis I would likely have to use two hands. There are certainly times where we may be a little further than the original estimated time however many times it is akin to the back-seat child or passenger asking “are we there yet?” and asking every 10 miles on a 500 mile trip.

To address this question however, we must first realize that initial estimates are just that, an estimated time based on similar cases and experience with other patients. Of course every patient is different and treatments between one patient and another may be dependent on growth, compliance (rubber band wear, oral hygiene, breakage and/or loss of appliances during treatment and making appointments as scheduled), bone quality, severity of crowding, nutrition, anatomy of the teeth and bone, impacted and/or missing teeth, and even oral musculature such as mouth-breathing or adverse tongue activity during swallowing. As an analogy, consider exactly how long it will take to build a large backyard playhouse or put together that set of cabinets that is always missing a part or gets a stripped screw. Now imagine a project that is expected to take anywhere from 18mo to 24mo and you can imagine how it is possible that the project may not finish exactly as first estimated.

Also, remember that good Orthodontists are perfectionists by nature; they are always trying to balance perfection with realistic expectations and time in treatment. Moving teeth around (on a moving platform) that all have multiple cusps fitting against multiple cusps is more complex than simply changing wires. Good Orthodontists are also using “potential growth” and “expected growth” in children when there is excessive overjet (a big overbite) or other discrepancies between upper and lower jaws/teeth. Kids mature at different times; they go through pre-puberty growth spurts differently and because we can’t completely predict when this will happen, many times we have to be in braces a little early to make sure we don’t miss the growth. When growth is slow, the correction can take longer. If growth does not materialize as expected, the treatment plan could change to compensate accordingly.

“Good Orthodontists are perfectionists by nature”

Beyond the physiologic and anatomic specifics we may be unable to control or completely predict, there are a few things that the patient and Orthodontist can control. To summarize some of the pitfalls that can delay Orthodontic treatment, I am listing some of the more predictable (and preventable) issues that will add time to Orthodontic treatment:

Breakage of Brackets

Breakage of brackets is a particular problem that can add significant time to treatment. When braces are first placed, there may be some teeth that hit brackets prematurely and can dislodge a bracket; as long as these are replaced in a timely matter, there should be no real loss of time. But consider that appointments are 4 to 8 weeks apart; if a bracket breaks free and the Orthodontist does not know for 1 to 2 months, once it is repaired the patient may lose up to 2 months of treatment. If this happens several times, you can start to see why a treatment extends 6 months past the estimate.

Missing Scheduled Appointments

Orthodontics can take two years or more in a moderately crowded case; appointments are set to allow enough time for a wire to work but not too long for the wire to lose strength. Also, even if the wire will be working for several months it is important to make sure nothing is broken while the wire works; if a bracket comes off without the patient knowing and the patient does not return for 3 months, then the tooth without the bracket can shift out of alignment to the point that the patient actually goes backward in treatment, adding not only the lost time but possibly another few months to an already extended treatment.

Not Wearing Rubber Bands/Elastics as Prescribed

Rubber bands, or elastics, are worn for several reasons but essentially they are used to use one set of teeth (or one arch) to move another set of teeth, usually in the opposing arch (i.e. using lower teeth to move the upper teeth and vice-versa). Because the lower jaw moves and grows separately, Orthodontists can use the elastics to “enhance” growth of the lower jaw but only during growth. These elastics are usually anchored on one end to the upper teeth (which are all tied together to provide maximum anchorage) and the other side attaches to the back teeth on the lower jaw to “pull” the lower jaw forward. In truth, we are simply placing forces in the mouth opposite of the natural muscle forces that pull backward and limit jaw growth. This forward pressure allows more growth than would otherwise occur but only if the elastics are worn full-time.

Elastics are also worn to de-program a backward shift in the bite after the front teeth are corrected and the jaw can now fit forward. If the front teeth lean backward, this will cause the lower jaw to bite backward which compresses the TMJ’s (jaw joints) and can lead to trauma and jaw pain with headaches over time (TMD). Even after the front teeth are uprighted in adults, it sometimes takes elastic wear to stop the lower jaw from pulling back; muscles have a memory and after years it takes some time to de-program this bite and relieve the joints. Without these elastics, it may take a year or longer for the lower jaw to return forward.

Remember whatever force is causing a resistance to growth (muscle forces, habits, etc.) is present throughout treatment; if we cannot overcome these forces with rubber bands, braces alone may not be able to fully correct the bite and we have to work longer to compensate for the jaws being out of alignment. If the lower jaw is even 2mm off, then every tooth in the lower jaw will be 2mm off (2mm is 25% the width of a normal tooth) making the final correction take much longer to finish.

Poor Oral Hygiene During Treatment

It is important to brush and floss when in braces! Plaque can build up around brackets and between the brackets and the gums causing demineralization (white spots) and even cavities over time. If the oral hygiene is poor, the guns become inflamed making it difficult to work with the braces and difficult sometimes to see the inclination of adjacent teeth. If an Orthodontist sees that oral hygiene is insufficient to continue care, he or she may remove the braces and delay completion (at additional cost) at a later date when the oral hygiene is improved.

Timing can still extend beyond the estimated time but with good compliance, good oral hygiene and good attention during treatment, it is likely that treatment will proceed as expected and the patient will have a beautiful and lasting smile to show for the effort and time.

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 35^th 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. 35^th Street

Austin, TX 78703

(512) 451-6457

Steiner Ranch

4302 N. Quinlan Park

Austin, TX 78732

(512) 266-8585

BracesAustin.com

Tuesday, February 16, 2016

Letting your teen guide his/her orthodontic treatment?

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults

Letting your teen guide his/her orthodontic treatment?

It seems every week I have a new patient exam with a mom and her teenager to discuss orthodontic correction when I am TOLD the teen wants Invisalign and nothing else. Typically it is a moderately crowded teen that has not had any early treatment (or was treated with some simple early retainer years before) and they simply want straight teeth. I always begin by introducing myself and examining the teen’s bite. If it is a simple case, I may give an estimation of what I would recommend, maybe even a rough cost (however if there is a more significant issue I prefer to have records before putting my foot in my mouth) and then I will discuss options of appliances (including clear aligners if relevant).

In most cases I have to tell the parent and the teen that Invisalign (really the generic term for a slew of different clear aligners available today such as Clear Choice and Orchestrate) is not the best option. It may be due to un-erupted 2^nd molars or too great of a tooth to bone size discrepancy (too severe of crowding), a jaw discrepancy where one jaw is too far forward or backward which of course makes the teeth not fit at all, or it may be something else altogether specific with that patient (an overly angled canine, a very deep bite or crossbite of teeth). After explaining the issues, it is inevitable that I get the “well my friends have Invisalign” or “this other doctor/dentist says I can do Invisalign”. I even get the defiant “I’m not wearing braces, I want Invisalign. I don’t care if it doesn’t work as well.”

Some teens understand and move forward (most know when it’s not a good idea and most know they won’t wear the trays as prescribed). But occasionally I see the patient move on and start Invisalign elsewhere. This is happening with a wrestling buddy of my son’s currently; friends of my kids usually ask them why I won’t give them Invisalign but another guy down the street told him he would. My answer is simple; I care more. I might know better and I certainly have much more experience but I think it is not so complex. The attitude today is that you have to give the patient what they want since they are paying and a lot of the new doctors take this path of least resistance. But I submit that those of us that performed Invisalign 15 years ago know well what it can and cannot do and we further know compliance is a nightmare with teens (even my own kids hence they got braces).

Let me also provide a brief description of exactly what Invisalign trays actually entail:

Invisalign requires a quick digital scan which is emailed to a non-medical center (Invisalign was in India last I checked, Clear Choice is local in Texas and Orchestrate can be done completely in-house) to digitize the scanned teeth. They then simply move the teeth in the digital image similar to morphing a picture from a start to a finish, then they send the data file to another lab that prints the models with a 3-D printer. Another lab tech (I believe in Mexico) sucks down plastic over each model and sends them to the doctor back in the US. Then the doctor is supposed to place the trays every two weeks. And there it is. $2000+ lab bill, essentially no time with the doctor and very little opportunity to make changes along the way when something doesn’t move or when the whole jaw shifts and now the teeth all fit different than the original scan.

In practice what I see is doctors having assistants (with high school education only) placing/delivering the trays and giving several months of trays to the patient so they can essentially treat themselves. If trays are lost, there is a new $500 fee to replace. When all the trays are finished, and a few times in between, the doctor looks and MANY times suggests braces to “finish the bite a little better” which is code for IT DIDN’T WORK. I even know of a local Orthodontist that evaluates patients via skype then sends them to an imaging center and has a different dental office deliver the trays. That really disgusts good doctors.

The results are varied, many cases that are planned well and are good candidates work out fine (rarely as good as traditional braces but may be acceptable), many others end up with heavy occlusion on front teeth (because the lower jaw was locked back before treatment and as teeth aligned, the lower jaw settled forward, with all the teeth now hitting hard in the front and no contact in the back), none are allowed to settle due to the trays between the teeth, and still many others end up with one or more of the worst teeth still crooked. Teens that treat have a terrible time holding onto trays and an even harder time wearing something that hurts full time when they know they can just remove it (For that matter, so do adults!). Then when they are confronted about wear time, they swear they have worn the trays and of course the parents confirm they always see them wear the “invisible” trays! In truth, its no surprise these patients are just given trays and sent out the door for months; sometimes its just frustrating as the Orthodontist to the point that the patient compliance is harder to deal with than the trays.

Regardless, there are too many cases floating around now that either gave up on the treatment, relapsed and don’t want to do braces, or were never fully corrected and there are more started everyday by inexperienced dentists and unscrupulous Orthodontists just trying to bring in dollars (and I am talking about those “doctors” that will put anyone who pays into Invisalign) . These patients then assume that this is what orthodontics is; straighten, maybe not even all the way, then expect the teeth immediately to move back or just remain imperfect. The experience for these patients is long and expensive and may prevent them from achieving the very correction they paid for and deserved in the first place. Then they spread “the word” telling everyone they know about their version of the experience. Not good for the Orthodontists and not good for other perspective patients that really want a good smile.

Teeth are one of the most important things we have during our lives; if you don’t believe this ask anyone with chronic dental problems. So just as you would not want your teenage son/daughter to pick the type of heart surgery he/she gets or the type of cancer drug they may need, it is unwise to allow them to decide that a specialist, with a minimum of 10 years of education and up to 20 years more of experience with aligners as they were being developed (by specialists) may not know what is the best way to treat their malocclusion.

It would be much easier to be the proverbial doctor down the street that tells everyone, “let’s just do Invisalign, we don’t use or need braces”, then sit back and do nothing. I mean really, if it were that easy and it worked every time don’t you think I would also say the same thing and just send for the scan and be done, collect my $5000 and go to the next patient?

Parents should be very wary of the Orthodontist or dentist that tells them what they want hear for profit. Keep in mind, we (Orthodontists) ALL know what the patients want to hear. I have been around when Invisalign was born, some of us have already gone through the pain of using Invisalign just to see the cases fail or relapse; having to tell the patient that we need braces to “finish” for one reason or another. It is the responsible and trusted Orthodontist, the local doctor that plans on being around as you and your kids get older, that will tell you what you need to hear even if it isn’t what you may wish to hear. Trust this specialist versus the one telling you just what you want to hear (even when it sounds too good to be true), for if it were as simple as an impression we wouldn’t have specialists in the first place and I would set up kiosks at every mall!

Central Austin

1814 W. 35^th Street

Austin, TX 78703

(512) 451-6457

Steiner Ranch

4302 N. Quinlan Park

Austin, TX 78732

(512) 266-8585

BracesAustin.com

Thursday, February 11, 2016

Why am I having to re-treat my previous braces?

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults

Why am I having to re-treat my previous braces?

Everyone has heard about teeth moving following a course of braces; either immediately following correction or later following the retention period. It is easy to think there was a problem somewhere that has led to this later movement such as improper treatment, removing braces too early or not wearing the retainer long enough.

Assuming true braces (and not an inferior clear aligner treatment), there are many reasons we see movement of the teeth following alignment and correction of a malocclusion. Looking beyond the simple causes such as not wearing retainers or not finishing treatment to completion (leaving the teeth fitting poorly in an unstable position), we must realize that teeth are in a growing and changing environment. A recent article by a well-known and respected Orthodontist points out that no one expects a crown to last forever; filings have to be replaced just as gingival tissue continues to change as we age possibly requiring grafting or replacement of teeth.

“no one expects a crown to last forever; fillings have to be replaced just as gingival tissue continues to change as we age possibly requiring grafting or replacement of teeth.”

In fact, no other doctor (whether it be a Dermatologist or Cardiologist) expects a static patient as we age; Orthodontists should know how to predict changes and realize there may be future refinements along the way to maintain the best occlusion as we age thus providing reasonable expectations and an opportunity for patients to have a beautiful and functional smile for a lifetime.

First, we must recognize that our teeth ultimately stabilize within a natural but unique equilibrium to each individual. Muscles act on the teeth from the outside (the cheeks) and from the inside (the tongue), habits affect muscles (tongue thrust, chewing on cheeks), breathing and airways affect muscles (mouth breathing, seasonal/chronic allergies, sleep apnea), the underlying relationship and size of jaws to each other and relative to the cumulative size of the teeth, etc., etc. As Orthodontists, it is our training and responsibility to place the teeth in the best alignment with each other, with the jaw bones, with the opposing occlusion and over the long axis of the roots and we must take into consideration the timing of when certain aspects of a near-perfect occlusion must be accomplished. Much has been discussed both in offices and online between friends/bloggers about “Phase Treatment” but most people miss the bigger picture.

“… teeth ultimately stabilize within a natural but unique equilibrium to each individual.”

Treatment can be broken down into several Phases:

There is the time during growth when the jaw size can be manipulated to either restore deficiencies in size through palatal expansion (with a fixed expander, not a removable retainer that only tips teeth) and by altering the early forces affecting jaw development between ages 6 and 10. This is why early treatment (Phase I) may be recommended for some patients since the size of the bone will affect how the teeth (whose sizes are fixed) will fit in each arch. Early treatment also allows us to change the relationship of the jaws to one another; after all if the lower jaw is half a tooth forward relative to the upper after growth subsides, then no matter what we do in the future the lower teeth will be too far forward leading to latent crowding of the lower incisors, spacing in the upper incisors or severe wear of the incisors (not to mention increased prevalence of TMD). Early treatment, when necessary, places the foundation of the teeth and future occlusion in a more ideal relationship. This is the reason for fewer extractions in modern orthodontics and how cases previously treated with surgery can now be controlled or even corrected with early appliances.

“Early treatment, when necessary, places the foundation of the teeth and future occlusion in a more ideal relationship.”

The next time to consider is the completion of the permanent dentition, usually from age 11 to 13. This is the traditional time for braces when actual alignment and fitting of the teeth takes place usually termed Phase II. Assuming the jaws are correct in size versus the size of teeth and the upper to lower jaw relationship is correct, then the teeth will generally fit well and any correction will be stable. If the equilibrium or balance is disrupted during the eruption of teeth (even if the jaws are corrected), we can still have problems; consider losing a baby molar too early and the space closes before the next tooth can erupt. Or consider when a permanent tooth doesn’t push the baby teeth out and “deflects” sideways (then the adjacent teeth collapse around the shifted tooth and so forth). Braces are used to correct these issues and align teeth into an ideal occlusion. If the teeth are too far off due to poor foundations/jaw relationships, then we have to consider removal of permanent teeth to gain space or even surgery to re-set jaw positions.

Retention following braces should do several things. First, it allows the Orthodontist to hold the correction as bone re-forms solid around the roots of previously moved teeth. Second it allows the teeth to “settle” into a tighter occlusion when retained with typical wire and acrylic retainers (clear aligners prevent this settling which is why I only use them as temporary retainers for patients’ special occasions). Third, it allows us to slowly, with control, walk the patient down from full retention to night-time retention and down to occasional wear while monitoring stability and any remaining growth. I typically watch all patients for 2 years following removal of appliances; wear of the removable retainers is 6mo full-time, 6mo PM only and then 6 to 12mo 3Pm/week down to 1PM/wk. After that I base further wear on stability and growth during the first 2 years.

So can teeth still move? Does it happen everytime? How much is normal?

All great questions but we as Orthodontists must resist a definitive answer. It is safe to say that a patient that has been treated on a life-long plan starting with early intervention (or simple evaluation if development is good from the beginning) followed by alignment of teeth as an adolescent which is then retained properly as teeth are allowed to settle will have the most stable bite possible for that individual patient. Muscle forces, breathing obstructions, tongue activity and adverse (to the teeth) growth will all still act on the occlusion and alignment but the better the fit and foundation, the more stable to resist long-term forces.

After years however, we can expect that the equilibrium may change leading to a late cascade of forces that can move otherwise stabilized teeth. If movement is slight, simple refinement can be performed with limited appliances or even clear aligners (assuming compliance did not contribute to movement). If movement is more significant, it might favor a more in-depth evaluation of the jaw relationships or tooth sizes which may suggest a different course of correction (extraction of teeth due to a tooth to bone size discrepancy or more definitive treatment to move roots with true braces if clear aligners were initially employed). Patients can lose supporting tissue/bone over time which allows muscles to shift what would have otherwise been solid teeth; teeth can be lost or loosened from trauma affecting the forces on adjacent teeth and so forth.

The point is that your teeth are a part of a living and changing system, just as your skin, your circulatory system and your muscular system. We all will change as we age and it is unreasonable for either the Orthodontist of the patient to expect these natural changes won’t have an effect on our teeth in some way, sometimes to the point of wanting to refine a previously corrected bite. This should not deter one from treating just because they did not go through any early efforts to align jaws; instead it should help to set expectations and guide long-terms efforts to maintain (and refine as necessary) a great smile throughout life. If both the patient and Orthodontist work together for a long-term goal, there is no reason every patient should not be happy with their smile no matter what changes may occur.

“your teeth are a part of a living and changing system … we all will change as we age and it is unreasonable … to expect these natural changes won’t have an effect on our teeth in some way”

Central Austin

1814 W. 35^th Street

Austin, TX 78703

(512) 451-6457

Steiner Ranch

4302 N. Quinlan Park

Austin, TX 78732