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. 


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