Wednesday, April 18, 2018

Braces ... For more than just a Smile.

Braces … for more than just a smile.

Advertisers and some dentists will have the public believe that Orthodontics is just about a pretty smile; line up the front teeth and all is well.  No mention of function, long-term stability, relapse, future wear, ability to chew, etc.  So it should be no surprise that clear aligners have become all the rage in today’s dental market.  Are we allowing advertising to make false claims?  Are advertisers and direct-to-customer companies lying by omission?

But is that all Orthodontics is?  Line up the front six and send them out the door?
Shouldn’t we be concerned with the back teeth?  Shouldn’t we care how the upper and lower teeth function together?  Shouldn’t we know why the crowding and rotations occurred before lining up the front teeth (just to fail for the same reasons)?  Should we expect to wear retainers for a lifetime?

What about health of the gums?  Does it matter if the teeth don’t actually fit in the bone; can’t we just keep pushing them outward until there is room to line then up?  After all, if the circumference is made large enough, any size or number of teeth will fit.  Does the bone get larger as we push teeth outward?

These are all important questions that seem to be brushed under the rug in many Invisalign dental offices today as well as the mail-order aligners advertised on late-night TV between the ads for the Foreman grill and the knife that can cut through aluminum cans.


Common sense should remind people that Orthodontists have to attend two to three years of additional residency after becoming doctors.  Does it make sense that a dentist can attend a weekend course in Vegas then offer the same quality and same outcomes?  Or a U-Tube tutorial (I would laugh out loud but I actually had a local dentist call and ask to borrow some braces from me after watching a U-Tube video!)?

“We used to call this practicing without a license and throw people in jail.”


Clear aligners are now essentially removing the doctor from the treatment.  Even when offered in the office, the doctor cedes his/her control to a computer and technician (usually in Costa Rica, India, China or Mexico).  There is no consideration of biology, no advanced learning of development or bone physiology by these technicians; no understanding of the computer technology by the doctors and little to no control of forces in the mouth.  We used to call this practicing without a license and throw people in jail.
Your Future Orthodontist?
Can a computer technician simply 3-D print a tooth and stick it in the mouth now?  Do you want the geek squad from Home Depot making you dental appliances/aligners to move your teeth?  How about some tech guy from Facebook making decision on what your teeth should look like with no consideration of chewing or function and no checking on the result by a professional; maybe we just need a robot instead of a human altogether?
We used to have greater standards and regulation; for instance a dentist would never consider placing a crown without contact to opposing teeth so why should we allow a company to do the same with our entire dentition?  Why would that same dentist think it is ok to leave the teeth out of function from aligner “treatment” just to line up the front teeth?  Is it just to sell the public a product? What is the standard of care?  What is the evidence in the research?

What does the Research on Clear Aligners REALLY show?
 “Our results suggested that about 1.5 mm of overbite improvement can be expected when the Invisalign appliance is used in deepbite patients. A previous systematic review on the stability of deepbite correction reported an average of 3 mm overbite correction with fixed appliances [50% more effective with traditional braces]” 
Khosravi, R. Management of overbite with the Invisalign appliances AJO-DO April 2017
Invisalign [treatment results] only 41% mean accuracy of tooth movement with a range from 18% to 47.1% (j.ajodo.2007.05.018;
Mean percentage of single tooth movement goal of only 57% (j.ajodo.2013.10.022). 
When results from Invisalign were compared to traditional braces using American Board of Orthodontic standards, the Passing rate of cases treated with Invisalign were 27% lower (j.ajodo.2005.06.002). 
Another more complete study (j.ajodo.2004.07.016) actually concluded that there was a “minimal improvement in occlusal score based on Board standards from 47 to 36.4 [0 being ideal] and there was a negative change (2.5x worse AFTER treatment) in posterior occlusion contacts with Invisalign.” 
This last investigator summarized Invisalign treatment by stating “According to the OGS [Objective Grading System used for the American Board of Orthodontics], Invisalign did not treat malocclusions as well as braces … Invisalign was especially deficient in its ability to correct large anteroposterior discrepancies [overjet] and occlusal contacts.”
Another article published April of 2017 in the AJO-DO (Journal of the American Association of Orthodontics) was published that confirmed previous findings (j.ajodo.2016.09.022) showing Inivisalign only 50% effective as braces in opening a deepbite and considering there is already an average relapse of @50%, the net change from Invisalign after treatment is zero.


The public has been brainwashed by for-profit companies (via social media, Internet advertising and TV ads) that moving teeth is harmless and simple; that going to the Orthodontist is no different than a trip to the nail salon or barber shop.  They have been so successful in dumbing down a very complex process that the public is now being told no doctor at all is needed (after all the dentists providing aligners have no real Orthodontic training either).

Does this mean braces are dead?  Not if the public wants full corrections and good function.  Aligners may correct minor rotations and make the teeth look straight-ish, but they are extremely limited in their ability to correct significant problems, the kind of problems that are obvious like excessive overjet, deepbite, openbites, underbites, severe crowding, severe spacing, asymmetries, functional jaw shifts among other common problems.

It does mean that good Orthodontists capable of truly treating moderate to severe cases will be harder to find and fees will most certainly go up.  Without milder cases to even out the moderate to severe cases, the cost to treat each case will have to reflect the average amount of time and work in correcting each patient.

It also means there will be many un-finished cases of aligners, relapsed aligner cases, mistreated cases or even aligner-caused malocclusions that require correction by real Orthodontics.  There may be loss of gum tissue, loss of teeth or chronic pain from poor treatment; sometimes there is such poor treatment that the damage cannot be undone even with braces and sometimes Orthodontists simply will effuse to get involved.

So when you are trying to decide how to treat your family, remember that there are few shortcuts in medicine and dentistry.  Just like investing your hard-earned money in the market; if something sounds too good to be true, perhaps you are not seeing the whole story.  Invest wisely in your family and you will not only get a beautiful and lasting smile, but you will get better function, stability and peace of mind.  Let a trained professional provide your family members with beautiful and truly functional occlusions that will serve them the rest of their lives.

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at 



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