James R. Waters, DDS, MSD, PA: The Fourth Dimension of Orthodontics ... Time (A reason Orthodontics should be left to Board Certified Specialists and why Invisalign can do more harm than good in younger patients)

The Fourth Dimension in Orthodontics … Time.

(A reason Orthodontics should be left to Board Certified Specialists and why Invisalign* can do more harm than good in younger patients)

It has taken many years of practicing as a Board Certified Orthodontist to feel that I have a complete and full understanding of development as it affects orthodontic treatment. This is because there are specific growth patterns, family histories, nutrition, normal and abnormal eruption patterns, and many other more localized variables we must consider and sometimes predict.

Orthodontists are specifically taught to consider three main dimension in space: the Transverse dimension (sided to side) such as posterior crossbites and narrow jaws, Anterior-Posterior dimension (front to back) such as an underbite or the dreaded "buck teeth", and finally the Vertical dimension which encompasses severe issues such as anterior openbites or severe deepbites. Most people can readily visualize discrepancies in any one of these dimensions just from looking at models and photos of the teeth/face.

But there is a very important Fourth dimension, that of Time. In fact, it can be easy to dismiss just how important the dimension of time can be with orthodontic treatment of children. "Time" in this sense does not mean just how long the actual treatment takes rather it is a dimension of the malocclusion which causes changes during the active treatment and during the prepubertal growth of a child, changes that are specific for that individual based on the direction of jaw growth, pattern of erupts and relationship of the jaws to each other.

Important Repercussions of Time as a dimension of Orthodontic treatment

1. It is ridiculous to use removal aligner trays/invisalign on children still growing as all of the trays are made from an initial scan; as the patient inevitable grows, the relationship of the jaws change. In the end, without constant re-scanning and new trays fabricated every few visits, the upper teeth may look straight(ish) but they will very likely not fit the lower teeth in function at all and may lead to interferences in the bite, instabilities and eventual relapse, excessive wear and/or chronic jaw pain (TMD). Sadly, parents may not see this for years after and may not even realize it was introduced by the poor orthodontics (Invisalign or any other of the dozen clear aligner systems on the market).

2. Every patient must be treated more individually the younger they are placed into appliances

3. Changes early on will magnify over time; this can either be a good change or can be a bad change; this magnification can create significantly different outcomes on the same patient based on when a patient is treated and how well their specific growth pattern is understood as it relates to the that very important fourth dimension of Time.

4. Clinician knowledge and experience may the most important factor in treatment outcome.

5. There are MANY clinicians that are either ignorant of Time as a dimension of treatment or they ignore growth and development while offering inferior options (Invisialign to pre-adolescents) for profit with little to no regard for your family’s health. Too many doctors just tell patients what they want to hear to get them into their practices.

Child Skull versus Adult skull

Examples of common Time dependent treatments

Consider the following more simple and common scenarios: as we correct the width of a narrow upper jaw in crossbite with a palatal expander (see my earlier blogs about expansion), we must also consider the growth over the next few years since the lower jaw grows bringing the wider portion of the lower jaw forward relative to the stationary upper jaw (causing a crossbite to "return" not from relapse, but because the jaw is now in a different relationship). Likewise, as we close an openbite, we must consider the direction of jaw growth and the rate of growth over time in treatment (and thereafter) as the angle of the lower jaw determines its relative growth forward v. downward and away from the stationary upper jaw. We have to consider muscle forces and swallowing habits, breathing issues during sleep and chronic seasonal allergies, we even must gauge and predict growth based on genetic predisposition despite diets with hormone injected meats and milk that skew our known predictors. And many times, we must adjust our treatment mid-stream to refine our goals over time and development. Orthodontics is a game of chess, if your doctor is playing checkers, you are in the wrong office.

Above all, experienced and thoughtful Orthodontists realize that changes in the pre-adolescent occlusion will magnify with time; better things can get better but problems can (and will) become worse. Understanding what will happen (or is likely to happen) throughout and after treatment provides a better correction and much more stable outcome while realizing adjustments must be made earlier in treatment prevent iatrogenic (doctor induced) problems form worsening. Understanding time as a dimension of orthodontic treatment also helps to determine when the best window for treatment may be; some cases must wait until growth is complete while others need to begin early in growth in an effort to accentuate that growth and "catch up" while there is growth available. Once growth stops, there is no getting it back; at that point we start considering surgery of the jaw to make large corrections.

"Above all, experienced and thoughtful Orthodontists realize that changes in the pre-adolescent occlusion will magnify with time; better things can get better but problems can (and will) become worse."

Take for example the following patient:

Note that growth of the lower jaw has been restricted and deficient; research has shown over the last 100 years that these patient, left untreated, will always remain deficient. This is a factor of muscle forces and occlusion forcing the lower jaw back against a rather subtle growth potential. Distal dislocation of the lower jaw essentially stops cell division at the growth area and the jaw simply does not grow forward. Knowing this, we can remove the roadblocks that are holding the lower jaw back, remove the obstructions that cause the patient to pull her jaw back (into the growth area) and actually enhance remaining growth as seen below.

Now after early treatment, you can appreciate the forward growth of the lower jaw. This could only be accomplished with early intervention during a time that the patient still had sufficient time to grow. It still required correction in all three other dimensions with expansion of the upper jaw (Transverse), opening of the bite (Vertical) and coordinating the lower jaw to fit in the forward position (Anterior-Posterior). But time was the most important factor, starting early, removing the obstructions early, de-programming the backward bite and allowing the patient to growth with forward pressure instead of backward pulling. Without growth over time, there would be no correction of the overjet, the teeth would not fit and we would have to consider more significant treatment such as removal of permanent teeth (adversely affecting the profile) or jaw surgery at a later date.

So who can you trust to determine the best time for treatment?

Only one professional is trained with the most current knowledge and builds the most pertinent experience to be able to consistently guide you and that is an experienced Board certified Orthodontist. Waiting for a referral from a dentist or pedodontist relies on their more limited knowledge and may handicap the treatment for your child. Orthodontists will be able to tell by around age 6 to 7 if there is a severe problem and if early intervention would be beneficial. If it is not recommended, they will monitor your child until the best window of treatment may arrive (or until it is determined no treatment is necessary).

"Waiting for a referral from a dentist or pedodontist relies on their more limited knowledge and may handicap the treatment"

A final note about Braces v. Invisalign* in kids under 14

So many times I am asked about why I "don’t like" Invisalign or why I recommend braces for kids more consistently. My answer is that braces are better, in almost every case and every scenario. Braces are faster (for similar movements), braces move roots much better and farther, braces are more consistent and non-compliance based, braces can push teeth down into the bone and pull them out of the bone to level smiles and open/close bites where Invisalign is simply inferior. Braces can also correct overjets or even underbites where Invisalign routinely fails. This is proven in peer reviewed literature over and over (see my blogs on Does Invisalign Work as Advertised?). Unfortunately (but by their design), paid advertising is all the public can find on google.

Ultimately if Invisalign is only 41% as accurate as braces (j.ajodo.2007.05.018;www.ajodo.org), has a 27% passing rate versus braces in Board reviewed cases and "deficient in its ability to correct overjet & occlusal contacts" (j.ajodo.2005.06.002;www.ajodo.org), can only move an incisor tooth 57% of what braces can do with very simple movement (j.ajodo.org.2013.10.022;www.ajodo.org), shows minimal improvement in occlusal scores after treatment and even negative changes in posterior occlusion (2.5x worse!) (j.ajodo.2004.07.016; www.ajodo.org); I can go on and on but really I would just say, I won’t treat to such a lesser standard if I can achieve a much better result with braces. If someone is willing to charge you for a 40% to 60% result then I would openly question their standards, motives and possibly their ethics. Many cases treated by Invisalign would be considered malpractice in the past but public perception is driven by direct advertising and false media/social media to the point, ignorance has become bliss because it allows some sort of "treatment" without appliances fixed to the teeth (braces).

Now if you know those limitations going in, then I can accept a lesser result to some degree but if I know the result will be unstable, detrimental or simply not effective at all, I won’t "treat" as this is a failure in any other arena and certain to relapse (as is so much more common with Invisalign even confirmed in a study released this year comparing braces to Invisalign). As a Board certified specialist, I am held to a greater standard.

*The term Invisalign is a trademarked name for the most widespread type or brand of clear aligners (provided by Align Technologies) which is credited for the development and early advancements of the technique using digital scans to produce a digital image of the teeth for manipulation. However there are more than a dozen nearly identical clear aligner systems under different brands, some specific only to specialists (Orchestrate 3D); for brevity, I generally use the name "Invisalign" to refer to any clear aligner system.

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 Summa Cum Laude graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Hospital 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. He is a Diplomate of the American Board of Orthodontics and member of the College of Diplomates of the ABO. Dr. Waters has been honored as one of “Texas Best” Orthodontists by his peers in the Texas Monthly magazine focusing on Texas healthcare providers for 14 years straight. Dr. Waters and his wife of 23 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 .