Are Braces "Old School" (and is that bad?)

Are Braces “Old School”

(and is this bad?)

I recently visited colleagues out of state who shared some information they received from a young referring general dentist concerning advice he had received from an Invisalign “Study Group”.  Among the typical tips and pearls usually discussed at these gatherings, there was significant discussion of how to “compete” with specialists (Orthodontists) and how to steer the public away from specialty care and especially away from traditional braces. Of course most of the Country sees Invisalign for what it is, an inferior product that produces inferior results and is many times simply discontinued altogether, but here in Austin like other metropolitan regions, Invisalign has advertised the public into near-submission and thereby allowed weekend-trained dentists and even real Orthodontists (who admit defeat and lower their standards out of fear of losing their entire practices) to offer and even push Invisalign despite its well-known limitations and failures.  This meeting out of state was a direct reflection of the “new school” of Invisalign providers.

 

The meeting went something like this:
 

First there was a defense of Invisalign and other clear aligner systems being provided by general dentists instead of Orthodontic specialists and a discussion about persuading the public that Invisalign aligner trays moved teeth just like braces move teeth (but without having to wear braces).  They suggested advertising Invisalign as “invisible braces” in this effort to equilibrate the two different products.

Of course Orthodontic specialists have seen this false advertising by Align Technologies, the parent corporation of Invisalign (and now Smile Club Direct) ever since Invisalign was opened to general dentists.  Studies quickly appeared revealing an effort to elevate Invisalign as an equal to the much more effective and proven traditional braces even though Orthodontists like me that tried Invisalign at the beginning 20 years ago learned about limitations very early.  Conclusions of studies investigating false advertising were published in dental journals early on (see below).
 

 

“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.” (1)
 

 

 

 

Next issue discussed was “how to prevent patients from straying”.  Members of this group were cautioned not to refer siblings to an Orthodontist because the specialist may inadvertently be asked about other family members and may accidentally or purposely discredit something the [untrained] dentist was doing with the other family case(s). In other words they didn’t want the experts looking at their work or being referenced for advice, a big red flag.  Not only is this suggested in recent research (2), but I can personally confirm this since Invisalign offices NEVER refer out patients (even severe cases or cases that need early treatment to prevent surgery) once they decide to treat with Invisalign.  In fact there is a discernible difference in the communication to patients and specialists from Invisalign-providing dentists versus communications with good family dentists that refer to specialists.  And I can’t help but believe this is has indeed become a purposeful effort to persuade patients based on ulterior motives.

 

“… there is a discernible difference in the communication to patients from Invisalign-providing dentists versus communications between good family dentists that refer to specialists.”
 

 

Another order of business in the meeting was a discussion of selling Invisalign as effective for most of the various traditional malocclusion in “straightening the teeth” with no mention of correcting function.  Members were cautioned to start by telling patients they only treated “certain cases” even if they planned offering the same Invisalign to all patients and never planned to refer out cases to the Orthodontist.  I can’t imagine a meeting of professionals scheming like this but it explains much of what we here now with bait and switch.

 

 

 

 

But what are the facts? Does Invisalign work as advertised; is there hard research on any limitations that the “new School” dentists and Invisalign-Orthodontists are purposely ignoring?  Surely a professional wouldn’t lie?
 

 

FACTS on the “new school” (i.e. Invisalign).

 

Orthodontists have investigated Invisalign treatment for over 20 years ago.  Papers studying Invisalign efficacy started to appear about 5 years after initial development and have periodically revisited this subject every few years.  I have placed the results of most of these below; keep in mind, these are not cherry-picked papers in some biased pseudo-journal of quackery; these articles were presented with methods and conclusions to a jury of experts and many published in the governing American Journal of Orthodontics & Dentofacial Orthopedics (AJODO), the very journal that sets treatment protocol and legal standards for Orthodontics as a whole.   

 

 

 Summary of Data in recent and current research on Invisalign:

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% (3)  

 

Passing Rate of cases treated Invisalign v. Braces: 27% lower

“Deficient in its ability to correct overjet & occlusal contacts” (4)  

 

Mean percentage of simple tooth movement goal (30 patients moving one incisor a single 1mm) only 57% (5)  

 

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” (6)  

 “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.” (4)  

“Invisalign may not be as effective as fixed appliances in achieving “great improvement” in a malocclusion.” (8)

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. (9)

 

One startling result was the amount of cases that simply discontinued treatment with a University of Washington study reporting only “[ONLY] Fifteen of 51 subjects (29%) completed their initial series of aligners.”  Even worse, “All subjects who completed their initial series had either an additional series of case refinement aligners or fixed appliances (braces) to finish their treatment.”(10)
 

 

Even in studies supposedly favoring Invisalign, biased researchers will cherry-pick data; such as a study looking at forces produced by thermoplastic (11) to individual teeth suggesting thermoplastic was effective at producing moments (allowing for root movement) however when the data is reviewed by an expert orthodontist, one could easily see that the aligner had re-active forces negating much of the possible movement since every force has an equal and opposite force and since aligners cannot differentiate the force down to different teeth, only adjacent teeth; “How can 2 moments in opposite directions produce root movement in the same direction … the researchers stated that … results suggest that bodily tooth movements…can also be performed using Invisalign aligners…” I do not agree that the data in this study showed this conclusively and feel that this is an irresponsible statement.” (12)

 

 

The authors of the initial study conceded with the following admission:

 

“An aligner has a complex 3-dimensional geometry that is loaded by placing the aligner onto the dental arch. We planned the aligner therapy so that isolated tooth movements should have been accomplished: ie, only the tooth in question should have deformed the aligner material around itself, delivering exactly the force system necessary for the desired tooth movement. Due to the complex aligner geometry, it is of course impossible to predict the exact aligner deformation for such an isolated tooth movement. Thus, the aligner steps usually are designed so that the tooth's crown shall be moved in small, incremental steps, ignoring biomechanically exact force systems. The complex deformation of the aligner will always generate additional force and moment components.”

 

Just as in Orthodontic movement, forces with braces are worked out to avoid the above illustration where no movement occurs.  Without knowing these forces and understanding them, some teeth may move, others may not at all and still others may move the wrong way. 

 

Research and experience continue to reveal that all removable appliances share the same disadvantages; they are poor to move roots, they cannot move stubborn teeth like canines, they are based on compliance and they cannot be used during growth to prevent surgery which is when many young patients need treatment the most.  If a dentist placed crowns with only 40% success, how many of you would go to them?  Unfortunately they aren’t going to tell you they treat to 19% or 41% or 57%; why?  Because that is FAILURE in anyone’s book!   
 

 

 

 

“If a dentist placed crowns with only 40% success, how many of you would go to them?  Unfortunately they aren’t going to tell you they treat to 19% or 41% or 57%; Why?  Because that is FAILURE in anyone’s book!”

The study group also explored ways they thought Invisalign could be sold as actually better than braces.  They focused on removable clear aligners being more hygienic and discussed how they would advise patients.

 

I guess I can assume this group, like many, were unaware that Orthodontists and Oral Pathologists had already studied this and published several papers, one as recently as February 2018 (13) debunking the very idea that oral hygiene was better in Invisalign:   

 

“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.”(13)

 

Other studies had already hinted at this by looking at bacterial adhesion to thermoplastic (used in clear aligners such as Invisalign, Clear correct and the many others on the market) back in 2012 (14) and matching these bacteria to saliva levels during orthodontic treatment as studied in a separate 2010 study (15).

 

“The observations made in this study contradict popular beliefs that removable appliances have a minimal effect on periodontal health”(14)

 

These internal notes from the out-of-state Invisalign “Study Club” junior dentist illustrate how such an inferior product can become mainstreamed despite its shortcomings and limitations.  And it is a wake-up call for all professionals in dentistry and medicine that a direct-to-public dental/medical device, marketed solely for profit by non-doctors and uneducated business investors, can actually change the perception and narrative of a profession directly against the research and established standards.

 

So what is true (old-school) Orthodontics?  Why do real Orthodontists in most of the Country (and all of the rural areas) still use braces in the majority of cases and why is 90% of the current literature still based on traditional braces and not this “new school” called Invisalign (which is actually over 20 years old)?

 

True Orthodontics (aka “Old-School Orthodontics”) is Evidence Based

 

True Orthodontics is an Evidence Based Medical Procedure, it is not based on speculation or hearsay and should never be influenced by direct-to-consumer advertising or propaganda even if it is what patients may think they want initially (after all patients want the result, not a certain product to wear just for fun).  Corporate advertisers’ job is to sell their product.  Our job is to give patients the facts, the risks v. benefits and any options.  We treat function AND esthetics.  If informed patients still choose to treat with an inferior product and assuming incomplete treatment does not create a significant risk of other more severe problems, then there is no problem with Invisalign or other clear aligners.

“True Orthodontics is an Evidence Based Medical Procedure, it is not based on speculation or hearsay and should never be influenced by direct-to-consumer advertising or propaganda even if it is what patients may think they want initially (after all patients want the result, not a certain product to wear just for fun).”

 

To be sure, moving teeth with clear aligners and plastic is not new to orthodontists (16); Invisalign works fine in some cases and can be an alternative choice to braces (and I do use clear aligners when appropriate or when patients choose them over braces knowing the facts and risks) but there is rarely if ever the case that Aligners treat better, faster or more stable than traditional braces; in nearly every case, the only advantage is that they are clear.  Of course even in those cases, we are assuming aligners are worn and the patient actually finishes treatment; yet one study revealed an “overall completion of the initial regimen of aligners in this study was 29%” with many subjects seeming to discontinue aligners due to “excessive tipping of teeth around the extraction sites” confirming moderate to severe cases incapable of being treated by Invisalign (10).

 

“we are assuming aligners are worn and the patient actually finishes treatment; yet one study revealed … overall completion of the initial regimen of aligners [in this study] was 29%” 

29%!  So if you are only offered removable clear aligners with no caveats or information about braces (including compliance), then you are not hearing all of the facts and you should question other advice you are being told by that dentist/friend/commercial/dream.

 

“Corporate advertisers’ job is to sell their product.  Our job is to give patients the facts, the risks v. benefits and any options.  We treat function AND esthetics.”

Parents should also use common sense and realize it is difficult to treat adequately with Invisalign when the patient is young, still growing and does not have all teeth erupted yet; since all trays are made from the initial scan, you would have to re-scan and fabricate new trays as new teeth erupt more or the patient grows (changing the relationship of the teeth).  If growth is needed to fix jaw positon (underbites, excessive overjet, openbites), waiting for all teeth to treat with Invisalign can and often leads to unnecessary extraction of permanent teeth, impaction and surgery to uncover blocked teeth and even jaw surgery that would otherwise have been prevented with “old school” dentofacial orthopedics/early treatment from a knowledgeable and experienced Orthodontist.  
 

 

Patient is in “Mixed dentition”, waiting for Invisalign will limit the correction and may lead to surgery instead of minor orthodontic treatment. Note the correction before permanent teeth are fully erupted to take advantage of patient’s natural growth.  There are many examples of these early treatments that can be seen in the smile gallery at www.bracesaustin.com

 

“…if you are only offered clear aligners with no caveats or information about braces (including compliance), then you are not hearing all of the facts and you should question other advice you are being told ...”

 

Finally, back to our study group of Invisalign dentists, there was discussion about how to compete with the experienced clinicians that may speak against universally using Invisalign or other clear aligners (people like me I suppose).  Suggestions ranged from focusing on new technologies and the digital age of laser scanning, advertising “computer aided appliance designs” to promoting young doctors that are fresh with “newer” education (with the accompanying presumption their knowledge is more relevant and/or accurate).  The one term agreed upon by all attendees was to call braces “Old-School” and Invisalign the new technology that any dentist can provide.

Here in Austin, I have a young and charismatic Invisalign Orthodontist around the corner from me who has claimed to be the best at everything ever since moving in and before he even finishing a single case! His back-handed compliment/code word for disparaging my experience? I was “old school” and he was the newer improved model with new technology (as if I wasn’t using Invisalign and the same technologies since its inception and as if I haven’t been deeply involved in continued education and review of the literature every year since).

In truth, I don’t necessarily mind being called “old school” if the “new school” is solely based on profit, loose facts, false advertising and propaganda.  But I recognize the derogatory effort in labeling a fellow professional as “old School” and what it can imply to other new dentists. 

 

Perhaps if the newer generations, or the “new school” reviewed the research and practiced based on evidence, facts and experience from the last 100 years they would be better suited to weigh the benefits and short-comings of new technologies without blindly following new trends (that really aren’t new in the first place).

 

They [general dentists] certainly would not place crowns that didn’t fit or fillings that only have a 41% success rate; that of course is malpractice.  The real question is “Why isn’t Orthodontic treatment with only a 41% success rate malpractice?”

 

Perhaps with better “old school” ethics, the new school wouldn’t force themselves to believe everything that a for-profit company tells them because it benefits their bottom line.  Maybe then these dentists could educate the public on facts from their own profession versus a narrative dictated by a publically traded corporation.

 

 

 

Perhaps if the self-appointed “new school” took their responsibility to “do no harm” more seriously, they would remember to treat to ideal function and not just line up a few teeth for a prettier smile.  They certainly would not place crowns that didn’t fit or fillings that only have a 41% success rate; that of course is malpractice.  The real question is “Why isn’t Orthodontic treatment with only a 41% success rate malpractice?”

And perhaps by listening to the experience of others that came before them (as I did) and by keeping up on current research (not reports or speakers funded by Invisalign or other corporations) these “new school” dentists would remember that poor function can cause anything from gingival recession, premature/severe and uneven wear of teeth, loss of teeth and even chronic joint pain and headaches which will ultimately require more significant correction later. That waiting on young kids to treat with Invisalign can lead to jaw surgery and facial disharmony (retrusive chin/excessive overbite/flat lips/protrusive lower lip or underbite).  Of course they would also learn that relapse is much higher in Invisalign.

 

Orthodontists with 15 to 20 years of experience were the doctors that actually developed Invisalign; we are the one’s that tried it, modified it and chose to limit it to minor cases (which is why it was designed).  Treatment with clear rubber and plastic retainer was around for many years, back to 1945 (17), 1964 (18) 1997 (19), prior to Invisalign using digital scans to expedite the fabrication of the models.  It wasn’t until general dentists started using Invisalign (and stopped referring to Orthodontists) that the new generation of orthodontists lost market share and  panicked, deciding if they couldn’t beat them to join them. 

 

Ironically, today’s Invisalign providing dentists now point to Invisalign orthodontists as validation for themselves.  And in even more Irony, in true Karma fashion, Align Technology (through their new subsidiary “Smile Direct Club”) is cutting the general dentists out and claiming no doctor is needed for treatment.  You will notice Smile Club Direct commercials have literally replaced 8 out 10 Invisalign TV/Social Media commercials.  I guess Align Technologies (Invisalign) figure there isn’t a lot of difference since their technicians are already doing all of the work as Dentists and Invisalign Orthodontists delegate staff to scan, check the online smile plan and deliver all the trays. Don’t believe it?  Ask your teen how their appointments are or consider what you have seen yourself if in treatment.  I leave the readers with the disclaimer provided by Align Technologies (Invisalign) for those that choose their new non-doctor Smile Club Direct product:  

 

“I further understand that my clear aligner therapy treatment will only address the alignment of my teeth and will not correct my existing bite condition. In order to correct the current condition of my bite, I will need to seek more comprehensive treatment via my local dental professional. Because I am choosing not to engage the in-patient services of a local dental professional, I understand and accept that my teeth will be straighter than they currently are but may still be compromised.” (20)

 

I include actual references in this article in my “old School” way to show my practice is evidence based, my patients can trust that I am informed and will always protect their interests and the interests of their family over corporate advertising/propaganda and I will never provide an inferior product without full discloser and without first providing REAL risks vs. benefits vs. costs vs. long-term effects.  I will continue to treat every patient as an individual and with a custom plan mutually agreed upon, whether it is with early intervention or orthopedic appliances for growth, traditional braces, removable retainers or clear aligners.

 

 

1. Ellis, Christine P, Letters to the Editor, American Journal of Orthodontics and Dentofacial Orthopedics, Volume 126, Issue 1, A20 - A21

2.  Referral patterns of pediatric dentists and general practitioners to orthodontists based on case

           Complexity,  Batarse, Allison Piazza et al. American Journal of Orthodontics and Dentofacial Orthopedics, Volume 156, Issue 1, 61 - 66

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

               Invisalign, Kravitz, Neal D. et al. American Journal of Orthodontics and Dentofacial Orthopedics, 2009, Volume 135, Issue 1, 27 – 35, https://doi.org/10.1016/j.ajodo.2007.05.018

4. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board

     of Orthodontics objective grading system; http://dx.doi.org/10.1016/j.ajodo.2005.06.002

5. Variables affecting orthodontic tooth movement with clear aligners; http://dx.doi.org/10.1016/j.ajodo.2013.10.022

6. Evaluation of Invisalign treatment utilizing the American Board of Orthodontics Objective Grading System for dental casts; http://dx.doi.org/10.1016/j.ajodo.2004.07.016  

8. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed

        appliances using the Peer Assessment Rating index, Gu, Jiafeng et al. American Journal of Orthodontics and Dentofacial Orthopedics, Volume 151, Issue 2, 259 - 266

9. Management of overbite with the Invisalign appliance, Khosravi, Roozbeh et al., American Journal of  Orthodontics and Dentofacial Orthopedics, Volume 151, Issue 4, 691 - 699.e2

10. Activation time and material stiffness of sequential removable orthodontic appliances. Part 1: Ability

to complete treatment, Bollen, Anne-Marie et al., American Journal of Orthodontics and Dentofacial Orthopedics, Volume 124, Issue 5, 496 - 501

11. Kravitz, N.D., Kusnoto, B., BeGole, E., Obrez, A., and Agran, B. How well does Invisalign work? A   

prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod

Dentofacial Orthop. 2009; 135: 27–35

12.  Analysis of data in removable thermoplastic aligner study, Kuncio, Daniel A., American Journal of Orthodontics and Dentofacial Orthopedics, Volume 146, Issue 5, 546 - 547

13. Aditya Chhibber,a Sachin Agarwal,b Sumit Yadav,c Chia-Ling Kuo,d and Madhur Upadhyayc

     Norwalk, Ohio, Melbourne, Australia, and Farmington, Conn, Which orthodontic appliance is best for oral hygiene? A randomized clinical trial, (Am J Orthod Dentofacial Orthop 2018;153:175-83)

14. Türköz, C., Canigür Bavbek, N., Kale Varlik, S., and Akça, G. Influence of thermoplastic retainers on Streptococcus mutans and Lactobacillus adhesion. Am J Orthod Dentofacial Orthop. 2012; 141: 598–603

15. Lara-Carrillo, E., Montiel-Bastida, N.M., Sánchez-Pérez, L., and Alanís-Tavira, J. Effect of orthodontic treatment on saliva, plaque and the levels of Streptococcus mutans and Lactobacillus. Med Oral Patol Oral Cir Bucal. 2010; 15,  e924–e929

16 Invisalign A to Z, Wong, Benson H., American Journal of Orthodontics and Dentofacial Orthopedics, Volume 121,                   Issue 5, 540 - 541

17. Kesling, HD. The philosophy of the tooth positioning appliance. Am J Orthod. 1945; 31: 297–304

 

18. Nahoum, HI. The vacuum formed dental contour appliance. N Y State Dent J. 1964; 9: 385–390

 

         19. Rinchuse, DJ and Rinchuse, DJ. Active tooth movement with Essix-based appliances. J Clin Orthod. 1997; 31: 109–112

 

20. https://webcache.googleusercontent.com/search?q=cache:https://smiledirectclub.com/consent/ (last

Visited June 28, 2019). 

 

 

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 .