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;www.ajodo.org)

 

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 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 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. 

 

 

 

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 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 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. 

 

Crowded teeth can lead to early tooth loss.

Does Crowding of teeth lead to early tooth loss?

 

 

I always try to temper initial exams when it comes to advising perspective patients of my services; sometimes I even may preface what I recommend by telling borderline cases that we want to avoid picking at everything slightly out of alignment just because I am an orthodontist.  Similar to a neck doctor that may always see neck/back issues or a foot doctor that can always seem to find a foot problem, I do not want to recommend treatment on every single case with just the mildest of rotations or crowding and certainly if they are more concerned about function and health and less so about esthetics.

 

That being said, there is an issue that has been debated in multiple disciplines of dentistry that is a significant consideration when making a decision to correct crowded teeth or leave them.  Before we entertain this though Americans in particular should realize that recent generations are keeping their teeth well into their older years and this is a good thing.  Our General Dentists have done a great job at restoring damaged teeth, protecting developing teeth (fluoride and regular cleanings) and keeping teeth that in the past may have been lost due to fracture, infection or simple neglect.

With keeping the teeth longer, we now have to focus on the supporting bone around the teeth; the gum tissue and alveolar bone.  Today, loss of teeth is mostly from Periodontal disease (disease of the supporting tissue around teeth) which is a bacterial infection of the gums that destroys bone and eventually causes the loss of supporting tissue for teeth; forces from chewing then eventually loosen the teeth to the point that the bone no longer can support the tooth or teeth and they are lost.  Of course there is a more complex mechanism leading to the bone loss which is dependent on types of bacteria and toxins released, but the idea can be summarized as an infection of the gums.  Clearly, as a dental professional, one of our main goals is to prevent prevalence and progression of Periodontal disease at every stage of patients’ lives in order to maintain the teeth as long as possible.

                                     

One significant factor to Periodontal disease can be crowding or spacing of teeth.   

 

So do crowded teeth cause Periodontal disease?

The answer is no; bacteria is the primary cause of the disease.  But the real question is how does the bacteria become detrimental in specific areas and mouths?

 

What are the ways crowded teeth can affect Periodontal Disease?

 

The most recent study in the AJO-DO explains this best by concluding that certain positions of teeth or “traits” such as incisor crowding provides “a poor environment for maintaining periodontal health …. due to food retention and subsequent plaque accumulation. (1)”

 

Consider the crowding in the patient below:

 

 

Crowding here has completely blocked the surfaces of several teeth from being cleaned; even with floss, cleaning these overlapped teeth is nearly impossible.  Over time, it is highly likely these teeth will be lost if not corrected. 

 

 

After correction you can see how the teeth can easily be cleaned and maintained.

 

Additionally, as teeth cross over and crowd, the roots are drawn closer together leaving less bone and supporting tissue between teeth.  This also can lead to more rapid progression of periodontal disease between adjacent teeth.  Soft tissue becomes obliterated from a lack of space to develop and there is less protection against bacteria between these teeth.

 

Finally, teeth that are crowded can push other teeth out of the arch and out of the bone.  This can lead very thin tissue on the outside of the teeth leaving these teeth more susceptible to periodontal disease (see the picture below).

Note in this patient how the severe crowding has caused the canines to be pushed essentially out of the bone which has led to recession of the gum tissue and loss of bone at the neck of these teeth.

 

How can spacing between teeth affect Periodontal disease?

Spacing specifically between upper incisors was also shown to contribute to Periodontal disease (2) by allowing food to pack between teeth and leading to chronic inflammation and eventual progression into periodontal disease and loss of bone.

 

This type of spacing has been shown to lead to more rapid progression of periodontal disease by allowing food to pack in between teeth.

Following correction, you can see how the area between front teeth is now protected from impaction of food and can be easily cleaned.

  

What can you do to make sure your teeth are not at risk of Periodontal disease from crowding?

 

Clearly the only way to reduce or eliminate this risk is to align teeth that are moderately crowded.  Research has shown that the areas of the dentition most at risk from crowding are the upper and lower incisors (2). When these incisors are crowded or overlapped, pockets are created that are not easily cleaned and although daily and meticulous flossing should theoretically prevent plaque formation in these areas, all too often we are not effective enough in our oral hygiene to fully clean these areas.

 

Prior to Correction with braces.

 

 



Following Correction with braces.

So in summary, alignment of crowded teeth is not only for esthetics; there is a real reason to align crowded teeth if we want to be able to keep our teeth for a lifetime of function and health.  this article only touches on the aspect of periodontal health and maintaining teeth however overall health is also affected by oral health; maintaining disease-fee dentition also prevents dissemination of bacteria into our bloodstreams; bacteria that can cause more severe problems such as systemic infections and even possible heart tissue infections.  The public should always keep in mind oral health can be a reflection of general health; it is all connected and very important over the course of our lives.

(1)  Hellgren, A. The association between crowding of the teeth and gingivitis. Trans Eur Orthod Soc. 1956; 32: 134–140

(2)  Alsulaiman, a. Incisor Malalignment and the risk of periodontal disease progression. AJO-DO. 2018; 153: 512-522  

 

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 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.