Fake Orthodontics Gaining Ground

Fake Orthodontics (Invisalign) Gaining Ground

(And the Culture of False advertising)

 

As a practicing Orthodontist I meet with dental specialists regularly for continued education, review of difficult cases and overall health of the profession; I have done so regularly for the last 23 years.  Now, at the middle of my career as a Board certified specialist, I feel somewhat qualified to reflect on the state of dentistry, and specifically specialty dentistry, in today’s marketplace.

Although politics has focused on medical insurance and general healthcare (for better or worse) there has been a curious lack of attention to engage the field of dentistry in the negotiations.  This has allowed dental related companies to hide in the shadows as they promote their own profit based treatments directly to the public, many now advertised as not even needing the doctor (and certainly not needing the specialists).  This phenomenon is a result of very large companies combined with social media campaigns that inundated the public with the company’s own agenda, directly to Facebook and other email lists.  Nowhere has this been more harmful than to the field of Orthodontics.

 

 

As the reader, you may ask “how can a company dictate dental care without doctors?”; you may even ask “aren’t there laws to prevent practicing without a license?”

 

In response, it has been a slow but deliberate strategy by certain unethical, profit hungry groups that employ un-ethical dentists and specialists to push them into the range of credibility.  Behind the scenes, there is a battle over standards of care but ultimately dentistry is a business and many succumb to the notion that if you don’t feel you can beat them, you have no other choice but to join them.  This is in fact exactly how Fake Orthodontic Companies like Invisalign (and their subsidiary Smile Club) have become the juggernauts in the room.  Currently there are nearly one hundred lawsuits by national and state dental organizations, boards and individual Orthodontists in the courts against Smile Club and other aligners, but they take time and they get buried by google ads paid for by …. you guessed it, Invisalign.

 

As a history, the idea of clear aligners was not a new one; many of us used clear aligners (made in-house) to hold and correct small rotations or mild relapse after treatment even 35 years ago.  However we all recognized and experienced the extreme limitations of removable plastic trays.  Also at that time, few dentists tried to perform orthodontics without specialty training; in fact family General Dentists would refer complex cases readily to their specialty counterparts/colleagues including surgery to Oral Surgeons, tough root canals to Endodontists, extensive gum disease to Periodontists, kids to Pedodontists and orthodontics to the Orthodontist.  This provided the environment for the General Dentist to become an expert in restorative care as well as the gatekeeper to more advanced treatments that required a higher level of training.

 

“Behind the scenes, there is a battle over standards of care but ultimately dentistry is a business and many succumb to the notion that if you don’t feel you can beat them, you have no other choice but to join them.  This is in fact exactly how … Invisalign [and other “Fake Orthodontic” clear aligner companies] have become the juggernauts in the room.”

 

So what happened?

As competition heated up in larger urban areas, we started to see general dentists pushing the limits to treat more complex issues to avoid losing the income stream from what they perceived as more profitable procedures (more “profitable” because they generally required specialty training to adequately and predictably treat).  Soon, there were whole groups of general dentists claiming specialty status to the public simply because they had seen what they felt like was a significant number of patients.  Of course they were learning on those very patients and were undoubtedly repeating the same mistakes over and over on those same [unsuspecting] patients. 

 

Many would then teach other non-specialized dentists so it became a cycle or grey area in dentistry.  But dentists far outnumber specialist by the definition and specialists had little power to dissuade the American Dental Association (the parent organization of all dentists including specialists) from allowing this progressing breach of standards and ethics.  It is now not uncommon for untrained newly graduated general dentists to see patients already in treatment and then question these cases that they don’t even have the records for and certainly not the training to fully understand.   This sews more discontent and distrust in the public as patients start hearing multiple stories from different doctors and it only serves to confuse patients and leave them open to professional advertising by companies directly.

 

What is the current state of the specialty of Orthodontics?

Today, Orthodontics has become synonymous with Invisalign (by their design, not ours) to new generations through social media and false advertising that would have never been allowed in traditional media.  Add to this a new generation of unethical dentists (and now Orthodontists) driven by pure profit, doctors that know very well they are not offering or providing the best care available (or sometimes even proficient/adequate care without introducing more problems).

 

As these general dentists stopped referring patients to the Orthodontists, the very Orthodontists began to move toward Invialign based practices.  They have done this despite the research that clearly and unequivocally proves Invisalign and the other dozen aligner systems far inferior to traditional braces.  But the public continues to be bombarded by advertising to the point now that Invisalign has purchased other companies like Smile Club that push aligner treatment with no dentist at all.  Ironically, now the general dentists are trying to fight the doctorless trend even though it is they themselves that are funding the company via their own Invisalign cases.

 

Clear aligner treatment; straight teeth but with no posterior contact; good luck chewing that steak!

“Straight” teeth from clear aligners with little to no contact and recession across the arch.

Teeth “straightened” by Invisalign but left protruding forward and out of the bone.

 

 

 

 

What is the Result for the Public?

By normalizing inferior treatment as the new acceptable standard, by accepting that Orthodontics is only used to line up the front six teeth (you will notice there is no mention of function on the many Invisalign commercials/testimonials), doctors and the public alike are rapidly turning a very scientific and complex profession into nothing more than a nail salon or mall kiosk (and there are no cliff notes to treat a patient).  In fact, these companies are not even attempting to hide this as they push to put kiosks in malls and drug stores.  Forget that it takes two to three years of post-doctorate study to even be remotely capable to treat moderate orthodontic cases.  Forget that poor function of your bite can lead to severe headaches, Chronic TMD, severe wear of teeth and early loss of teeth.  Forget about the airways, facial proportions and the chewing efficacy, forget about sleep apnea and periodontal disease.  According to these companies, if the front teeth are straight, then the job must be good/acceptable.

 

Determining Facial esthetics when treatment planning; moving teeth can affect the facial height and smile line relative to lips; but not with aligners like Invisalign or other Fake Orthodontics.

 

 

 

 

 

 

Typical forces figured in moving teeth.

 

 

 

 

 

 

Physics mixed with Biology: A key component in Orthodontics.

 

Is there any case that can be treated better or faster with Invisalign (Fake Orthodontics) v. traditional braces?

I cannot think of a single case that is treated better or even remotely as quickly as traditional braces and research bears this out over and over (see research cited in my other blogs on Does Invisalign work?) In fact there are inherent disadvantages including compliance, weak material that fatigues, trays that loosen and cannot move certain longer teeth, lack of root movement and even opening of the bite in many cases.  There are certainly mild cases that can be treated  (which is why Invisalign was accepted early on) but today, aligner trays are pushed on everyone as “invisible orthodontics” because doctors can run four or even five locations and just give out trays instead of monitoring patients and actually treating them. And if the standard of care is just to straighten the front six teeth, well that really is simple.  Lucky for these snake-oil doctors, you may well not get the joint pain, recession, tooth loss or damage for years so they will be long-gone and past the statutes of limitation for any recourse.

 

Does my Dentist Care about the Best for Me and My Family?

If your doctor is not a specialist, then they do not have the knowledge to be the best.  It could be a poor diagnosis, an inability to see problems, a lack of collecting the correct data or lack of interpreting data correctly; it could be the unethical approach of treating to a lesser standard or allowing a computer tech to design and move the teeth for them with no doctor or experience at all.  Either way, only the Specialist has the complete knowledge, experience and skill to give you the best.  Do you need the best?  Maybe not; but can the untrained spot the difference between those cases? My experience is they cannot.

 

 

“If all you are being told is what the doctor thinks you want to hear (or what your kid thinks is popular), then you may as well head to the kiosk and save yourself some money.”

  

Now if you go to a specialist and they only offer aligner trays claiming they are superior/faster or more reliable to traditional braces, then you are being a fed a tall tale from someone who definitely knows better.  If you have a simple alignment case/relapse or if you are offered aligner trays with the disclaimer of expecting less of a result on more moderate cases, then that is a decision you can make (but it is you making an informed decision).  If all you are being told is what the doctor thinks you want to hear (or what your kid thinks is popular), then you may as well head to the kiosk and save yourself some money.  Ultimately, it is the public that will determine the fate of Orthodontics in the US; laws are driven by public desires (just look at legalized drugs).  There will be those of us that adhere to a higher standard, those Orthodontists that won’t put their name on inferior treatment even if it costs them those patients and families.   But we/they will be a dying breed and if you or your family present with a moderate to severe malocclusion, you may certainly be out of luck.

Central Austin Location, 1814 35th St.

 

 

 Steiner Ranch Location, 4302 N. Quinlan Park, Austin

 

 

 

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 .

 

 

 

 

 

 

 

 

Closing space between upper teeth (and keeping it closed)

Why does space between top front teeth keep opening up after orthodontic treatment?

Probably one of the most noticeable malocclusions in people with otherwise straight teeth is that of spacing between upper incisors.  In fact, there usually is fairly good alignment of the upper teeth in these cases so many times patients and parents think this is an easy fix.  Many may even try to close space with an upper clear aligner or upper braces alone only to find the space(s) return soon after closure. 

Space in the upper front teeth as an adolescent (after the upper cuspids have erupted) when there is no space in the lower can be a sign of heavy occlusion of the front teeth which in turn holds or pushed the upper front teeth outward; as the arch circumference increases (but the tooth sizes remain constant), the patient experiences gaps, usually between upper central incisors and lateral incisors.  It can be gradual or even develop as the patient transitions from baby teeth to permanent teeth.  If the patient is waiting on upper canines to erupt, the space may close when these canines fully erupt.  If the space is present after canines erupt, then there is usually a problem.  Over time, heavy contact can lead to excessive wear of the teeth, mobility or even recession.

 

Over time, the heavy contact on font teeth caused the enamel to wear down as the lower teeth continued to drive upward into the wearing teeth more and more; once into the softer inner dentin, the wear accelerated.

 

This heavy contact can be from excessive growth of the lower jaw forward (which brings lower teeth forward essentially “jamming” them into the back of upper incisors), upper front teeth leaning backward (termed “Division II”) or can from smaller than average upper teeth.  In rare occasions there can be an extra tooth under the gums which must be removed.  The sequence of eruptions and the timing of the lower jaw growth can also lead to a deepbite (early over-eruption of lower incisors) which also can cause heavy contact and spacing.

Extra tooth in the upper midline (termed a “mesiodens”) not allowing upper central incisors to move together.  These extra teeth must be removed (I prefer to remove them before treatment if there is already space for access).

 

Deepbite with premature contact on upper incisors.  This patient also presents with congenitally small lateral incisors making the space even larger between from teeth.

 



Following treatment with braces, spaces between front teeth are closed, the deepbite is corrected and the small lateral incisors have been built up with white “composite” material.

Sometimes the upper front teeth grow in and lean away from each other making the appearance of a large gap (see patient below); there may be contact but is hidden under the gumline.  In these cases, the teeth must be uprighted so that they lean back toward each other, this brings the contact point from below the neckline (below the gums) up to the top 1/3 of each tooth which can completely close the space.  This is something I see left in cases after treatment as patients come in with retainers “that won’t close the space” from other offices.  I have to explain to these patients that the teeth ARE in contact but it is below the gumline; to “close” the visible space we have to attach brackets to the teeth and tip them back toward each other as we shift the roots away from each other.  No retainer can close space when the teeth are leaning away from each other and already in contact below the gumline.

 

Patient previously treated with relapse due to divergent upper incisors; corrected by tipping the crowns of the teeth toward the midline while moving roots away from the midline. There was no treatment in the lower arch in this case as most of the upper space was secondary to poor root position.

 

So how can we fix the spacing and keep it closed?

If upper incisors are leaning backward then these upper front teeth must be uprighted first; this is a different type of case and is covered in other articles due to the unique complications of that malocclusion.

 

Upper front teeth leaning backward with lower front teeth over-erupted.  To close this space, the upper teeth must be “pushed” back up and the lower incisors “pushed” down as we also pivot the upper front teeth forward (see below).

Same patient after correcting front teeth, notice the space closes easily once the occlusion allows the teeth to bite normally.

 

 

Cephalometric Radiograph to asses tipping of front teeth (Division II)

 

But if the front teeth are not leaning backward (Orthodontists use a cephalometric or side-view X-Ray to determine and quantify this angle) then the answer is we must focus on the lower teeth first.  In almost EVERY case of heavy incisor contact and spacing in the upper arch, the first step is to pull lower front teeth back, away from the upper front teeth.  Once pulled back and there is room for upper teeth to also be brought back, then the upper space between incisors can be closed and held.  Patients should be given a couple of months at the end (before removing appliances) to allow the lower jaw to shift or “settle” because it may have been pushed back and held back by the patient subconsciously so that once it gains the freedom to move, it may come forward bringing the lower teeth forward back into contact; this requires more retraction of the lower teeth or the space will return. 

 

If lower jaw growth is significant enough, and the patient young enough, we may consider bringing the upper jaw forward (see my article on when to treat underbites). 

This 7 year old patient presented with an early developing underbite; correction required pulling the entire upper jaw forward with protraction headgear (see blog on when to fix underbites).

 

At 12 years old, following correction of the underbite from age 7 to 8, the patient no longer has space or heavy contact on front teeth.  In fact, no further treatment was needed or recommended.

 

Growth later in life can increase space that used to be minimal; the patient below is an example of exceptional lower jaw growth that was not corrected early as in the above patient.

This patient’s lower jaw has grown forward beyond the ability to simply reposition teeth; here, as an adult patient, we must either remove teeth and close space or even shift the entire lower jaw back with surgery before being able to close space in the upper arch.

Finally, once the lower teeth are pulled back (and aligned) and upper space closed and held to allow time for the lower jaw to shift, then retainers must be placed and monitored closely for the next 6 to 12mo to check for any heavy contact returning on individual teeth.  If a single tooth is still mobile 3mo following braces, you can safely assume heavy contact and relapse of space; this tooth should be marked with articulating paper (typewriter ribbon for us older folks) and adjusted with judicial polishing of the enamel in the offending spot(s).

If the patient can tap/bite on their back teeth and feel no movement in the upper front teeth, they are safe to go back to regular retainer wear.  But this should be checked regularly over the first year (and even further depending on the patient’s age and growth pattern) if you expect to keep the spaces closed.

“I have heard that the gums between front teeth must be cut to close the space,” what about this?

 

In the past, cutting the gum tissue between teeth with large space in the midline (frenectomy) was sometimes performed if the attachment of the lip was high and between the teeth (similar to being tongue-tied in the lower arch).  When this attachment is the problem, it is very deep and will require an oral surgeon to separate the tissue all the way to the bone (See picture below).  Unfortunately this is almost never done completely during “typical” frenectomies.  In truth, the tissue between two front teeth that have a gap is usually just filling the space because the space is already there; it is not normally the cause of the space.

 

These pictures illustrate a before and after frenectomy due to attachment of the frenum directly between the front central incisors.

Does that mean patients never need a frenectomy?

No. Sometimes the gap has been present so long that when the teeth are brought together, the tissue “bunches up” and becomes chronically inflamed.  In these cases, the excess soft tissue can be removed following space closure using a laser with minimal discomfort and quick healing.

 

My doctor wants everyone to have a laser frenectomy, is that wrong?

 

 

A good case from relieving the tissue that connect the lip to the gums (frenum or frenulum); if left to during development, this thick tissue will hold front teeth apart.

 

I believe there is a trend in offices that get lasers to be more aggressive in prescribing laser frenectomies.  There is some logic in reducing this tissue in some cases (see above) but until lasers, we just rarely sent out frenectomies for anything less than the most significant space.  I have seen no evidence that routine laser frenectomies are effective in most cases of spacing but I will continue to monitor the journals for a juried study to come out.  I will say that the sales people that market these soft-tissue lasers certainly stress the profitability based on X percentage of patients getting laser frenectomies every week which makes me a little wary if not somewhat nauseous.

This photo (borrowed from the Internet) shows a “successful” frenectomy that has healed nicely but you can see there is no effect on the initial spacing from removal of the frenum.

I do like the lasers for more surface-based frenectomies, they are faster than the scalpel and have less side effects/bleeding/discomfort, but I have seen early recession in one case so for now and as I mentioned previously, true cases of frenum attachment goes to the bone which requires actual surgery and not just a surface release of soft tissue.  So I am personally reserving referrals of my patients to really obvious and significant cases only.  And I rarely refer until the space is closed to prevent scar tissue from building which may actually make space closure more difficult.  

Laser fenectomy.  As you can imagine, this really should not be a routine service if not necessary.

What about just placing a permanent or “fixed” retainer on the upper teeth?

 

Sometimes you will hear of a friend or Internet buddy telling you a wire was bonded behind front teeth to hold space closed.  This is NOT the accurate way to keep space closed; although a wire may keep space closed, it may also leave the front teeth in heavy contact and cause sever wear, long-term mobility of teeth, enhanced periodontal bone loss or even lead to mild TMD (jaw pain).  It is a band aid and not a fix.  Now if a wire is bonded AND the bite monitored and adjusted for any heavy contact than that can be acceptable BUT in a good bite, there really usually is no room to bond a wire behind the upper teeth without causing heavy contact with lower teeth.  Also, bonded retainers hold plaque and can lead to decay and enhanced periodontal disease if not taken care of with ideal oral hygiene.

 

 

A bonded upper “retainer” behind front teeth; this makes cleaning very difficult and can cause heavy/premature occlusion with the lower teeth which can push the entire segment of upper teeth forward or lead to excessive wear in the lower teeth.  It can even push the lower jaw back.

 

 

 

 

 This retainer is in contact which is causing lower teeth to push the entire segment held by the wire forward.

 

A similar case where the fixed “retainer” held space closed at the midline but allowed lower teeth to push the entire segment forward (note the space on the left side).  You can also see the gingival margin inflamed.

 

 

Best advice?

Seek out a competent and establish Orthodontist that offers traditional braces and can show you before and after pictures years after treatment.  Space in the upper front teeth can only be properly closed (and held closed afterward) if the reason for the space is identified and corrected.   Just like any other field, there are doctors and there are really good doctors, it is up to you to find good advice and not just find someone who will tell you what they think you want to hear.  In this particular scenario, there is usually one right way and lots of wrong ways to close space; many will lead to relapse but good treatment with good retention will give you a life-long smile.  The most expensive orthodontics is that which has to be done twice (or more). 

 

 

Case previously shown before treatment; braces were used to pull lower teeth back THEN space was closed in the upper arch

 

 

Same patient 2 ½ years AFTER removal of braces showing good stability.  Retainers were discontinued at 18mo after 6mo of full time wear and 12months of nighttime wear.

 

 

 

 

 

Adult with spacing her entire life which led to fracture of a front tooth.  Correction with braces included retraction of the lower teeth followed by space closure in the upper arch.  After space closure a new crown was fabricated for esthetics.

 

 

This photo was taken a full 3 years after removal of braces and the space has remained closed; regular visits were used to monitor for any heavy contact on front teeth.

 

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.