CHOICES in Orthodontics
By Dr. Barry Raphael
A Review of the Choices available at our office and some of the "Brand Names" involved.
Part 1: Choices
I have always said that orthodontists are a rather inventive lot.
Since the beginning of modern orthodontics – almost 130 years – we
have always been searching for a better way to move teeth. Every decade
brings a new wave of gadgets and gizmos that makes orthodontics more efficient,
more comfortable and better looking.
As an orthodontic specialist, it is both my obligation and my joy to learn and to use the latest in orthodontic technologies. Now, more than ever, I find that I am able to offer my patients a wide range of CHOICES for their treatment.
For example, for the very common problem of excess overbite, I can often use five or six totally different techniques. I can use appliances (ie: any device that’s applied to the teeth to move them) that are attached to the teeth (fixed) or that can be taken out by the patient (removable). I can use appliances that are fixed to the front or to the back of the teeth. There are appliances that are totally clear or tooth colored. Some appliances are worn only at night. Some are smaller, some colored and some glow-in-the-dark. Some are shaped like footballs or flowers. And on and on.
They can be powered by elastics, springs, flexible wire, or even magnets. They can be anchored to the teeth, to the jaw bone, or even to the neck (the old-fashioned headgear). They can move your teeth or they can help your bones grow. They can teach you to breathe through your nose or teach your tongue to swallow properly. You get the picture?
When you come to an office such as ours, my job is to figure out which of these appliances can work for you and discuss the pros and cons of each so you can choose which is right for you. You get to CHOOSE which one matches your preferences, your lifestyle, and your ability to handle it comfortably as well as one that fixes your teeth. We fit the appliance to the patient and not the patient to the appliance.
Part 2. Brand Names
As with so many things in American life, and in health care, too, the companies that make and supply these appliances to orthodontists have begun to brand their products and market them directly to the public. Who hasn’t seen an Invisalign commercial yet? Or heard about the new “Damon bracket”?
While attracting the public to orthodontics, these ads can be confusing because they only give part of the picture (Don’t all ads?). They want you to think their product is better than others, of course - just like Honda says it’s better than Toyota. Both cars get you where you’re going, though, and all appliances can be used to get the best results if they are used properly in the right situation. And ALL appliances have their limitations – just ask any orthodontist who will be frank with you. It can be confusing, right?
So to clear the confusion, this article will introduce you to some of the brand names you may hear about that we use (If I wrote about them all, it would become an encyclopedia). I’ll talk about some of the pros and cons of each. You can click on the logo to find more information. If there are any other brands you hear about that make you curious, you can write to me at mailto:drbarry@alignmine.com .
Let’s start with basics. A bracket is the little
handle in braces that’s attached directly to your teeth. It holds the wire
that crosses the teeth. 
In the past, the wire was held to the bracket with little rubber bands or thin wire ties. SPEED was one of the first to have a built in clip that holds the wire. This makes it faster and simpler to place the wire. It also increases the control and efficiency of the wire since the flexible clip bears down on the wire. Orthodontists call this “active self-ligation”.
Also, the
SPEED brackets are very small and easier to clean. For a metal bracket,
they have a nice look. But with every blessing there’s a curse: if you are
tough on your braces by carelessly eating hard and sticky stuff, they are easy
to detach from the tooth. That slows progress.
The SPEED brackets are extremely accurate and have to be placed precisely on the tooth. You may often find your orthodontist having to “reposition” brackets or make bends in the wire before the teeth are properly aligned.
Notice the “ask
for it by name” kicker in the ad? That’s America for you. Always the
latest in fashion…
Named for the
orthodontist that developed it, the Damon bracket is also self-ligating.
But the clip doesn’t bare down on the wire. Instead it forms a square tube
around the wire (yellow arrow). This allows the wire to slide through it
quite freely. This is called “passive self-ligation”.
The benefit is that it uses extremely light forces to move the teeth. We’ve known that light forces move teeth the fastest ever since the Australian orthodontist, P. Raymond Begg introduced his Lightwire Technique in the 1940’s, but to listen to the ad, you’d think Damon “invented” it. Modern metallurgy has brought us flexible wires made of nickel-titanium (and other similar compounds) that do allow for very gentle forces (just a few ounces of pressure – like pressing your finger on your arm just enough to push in the skin). Contrary to common sense, we have found that gentle pressures work far better, and much more comfortably, than hard pressures when moving teeth. THAT is the secret to this “system”.
The Damon bracket is a little larger than most, and they’re still working on improving it. The orthodontists that use it seem to love it. It works especially well with very crowded teeth. But because of the large “tube” effect, it requires extra effort to get precise control of the tooth (Blessing-curse again).
Beware the hype of the heavy ad campaigns. I find it’s good to have a choice between active and passive self-ligation. It’s your orthodontist that plans your treatment, not the braces.
The newest
trend in orthodontics is to have computers build brackets and wires specifically
to match your mouth. While this may add some time and expense to the
beginning of your treatment, it saves time in the long run by having the braces
move your teeth more directly from the beginning to the end goal.
To start, we take very precise impressions of your teeth with a special material in a tray and use that to create a digital 3-D model of your teeth. (There are also new techniques for using special cameras or x-rays to create a digital model, too).
Then, I prescribe the movement of your teeth and it is programmed into the computer. Robots manufacture brackets and wires to match your “straightened” teeth. When I place these appliances on your teeth, they already know where to go. This makes for a quicker treatment. Cool, right?
iBraces uses
the same concept as Insignia using computers to make custom wires and brackets,
but places the brackets on the back of the teeth. There they cannot be
seen at all.
In previous
versions of “lingual” (meaning “tongue side”) braces, the brackets were large
and uncomfortable to the tongue. But with custom brackets, they can be
designed to fit your mouth better. All braces take some getting used to,
of course, and lingual maybe a few days longer, but with iBraces, not much
longer at all.
Since lingual is somewhat harder for the orthodontist to work with, and since these brackets are custom-made of cast gold, they are considerably more expensive than the “labial” or outside braces.
Speaking of
lingual braces, we are using a system of tiny, self-ligating lingual brackets
(getting the hang of the terminology?) that is great for minor cases of crooked
front teeth.
This system is perfect for people that notice some minor alignment problems of the front teeth, or people that had straight teeth from braces but failed to wear the retainers enough to prevent re-crowding. Typically, these treatments can be finished in just a few months.
Align Technologies, the makers of Invisalign, have spent more money advertising this product than any other company in orthodontic history. They have pushed the industry into its current logo-making, “system”-pushing frenzy.
Invisalign also
uses a computer modeling technique to create a series of clear plastic aligners
that fit over the teeth like contact lenses fit your eyes. They are
created to be slightly straighter than your teeth are, so when you put the
aligner over your teeth, they nudge the teeth slightly. In two weeks you
get another slightly straighter aligner to go the next step. A full series
may have 10 or 20 or more aligners. Often you get more than one series to
get the best result.
The aligners are clear and smooth and can be taken off for eating and cleaning. They are not completely “invisible” since some plastic shows. Their thickness does affect speech at first, though your tongue will accommodate in short order. Often small tooth-colored “attachments” (like small brackets) are placed on the teeth to give the aligners more control. It takes some discipline to fit the aligners into your lifestyle, since removing them in public for eating and cleaning can be a bit of a hassle (again with the blessing and curse thing).
Don’t doubt that they work, though. Their effectiveness and efficiency rivals regular braces when they’re used in the right situations and planned properly. For more difficult cases, they can be used in combination with other techniques or (since Align loathes the word “braces”), with “adjuncts” (as in “add junk”). The company makes great effort to see that they’re used properly by training general dentists in their use. But a specialist in orthodontics can apply it to a broader range of cases by knowing the limitation of the appliance and having other techniques to incorporate.
Before there was Invisalign, there were “positioners”. Positioners, like aligners, are removable appliances placed over the teeth to place pressure on them. Unlike like plastic aligners, they are made of rubber and look like athletic mouthguards.
Recently, Australian orthodontist, Dr. Chris Farrell, has developed a system of positioners, or “trainers”, that are used not only to straighten teeth, but to help strengthen and coordinate the muscles of the mouth for better function and development.
The theory is that teeth are often
crooked because of the way the muscles of the mouth – tongue, cheeks, and lips –
press on the teeth during breathing, biting, chewing, swallowing, speaking and
resting. In fact, these pressures mold not only the teeth, but also the
jaw bones during the growing years. Habits like tongue thrusting, mouth
breathing, lip sucking, finger sucking, and more, have a detrimental
effect. Correction of these problems requires a “myofunctional” approach
to normalize muscle function. Correcting these habits leads to a better
and more STABLE orthodontic result.
There are MyoBrace appliances for virtually all types of problems and for all ages. The MyoBrace is typically worn for 1-2 hours a day during which exercises are done to strengthen muscles and restore good habits. These can be done during studying, TV, video game, or reading time. Of course, this means quiet time, too (mothers’ love this). And it is worn throughout the night while sleeping too.
The biggest drawback of this technique is that it requires 100% cooperation in wearing and exercising. They are easy to wear, but they do not fit every kid’s lifestyle. Also, while they are said to replace braces, that is not always true. Often, I use them as a head start to braces or to minimize the amount of time that braces may be needed. That’s a good thing if you hate the idea of braces. Often they require other adjuncts, like “inside wires” to help them along.
Part 3. Making your Choice
This is only a sample of the many different options that a specialist in orthodontics can offer you. There are also many ways to avoid the use of headgear, for instance. Also, if your teeth are very crowded, you may have to make a choice between spreading the teeth out or removing some teeth to make more room. There is also the decision about the best time to start treatment. There are different options if you are missing teeth, or if your jaws are not growing properly, and so on.
While you have to rely on your orthodontist to decide which options can be used successfully in your case, don’t go in assuming that there is only one best option. In the name of expediency, some patients assume they need “braces” and go in ready to start on their first visit.
But the wise consumer will ask the question: Are there any other options for me or my child? In my experience, 95% of the time the answer is: “Yes, there are options.”
It may take some time and patience to learn about these options, but if your orthodontist is willing to take the time to explain them, it will be well worth it in the end. You will have a treatment plan that fits YOU, not just your teeth. This will make for a more pleasant experience and a better result. When YOU or your child chooses the treatment, it empowers you as a “teammate” in the treatment, and you’ll have more control of the outcome – an outcome that you can be proud of and will last you the rest of your life. An outcome you can smile about…
[Remember to click on the logo icons for more information, or email questions to me at mailto:drbarry@alignmine.com ]
Copyright © 2008 Barry D. Raphael, DMD PA.
All rights reserved.
Revised: 9/28/2008