Monday, February 18, 2013

Did my wisdom teeth make my other teeth crooked?

I often have parents of patients ask about wisdom teeth and when they should be removed.  One concern people have is that the wisdom teeth are going to come in and ruin the orthodontic result.  While the wisdom teeth get a lot of blame for the recurrence of crowding in the dental arches, how much of it is really warranted?  Do the wisdom teeth really cause that crowding?  And if not, what does?

Usually the wisdom teeth start to come in (if there is enough room for them) in the late teenage years or early 20s.  Research done at the University of Iowa has shown that as these teeth erupt, they do not put enough force on the adjacent teeth to cause crowding to occur.  Pressure sensors were placed between the teeth to measure the pressure on the teeth with and without wisdom teeth being present, and there was no difference.  Other studies have shown that crowding in the adult teeth will occur with or without wisdom teeth ever being present, and whether they are extracted or not.

So if wisdom teeth aren't to blame, then what causes the teeth to crowd up in these cases?  Orthodontists have a few ideas.  One is that as the lower front teeth wear a bit on the edges, the upper teeth exert a bit more pressure on them pushing them back toward the tongue.  Another possibility is a small amount of late jaw growth which puts a bit of extra pressure against the backs of the upper front teeth.  Also, as we get older there are natural, yet undesirable changes that tend to occur.  One such change is a narrowing of the lower arch as the canines tip in slightly.  This takes away some of the space for the lower incisors causing them to shift.

So what can be done to prevent this relapse from happening?  Although there are valid reasons for removing the wisdom teeth if there is not room for them, preventing the teeth from crowding up shouldn't really be one of them.  The secret to keeping our teeth straight long-term is really no secret.  The answer is long-term retainer wear.  Permanent, bonded retainers are a great way to do this (and will be addressed in a future post) but removable retainers will work just as well, assuming they are worn as directed.  I think the main reason that patients see shifting when they are in their late teens and early twenties is not due to wisdom teeth coming in.  I think it's because they have stopped wearing their retainers and one of the other factors mentioned is in play.  Wear your retainers and your teeth won't move, and you will preserve that beautiful smile for as long as you like.

Wednesday, February 6, 2013

What is the purpose of an orthodontic "supervision" appointment?

We know that moms and dads have busy schedules. Leaving work, picking up their children from school and taking them to the orthodontist is no small task. Sometimes the appointments are very short and seemingly meaningless. One of these appointments is the observation or supervision visit. These appointments are usually less than 15 minutes and many wonder if they are necessary at all. Supervision or observation appointments are very important, however!

Observation or supervision visits are scheduled for orthodontic patients who are either not yet quite ready for braces or have had an interceptive phase of treatment and are waiting for their remaining permanent teeth to come in. The orthodontist may take a progress x-ray at this appointment to help him evaluate your child’s dental development. There are three things that I look for when your son or daughter is in my chair.

First, if the patient has had an interceptive phase of treatment, it is important to check the condition of the retainers. The Phase 1 retainers that we use on the lower teeth are often bonded directly to the teeth.  Sometimes the bonding material wears thin with normal eating or the bonding material comes loose from the tooth surface. If a retainer comes loose or is lost, the teeth can move and the result of the initial treatment compromised. It only takes a couple of minutes to add cement to an intact retainer. If teeth have shifted due to a broken bonded retainer oftentimes braces must be put back on in order to restraighten the teeth. On the upper teeth we normally use a removable plastic-and-wire "Hawley" retainer.  These retainers may need periodic adjustment and tightening if they become loose fitting.  As well, the new permanent teeth that are erupting are a different size and shape than the baby teeth that were lost.  We can trim the plastic on the retainer to accomodate these new erupting teeth and keep the retainer fitting well to preserve the correction we gained.

The second objective of this appointment is to evaluate the loss of primary teeth and the eruption of the permanent replacements. Losing primary teeth on time and in the right order can help the permanent teeth come in straighter. If I notice that a baby tooth is not falling out on time, or I identify in an x-ray that the permanent teeth are headed in the wrong direction, I usually recommend that a patient see their family dentist to get the offending baby tooth removed. Evaluating the loss of primary teeth and the eruption of permanent ones doesn’t take much time, but ignoring developing problems can add months or years to a patient’s orthodontic treatment.

The third objective of an observation appointment is to advise the family about the timing of the next phase of treatment. My philosophy is that I will begin no treatment before a patient is ready. This might mean waiting a few months or even years. If we start too early, your son or daughter may have the braces on longer than necessary. If we wait too long, we might miss the opportunity to keep treatment as short as possible, or miss a growth spurt needed to correct a bite problem.

Having your orthodontist follow your child’s development will help them receive the care they need when they need it. Although they are short and sometimes seem like a wasted trip, your orthodontist knows exactly what to look for at an observation or recall appointment and will make sure that your child is progressing towards an excellent orthodontic result. Next time your son or daughter has an observation visit with your orthodontist, make sure and ask for an explanation of the things he was looking for and what was found. I think you’ll find that these short, to-the-point appointments are as important as any you’ll have.

Friday, February 1, 2013

When Clear Braces are Better than Invisalign

Many people who want straight teeth never go through with treatment because they just don’t like the way braces look. In 1998, Align Technology introduced Invisalign tooth positioning aligners. Up until that time, the only cosmetic alternatives to silver braces on the teeth were clear (ceramic) or lingual (inside) braces. Why do orthodontists still use braces when Invisalign seems so much better?

Align Technology’s introduction of Invisalign changed orthodontics forever. First, for appropriate cases, Invisalign does provide the esthetic alternative to braces that many patients are seeking. Second, because Align bypassed professional providers and marketed directly to the public (think Little Purple Pill and Viagra), they created a demand for their product and an expectation that teeth can now be straightened without wires and brackets glued to the teeth. Third, because the Invisalign system seems so much easier to use than conventional braces, more than 300,000 non-specialist dentists are now also offering orthodontic services in their practices. Although these changes have encouraged more patients to seek treatment, Invisalign is not a replacement for braces in all cases.

First, although clear aligners are appropriate for many orthodontic problems, they are still biomechanically inferior to conventional braces in many situations. Because it is more difficult for plastic shells to create some of the forces required for complex tooth movements most orthodontists still prefer to use brackets and wires for moderate to severe cases.

Second, by taking Invisalign directly to the public without explaining its limitations, Align makes orthodontists give disappointing news to overly optimistic prospective patients. In my practice only a small percentage of patients who come in hoping for Invisalign actually have problems that qualify for aligner therapy. The others would be treated to a better result with braces.

Third, because Invisalign appears easier to use than braces, dentists with little or no orthodontic training are now also offering orthodontic services to their patients. Since most of us trust the advice of our family dentist, rarely do we question when he recommends a new service. The results obtained by any doctor however are determined by his skills and experience. Eliminating brackets and wires does not eliminate the need for accurate diagnosis, treatment planning, and case management. Invisalign is simply a tool. Just because I can buy the same golf clubs as Tiger Woods does not mean that I can shoot the same scores as he does!

I use Invisalign in my orthodontic office. It is effective for mild to moderate crowding and alignment cases. It is especially good for patients who have had previous orthodontic treatment but did not wear their retainers and have experienced some relapse. I like the fact that my patients can take out their aligners to eat and brush. Patients like it because it looks better than braces. And sometimes the benefits of being able to selectively move only certain teeth while maintaining the positions of others makes Invisalign the treatment of choice.

If Invisalign isn’t appropriate for your particular problem, what other options do you have? The most tried and true, esthetic, economical alternative is clear braces. They have been around a long time and are now better than ever! Modern manufacturing techniques have created clear brackets that are stronger, smaller and stain-resistant. They can be used for the exact same complex movements as metal brackets and move the teeth just as efficiently. In my office I have exclusively used tooth-colored ceramic braces on the upper teeth for many years now because I want every patient to have the most esthetic treatment option possible.

Invisalign might be perfect for you if your problems are only mild to moderate. If you want the ultimate invisible treatment, you could consider lingual braces, which go on the backside of the teeth, but can be more irritating to your tongue and tend to cost significantly more than traditional "frontside" braces. If you want the most cost-effective esthetic alternative to “railroad tracks” that can actually move your teeth like metal braces however, ask your orthodontist to show you today’s clear braces.