Do-It-Yourself Orthodontics

A frequent topic that I discuss is do-it-yourself orthodontic aligner companies. Their usual claim is that their product is quicker and more affordable than “traditional” methods to improve your smile. They often advertise that your smile can be corrected within 4-6 months.  My goal with this article is to give you my thoughts regarding this type of treatment, as well as provide you with some things to think about when you are considering orthodontic treatment, no matter what you want improved.

Now as a disclaimer, I have not used any of the direct to consumer orthodontic appliances that are on the market today.  Most of my comments are not directed to specific companies, but rather on the concept of remote orthodontics, in general.

Another disclaimer: I am an orthodontic specialist and I have 2 years of specialty training in the diagnosis and treatment of orthodontic problems, in addition to the 4 years of training as a dental professional. Now, in order to properly diagnosis and treatment plan for an individual, we look at not just crooked teeth, but also your oral health, gum tissue, jaw relationships, jaw discomfort, biting issues and any potential growth considerations. If there are any dental issues that would affect the success of orthodontic treatment, it is important that you have an orthodontic professional that explains these issues to you and why it is important to have them corrected before orthodontic treatment has started.

Additionally, orthodontists are more cognizant of what can, and more importantly, can’t be accomplished in treatment.  With the increase in clear aligners, the use of computer-generated tooth movement and predictions for treatment are becoming more common.  While these predictive models are useful visual aids, they still do not take an individual’s biology and the biomechanics of tooth movement into account.  Therefore, these computer predictions also cannot guarantee your result will be ideal and the companies may not tell you that.  When you are considering orthodontic treatment and are looking into the direct-to-consumer companies, please be cautious and ask questions.  Here are a few things to consider before beginning treatment:

-Do they diagnose oral health issues?  Moving teeth in a comprised oral environment can lead to detrimental effects.  I require that all of my patients be up-to-date on their cleanings and dental check-ups before beginning treatment.  All dental concerns need to be addressed prior to initiating orthodontic treatment.  What does the company do if any oral health problems arise? Do they tell you?

-Who is treatment planning your case?  There needs to be someone that is trained in orthodontics, not just someone who is trained to use software.  If they claim to have orthodontists that treatment plan your case, do you know the name of them?  Can you contact them directly with your concerns during treatment?

-As part of the fees that you pay, do you receive any in-person visits? How many? Do you receive retainers after treatment is done?

-What happens if there is a problem with your case?  Cases do not always go accordingly to plan for various reasons.  An orthodontist is trained to expect and adapt to that.  Aligners do not always fit properly on your teeth and teeth do not move according to what is prescribed on a computer. We may need to add rubberbands or change the fit of the aligner or order a new set to make sure that your treatment is progressing.  Adaptation is essential in orthodontic treatment, regardless if we are using braces or aligners. You need to be sure that they give you an idea of what happens if something goes wrong with your treatment.

-What happens after treatment has concluded? What happens if there are teeth that still need to be moved?  Do they continue working on your case until it has corrected or do they ask for more money to re-start your treatment? 

-Do they tell you if your treatment is too severe or if your case cannot be completed by their system? 

Lastly, can you trust that someone that you’ve never met you has your best interests in mind when they are planning your case? Again, you want to work with someone that is open and honest with you. I try to treatment plan and oversee every case as if they were an immediate relative of mine. 

I know that some people usually just say, “I know all that, but I just want to straighten my lower teeth”.  I really do understand that, but your oral health is just as important to me as correcting your smile.  I know that in this day and age of everyone wanting things quick and easy, orthodontics seems like a lifetime process for just realigning some teeth, but it is essential that treatment is carried out effectively, not just quickly.  I think that most everyone would agree with me that you want your teeth straighten the right way on the first try and not the quick way that may result in more time and money later down the road.  Orthodontic treatment is a complex dental process and, just like any other medical or dental procedure, I need an experienced doctor that has the skills and training that I trust with my health.  A local orthodontist will evaluate your oral health, create a personalized treatment plan and then regularly monitor your progress, adapt to any problems and try their best to get to your ideal outcome.  The last thing that I want from any patient, not just my own, is that you get done with your DIY treatment and then you have to spend more time and money to get your treatment re-done.  Please, for your own health and benefit, do your research and ask questions before beginning your orthodontic treatment with a direct-to-consumer company.

Why Aren’t My Child’s Permanent Teeth Coming In?

If your son or daughter has lost a baby tooth and there is no sign of a permanent tooth coming in after a few months, there can be a couple of common and a few uncommon reasons why this may occur.

One of the main reasons is that there may be a lack of space for the permanent tooth to erupt.  This is especially true in the front of the mouth, where the adult teeth are much wider than the baby teeth that they replace. So if there is not enough space, there is a chance that the adult tooth is having a hard time erupting and won’t appear in the mouth. 

Another reason that they may not be erupting in the proper space that the permanent tooth could be moving in a different direction.  There are some instances when a developing permanent tooth can move away from its usual spot.  In this instance, it does not follow and replace the baby tooth, but may interfere with the development of other teeth.  The term for this instance is often referred to “an impacted tooth” by orthodontists and dentists. The most common impacted teeth are upper canines (often called fang teeth by patients) and lower second premolars.  If a tooth has been spotted to have a deviated eruption path, it could help to remove a baby tooth to get the tooth back on track, as soon as it is noted.  If the path doesn’t change, orthodontic treatment is often necessary to help guide the displaced tooth into the proper position.

In addition to these main concerns, there may be additional factors that orthodontists need to consider when dealing with impacted teeth.   One of these rare conditions is that the permanent that usually replaces the corresponding baby tooth may have never developed.  This is often not known until we take xrays at an orthodontic office to see if a tooth is not present. 

Another rare condition is something called “primary failure of eruption”, which ultimately means that the tooth will not come in on its own and needs help to erupt.  A combination of oral surgery and orthodontics is needed to help these teeth erupt into the proper place.  There be more than 1 tooth that is affected by this condition and orthodontic treatment may take longer than the usual 2 years. 

Lastly, ankylosis is another less common reason for adult teeth to not erupt.  Essentially, this is when a baby tooth becomes fused to the bone and won’t move.  The most common solution to this situation is their removal or leaving them in place until a future restorative option can be determined.

If your son or daughter has lost a baby tooth and you do not see a replacement adult tooth after a few months, you should have him or her evaluated by an orthodontic specialist.  An orthodontist a dental specialist that is trained in the diagnosis and treating the problems related to development of teeth.  They can determine if treatment is warranted, the optimal timing for possible treatment, or just reassurance and peace of mind if treatment is not needed.

 

Keeping Your Teeth Healthy While in Braces

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It's National Children's Dental Health Month!  What better way to celebrate than to pick out some helpful tips to keep your teeth clean while you are in treatment.

1.       Contrary to what you might think, a soft toothbrush is better for you during orthodontic treatment.  Medium and hard bristle toothbrushes should be avoided and can actually harm your gum tissue.

2.       Start your brushing with just water on your toothbrush.  This way, it is easier to see what you are doing and see how much plaque is coming off during your brushing.  Then, place a small pea-sized amount of toothpaste on your toothbrush and brush for 2 minutes.

3.       If you are having a hard time brushing for longer than 30 seconds, play a song on your phone or radio, and brush until the song is over.  Most songs are over 2 minutes, so once the song is done, you have reached the critical 2-minute goal.  Just as important, spread your brushing over all surfaces on top and bottom, so that you aren’t missing a spot.

4.       Toothbrushes that are placed at 45-degree angles and moved in circular motions against the teeth, braces and gum tissues are the best ways to make sure that the food stuck between your braces and your gum tissue is effectively removed.

5.       After you brush your teeth at night, spit but DO NOT RINSE the toothpaste off your teeth.  By leaving the fluoride on your teeth, it can help provide a critical layer of protection during the night while you sleep.

6.       Do not attempt to whiten your teeth while in orthodontic treatment.  Whether it is whitening gel, whitening toothpaste or whitening treatment offered by your dentist, it is best to wait 3-4 months AFTER your orthodontic treatment has been completed before you attempt to whiten your teeth.  

7.       Manual or electric?  Electric toothbrushes have shown to be more effective at removing plaque and bacteria for patients in braces.  However, some patients do not like the vibrations on their teeth.  I am in favor of whichever toothbrush that a patient can use effectively and consistently.

Do I need to have my wisdom teeth removed?

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This is a common topic that is discussed in dental and orthodontic offices everywhere.  Wisdom teeth, also known as third molars, usually can be seen on dental x-rays between the ages of 10 and 16.  There are some occasions where a patient can feel their wisdom teeth because they start hurting, but most of the time, wisdom teeth need to be discussed with a dental professional to determine the best course of action.  Most people have them removed, but the question that is usually asked is “Why?”.

One of the major dental myths that has persisted, is that wisdom teeth need to be removed because they can push all other teeth forward and make your front teeth crooked.  To my knowledge, there has not been a scientific article that shows that wisdom teeth specifically cause crooked teeth.  However, there was a study published that examined whether or not patients, previously treated with orthodontics, exhibited an increase in crooked teeth if they had their wisdom teeth compared to patients that had their wisdom teeth removed.  Their results showed that their was no difference in the amount of crowding, (or crooked teeth) between the two groups.  So, if wisdom teeth don't necessarily cause crooked teeth, then why should they be extracted?

First and foremost, there may not be enough room for them to adequately erupt in the proper position.  The other reason is that even when there is room and they are the proper position, it can be difficult to properly take care of them.  It is critical to brush and floss around these teeth. Due to their position at the back of your mouth, it may be difficult to keep them clean.  If you get cavities and gum disease associated with wisdom teeth, your dentist may want to remove them anyway.

So, when is it appropriate to keep your wisdom teeth?  If there is enough room for them to fully erupt into the proper position and you can keep them clean, then it may not be necessary to have them removed.  While most people have their wisdom teeth removed, it's not because they are causing the rest of your teeth to become crooked, but rather to help you maintain proper oral health throughout your life.  Every patient's situation is different, so ask your dental professional if you have any questions regarding your wisdom teeth.

Retainers

Why do we need retainers?

There are a few main reasons why it is necessary for patients to wear their retainers after the completion of orthodontic treatment, but it mainly involves your biology. 

The structure that allows teeth to be moved in the first place is also the reason that your teeth want to move back- the periodontal ligament.  This structure, along with gum tissue fibers, and bone are the structures that adjust and reorganize to allow teeth to move from one position to another during treatment.  Once your teeth are the position that we want, all of these structures need time to adjust to this new position.  New bone forms and gum tissue fibers re-organize to help the teeth stay in their new place.

Because this process is not a fast one, retainers are used to help your teeth stay in place while the secondary structures “settle-in” to their new position.  By wearing retainers all the time (except for when you are eating or brushing your teeth) for the first several months, you are ensuring that your teeth stay in those final positions and maintain a great result even after your active treatment has been completed.

Which retainers are the best?

The answer to this questions is…. it depends.  There are several variations to retainers that orthodontists use to help maintain a successful outcome and each one of these retainers may be used in different situations.  Your orthodontist can help explain which retainer would be best for yourself or your loved one.

How long should my retainer last?

The length of a retainer’s durability depends on the type of retainer.  The fixed retainers that are bonded (or glued) to the back of your teeth can, over time, wear away.  The glue that holds a fixed retainer can erode from toothbrushing, food, drinks and other abrasive forces.  Some can dislodge within a couple of years and some can last 20 years or more.  If you think your fixed retainer is loose, see your orthodontist today.

Removable retainers can usually be separated into 2 general varieties: clear retainers that cover the teeth or acrylic/plastic retainers that usually have a bar that wraps around your front teeth.  The clear retainers need to be replaced if: you accidentally place them in hot water which warps the plastic, you wear them down with your bite, they turn gross, or your teeth have shifted enough that they do not fit.  The acrylic ones may need to be replaced if they turn gross or break.

In any case, no matter what retainer you have, if you notice changes in the position of your teeth while you have a retainer or if the retainer does not fit right, call your orthodontist to see if you need a new one.  The longer you wait, the more your teeth will move and the less a retainer can help correct it.

When do I stop wearing my retainer, even if I have perfectly straight teeth?

The simple answer is never.  As long as you want straight teeth, you should never get rid of your retainer and should always keep it with you.  Now, that does not mean that you will have to wear your retainer all the time, but it does mean that even if it has been 20 years after your orthodontic treatment has been completed, you should at least try your retainer in to make sure that the retainer is not too tight.  If the retainer does feel tight, make sure to wear it for at least a full 12 hours to get the teeth back into position.  If your retainer does not seat properly and you cannot fit in around your teeth, that means it is time to see your orthodontist to determine if you need another retainer to help correct some of the developing issues.  New retainers can provide very limited movement of teeth, but for more extensive cases of relapse, other options may need to be discussed.

What are my child’s options if he or she is missing an adult (or permanent) tooth?

The age at which children lose their baby teeth can vary greatly depending on the individual.  I have seen some children who have lost all their baby teeth by age nine and some children who still have baby teeth in the late teenage years.   In general, most children lose their last baby teeth by the age of twelve. After a child does lose his or her baby tooth, it is usually replaced by an adult tooth soon after.  So, the question is: what if a baby tooth has been lost and you don’t see an adult tooth erupt after several months?  It could be that the adult tooth may be missing and therefore, will never erupt.  Because it is difficult for you to tell by just looking at the mouth if an adult is not present, a great supplemental way to assist in this determination is an x-ray.  An orthodontist will often take an x-ray that is usually called a panoramic x-ray.  It can also be called a “pano” or a “panorex”.  This kind of x-ray shows the whole mouth and can assist in displaying all developing adult and baby teeth that are present, even the ones you cannot see when your child opens his or her mouth. 

At what age can you tell that an adult tooth is missing?  Well, it depends on the type of tooth.  There are some adult teeth that start developing early in a child’s life and others (like 3rd molars aka- “wisdom teeth”) may not be seen until a child is at least twelve years old.  The variance in tooth development is one of the main reasons to see an orthodontist for an initial consult for your child by age 7.  While there may be no treatment recommendations at an early age, it is helpful for both parents and their children to be informed about this situation and to plan for future options.

So, let’s say that we take a panoramic x-ray and we find that there is a missing adult tooth.  What are the options for your child? What are some of the benefits to each of the options?  First, it is important to note that not all options would work for every patient.  Each child presents different diagnostic criteria that are important and helpful in determining which option would work best for your child.  With that said, when an adult tooth is determined to be missing, there are a few different possibilities: keep the baby tooth (if still present), replace the missing tooth with a restorative option, or close the space using orthodontic mechanics.  Some of these options work better than others depending on a variety of other factors, so they are not necessarily transposable.  If the child’s bite looks ideal and there is minimal crowding in both upper and lower teeth, then it may be best to keep the baby tooth as long as possible, perhaps indefinitely, if the root of the baby tooth permits it. 

If the root of the baby tooth appears to be in poor condition or is not there, it may be replaced by a future restorative option, such as an implant or a bridge.  In this case, treatment planning involves several dental specialties (orthodontist, dentist, oral surgeron, etc.) to accurately assess and provide the proper information involving the whole treatment, including ideal timing.  When discussing implants, it is important to know that tooth implants are best placed after the child has completed his or her pubertal growth spurt.  This provides the best result in terms of both esthetics and function, while limiting some future issues that can arise if the implant is placed at a young age.  If an implant is planned in the future, and orthodontic treatment has completed before the ideal time for the implant, your orthodontist will typically fabricate a retainer that usually has a fake tooth placed on it to help

The option of “closing the space” is optimal in patients that present more severe cases of crowding.  In this option, the space present can be used as part of a detailed treatment plan to address other areas of concern, including crowding, as well as attempting to address the missing tooth.  It needs to be noted that the process of closing space usually increases orthodontic treatment time than the option of keeping the space available for a future restorative option.  It may also be difficult to orthodontically close the space, depending on the bone density that is available, and the mechanics that are needed to asymmetrically close space.

With all of this information, what is the best and most appropriate treatment for your child? The answer is that it depends. As you probably guessed, every child presents different circumstances that need to be considered.  An examination by an orthodontist can help diagnosis and determine all the factors that should be considered before going forward with any treatment.  They will consider your child’s bite, and crowding, among other things and discuss your options with you and your dentist before beginning any treatment option.  This is ideal to make sure that your child has the best smile possible after all dental work is complete.

Why is summer the best time to start orthodontic treatment?

There are a lot of factors that go into the decision to begin braces or other orthodontic treatment. For parents of children starting in braces they have to consider their own work schedules, school schedules, after school activities and sports, and of course, available funds.

For many people the summer time offers the most flexibility.

Why Summer is a great time to start orthodontic treatment:

  1. No school = more appointment flexibility and no missed school.  There is no question that during the school year, everyone wants to avoid missing school (well, okay, maybe some children would prefer to skip a test or two).  But typically, parents like to schedule appointments at the beginning and end of the day to allow children the more time in the classroom.  Longer appointments, like those needed when starting braces, are usually scheduled in the late morning and early afternoon. Summer time allows the flexibility in your child’s schedule to take advantage of this without missing school time.

  2. Avoid the Rush.  Most parents (and most kids) want to either have their orthodontic treatment completed before end of the year photos or before the beginning of a new school year.  By starting in the summertime, there is a better chance of treatment concluding before these important times of the year.

  3. Minimize Mother Nature’s delays in treatment.  Lots of things throughout the year can cause missed appointments:  hailstorms, thunderstorms, heavy snow and ice conditions can cause missed appointments and may ultimately delay the progression of orthodontic treatment.  The critical first few appointments have less of a chance of being ruined by Mother Nature if they occur in the summer.

  4. Recover at home, instead at school.  Newer advancements in the orthodontics have minimized the discomfort that can be felt by patients, but it’s still possible to have tender teeth and gum tissues.  Discomfort is most common during the initial stages of treatment while teeth are adjusting to braces or aligners. For many, it is easier to deal with this discomfort at home than at school. Home is where most people are most comfortable and there’s no risk of temporary discomfort distracting from important school tasks.

  5. Flexibility to tackle the unexpected. There tends to be an initial learning curve for patients when they first get braces. The beginning in the summer allows them to have the time to learn how to brush, floss and eat differently.  Additionally, if there is a problem or broken bracket, it can be repaired in a quicker time frame.

For those reasons and more, summer time offers many benefits for beginning the journey to a beautiful and healthy new smile.

When is the best time for your child to see an orthodontist?

According the American Association of Orthodontists, all children should have a check-up with an orthodontic specialist no later than age 7.

Why do they recommend being seen by age 7?

Generally, it is around this time that some permanent teeth have erupted and there are several conditions that can be assessed at this age including, though may not require treatment:

  • Initial crowding

  • Deep bites

  • Open bites

  • Crossbites

  • Jaw discrepancies

  • Bite relationships (occlusion)

What will happen if my child has not been seen at age 7?

At this age the most important thing is to gather information and assess your treatment options.  Even if treatment cannot be performed or is not recommended, it is better to be aware of the conditions that are present to determine when treatment is right for your family member.

Will every child need some orthodontic treatment at this age 7?

In general, no.  Most of the time, treatment at younger ages is geared toward correcting a specific need that could otherwise affect the child’s growth and development of facial structures through puberty.  

There are often conditions that do not need treatment at an early age and can be corrected at a later time.  It is important to note, not all treatment at this age will prevent the need for future orthodontic treatment, but rather it can prevent a problem from getting worse or improve a specific condition.

What should I expect for my child’s first visit?

Most orthodontists will perform routine exams, assess oral conditions and discuss any recommended treatment options with you.  Sometimes, treatment may not be needed and your orthodontist will only want to monitor the child’s growth and development to determine when would be the best time to begin orthodontic treatment (if it is needed).  

It’s always comforting to be informed about the health and growth of your child. So while treatment at age 7 is not typically required it’s a good idea to see your local orthodontist to get a baseline and an understanding of your child’s potential orthodontic needs.