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Esthetic Orthodontics 103: Invisalign

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Esthetic Orthodontics 103: Invisalign

Esthetic Orthodontics 103: Invisalign

“Invisalign” is a brand name of the biggest and best manufacture of clear “aligners” that can be used to move teeth.  The idea of moving teeth with clear trays is not a new one.  Orthodontists have moved teeth with clear trays for more than 50 years!  In the past, an orthodontist would make a physical model of a patient’s teeth and then move one or two teeth a small amount and make a clear tray to fit the teeth in the new position.  When worn by the patient, the tray would put pressure on the teeth that had been moved on the model and the patient’s teeth would adapt to the new position.  It worked great, but it was extremely limited because we could not move “all” the teeth and for every tray we made, it would require a new impression and new model.  So moving teeth very far was not really practical.

The genius of Invisalign is that they applied a computer design and manufacturing process to this idea of moving  teeth with clear trays.  This allows an orthodontist  to model “all” the teeth moving and also allows tray after tray to be made in a series without the need for multiple impressions!  Yeah!  In fact today, we can do the whole process without a single impression  by using a digital scan of the patient’s teeth (but the advantages of a digital scanner will have to be a blog for another day;  stay tuned).

The Primary Advantage of Invisalign is Esthetics.

Of course, the reason that Invisalign has capture so much of the orthodontic market is because it allows patients to have the tooth movement that they need without the look of braces.  The trays are clear and are changed every two weeks so they stay very clear and unnoticeable in social situations.  Another huge factor in the “esthetics” arena is the fact that the aligners are removable.  So if you have a particularly important speaking engagement or photographs to take, you can remove them for the special occasion.

Here is one of our patients, wearing her aligners.  As you can see (or should I see can’t see), it is very unnoticeable.  

The Seconday Advantages are Numerous.

Patient’s understand the esthetic advantages of the aligner process, but often underappreciate the other advantages of moving  teeth in this way.   At the risk of being  too long-winded.  Here is the top 10 reasons that aligners are cool (beyond the estethics).

1. Brushing and flossing  are tons easier!  The fact that the trays are removable can be a great benefit to the ability of a patient to clean their teeth.  Instead of brushing and flossing ‘around’ the orthodontic appliances affixed to your teeth, you remove the trays and ‘have at it’.  

2. Aligners are much more comfortable than braces.  Braces take some getting used to in terms of the lips and cheeks or tongue adapting to the roughness of the braces.  Aligners are very smooth and being removable, can be easily modified if there is part of the tray that is rubbing. 

3. The forces are very controlled.  Because each step along the path is calibrated to very precise degree, the forces that patients’ have on their teeth is much more controlled and limited.  The ‘soreness’ that patients can have with braces is almost completely eliminated  with aligners. 

4. The tooth movement is pre-planned.  With aligners we pre-program the system to achieve a desired end-result.  This is very different than with traditional braces where our ‘target’ only exists in the mind of the orthodontist.  If the teeth are being moved to facilitate some other dental work, the final result can be visualized before the treatment begins.  This also allows us to be selective about which teeth to “NOT” move or stay in the pre-treatment position.  Maintaining an exact pre-treatment position is often difficult with braces, but is simple when the movement is pre-planned.

5. Emergencies are almost entirely eliminated.  With fixed braces, there can be discomfort associate when a wire or bracket becomes detached from the rest of the orthodontic appliances.  This can lead to pokey wires and undesired tooth movement if the patient is not seen fairly shortly after the bracket or wire breaks.  With aligners, there is almost nothing to ‘break’.  If a tray is lost, we have the patient go to the next tray and continue on the sequence.  This makes aligners particularly attractive to patients who come to see us from great distances.  If getting to our office involves a plane trip, we want to minimize the risk of extra ‘emergency’ appointments.

6. Speech is largely unaffected.  Most patients adapt to speaking with the aligners within a couple of days of wearing them.  With some other orthodontic appliances, speech affects can be much more. . .eh-em. . . . ‘pronounced’.

7. Tooth wear from grinding is prevented.  With the trays covering the teeth, if you grind your teeth, you simply wear the plastic.  So if you are prone to grinding this is a great way to protect the teeth during your orthodontic care.  With traditional braces, this is a challenge because a nightguard will stop fitting as the teeth are moved with braces.  These following photos are of a patient who was specifically concerned with tooth wear from grinding.  You can see the wear on the edges of the teeth in the first picture.  Then the second picture is with the aligners on the teeth.  Notice that there is plastic between the teeth protecting them as they move.

  Without Invisalign

Without Invisalign

  With Invisalign

With Invisalign

8. Tooth bleaching can be done with the aligners.  As patients’  teeth straighten, many also desire show off their pearly whites with ‘more white’.  The invisalign trays can actually be used as a bleaching tray to whiten the teeth as we go along.

9. Retainers are digitally stored and can be reordered.  With traditional braces, the retainer is made on a plaster model that is destroyed in making of the retainer.  If a patient loses or fails to wear the retainer and the teeth shift slightly, often the best option is just to make a new retainer in the shifted position to prevent further shifting.  When aligners are used, the patient’s final tooth position is saved and the retainer can be made to the ‘digital model’.  If a new retainer is needed, another can be ordered without the need to take another impression.  If the teeth have shifted (a very small amount) the new retainer can move the teeth back to their final position.  If the shifting is more pronounced, then the new retainer may not fit.

10. Patient’s love them.  For the most part, our aligner patients really appreciate how easy this process is for them.  Of course, there are some who struggle with remembering to wear the trays or find it inconvenient to take the trays out for meals, but for the most part, patients really like the Invisalign process.  This is especially true for patients who have worn braces in the past.

 

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Loss Aversion and Esthetic Orthodontic Treatment

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Loss Aversion and Esthetic Orthodontic Treatment

The last few blogs have addressed some of the esthetic benefits that we can achieve with orthodontic treatment.  So now I would like to turn our attention to the possibilities of achieving the outcome in an esthetic way.   But of course, we need to back-up and elucidate the psychology behind the importance of keeping orthodontic treatment esthetic. 

There are lots of great examples of how despite our belief that we are making strictly rational choices, we are in fact subtly guided by tendencies of which we have no conscious awareness.   One of the best examples of this irrational behavior is called “loss aversion”.  Loss aversion, simply put, is the almost universal tendency to avoid losses over pursuing similarly sized gains.  We avoid pain more than pursue pleasure.  Think of a five dollar gamble on a coin flip.  For most of us, losing the flip and the five bucks is FEELS much worse than the winning FEELS good.  Psychologist have actually quantified this tendency and have found that it is nearly 2:1 depending on the study.

One of my favorite examples of Loss Aversion in a study comes from Dan Ariely (Predictably Irrational, 2009).  I like this example because it shows how even kids are guided by Loss Aversion.  In the study, he offers kids a choice:

Two Hershey's Kisses
OR
A Snickers bar

Now (of course) the overwhelming majority of kids want the Snickers because it is just MORE chocolate.  But Dr. Ariely then gives a different group of kids the same choice but offers it a bit differently, and here is where it gets interesting.  

In the second group he gives the kids one Hershey’s Kiss to hold in their hand.  This first Kiss becomes “theirs” and its value is greatly elevated.  Dr. Ariely then tells the kids that they can have one of two choices again. 

He offers one more Hershey's Kiss "for free
OR
He offers them the option to trade in the one Hershey's Kiss for a Snickers bar

Notice that the end points of the choices are the same as the first scenario; either the kid will end up with two Hershey’s Kisses, or the kid will end up with one Snickers bar.  So the choice seems exactly the same as the first scenario, only now the outcome is just the opposite. The overwhelming majority of the kids will keep their Hershey’s Kiss and take another “for free” rather than give up the one that they have for the Snickers.

What does this have to do with orthodontics?  Well, it turns out to have very much to do with “esthetic orthodontic treatment”.  One of the main reasons that patients seek orthodontic care is to help them (and their smile) look better.  So when they come to the orthodontist, they are seeking some improvement in smile esthetics, but are faced with the potential loss of smile esthetics associated with the application of braces on the outside of their teeth.  Because these patients are ‘loss averse’ they cannot get over the psychological hurdle of ‘the look of braces’.  This ‘aversion’ is particularly poignant because it is a loss of the same quality for which the patient is seeking care for in the first place.  That short-term loss of dental esthetics looms much larger (in their minds) than the long-term gain after treatment is complete. 

All of orthodontics is a short-term liability for a long-term gain in better dental esthetics.  Just imagine if I could tell you that if you exercised for 18 months that you could have the body of your dreams for the rest of your life.  Who wouldn’t do that?  I have to say that one or even two years of braces does not seem like a big deal to me when the reward is a lifetime of a beautiful smile and proper bite, but that may just be the orthodontist in me talking.  I have come to appreciate that for many patients, an esthetic means of treatment is the only way that they will consider care. 

For these esthetically minded (and loss-averse) patients, we have a whole myriad of choices that we offer.  We offer clear (ceramic) brackets, Invisalign and lingual braces (that are placed on the backs of the teeth).  Each has some definite advantages and disadvantages, and I will spend the next few blog posts high-lighting each in turn.  So if you have thought about improving your smile but have thought that the process would be too much to consider, stay tuned. . . .

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Orthodontics and Facial Beauty, Part IV: Mid-line Discrepancy

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Orthodontics and Facial Beauty, Part IV: Mid-line Discrepancy

In the past few posts, I’ve shown examples where our patients started out with pretty straight teeth, but because the manner in which the teeth were positioned within the lips led to imbalances in the profile, lips, and smile.  This post will address another such example that we deal with routinely in our practice.  When the teeth are not centered in the smile, we call this a mid-line discrepancy.  

Mid-line discrepancies are very common in our patient population (people who have come to us because of crooked teeth or a bite related problem).  Most pre-orthodontic patients have some degree of mid-line discrepancy in either the upper or lower teeth, and sometimes in both.  Mid-line discrepancies are often an indication of a more significant functional problem with the manner in which the back teeth bite together.  Upper mid-line discrepancies can detract from the beauty of the smile, and today I’d like to show you the treatment of an adult patient who had an upper mid-line discrepancy.

Here is an initial photograph of a patient who had pretty straight teeth, but the upper mid-line is not aligned with her nose or the center of her upper lip.  The little dip at the top edge of our upper lip is called the cupid’s bow, and the upper teeth should be centered with the cupids bow.

A closeup picture of her teeth shows that the upper mid-line does not line up with her lower mid-line either.  This was an indication to us that there was a bite problem with the way in which the back teeth were biting together. Correction of her bite problem would correct the problem with her upper mid-line as well.

Facial Beauty Part 4 Pic 3.png

A progress photo taken part of the way through treatment shows that the mid-lines have been aligned with each other as the bite problem is being corrected.  This patient wore Speed braces, and had her upper left second premolar tooth removed to provide the necessary space to correct her upper mid-line discrepancy, and to correct the bite problem that was primarily on the left side of her mouth.

Here is a picture of her final result.  You can see that her upper mid-line now is in perfect alignment with her nose and her cupids bow.

If we look at a closeup photo of her teeth after treatment, you can see that her upper mid-line is now almost perfectly in line with her lower mid-line.  Her bite problem was corrected, and her dentist remade the porcelain crown on her upper left front tooth that had begun to deteriorate.  The patient’s concerns about her upper mid-line deviation, and her dentist’s concerns about her bite being off were both addressed with her orthodontic treatment.

Smiling is an expression that conveys pleasure, happiness, friendliness, and amusement.  Therefore, it is one of the most important features associated with facial beauty.  In our last few posts, we have written about how subtle things (like how much gum tissue shows when we smile broadly, if our teeth are not level with our eyes and other facial features, or if our teeth are not well centered in our face) can detract from the appearance of our smiles.  More importantly, it can create a self-conscious smile in which we seek to hide our true smile.  Our happiest of smiles (one that involves our mouth AND our eyes) is called a Duchenne smile, named after the 19th century neurologist Guillaume Duchenne who discovered that we have two kinds of smiles-a “fake” smile that involves our mouth only, and a “true” smile that involves our mouth and our eyes.  Recent research shows that it is only our “true” smile that is associated with positive emotions.  For these reasons, it is important that we not be self-conscious about our smiles.  When we are happy, we need to show that we are happy-without reservation.  In this way, we are able to convey to the world that we are friendly, happy, and approachable.  Anything less, and we might send the wrong message to those around us.

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