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Esthetic Orthodontics 104: Incognito

Esthetic Orthodontics 104: Incognito

We have come to what is largely considered the “State of the Art” when it comes to esthetic orthodontic treatment, Incognito™.  Incognito™ is a whole system that involves a patented technology to allow braces to be placed on the inside (tongue side) of the teeth so that the braces do not show.  This is generically called “lingual braces.”

At first, lingual braces appears fairly simple, but there is actually a lot more to it than just putting the brackets on the inside.  In the past, lingual braces were performed by orthodontists with mixed success.  The problems were that the brackets were much more bulky and uncomfortable and the mechanics were very difficult for the orthodontist to get just right.  3M makes the Incognito bracket system to overcome these shortcomings of the past.  Through a proprietary system of customized brackets, wires and tooth planning, they deliver on the possibility of achieving the results that we get with braces on the outside of the teeth.
The first innovation is that the brackets are custom made for each patient.  This allows the brackets to be made very thin and close to the tooth surface.  This increases comfort and helps the brackets stay on the teeth.  Next, the wires are also customized by having the whole set of wires bent by the lab.  This removes the challenge of bending the wires for the orthodontist and allows a very high level of precision to be obtained.  Finally, all of the tooth movements are pre-planned.
Pre-planned and customized tooth movements are quickly becoming the way that orthodontic treatment is planned.  We can set a goal on the computer and then have the brackets and wires manufactured to achieve that end result. 
Here isan example of what a “set-up” looks like for a patient.  The orthodontist role is to guide the lab and make sure that the tooth movement is correct and the end result achievable.

We can even superimpose the final ‘goal’ with the ‘initial’ position of the teeth to better plan the tooth movement.  Here the initial position is in purple and the final position is represented in white.

The most impressive aspect of the Incognito system is that fact that we can achieve with great precision the tooth movement that we set out to accomplish.  In other words, the final result will match the “set-up”.  Published in AJODO in 2011, “Accuracy in tooth positioning with a fully customized lingual orthodontic appliance” by Dan Grauer and William Proffit showed how the system can produce the set-up goal in actual clinical patients.

But of course, what patients care about is that the brackets do not show and yet we can accomplish all of the movement.   This patient has lingual braces on the upper and lower teeth and has even had a teeth extracted.

We also have lingual braces on just the upper teeth as shown here on a different patient.  This helps reduce the added cost of the customized braces but improves the esthetics of the smile during  treatment.

To see more videos of our patients with lingual braces and to hear how this might affect speech, visit our video library.
 

 

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Esthetic Orthodontics 102 - Ceramic

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Esthetic Orthodontics 102 - Ceramic

Esthetic Orthodontics 102 - Ceramic

The next step up on the “esthetics” ladder for orthodontic options is to consider ‘clear’ or ceramic brackets.  These have traditionally been made out of a variety of tooth colored materials, but the state of the art today is to make these esthetic brackets out of porcelain.  Being made out of porcelain means the brackets are strong enough to withstand the rigors of being in a patient’s mouth, and still hold up and deliver the correct forces to the teeth to create the desired change.  Porcelain is also very resistant to picking up stains, which of course is important to the esthetically minded patient.

The ceramic brackets that we recommend incorporate a gate to hold the bracket to the wire similar in design to the Speed brackets that we use.   This again eliminates the need for using ties which helps with a number of mechanical properties, but also eliminates the staining of the ties.  Clear brackets that require ties can be prone to looking bad due to the rubber tie itself staining.  Our brackets eliminate this problem by eliminating the rubber tie.

Finally, this photograph shows how we recommend to avoid using ceramic braces on the lower teeth for most patients.   First off, the lower teeth just do not show as much; and second, it avoids the risk of chipping the upper front teeth.   Although there are some exceptions, usually the upper front teeth have some risk of contacting the lower braces because of the overlap of the upper and lower front teeth.  Since ceramic is a much harder material than tooth enamel, there is a risk of chipping the upper front teeth if the ceramic brackets on the lower teeth come into contact with the edges of the upper teeth.  Metal brackets do not have this risk as the metal is softer than tooth enamel.  This is main reason we almost always recommend metal brackets on the lower teeth.
While improving the esthetics of the orthodontic treatment, ceramic brackets allow us to retain all the functionality and flexibility of orthodontic treatment with braces.   We can easily make adjustments along the way and change the treatment as needed.  If you are looking for ideal control of the teeth with some improved esthetics over metal braces, then ceramic braces might be the perfect choice for you.

 

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Esthetic Orthodontics 101

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Esthetic Orthodontics 101

Esthetic Orthodontics 101

It may be surprising to some of you, but I am going to begin our discussion of esthetic choices for orthodontic treatment with metal brackets.  I know, you are thinking “what an orthodontist!”  However, by the end of this blog, I hope that you will see that there is really no better place to begin!   You see, NOT all orthodontic brackets are created equally, and I could spend the next several blogs talking about the wonders of this little masterpiece of engineering wonder.  At the risk of not boring those of you who are not in the dental field, I will limit my discussion of the advantages of this bracket solely in regards to ESTHETICS.  

speed bracket small.png

This is a Speed bracket and it is THE MOST esthetic metal orthodontic bracket on the market today.   Now before you say, “A metal orthodontic bracket cannot be esthetic.”  Let me show you some brackets from the past and present.   30 years ago, each tooth had a band that went all the way around the tooth which obviously was not very esthetic.  When bonding brackets directly to the teeth became possible, the esthetics improved, but orthodontists needed to use little rubber rings to connect the brackets to the wire.  These brackets were better than bands in regards to esthetics, but still nowhere near where we are today.  

Not so good old days of Full bands.  No orthodontist uses these anymore.

Standard brackets with bands on the molars.  Most orthodontist still use these style of brackets.

Our brackets (made by Speed Systems) are much smaller than traditional brackets!

Here is side-by-side comparison between speed braces and some of the other brackets (both metal and ceramic).  You can easily see how much smaller the speed brackets are which (of course) means BETTER ESTHETICS!

Ok, let’s take another look, because there is another feature that will greatly enhance our esthetics of these brackets.  Speed brackets have a gate that holds the wire and therefore do not require the rubber rings of traditional brackets.

A patented gate holds the wire to the bracket thus foregoing the need for ligature ties.  By using a gate instead of the rubber ligature rings, it not only improves the reliability of the bracket-to-wire connection, but it GREATLY improve oral hygiene!  This was actually proven in a study from the University of Texas Health Science Center in San Antonio, but here is a patient that shows how much this can make a difference.

Here is a patient that came to our practice with traditional braces and very poor hygiene!  We informed him that to finish his treatment we would have to change his brackets to Speed braces that would be easier for him to keep clean!

This is the SAME patient one month after we changed out the brackets to Speed braces!  WOW!  Hard to believe that this is the same patient, but this is how his teeth looked walking in to our office for his first adjustment with his Speed braces.  Much of this improvement can be attributed to better brushing, but I think having the smaller Speed braces without the rubber rings really enhanced his ability to keep his teeth clean!   They were this clean at every remaining appointment that this patient had.

“What about colors?” you might ask.  We have many patients that really want to decorate their braces with the colors.  Of course, we allow them to do so, but only if they are keeping up their part with good brushing!

Image from Speed website

Image from Speed website

So there it is, all the reasons that I thought the discussion of “ESTHETIC ORTHODONTICS” should begin with our little metal braces.  Tune in next time for the next step toward better esthetics by looking at clear (ceramic) braces.

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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 I

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Orthodontics and Facial Beauty, Part I

We’ve established in our last several blog posts that the face and the smile are REALLY IMPORTANT!  We are hard wired in our brains to notice faces, and react to them emotionally on a very deep level.  In this blog post, we’d like to discuss the impact orthodontic treatment can have on faces, and how the decisions that are made can affect the appearance of our patients’ faces for the rest of their lives.

The profile is the view of the face or head when viewed from the side.  Although orthodontic treatment does not alter the shape of the forehead or the nose, we should consider the shape of these structures when evaluating our patient’s profiles.  Orthodontic treatment can have a dramatic effect on the shape of the lips and the chin, and we want to make sure that all the elements of the profile are well balanced, and in harmony.  There is actually a lot of science about how to measure a “balanced profile”, and we are taught in our orthodontic residencies how to “measure” a profile to see if the nose, lips, and chin are balanced.  We also know from research that the profile changes over time, with the nose and chin becoming more prominent as we age.  We also learn how important it is that our patients be able to easily keep their lips closed when breathing, chewing food, or simply resting.  If the mouth is held apart (because it is too difficult to close the lips, or because it is difficult to breathe through the nose), then the tongue is lowered inside of the mouth, and the muscle balance between the tongue and the lips/cheeks is disrupted.  This can cause the teeth to shift over time and contribute to the long-term failure of orthodontic treatment.

So how can good orthodontic treatment affect the balance of the profile?  Primarily by decisions that we make in regards to how we fix bite problem.

Facial Beauty P1 - Patient 1.jpg

This patient’s profile is affected by the position of his upper and lower front teeth.  Because the teeth are positioned too far forward, his lips cannot close easily.  When he forces the lips together, the chin muscle contracts, thus flattening out the chin.  This is not a balanced profile.  When they are closed together, the lips push out in front of the chin, and are strained.  Our goal is to help this patient to be able to easily and naturally keep his lips closed, without strain.  This will allow the chin muscle to relax, thus helping establish a more normal chin contour.

So the goal of this patient’s treatment was to bring the upper and lower front teeth inwards, to allow the lips to close more easily, and allow the chin muscle to relax.  How can the orthodontic treatment do this?  We did this by having the patient have 4 premolar teeth removed before the placement of his braces (these are the teeth halfway back on the sides).  The removal of these teeth created gaps that were closed with braces.  When the gaps were closed, the front teeth were brought back (which was the original goal of treatment).

If you look closely at these pictures, you’ll notice that the front teeth are not angled outward as much, and that there are fewer teeth in the right hand photo.  Orthodontic treatment was done in order to reduce the forward protrusion of the front teeth, and to bring the teeth further back so that the lips and profile could be affected in a positive manner.  The patient wore braces for 20 months and currently wears his retainers at night only.

After orthodontic treatment, this patient was able to easily and naturally keep his lips together, without straining his chin muscle.  This is the direct result of consciously directing his orthodontic treatment to resolve the specific problem of his front teeth being too far forward in his mouth.  As a result, it almost appears as if his chin grew, but in fact, the chin was unchanged.   The chin looks different because the muscles are no longer strained.  

Naturally, nobody desires to have teeth removed as part of orthodontic treatment, but sometimes, it is the best thing to help the profile.  The key here is that we keep the goals of treatment in mind when making up a treatment plan for each individual patient.  Sometimes, patients have wonderfully balanced profiles with very crowded teeth.  In these situations, we might recommend the removal of teeth like was recommended for this patient just to preserve the beautiful balance that is already present, while at the same time, straightening the crooked, crowded teeth.

The flip side of this story, of course, is that if the lips are flat and lacking support, good orthodontic treatment can help move the front teeth forward, thus giving the lips better support.  

Here is a young patient who’s lips were lacking support because her front teeth were “pushed back”.  Her mouth was very crowded, so the removal of premolar teeth as described above could have been considered.  However, because her front teeth and her lips would benefit from moving forward, we chose NOT to have any premolar teeth removed so that we could use braces to move her front teeth forward as they were uncrowded.

After orthodontic treatment, her front teeth are no longer “pushed back”, and they give her lips better support.   This is especially important as she ages, as her chin and nose will become more prominent with age.  Helping our patients have a well balanced profile throughout life is our goal, and the decisions we make when they’re teenagers can have important effects long into the future.

Hopefully, you now have some understanding of how orthodontic treatment can be planned to improve the profile, and create beautiful, balanced faces in addition to beautifully straight teeth.  We’ll talk more in future blog posts about other ways in which orthodontic treatment can affect facial attractiveness, and why it’s important to consider the WHOLE patient when planning orthodontic treatment.

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Psychology of Smiles, p. 4

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Psychology of Smiles, p. 4

Part 4 - Eye tracking and the Thatcher Illusion

So our brains are hardwired to see faces, but what does that have to do with smiles?  Well it turns out that the smile is one of the most important features of the face and this can be confirmed with eye tracking studies.  In these studies, a computer can register what parts of image the subject is focusing on.  These studies confirm that when we look at the human face we spend most of the time looking between the eyes and the mouth.  Most of our social cues come from these two areas, and our ability to read social cues may rely on this natural fixation.  Studies on patients with Autism seem to indicate that they have an an altered gaze pattern when looking at faces.  There are even studies that show that we when look at a smiling face, our eyes are drawn first to the smile itself first even before we look to the eyes!

Here is an example of how our gaze naturally focuses on the eyes and the mouth:

The Thatcher Illusion

Arising from our natural tendency  to focus on the eyes and the mouth, comes a fun visual illusion called the “Thatcher illusion”.  Look at the next two faces and you should find the one on the right far more disturbing than the one on the left:

The interesting fact is that these two images are exactly the same, only rotated 180 degrees.   (You can turn your computer screen upside-down to verify that last statement).   When the head is upside-down but we see the eyes and mouth are oriented correctly, it looks ‘ok’.  Our brains don’t mind that too much.  However when we see the eyes and mouth upside-down on an upright face, it really looks bad!  This illusion illustrates that when we look at a face, we really focus on the individual parts, the eyes and the mouth.  This is why it is so important that these parts of our face represent us well!

Let me "Thatcher-ize" you!

So for this week’s fun, if you will post a close-up selfie of just your face on our Facebook page, I will “Thatcher you”.  It is a little disturbing so be prepared.  Here is a picture of me “Thatchered”.   The left should look a little less weird, but if you ask me, they both look scary!

Here's my face "Thatcher-ized!"

And here is Rebekah's!

Read Part 1, Part 2, and Part 3 of our Psychology of Smiles series.

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Psychology of Smiles, p. 3

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Psychology of Smiles, p. 3

Part 3 - Pareidolia

Over the last couple of posts, I have introduced how much our brains are hard-wired to see and recognize human faces.  Now it is time to have some fun with our cognitive quirks.  Pareidolia is the phenomenon to perceive complex images in everyday objects, and the most common form is seeing human faces in all kinds of things. We see faces EVERYWHERE!  Here are some of my favorites from the internet:

Everyone remember the man on Mars?

Or what about this bashful face in the mountain?

Notice how when we look at these next ones that we not only see faces, but we naturally ascribe emotions.  This again points out how intimately our emotional centers are connected to facial recognition.

How can you NOT see this happy car face?

Or this over-worked and angry mop?

Click here to see 45 more found faces!

What are some of your found faces? Share your pictures with us on our Facebook page, and we'll pick the best picture to win a $50 Visa gift card. It has to be one you've taken; no internet searches allowed! 

Read Part 1, and Part 2 of our Psychology of Smiles series. 

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