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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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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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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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Orthodontics and Facial Beauty, Part III: Tilted Teeth

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Orthodontics and Facial Beauty, Part III: Tilted Teeth

In my last post, I showed that straight teeth don’t necessarily make for an attractive smile.  If the smile is too “gummy”, the smile is not as attractive as if the teeth are positioned properly between the lips.  If the smile is not attractive, it is natural for a person to “hide” their smile.  “Hiding” the smile can be done quite literally by hiding the smile with the hands, or can be done in subtle ways like turning the head or avoiding a broad smile altogether.  I think that sometimes, a cynical personality can develop from a lifetime of hiding a happy smile.

So have you ever considered what it would look like if the right side of the smile was not level with the left side of the smile?  We encounter the situation of a “tilted smile” every so often, and correction of this problem has a dramatic effect on the beauty of the smile.  This particular problem is technically called a “canted occlusal plane”, and oftentimes, the problems roots like with the manner in which a person’s jaws have grown.  Uneven growth of the lower jaw changes in the way that the upper jaw grows, leading to a tilted smile.

Here is a patient who exhibited a tilted smile.  You can see that although her front teeth are pretty straight, the edges of the front teeth are not level.  They tilt down on her left side.  The photo is cropped with her eyes and her ears level, and her head is held straight, so the problem is clearly with her teeth.

When we asked her to hold a stick between her teeth, the problem is readily apparent. 

Here you can see progress being made part of the way through her treatment.  We used Speed braces, and we used something called a temporary anchorage device (TAD) to help move the teeth on her left side upwards.  We will write more about the relatively new technology involved with TADs in a future post.  Combining this with the use of rubber bands on her right side to move those teeth downwards a bit is creating a level appearance to her teeth.

After the completion of her orthodontic treatment, you can see that we’ve completely corrected her tilted smile.

Just as verification, we had her hold the stick between her teeth again, and you can see that indeed her smile is no longer tilted down on the left.

Comparing her beginning smile to her ending smile shows the dramatic effect that having a level smile line can have on the beauty of the smile.

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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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