Specialists In Orthodontics

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June 27, 2017

Invisalign is Invisalign, right?

 

Life is always changing!  Last post, I wrote about what has changed and what is new in my life and in the practice.  Well, we have a new addition to the family!  A couple of weeks ago we adopted a wonderful dog, who we have named Tippy (the name is a long story so if you want to know more ask me in the office).  She was surrendered to the rescue as her original owner could not take care of her anymore due to health concerns.  It was an interesting first few days but she has settled in beautifully and the kids love her!  The cat, very much on the fence still…  Hopefully in time.

 

We get a lot of people in the office who are interested in Invisalign, and why not?  Invisalign has come a very long way in the last few years and has become a very effective treatment option for a large percentage of people seeking orthodontic treatment.  This includes adults and teenagers.  A question that we get on occasion (and I’m sure people are thinking more than they ask) is: my dentist does Invisalign, isn’t it all the same?  The answer is a complicated yes, and no.  How can this be, you ask?  Let’s dive into it.

 

Invisalign is a treatment option that is composed of a series of clear aligners.  These clear aligner sequentially, and slowly move your teeth into their new positions.  The aligners are changed weekly since the average amount of movement per aligner for each tooth is approximately .25mm (a very small amount).  While it is true that the Invisalign that you from Dentist A is the same as from Orthodontist B, which is the same as you would get from TDR; the truth is that the result for the same case can be very different between the three offices.

 

The reason for the difference is that there are varying levels of experience using Invisalign as a treatment option.  The way that Invisalign works is we collect a set of records and intraoral scan (those messy impressions haven’t been around at TDR for years).  This data is sent to Invisalign where a technician works up the case according to your preferences and instructions.  Here is where the big difference comes: the more Invisalign you do the greater the chances that you have a dedicated team of technicians to work with who learn your preferences and techniques and the more knowledge that we have as providers as to what movements are predictable/less predictable.  The software automatically suggests attachments according to advanced algorithms that have been developed over the last 20 years and 3 million cases treated.  However, even the best software can’t trump years of clinical experience with the system.  At TDR, we work closely with our dedicated techs and customize each treatment plan according to what the goals are.  The Invisalign technicians may be very good, but they have no official orthodontic training and may now know what is viable in the real world versus the digital world. This is something that not every Invisalign provider can claim.  It is much more common for providers to simply accept the initial plan that is generated by the Invisalign technician versus modifying and perfecting the plan according to the provider’s experience.  We take great care to ensure that every patient experiences efficient and effective Invisalign (and braces) treatment.  In fact, TDR is among the top 1% of Invisalign providers in North America and consistently the top Invisalign provider in the Midwest.  That is a lot of smiles created!

 

So now you understand how the answer to: Isn’t all Invisalign the same? Is a resounding yes, and a very convincing no at the same time!

 

If you are interested in a complimentary evaluation for Invisalign (or braces) please give our office a call!

 

Thanks for reading,

Dr. Groth

June 2, 2017

Good to be back!

It has almost been 2 full years since we have updated this blog and boy have things changed!  I’m excited to get back into this and hope to continue more regularly with some fun and hopefully educational posts.  But before that, let’s review some things that have happened over the last couple of years.  One of the biggest pieces of news, if you ask me, is the arrival of my son, TJ!  He is now 18 months old and every bit of a toddler boy.  He loves trucks and animals and you can usually find him climbing on anything and everything that is close to his height.  Reese is turning 4 (what?!) in August.  She continues to be an amazing ball of energy and has daddy’s height and both mine and my wife’s affinity for the water.  Maybe a future Emory Eagle?

 

New technologies

 

We have gone through a technology evolution recently.  The biggest news is that we established a commercial 3D printing lab, Motor City Lab Works.  TDR had been doing so much 3D printing with outside sources that it made sense to bring the process “in house.”  In order to not pull our staff in too many directions we set this up as a fully separate company.  We not only work with all TDR offices, but also close to 150 offices all over the country.  We are committed to helping other orthodontic offices transition to digital technology.  Having our own 3D printing lab has allowed us to deliver high quality appliances with a faster turnaround than using an outside lab.  The lab is in the Birmingham rail district but not in our Birmingham office.  The photo below is of our print room that houses two Stratasys Eden 3D printers.  The technology is amazing!

 

Just a few months ago we made an upgrade to our intraoral scanners.  It has been a few years since we purchased our iTero scanners and the landscape has changed immensely.  Since our initial iTero purchase we have completely eliminated impressions from the practice.  The only downside is that our children will no longer be able to complain about the nasty impression at the orthodontist!  They will go through treatment without ever having to experience something that almost defined orthodontics in the past.  Our 3Shape TRIOS scanners are significantly faster (sometimes just a couple of minutes for a full scan compared to close to 10 with the iTero), do not blow any air on the teeth (which can cause discomfort for those with sensitive teeth), and integrate directly into the 3Shape system that we are utilizing in the lab (makes the whole process a lot easier on our side).  We still have a couple of the iTero scanners in the office that are used when we are in a bind but that is not terribly common.

 

We have maintained our Top 1% in North America status with Invisalign.  This is the result of taking our time and studying how to move teeth with plastic.  I will go more into this in a future blog post but it comes with many hours of studying, taking continuing education courses, and asking colleagues how they are approaching difficult cases.  It was not that long ago that Invisalign was not suitable for the majority of cases, and now it is safe to say that Invisalign IS suitable for most cases.  We take great pride in our ability to leverage technology and cutting edge treatments in a very efficient and pragmatic manner.  Invisalign is a great part of our toolbox that we have learned to use very effectively.  Both of the cases above were treated in under 1 year with Invisalign!

I look forward to getting back into posting more blogs and will have some help from Dr. Hallal!

 

Thanks for reading,

Dr. Groth

June 8, 2015

Deciphering the Truth on Self-Ligating Braces

(Self-ligating braces are braces that do not require the “color ties” to hold the wire to the braces)

A patient’s mother recently asked me about the claims made by another office with regards to their bracket system. It is an all too common question in our office so I figured I would take a moment to set the record straight.

For most of us, large corporations and their carefully manufactured marketing plans rule what we hear and see. As I sit in my family room with the television on, I only need to watch a few commercials in order to prove this statement. Unfortunately, orthodontics is not above such marketing plans and the public is none the wiser. Below I hope to dispel some myths surrounding one of the greatest product marketing teams in the history of orthodontics.

In orthodontics there are two broad types of braces/brackets. Conventional ligation is what most people identify with. Conventional brackets use either a rubber band (the fun colored rubber bands that the kids enjoy) or a tiny steel wire to hold (ligate) the wire into the bracket.

ties on typodont

Self-ligating brackets, on the other hand, use some form of door or clip to secure the wire thus eliminating the need for those colored rubber bands or tiny ligation wires. The idea of self-ligating brackets is nothing new, they were first conceived in 1935. The most popular and well known of these brackets is the Damon System, developed by Dr. Dwight Damon and made by Ormco.

Damon Braces 3MXdamon model

There are many claims coming from the companies and practices utilizing these brackets including: lower levels of friction resulting in more biological forces, fewer extractions and expanders, decreased treatment times, less discomfort, fewer broken brackets, fewer visits to the office, faster space closure, and fewer periodontal complications. These claims are great but what does the scientific literature say? Do self-ligating brackets possess some sort of magic that allows us to straighten teeth more quickly, with less pain, and better results?

Fortunately, there is a cornucopia (I love using that word) of research on self-ligating brackets because their use has skyrocketed in recent years (between 2002 and 2008 the use of self ligating brackets went from 8.7% to 42%). If you are interested in my sources I will list them at the end of the post.

  • CLAIM: Self-ligating brackets align teeth more quickly and allow for faster space closure
  • TRUTH:  Several studies have DEBUNKED this idea. In fact, at least one study has found that initial alignment of the teeth was significantly SLOWER with self-ligating brackets.
  • CLAIM: Using self-ligating brackets decreases the need for extractions and/or palate expanders.
  • TRUTH: Let’s first tackle the expander issue.  There are two types of expansion in orthodontics: 1) dental expansion where the teeth move within the bones, 2) orthopedic expansion where we move the bones themselves.  Dental expansion is something that any bracket system can do regardless of the ligation method.  All we need to do is use a wire that is wider than the teeth (the wire is the driving force behind tooth movement not the bracket).  Orthopedic expansion is what we use palate expanders for.  These are used in cases where the upper jaw is literally too narrow compared to the lower jaw.  Why would you want to widen the teeth when the bones themselves are deficient?  The expansion that brackets and wires do is NOTHING like the expansion that expanders do.  Now let’s talk extractions.  When you boil this down to the most basic idea this is a simple math question.  You have a set width of teeth and a set width of jawbone available to fit teeth.  We can modify the width a bit (with dental and orthopedic expansion) but at a certain point there is simply too much tooth structure to fit in the mouth.  There is no magic to this.  A specific type of bracket does not change simple mathematics, period.
  • CLAIM: Self-ligating brackets result in faster treatment times and fewer visits to the office
  • TRUTH: Treatment with self-ligating brackets DOES NOT reduce treatment time or the number of appointments. There is a lot of evidence showing that treatment time is NOT related to the type of bracket that is used. One thing IS true. Self-ligating brackets do seem to decrease the physical time in the chair because the doors are generally faster to close compared to putting on a rubber band, but they DO NOT reduce the total treatment time. The time reduction in the chair is relatively insignificant for any single patient (usually less than 60 seconds per appointment).  For an orthodontist who sees 100 patients a day these small numbers add up over time but you as a patient will not notice much of a difference between a self-ligating bracket system and a conventional bracket system.
  • CLAIM: Self-ligating brackets have less friction, which results in lower, more biological forces and more efficient treatment.
  • TRUTH: A recent review found that self-ligating brackets DO have lower friction; however, this is ONLY true when the teeth are already straight and small round wires are used.
  • CLAIM: Treatment with self-ligating brackets is less painful than conventional brackets.
  • TRUTH: Things are a bit unclear here. It seems that the type of bracket has much less to do with discomfort than the type of wire that is used. Studies where half of the mouth has self-ligating brackets and half has conventional brackets show that there is slightly less discomfort with the self-ligation; however, the self-ligating brackets were much slower to align the teeth. A randomized controlled trial (gold standard for research design) showed that there was no difference between self-ligation and conventional ligation when it comes to comfort/discomfort of moving teeth.
  • CLAIM: Self-ligating brackets break less often than traditional brackets
  • TRUTH:  This is a silly claim, in my mind. There is NO evidence that this is true. Getting brackets to stick to the teeth is much more related to the technique used when placing them than the bracket used.  There are many reasons why brackets break off of teeth.  One of the most common causes of broken brackets is eating the wrong foods while wearing your braces!
  • CLAIM: Self-ligating brackets are more hygienic than conventional brackets.
  • TRUTH: There is some truth to this claim. The rubber band that holds the wire in can harbor more plaque than a self-ligating bracket; however, for kids who are good brushers this is insignificant.
  • CLAIM: Self-ligating brackets result in fewer periodontal and root problems compared to conventional brackets.
  • TRUTH: There is no scientific evidence to support these claims. Studies have shown no difference between the type of bracket and the condition of the periodontal tissues and roots of the teeth.

Take Home Message:

Your teeth do now know what type of bracket is placed on them. Damon braces do not have a contract that allows doctors who use them to move teeth more quickly, with less pain, resulting in fewer treatment complications compared to traditional braces. I often compare braces to cars. This may seem like a weird comparison but it makes sense. What makes a car move? The engine. How does the car move? The wheels/tires connect it to the road. Braces are no different, the wire is the engine that moves the teeth and the bracket is what connects the wire and the tooth. The only thing the teeth feel is a force to move. This force produces inflammation around your teeth and that makes the teeth sore.

Please don’t read this and assume that I am a “hater” of self-ligating brackets.  They are great brackets.  The Damon bracket is a very well built, high quality bracket.  However, the things that many people say make these types of brackets different really do not hold up when examined scientifically.

In reality, every orthodontic system works.

What you pay for is not the type of bracket or wire system that a doctor uses but rather their expertise in using the system. I always tell people to go to the office that makes them feel the most comfortable. As long as the office and doctor are up to date on the latest technologies, the team is friendly and skilled, and the office is clean, you should have a result of straight teeth and a healthy bite. The difference lies in the doctor’s skills and interpretation of the aesthetic outcome and his or her ability to harness the technology to work for you. Our dedication to our patients is to cut through the plethora of treatments available, not be swayed by the amount of advertising dollars spent by the manufacturers, and find the treatments that truly benefit our patients. Orthodontic treatment is a short-term partnership between the patient and the doctor and if you are not comfortable with the office treatment, your treatment will not be the pleasant experience that it should be.

References

Songra G, Clover M, Atack NE, Ewings P, Sherriff M, Sandy JR, Ireland AJ. Comparative assessment of alignment efficiency and space closure of active and passive self-ligating vs conventional appliances in adolescents: a single-center randomized controlled trial. Am J Orthod Dentofacial Orthop. 2014 May;145(5):569-78.

Miles PG. Self-ligating vs conventional twin brackets during en-masse space closure with sliding mechanics. Am J Orthod Dentofacial Orthop. 2007 Aug;132(2):223-5.

Turnbull NR1, Birnie DJ. Treatment efficiency of conventional vs self-ligating brackets: effects of archwire size and material. Am J Orthod Dentofacial Orthop. 2007 Mar;131(3):395-9.

Johansson K, Lundström F. Orthodontic treatment efficiency with self-ligating and conventional edgewise twin brackets: a prospective randomized clinical trial.  Angle Orthod. 2012 Sep;82(5):929-34.

DiBiase AT, Nasr IH, Scott P, Cobourne MT. Duration of treatment and occlusal outcome using Damon3 self-ligated and conventional orthodontic bracket systems in extraction patients: a prospective randomized clinical trial.  Am J Orthod Dentofacial Orthop. 2011 Feb;139(2):e111-6.

Fleming PS, DiBiase AT, Lee RT. Randomized clinical trial of orthodontic treatment efficiency with self-ligating and conventional fixed orthodontic appliances.  Am J Orthod Dentofacial Orthop. 2010 Jun;137(6):738-42.

Miles PG, Weyant RJ, Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment. Angle Orthod. 2006;76:480–485.

Pandis N, Polychronopoulou A, Eliades T. Failure rate of self-ligating and edgewise brackets bonded with conventional acid etching and a self-etching primer: a prospective in vivo study. Angle Orthod. 2006 Jan;76(1):119-22.

Pandis NVlachopoulos K, Polychronopoulou A, Madianos P, Eliades T. Periodontal condition of the mandibular anterior dentition in patients with conventional and self-ligating brackets. Orthod Craniofac Res. 2008 Nov;11(4):211-5.

Pandis N, Nasika M, Polychronopoulou A, Eliades T.

External apical root resorption in patients treated with conventional and self-ligating brackets. Am J Orthod Dentofacial Orthop. 2008 Nov;134(5):646-51

Chen SS, Greenlee GM, Kim JE, Smith CL, Huang GJ.Systematic review of self-ligating brackets.  Am J Orthod Dentofacial Orthop. 2010 Jun;137(6):726.e1-726.e18

May 8, 2015

Teeth Gone Wild – The Impacted Tooth Story, Part II

Snow day! Well not for us at TDR but for all of the lucky kids in the area. Check out the snow outside of our back door! Hopefully all of you in southeast Michigan are digging out safely and get to enjoy the beautiful, snowy, sunshine today.

TDR Birmingham office

The snow outside our office!

Getting to more interesting information, I know that most of you have been waiting for the sequel to Teeth Gone Wild – The Impacted Tooth Story, Part I. I am thrilled to announce that the wait is over! As you may recall, Part I included some mean old “wisdom” teeth who decided to go off the beaten path and do damage. Part II will star the ever popular CANINES! I know, you probably predicted this, but we had to keep it a secret for as long as possible. Canines are the most commonly impacted teeth and, much like a puppy, they can be unpredictable. Let’s talk about the different types of canine impactions, how we can try to avoid them, and what happens when nothing seems to go our way and we must go chasing them down.

Potentially impacted canines on panoramic x-ray

Typical presentation of potentially impacted canines around age 10

An impacted canine occurs when the tooth does not get the instructions on where to go. The tooth then goes off exploring on its own and can cause problems if it is not re-directed. Impacted canines are very common so if you have one you are NOT alone! There are two types of canine impactions: buccal (pronounced: buck-al, and meaning on the cheek/lip side of the mouth) and lingual (towards the tongue). Many times when we identify them early enough we can take action to prevent an impaction. Research has shown that removal of the baby tooth along with a palate expander can increase the likelihood of re-directing a potentially impacted canine up to 60%. The case below is very interesting because one baby tooth was removed and the other was not. Coincidentally, the side where the baby tooth was left in was left with an impacted canine while the other side looks beautiful!

Impacted left canine shown on panoramic x-ray

Right baby canine extracted while the left was not. The left canine became impacted.

Now, even in the face of our best efforts during a first phase of treatment some canines go down the bad road. When this happens we must give them a little help. Once the braces are placed and the space for the tooth is prepared the oral surgeon will place an attachment with a small gold chain that we use to gently guide the tooth into place. This process can take anywhere from a couple of months to almost a year depending on how deeply impacted the tooth is. In addition, care must be taken while directing an impacted canine into place because if it is not done carefully damage to the roots other teeth can happen (see below).  In most cases the damage does not have any effect over the long term prognosis of the tooth but on occasion it can be so extensive as to requiring the extraction of the tooth.

Panoramic x-ray showing two impacted canines

Pre-treatment radiograph depicting two impacted canines

Previously impacted canines damaged the lateral incisor roots

Damaged lateral incisor roots

The canines made it into the mouth but there is damage to the roots of the laterals incisors. You can’t save them all! Rarely a case will come by that the tooth is so off track that we risk the health of several teeth to bring it in. With these types of cases the best course of action is to remove the impacted tooth and plan for an implant replacement in the future.

Hopeless impaction

This tooth truly lost its way! We have no chance of bringing this tooth into the mouth.

There you have it. This has been conclusion of the impacted tooth story. It has been quite a journey and hopefully you have found this helpful. Thanks for reading! Dr. Groth

November 3, 2014

Hire Me!

Hire Me!

 

While the next post was planned to be part 2 of the Impacted Tooth Story (Canines and Premolars, OH MY) I have decided to delay that post because of some interesting new research that just came across my desk. In the latest issue of the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO, for short) the cover story reads “Do dental esthetics have any influence on finding a job?”

We have known for a very long time that there is a close relationship between physical and social attractiveness. The face, and smile in particular, play a pivotal role in this relationship. People that are deemed “attractive” are seen as being more intelligent, capable, and responsible. Those same people have been shown to be happier and more successful than those who have been rated as “less attractive.” Now, does any of this cross over to our professional careers? Unfortunately, it does.

This study took 10 people (shown in the photo) with a variety of orthodontic treatment needs. Each person’s teeth were digitally corrected (so the patient had two photos: one with bad teeth and another with perfect teeth). These photos were shown to 100 people that are responsible for hiring for commercial companies. Each person was rated on their likelihood of being hired, honesty, intelligence, and work efficiency.

Before and after digital treatment

The results of the study are as follows: the photos of the perfect smiles were rated as having a greater likelihood of being hired and as more intelligent than the non-ideal photos. However, the smiles had no effect on the honesty and work efficiency rating, thankfully.

There is further scientific proof that a great smile opens doors that may be closed otherwise!

 

Thanks for reading,

Dr. Groth


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T|D|R proudly providing braces, Invisalign, and orthodontics to Rochester Hills, Birmingham, Novi, Shelby, Lake Orion, Troy, Bloomfield, Royal Oak, Farmington Hills, Northville, Livonia, Walled Lake, and surrounding communities with a long list of straight teeth and happy smiles! An orthodontist receives two to three years of education beyond dental school and are the only ones allowed to call themselves “orthodontists”. Only orthodontists may be members of the American Board of Orthodontists.