Phase I Versus Phase II Orthodontic Treatment

So what exactly is Phase I orthodontic treatment?  It is early interceptive orthodontic care that precedes the placement of full-mouth braces.  Active Phase I treatment usually takes between 12 to 18 months to complete and it can range from a simple retainer or headgear to placing braces on the front teeth and expanding the arches.

When is Phase I orthodontic treatment done?  Typically it is done when the front teeth, or the four upper and the four lower incisors are in place.  This is usually between the ages of 7 and 9 depending on how rapidly these teeth erupt and the severity of the orthodontic problem.

What happens after Phase I orthodontic treatment has been completed?  In most cases, retainers are placed to provide the young patient’s teeth with a resting period while the remaining permanent teeth erupt.  Periodic recall appointments are scheduled every 3 to 6 months to supervise the eruption of the permanent teeth and to monitor the correction achieved during Phase I treatment.

What is Phase II orthodontic treatment and why is it necessary?  Even though a child may have completed a first phase of orthodontic treatment, over half of the adult or permanent teeth have yet to erupt.  The permanent teeth erupt into the mouth in two time periods.  Usually, from about age 5 to about age 8½, the front four upper incisors, the front four lower incisors and the four back 6-year molars erupt.  That accounts for 12 out of 28 teeth (not including the wisdom teeth).  The remaining permanent teeth erupt into the mouth from about age 11 to age 13.  Every tooth in the mouth has an ideal location in harmony with the lips, cheeks, tongue and other teeth.  When this equilibrium is established, the teeth have the best chance of functioning properly, remaining healthy and looking attractive.  Phase II involves placing braces on all of the teeth and this phase of orthodontic treatment takes between 18 to 24 months to complete.  Final retainers are then delivered to hold the orthodontic correction.

What are the advantages of two-phase orthodontic treatment?  The primary goal of two-phase treatment is to maximize the potential for an ideal, healthy and functional bite, and for an aesthetic and pleasing smile.  Two-phase treatment can accomplish the following:  improve jaw discrepancies, create more space for erupting teeth (thus encouraging proper alignment and reducing the need for extraction of permanent teeth in some cases), eliminate abnormal muscle habits, correct harmful crossbites, realign crooked or protrusive front teeth (thus reducing the chance for traumatic injury), and improve the young patient’s facial appearance (often resulting in enhanced self-esteem).

Are there any disadvantages of doing two phases of orthodontic treatment?  Usually a child will begin Phase I orthodontic treatment at age 7 or 8 and eventually complete Phase II at about age 14.  Obviously this a relatively long span of time (6 to 7 years) and some children feel like they have spent innumerable years going to the orthodontist and even show signs of burnout during Phase II.  The other factor is expense.  The cumulative costs of Phase I and Phase II orthodontic treatment are often as much as 50% more than waiting and just doing a single phase of treatment at age 13.  For this reason, some orthodontists may try to simplify Phase I and only place space maintainers to help alleviate crowding.  Many space maintainers can be billed under “dental” insurance instead of “orthodontic” insurance thus deferring some costs until later.  In addition, some orthodontists will delay the start of treatment until age 12 or so and treat a child in one long phase by starting with a headgear when only a few baby teeth remain and then place full braces a year or so later once the last few permanent teeth erupt.

By Gary Reichhold, DDS

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Most people think of orthodontic treatment as being expensive.  The typical costs for braces or Invisalign treatment for the average teenager is anywhere from $5000 to $7000 depending on where you live and the complexity of the treatment.  Clearly that’s nothing to laugh at!  To most people, that’s a lot of money.  However, when you consider that the average treatment time is anywhere from 18 to 24 months, it really brings the value into the proper perspective relative to other areas of dentistry.

For example, the cost for a single crown or a porcelain veneer is likely in excess of $1000.  The same is true for a root canal on just one tooth.  These procedures typically take just a few hours from start to finish to complete.  Consider that orthodontic treatment takes several appointments of anywhere from 15 to 20 minutes every 8 weeks over the course of 18 to 24 months, and it becomes clear that the costs for orthodontic treatment are actually quite reasonable.  Add in the fact that most orthodontists offer no-interest financing and it becomes even more of a bargain.

One way that people try to cut the costs of orthodontic treatment is to seek care through a non-specialist or through a clinic.  Non-specialists are usually general dentists who offer orthodontic treatment as an adjunct to their other routine dental services.  Unfortunately, most general dentists have very little advanced training in orthodontics, so they clearly lack the experience that most certified orthodontists have.  They may have taken a few weekend courses on orthodontic treatment, but they really are not truly equipped to take on most orthodontic cases.    Typically their main focus is simply to “straighten the teeth”.  All orthodontists are required to have at least two years of advanced training and many have had at least three years.  Orthodontists are highly trained specialists that not only have the ability to straighten teeth; they understand the importance of providing good function and long-term stability for every patient they treat.

The other avenue that people may choose to reduce orthodontic costs is to go to a dental clinic.  There is one prominent dental clinic in California that provides dental services and some specialty services such as orthodontic treatment.  Their fee for orthodontic treatment is often less than $5000, so it’s much more affordable to many people.  Unfortunately, what people don’t realize is that there may be an orthodontist on staff in the office only one day a week (and often only one or two days a month) and this orthodontist is frequently fresh out of school.  These young orthodontists often use these dental clinics as a stepping stone to their next orthodontic practice, so there tends to be a high turnover of specialists in these clinics.  That leads to discontinuity in patient care which in turn leads to extended treatment times and poor results.  How do I know this?  I see it regularly in my own practice.  The influx of people who start their orthodontic treatment in these clinics and transfer to my practice (and I’m sure to other well-qualified orthodontists) is astounding!

What we see is people who are very dissatisfied with their orthodontic treatment and they want to see that it’s done right.  Their complaints range from ridiculously long waits in the reception room to continuous modifications in the treatment plan due to changes in the orthodontists (one leaves and a new one takes over).

Orthodontic treatment is something that should not be taken lightly.  It is a very long process that should be entrusted to an expert who can complete the treatment in a timely fashion to the highest level of competency.  Also, since it is a long process, it is essential that the patient feels comfortable throughout the entire experience with the individuals providing the treatment.  There is really nothing worse than entrusting your child to the care of someone who really doesn’t have the qualifications necessary to complete your child’s treatment to the highest standards.  No one wants to find out after two years that the treatment results are compromised and you truly “got what you paid for”.

By Gary Reichhold, DDS

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Benefits of Working with a Trained Orthodontist

When I was a dental student, I had a keen interest in orthodontics.  I had braces on my teeth when I was in college, so the memory of the day when my braces were removed was still fresh in my mind.  I remember smiling all day long and thinking how cool it would be to be an orthodontist.  The idea of creating beautiful smiles seemed like a really rewarding profession to me, so I decided to forge ahead and focus on someday becoming an orthodontist.  However, my dental school didn’t outwardly encourage their students to delve too deeply into orthodontics.  It was almost as if there was this unwritten rule that “orthodontics was best left up to the orthodontic specialists themselves”.  There was little attempt at educating their dental students in the fine art and science that is orthodontics.  My dental school had it right all along.  I didn’t understand this way back then, but I certainly do now.

It wasn’t until very early in my orthodontic training that I learned what braces were really all about.  You see, straight teeth are important, but proper function is equally important.  When a patient is first evaluated by an orthodontist, several measurements are taken to help determine how best to treat that patient.  It is not a “cookie-cutter” process because everyone’s bite is different.

For example, if a person has severe crowding, it is usually necessary to remove some teeth to alleviate the crowding and create sufficient space so that the remaining teeth can be straightened.  On the other hand, if in another person there are spaces between the teeth, no teeth will need to be removed and the spaces can simply be closed.

Growth is another important factor in how some people are treated.  If a child has a large overbite, it is still common to have the child wear a headgear at night to help retract the upper front teeth.  However, if an older teen or an adult has a large overbite, there is little or no growth left.  Thus a neckgear will not be effective in an older person.  Therefore, sometimes it makes sense to remove two upper side teeth so that the upper front teeth can be retracted to eliminate the overbite.  These are examples of different methods to establish the proper function of the teeth.

Straightening teeth is basically a given.  It’s simply a natural part of the entire orthodontic process. The hard part is determining how to establish the proper function.   As I stated earlier, most dental schools are not in the process of educating their students in the area of orthodontics.  It takes someone with advanced training in orthodontics to truly know how to not only straighten the teeth, but to make them fit together properly as well.

For many years, the task of providing people with quality orthodontic treatment was left up to the orthodontists themselves.  Yet there always have been a small percentage of general dentists who have dabbled in orthodontics to help supplement their income.  For most general dentists however, providing a service like orthodontic treatment to their own patients wasn’t worth their while.  The reason was simple, most general dentists felt that they never were adequately trained in orthodontics and it wasn’t worth carrying the necessary inventory of braces to truly make it cost effective.

With the advent of Invisalign, things are changing in the area of orthodontics.  Invisalign is a relatively new way of straightening teeth.  In essence, a series of clear aligners are custom-made by a company called Align Technology for each patient that very gradually move and straighten the teeth.  It’s still in its infancy relative to braces.  It was developed in the late 1990’s, and it wasn’t until the early 2000’s that it became readily available to orthodontists.  It’s so new in fact that most orthodontists today had to take special courses just to learn how to use it in their own practices.

More recently, Invisalign has been introduced to general dentists.  With the down-turn in the economy and the fact that there is minimal inventory required since the aligners are manufactured elsewhere, many dentists are now turning to Invisalign as an easy way to help supplement their income.  Remember though that straightening someone’s teeth and providing the proper function are two entirely separate things.  As a colleague recently said to me, “just because they’re straight doesn’t mean it’s great”.  How true, how true.  Unless it is a simple case, it really is best to leave it up to the orthodontic specialists themselves to straighten teeth and obtain optimum function.

By Gary Reichhold, DDS

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Braces Versus Invisalign

Braces are made up of metal or ceramic brackets and metal wires.  A single bracket is affixed in an ideal position on each tooth.  A wire is then inserted through each bracket and this wire gently draws the teeth into their proper alignment.  An orthodontist is responsible for positioning a bracket onto each tooth in a very precise position.  The wire and brackets form the braces that work together and very gradually straighten the teeth over time.

Invisalign aligners are a series of clear, computer-generated removable trays that are ideally worn 20 to 22 hours every day over a period of two weeks.  These trays are completely customized to fit intimately to the patient’s teeth.  A new set of trays replaces the preceding set and again they are worn for two weeks before progressing to the next set.  Each set of aligners incrementally moves each tooth a fraction of a millimeter at a time.

One of the biggest advantages of Invisalign is that the trays are relatively invisible and hence the name Invisalign.  Some people simply don’t want anyone to know that they are wearing braces.  Since the aligners are removable, they provide people the option of removing them in social situations and then simply replacing them afterward.  The aligners also are more comfortable than braces and they do not affect a patient’s speech.

Invisalign treatment usually works more efficiently than braces in the simpler cases.  For patients who have a relatively good bite, but their teeth are somewhat crooked and the crowding between the teeth is not too severe, Invisalign aligners typically move teeth into their proper positions faster than braces.  We have found in our practice that for cases with braces that would take anywhere from 18 to 20 months to complete, Invisalign patients complete their treatment in 12 to 14 months.  These are cases that do not require the extraction of teeth nor do they require the use of auxiliary appliances such as a headgear or extensive rubber band wear.

There are plenty of reasons why a person might choose braces over Invisalign.  Patient compliance is crucial in the successful outcome of patients undergoing treatment with Invisalign.  Obviously if a patient doesn’t wear his or her aligners, the teeth will not move and therefore they will not be straightened.  Braces are not removable, so patient compliance is a lot less of a factor in the overall outcome. This is very important for parents when they are trying to decide which treatment option is best for their child.  If a parent suspects that his or her child will not be fully committed to wearing Invisalign aligners, it’s usually best to go with braces.

Another reason why braces may be better than Invisalign aligners is in instances where there are some teeth that are severely rotated.  For example, if a bicuspid is rotated a great deal, it is very difficult to turn the tooth with a removable aligner.  A bicuspid is basically a cylindrical or round tooth.  The aligner is not able to grip the surface of the bicuspid very effectively without essentially slipping and thus the tooth will not align properly.  This is not the case with braces because the bracket is affixed to the tooth and it will physically turn the tooth into its proper position easily and efficiently.

One final reason why braces may be a better option than Invisalign is that they are much more effective in moving the roots of teeth through the bone.  This is especially true when the extraction of teeth is necessary.  For example, oftentimes some teeth must be removed in patients that have a lot of crowding.  The spaces are then closed during orthodontic treatment by moving the two adjacent teeth together.  This requires a great deal of tooth movement which includes the movement of the roots of these two teeth toward one another.  Invisalign aligners simply cannot achieve this type of tooth movement as effectively as braces.

Which is better:  braces or Invisalign?  Ultimately it comes down to determining the specific needs of each patient, the patient’s esthetic concerns, and the patient’s motivation and level of commitment when it comes to compliance.

By Dr. Gary Reichhold

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Straight Teeth: The First Month With Invisalign

Is Invisalign treatment recommended for teens? Yes! I’m a member of the Teen Invisalign Mom Advisory Board, and my son is receiving complimentary treatment. I was surprised to hear that many teens don’t get Invisalign because they think braces are better for them. Some people think Invisalign is more expensive or that their child will not be responsible enough to wear them correctly. I have to admit, – See more at: http://momitforward.com/straight-teeth-the-first-month-with-invisalign#sthash.jsn6wCcQ.dpuf

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So why are patients still being told that they can’t use Invisalign and must instead wear full braces for their entire treatment?  The most likely reason is that many orthodontists simply lack experience with Invisalign.  Invisalign was developed in the late 1990’s and was not readily available and in use until the early 2000’s.  Thus there are thousands of orthodontists out there with many years of experience using braces, but Invisalign is still relatively new to many of them.  Due to this lack of experience with Invisalign, many orthodontists believe full braces are easier to use and better for the patient in the long run.

The reality is that this simply is not true.  Teeth can be moved effectively with either braces or Invisalign aligners.  The main difference is that braces can both “push” and “pull” teeth by means of the archwires that run through them.  This is because the braces are firmly attached to the teeth.  Invisalign aligners on the other hand can “push” teeth quite effectively, but since they are removable appliances, there isn’t the ability to “pull” teeth into their desired positions.  This can create some limitations with Invisalign when there are more complex tooth movements involved.

However, orthodontists have the ability to mix and match when it comes to the more difficult cases.  Braces can certainly be placed on some teeth for a relatively short period of time to achieve the more difficult movements, and then the patient can be switched over to Invisalign to complete their treatment.  We do this routinely in our practice and we have found that our patients are happier to wear braces on a few teeth for a few months and Invisalign aligners the rest of the time, as opposed to wearing braces for the full period of treatment.

Finally, it’s important to note that Invisalign may not be for everyone.  It is an orthodontic treatment modality that is compliance driven and obviously the aligners must be worn consistently as instructed by the orthodontist to achieve the desired results.  Therefore, the only patients that should not be treated with Invisalign are those who question their ability to wear the aligners 20 to 22 hours every day.

Remember, if you are interested in orthodontic treatment and you’re motivated to get that great smile that you’ve always wanted, Invisalign may very well be an option for you.  Simply click on the link below to find a well-qualified orthodontist with experience using Invisalign near you!

By Gary Reichhold, DDS

http://www.invisalign.com/

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Orthodontists on the other hand are one of nine different specialties within the field of dentistry. They specialize in the alignment of the teeth and jaws, taking into consideration the profile of the lips and the face. Orthodontists look at more than just how straight your teeth are. They slowly move the teeth and jaws to the proper position, allowing them to function properly so that you can eat, talk and breathe better. Since altering the position of the teeth and jaws can change your appearance, orthodontists look at the entire face instead of just the mouth like dentists.

All dental professionals go to four years of dental school and become dentists. They all have the knowledge and skillset to treat a wide range of dental issues. However, some dental students decide to continue their education after dental school. Only the very top students are selected to continue their education. These dental specialists complete an additional two to three years of rigorous schooling and clinical training beyond dental school. During those years, they focus solely on an area of specialty and become experts in their field. Therefore, it is important to note that although all orthodontists are dentists, not all dentists are licensed orthodontists.

Many people don’t know if their malocclusion should be treated by an orthodontist, or why it even matters. Some people would prefer to have their general dentist do their orthodontic work because they know their dentist well and it’s convenient. Although some dentists have taken an evening or weekend course to learn the basics of orthodontics, they don’t have the level of training and experience that orthodontists have. That’s why it’s important to have an orthodontist take care or your orthodontic needs rather than a general dentist. After all, you wouldn’t have your primary care physician do your back surgery would you?

By Dr. Gary Reichhold

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Shortly after my braces were removed, most orthodontists were converting to metal brackets on the front teeth. Brackets are much smaller than metal bands, so they were a great cosmetic improvement at the time. Instead of cementing a band around a tooth, the bracket is simply bonded (or glued) to the front surface of the tooth.

Another major advancement in orthodontics was the introduction of alloy wires. For many years, the only material that was used in the fabrication of orthodontic wires was stainless steel. These wires are still used today, but they are very rigid and thus they can cause quite a bit of discomfort when adjustments are made to them by the orthodontist.

Nickel-titanium is an alloy wire (a mixture of nickel and titanium metal), and they are very flexible. These wires are typically used in the beginning of treatment when the teeth are crooked because, unlike stainless steel, they can easily be bent into the brackets on the misaligned teeth. Another feature of these alloy wires is that they have “shape memory”. When they are manufactured, they are created in the ideal curvature of the dental arch as if all of the teeth are perfectly straight. When left in place within the braces over a period of time, these wires slowly and gently move the teeth into proper alignment with much less discomfort than stainless steel.

Clear or ceramic brackets were developed in the 1980’s. They are very similar to metal brackets, but they are more esthetic because they are even less conspicuous to the eye. They also are more expensive to manufacture and thus they are more expensive for the patient too. Most orthodontists offer clear brackets for a slightly increased fee for those patients who are interested in them.

Self-ligating brackets were the next innovation in orthodontics. They became commonplace in most orthodontic offices in the 1990’s because they do not require an elastic or wire ligature to be placed around the bracket. Instead, they have a small metal door built into the face of the bracket that can easily be opened and closed to secure the archwire in place. Self-ligating brackets are more hygienic than traditional brackets and they cause less friction between the bracket and the archwire, so treatment typically is slightly more efficient and takes less time overall.

Dental x-rays dramatically improved in the 1990’s as well with the advent of digital radiography. Originally, all x-rays used film to produce the images. Like the film you use in a camera, it had to be treated properly and images had to be developed in a darkroom or a large darkbox. As technology developed, digital x-rays were introduced, using digital sensors rather than film, to produce excellent quality images that are available immediately and need no development. Diagnostic x-rays can now be viewed within seconds, manipulated as needed for better resolution or contrast, instantly stored in a computer database and even emailed immediately afterward to the patient or other dental specialists so that they too can view them. This is all done now without the use of environmentally damaging chemicals, expensive film and the need to store the processed film. Furthermore, the radiation exposure is a fraction of what it was with conventional x-rays.

By the year 2000, an entirely different method of straightening teeth was being developed. A graduate student at Stanford University in California had completed his orthodontic treatment and he was given thin, clear retainers that fit over his straight teeth. At times he wasn’t very compliant in wearing the retainers, so his teeth would shift a little bit. Once he started wearing his retainers again, he noticed that his teeth would magically realign. The light bulb went off, and he and another graduate student created Align Technology, the maker of Invisalign aligners.

Invisalign works by wearing a series of custom made aligners 20 to 22 hours each day over a period of two weeks. After two weeks, the patient changes to the next set of aligners in the series and the teeth are slowly and gradually moved into their proper positions. The aligners are removable and virtually invisible, which means you can straighten your teeth without anyone knowing; and you can still eat and drink what you want. For obvious reasons, Invisalign has become very popular with both adults and teens.

Most people have experienced having impressions taken of their teeth with a mouthful of gooey putty. It can be uncomfortable and a major hassle. Fortunately, digital scanners were introduced within the last decade as a means of digitally capturing an image of your teeth. Digital scanners are far more accurate than any impression that could be taken with the old method of a mouth full of impression material. This technology allows us to capture three-dimensional images of a patient’s teeth with amazing accuracy and visually see the result on the computer in real-time as we are scanning the teeth. The scanner head fits in the mouth easily and we are basically taking digital photos of the teeth and sending them directly to the computer. The digital data can even be sent directly to Invisalign to get Invisalign treatment started sooner. The Invisalign aligners that are made from the digital scan fit up to 7 times better than those made from a conventional impression.

Another recent innovation in orthodontics is the use of temporary anchorage devices (or TADs). A TAD is essentially a very small screw made of titanium metal that can be placed inside a patient’s mouth in bone to provide a rigid point of anchorage. There are many advantages to utilizing TADs during orthodontic treatment. Since TADs don’t move, orthodontists can use them to move teeth in directions and amounts that previously were not possible. TADs are comfortable, they can reduce treatment time, they can help to improve esthetics, they reduce reliance on patient cooperation such as wearing a headgear, they sometimes can eliminate the need for jaw surgery, they enable us to move and place teeth into healthy positions that otherwise would not be possible and they can help close spaces more efficiently.

https://www.youtube.com/watch?feature=player_embedded&v=rA_HBJ660Qc

The most recent development in orthodontics is accelerated tooth movement. Last year, AcceleDent was introduced to orthodontists for the first time. It basically is a hands-free medical device that is worn by a patient 20 minutes every day and it produces light vibrations or micropulses that accelerate tooth movement by up to 50%. It even allows orthodontists to reduce the number of visits for their patients using the appliance. A good example of this is with Invisalign patients. As stated earlier, Invisalign patients wear a set of aligners for two weeks and then advance to the next set for another two weeks. Those aligner patients using the AcceleDent appliance wear their aligners from between 4 days to 7 days and their teeth move beautifully and with minimal discomfort.

Orthodontics has a come a very long way in the last several years. As you can see, there are many new and exciting innovations that make orthodontic treatment more desirable and efficient to both children and adults!

By Dr. Gary Reichhold

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