How do braces work? How do teeth move?

You're probably not an orthodontist, but if you ever wondered how braces work, this info is for you.

Teeth "float" in the socket, held in place by the periodontal ligaments.  The periodontal ligament acts as shock absorber for your teeth.

Applying pressure to a tooth causes it to move.  If the pressure on a tooth is intermittent or short lived the movement is temporary.  Chewing won't cause a tooth to change it's position.   When the pressure on a tooth is gentle and consistently applied, the body react to this pressure by activating the cells which cause bone to remodel. Thumb sucking or a tongue thrust will cause the teeth to move because the pressure is gentle and consistent.

If the pressure on the tooth is too heavy, the tooth will resist movement.When heavy pressure is applied to a tooth, the blood which surrounds the tooth in the periodontal ligament is forced out. Some cells build bone, some cells resorb bone.When there is no blood flow in the periodontal ligament the result is pain (ischemia related) and the cells needed for movement can't function properly.

Any given tooth has an ideal force which will promote its most rapid movement.

This basic biology is important because orthodontic treatment has to be consistent with these 'rules'.
Braces are the handles that are attached to teeth.  The wires which connect the braces provide the force needed to apply the pressure needed for tooth movement.

We'll talk more about the importance of wires and bracket design in a later post.

Intraoral Scanner

I'm a gagger.

I struggle to keep it together when I get impressions. Thankfully, I haven't needed to have a lot of impressions, but sometimes they are unavoidable. Until now.

An intraoral scanner can make an exact copy of the mouth without goop, trays or fuss.

Intraoral scanners have been around for a few years.  They use a beam of light or a laser to capture a series of images which a computer converts into a 3d digital image.  Software is then used to manipulate the image.  In orthodontics we can use the images to analyze the way the teeth fit together, make a physical print, or digitally manipulate the teeth into a better smile. Let's take a look at what this means.

We've been using digital models for years, but we took traditional moulds of the teeth and then have them scanned by a service to create a virtual model.  These were great because they were easy to store electronically and we could take simple measurements of teeth.  Their drawback was in being unable to move from the virtual world to the real world.  They were a great diagnostic tool but that's where it ended.

Digital prints are a game changer.

A digital print is a physical copy of a virtual model.  Today we can print an exact copy of the mouth. In it's simplest form, we can make a retainer from a digital scan.  Taking the process to it's highest level means creating a virtual smile, then use CAM to achieve that ultimate smile in the real world. (I'll talk about that in my next blog)

Why alginate impressions are passé.

In the past, taking a mould of the mouth meant a bunch of steps in the process.  During any one of those steps, errors could be introduced which resulted in retainers or appliances not fitting.  The digital scans are more accurate than any impression. The other thing that happened with the plaster models of yesterday was that, most of the time, a model was a one use item.  The plaster model got destroyed in the fabricating process.  A scan can be re-used countless times.

We started using our intraoral scanner in October 2013. About the same time, our lab got a digital printer.  Karma, Fate, God's love? For whatever reason, everything fell into place.  It's hard to imaging going back to using impressions.

Here are a few real examples of how digital orthodontics has helped us solve problems:

We have a young boy of about 6 in our office.  He had a problem with his bite which needed prompt intervention.   Despite being a really cute kid, he did not have the ability to cooperate with getting a model of his teeth.  We were able to scan his mouth without incident and begin treatment.  We see patients at all ages breathe big sighs of relief when we tell them no impressions.

A teenage girl lost her retainer.  She was afraid to tell her mother and the girl's teeth moved. Because
we captured a digital image of at the end of treatment, we were able to make a duplicate retainer and quickly resolve the issue.

The father of a family of 4 kids we treated came to see me.  He was bothered by a lower tooth which had move slightly.  He didn't need or want braces and Invisalign was too expensive.  We created a virtual correction of the tooth, then had the set-up 3d printed.  We made him a clear retainer from the printed model.

A college student quit wearing his retainers. Over about 3 years, they moved to the point at which he decided he wanted them straight again.  We did a virtual set-up to a perfect smile, then had the software make a series of 4 aligners.  We did limited aligner treatment in the office.

We have an adult patient who wants a great smile, but has lots of crowding and bite issues. Treatment options included extracting teeth and/or jaw surgery.  He would prefer neither.  We did a few virtual set-ups which show the resulting smile and bite we expected. Seeing the result ahead of time helped him make a more informed decision about the option which would work best for him.

In my next blog I'll explain how digital orthodontics can get a better result in less time.

Looking forward

Digital Orthodontics, the Future is Now!

I was in Ann Arbor for an orthodontic symposium in March, The Moyers Craniofacial Growth Symposium.  My orthodontic colleagues just call it Moyers. What I learned at the Moyers Symposium was a wake-up call for me.

This was the 40th year for the Symposium and represented a milestone.  It's theme was a reflection on the recent history of orthodontics as represented by the Moyers Symposium. The Symposium has always attracted the best and brightest of evidence based scientists. The Moyers is more academically oriented than many orthodontic meetings, which tend be more 'commercial' in nature.  By 'commercial' I mean things like practice management  and gadgets for an office.  The Symposium is more scholarly and attracts academics and students.
 
Jim McNamara is the force behind the Symposium and he is an amazing talent in orthodontics.  I was blessed to have him as my orthodontic chairman during my residency at Michigan.  He has been the key influence on my development as an orthodontist and is a inspiration to me on a personal level. So when he asked me to attend this year's Moyers Symposium, I readily accepted. (I need to do a post about the influence Dr. Moyers had on me, but that will have to wait for later.)

When I finished my orthodontic residency in 1991, I thought I had all the tools I would ever need to be an outstanding orthodontist, boy, was I wrong.  I had attended the best dental school in the world, Michigan, and finished at the top of my class. Then I completed a 3 year residency at the best institution for orthodontic education in the world under the most prominent faculty.  

I have never been an early adopter of the latest fad in orthodontics.  I have always been content to wait until a new technique or gizmo had been proven before investing the time and energy into something which would not give our patients either the best care possible or shorten their treatment time. And believe me, everyone's goal is better care in less time.  The orthodontic vendors know this too.  I remember a few years ago when everyone was jumping on the self-ligating bracket bandwagon. Each supplier had their bracket-du-jour with promises of shorter treatment time and too-good-to-be-true advantages.  I tried a revolutionary style of brace in my office which promised orthodontic nirvana.   It turned out that the hype had failed miserably; in almost every way.  Those braces caused more discomfort for our patients and actually prolonged treatment time.  That experience only reinforced the natural skeptic in me.

At Moyers this year, most of the speakers reflected on a career filled with change, and most looked to the future for further enlightenment.  I was struck with several powerful insights:

1. I was trained during the "golden age" of orthodontics, by faculty whom have all made major contributions to the knowledge base of my profession. Most who left U of Michigan became either a dean or a chairman elsewhere.
2. I was fortunate enough to have professors who recognized that evidence based data collected through randomized clinical trials was the only way to evaluate clinical data, and trained me to do so.
3. The future of orthodontics is moving in a digital direction.
4. The practice of orthodontics will continue to take advantage of new technologies.
5. Orthodontic practices who don't adopt new ideas will fade into obscurity.

So what do those insights mean to me?  I will be making some major changes to way we practice orthodontics. In particular, I made a huge investment in technology. I'll be sharing those technologies on these pages as we implement them. Stay tuned for updates.

Camping

I have camped for as long as I can remember.  It’s something that is part of me.  I know that camping isn’t for everyone, but to me, there are amazing things that happen outdoors. I imagine when I say camping, most people have images that pop up in their mind about their own camping experiences.

I should explain my definition of camping. A sleeping bag under the stars, in a tent, or in a camper is camping. Camping is not sleeping under a non-mobile roof structure. Sleeping inside your house or at a hotel is not camping.  When our kids were younger we pitched a tent in the yard or on our deck, I’d call that camping. Today, my definition of camping includes be away from home. “Roughing it” has a personal definition for everyone. To me, roughing it is no running water or electricity; no bathroom, no hot water, no light bulbs.  My Sister-in-law’s “roughs it” in three star hotels.

The first camping experience I remember was camping with my Dad and older brother, Rusty.  I think my dad only took us once, he worked 7 days a week, so maybe that’s why this was so special to me.  He and his best friend Ed Holden, who had two sons our ages, went along.   We must have been about five or six, maybe younger.  We piled our stuff into a van that my dad borrowed from work.   It was painted the pale yellow and forest green of all the trucks at my dad’s business.  “Kampas Bros” was painted on the side. It was a van manufactured in the early sixties. In those days, vans were purely functional work vehicles.  This one had two bucket seats in the front, no windows in the back and a hard metal floor.

 I know the floor was hard because I recall great relief when we were finally released at the end of the journey.  Interstates 79 and 80 had not yet been built, so it was two lane roads to Cook Forest.  I actually remember very little about what we did there, but I know we cooked over a fire, we four kids crammed into a pup tent too small for us and we bathed in the stream next to our campsite.  The stream felt like it was made of liquid nitrogen. I remember the smell of fresh pine and seeing trout lazing at the bottom of the crystal river.  The fish snubbed the worms we dangled in front of them.

One of the regular things Rusty and I did was to sleep outside during the summer. While not technically camping, because we were not away from home, we had the fresh air of the outdoors and used sleeping bags.  One to five of the neighbor kids were always there too.  We didn’t have air conditioning, so on hot summer nights we’d sneak into the swimming pools of various neighbors to cool off.  We debated everything important to kids, from whether an M-80 will explode under water to what we’d do with a mountain of gumballs. It was a simpler time, before video games and M-TV.

I started camping on my own when I was sixteen.  My best friend, Eric Hoffman, and I were always doing something adventurous.  We had been exposed to rappelling through our youth group at church and became hooked.  We pooled our resources and bought a clothesline from Woolworths. We fashioned our harnesses of hemp rope wrapped into a swami belt.   Through some combination of luck and divine intervention we survived our early forays.  Later, while practicing commando rappels(upside down) with our upgraded hardware store nylon rope, we met some guys at McConnell’s Mill State Park who were starting a rock climbing school. We signed on immediately and within weeks were ‘real’ climbers on our first overnight adventure.  It didn’t take long to realize that there had to be more comfortable ways to sleep on the ground.  Our giant cotton sleeping bags would get replaced by slick, lightweight down filled mummy clouds.  The pebbles that morphed into boulders overnight were smoothed over by a thin piece of foam padding that aged into something that resembled a giant curling potato chip.  It was through rock climbing that I learned to love the smell of nylon and the joy of being lulled to sleep by the symphony of raindrops on the fly.

I climbed and camped all over the country for the following 20 years, but I’ll save those stories for another post.

I am blessed to have a great wife who loves to travel. When we met, Stephanie would have probably have preferred to stay in a nice hotel, but now she's hooked.  An opportunity to travel, even if it’s camping, is preferred to staying home.  We started out camping in a tent, just as I always had.  After our daughters moved out of baby mode, we started camping as a family. Within a few years, Steph took pity on me for all the effort it took to set up camp. It was she who suggested that we get a pop-up.  We loved that camper because it was easy to haul and the feeling of being in a tent was there.  Unfortunately, the pop-up still required a significant amount of set up time and energy.

Last Spring we broke camper protocol.  The accepted sequence of camper ownership flows like a well choreographed ballet.  We should have moved to a hybrid camper. A hybrid is a cross between pop-up and hardside camper . The hybrid has tent ends which fold out, plus they have the kitchen and bathroom of a travel trailer.   Our mistake was taking the whole family to look at campers . Instead of a hybrid, we moved from a pop-up to a 33 foot long rolling hotel suite.  Think of how the Stay Puff marshmallow man lumbered in “Ghost Busters” and you’ll know the feeling of seeing our camper chasing you in the rearview mirror.   Who wouldn’t prefer a rolling Taj Macamper.  

The kids have their own bunks and with enough beds for 9 people, each can bring a friend without feeling cramped.  The key ingredient  for a family with three daughters and wife with thimble size bladders is the bathroom.

We have had a great time this summer. The experiences that we’ve shared as a camping family will stay with us forever.  They are priceless memories.

How much do braces cost?

How much do braces cost?

How much do cars cost? Big variability huh?
 
Short answer: The fee is based on the length of time and complexity of the treatment.

What you really want to know is how much your braces will cost. Get an orthodontic exam to find out. There really is no other way. Most orthodontic offices provide evaluations at no cost (we do) or charge a small fee if x-rays or impressions are taken.
There are community and regional differences in fees. Braces in Manhattan cost more than braces in Pittsburgh.

What may be more important is "How affordable are braces?" In other words, if a treatment plan is $4000 and one office wants a lump sum and another office agrees to accept $33 for ten years, for some people this can make the a huge difference in starting treatment. Affordability matters.

Most offices have policies in place about fees. Many will ask for a down payment and spread the balance over the treatment time. Don't be afraid to ask how flexible the office can be. Some offices use third parties for financing (with interest) others will create zero interest payment plans and finance the treatment through the office.

Some offices offer discounts for family members of current patients or for church members. Insurance can lower the out of pocket costs, however some plans have elimination periods before the benefit takes effect. Most insurance will only pay their portion over the course of treatment. The effect of both of these policies is to ensure that you don't get coverage for a short period of time but max out the benefit. Last week I talked to a mom who did the calculation and the additional premium for ortho coverage was roughly equal to the benefit (Hmmmm).

Huge $ savers are the HSA or FSA's, these plans, are funded pre-tax. Orthodontics is a qualifying medical expense (check your specific plan to make sure). So if you can pay with a flex, you get your tax rate as a discount. Wow! With proper planning the orthodontic office can maximize your benefits. Please be aware that proper planning does not mean calling your orthodontist the evening before or day that you have to make your election for the following year. We've had those calls and do what we can. By the way, we can often make use of the "use it or lose it" funds towards the end of the year.

Do you have a common question about orthodontics?

When should my child see the orthodontist? PART 2

AGE 6-7

The American Association of Orthodontists recommends that all children be seen by the age of 7.
Yes, that sounds self serving, but orthodontic problems may not be obvious just by glancing.  Wouldn't you rather know if something is up? Some parents argue that they didn't see the orthodontist until they were 12 or 13.  These are the same parents who miss cassette tapes for music. Old school. We now treat early because it's more effective and we get a better long term result. Certainly every child does not need interceptive treatment.  It's just nice to know for sure.

Many parents will wait for the dentist to give them the go-ahead to schedule an orthodontic exam. Some dentists are great at screening, but some haven't thought about orthodontics since dental school.  I know a dentist who didn't send her own daughter for an evaluation until it was obvious that a tooth was completely blocked out.   She told me that she learned in dental school that the orthodontists could address problems at any age. Yes, we do treat problems at any age, but I'd rather take care of something at the right time. A dentist who fails to refer for an evaluation is not practicing to the Standard of Care.

By age seven the upper and lower incisors should have erupted. If they haven't erupted, it doesn't mean that something is wrong, but we discover teeth unable to erupt due to lack of space all the time.  Worse, we find that teeth are missing. Missing teeth are far more common than anyone believes.  I see new patients in my office every week who have missing teeth.  Most of them didn't know the teeth were absent.  The only way to properly evaluate unerupted teeth is to have a panoramic x-ray taken. Missing teeth require planning.

Indications for Early Treatment (Interceptive Orthodontics)

• Crossbites- The upper and lower teeth don't meet properly.
• Crowding- Not enough room for teeth to erupt.
• Jaw discrepancy- Poor relationship of the upper to lower jaw
• Protrusive upper teeth (Buck teeth)
• Regaining space lost by early loss of primary teeth
• Harmful oral habits
• Self conciousness or low self esteem due to smile

What doesn't need early correction?

• Extra space between teeth
• Mildly excess overjet (front to back distance of upper to lower front teeth)
• Mildly excess overbite (vertical overlap of front teeth)
• Jaw position which will improve with normal growth
• Kids who want treatment because their friends have it or they think it's coolAge

AGE 8-11

If you missed the boat on early treatment, it's not too late to get onboard. As I posted earlier, chronologic age matters less than dental age.  We can still do many of the interceptive treatments and make things easier when every tooth has emerged.  At some point is makes more sense to do one phase of treatment, comprehensive. Again, an exam can go a long way to exploring orthodontic treatment options. Keep in mind that the older the patient, the more limited the treatment options may be.

AGE 12-15
If your child hasn't been evaluated, time is running out. Get off the computer and call an orthodontic office, now.   No, I mean stop reading and come back to this later, or you'l just keep putting it off until you run into the next age range.

AGE 16-18
One of the significant treatment options is now lost, the expander.  Expanders can no longer be effectively used.  Yes, some practitioners use them this late, but the biologic basis for their use has past.  If one is used now, it hurts like heck and is very uncomfortable. Patients seeking treatment at this age are generally self motivated. They have issues with their smile and want treatment. Invisalign Teen can be used, and ceramic (clear) braces are always on option.

Summary

When is the best time to have an orthodontic evaluation? Now. Earlier is better. Even is nothing needs to be done, you'll have peace of mind. By the way, most orthodontic offices do not charge for an exam. It will only cost you some time, but you'll have invaluable information.

This post is not intended to replace the advice of your local orthodontist and is provided for informational purposes only.

 

drkampas.com

What are braces?

What are braces? and other common questions about orthodontics

Braces are fixed dental appliances designed to move the teeth.  Well, that was pretty clinical. 

Braces are used by an orthodontist to improve the smile and bite.  An orthodontist is a dental specialist who has completed a two to three year residency following dental school.  More broadly, orthodontists correct the alignment of the teeth and jaws to provide an esthetic and functional alignment of the teeth and jaws.

The orthodontists use fixed and removable appliances.  Fixed appliances are defined as those devices which stay attached to the teeth, removable appliances may be taken out by the patient (retainers are a great example). 

How can you get braces? 

The first step is to have an orthodontic exam performed by an Orthodontist. I capitalized orthodontist because some general dentists provide orthodontic treatment.  Maybe I'll rant about this later, but if you had a need for stomach surgery, would you let your family doctor do it? Some people would, but you may not be happy with the outcome.  See a real orthodontist.

Back on topic..call an Orthodontist and get an evaluation.  The orthodontist should listen to your concerns about the bite or smile. They will usually take photos of the teeth and face and may additionally get x-rays and moulds of the teeth. An full oral exam should look at the jaw alignment, musculature, jaw movement, TMJ, tooth position, eruption timing and examine the swallowing pattern.  A panoramic x-ray can determine timing and check for the presence or absence of teeth.

Once a complete exam is performed, the orthodontist will present a tentative treatment plan or plans and estimate the length of time the treatment will take.  The treatment plan should address all your concerns and correct any additional problems discovered during the exam.  The office should be able to present a fee based on the tentative treatment plan.  Payment options are also often offered.

By this point you should have the info to decide if the office is a good fit, that you are comforable with the pace of the office.  You should have confidence that your concerns have been addressed.  If you have a feeling that something doesn't make sense or unsure of what is being recommended, stop ask for clarification. If you're not satisfied, get a second opinion.

Do you have a common question about orthodontics?