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Braces with Indirect Bonding

One of the scariest experiences in the dental office is the bonding appointment. This is the point in the treatment the braces are attached to the teeth and bands may be placed on the molars predicated on what treatments are required. This experience can be less than enjoyable and is often a discussion point of our younger patients. There are tales they hear from their friends and classmates, about their mouth being pulled and forced open. There are chemicals placed on the teeth and washed off only to be replaced. These applications are often placed a few teeth at a time. All the while the patient is ordered to stay open, don’t get saliva on the treated teeth, and put “your” head into an uncomfortable position. This is repeated multiple times during the bracket placement appointment.

I feel there is a better way to provide that case. That is INDIRECT BONDING. With indirect bonding the procedure is as follows: First, we take impressions of the teeth. Second, the impressions are poured in cast stone. Third, models are trimmed, cleaned and treated with a separating solution. Fourth, the assistant then places the appropriate bracket on the teeth (these are placed with bonding cement). Fifth, the orthodontist adjusts the brackets into the proper treatment position (this is done while reviewing the case and checking the X-rays). Then the braces are prepared for placement on the teeth. Sixth, the assistant completes the process by placing a mouth guard material and a hard tray over the patients mouth. Upon the completion of the laboratory procedure the brackets and trays are scrubbed with soap and water and set aside for placement into the patients mouth. The patient is appointed for the placement of the brackets into their mouth.

What are the benefits of this approach?

The trays can be used to place the brackets on the patient’s teeth either as a single tray for each arch or the trays can be halved, and the brackets can be placed on an individual quarter of the mouth.

The braces are not placed individually on each tooth but rather 6-12 at a time.

The brackets are placed using the lollipop technique which allows us to use a bonding solution that does not have to be washed off and retreated.

The accuracy of the brace placement is improved as it is not necessary to try and accurately place a brace on a moving target and in an extreme environment,(the analogy is cutting a diamond under a waterfall)

Using this methodology allows us to place the braces, with the wire in place, in under an hour. This is much more accurate and quicker than the traditional approach.

What does this mean?

Less time in the chair

Much less discomfort

Greater accuracy of bracket placement

Upon the completion of the appointment, there is almost universal agreement, there was little discomfort, and it was completed in much less time than expected. Most of the juvenile patients advise is that the expectations they were led to expect did not occur. The statements about the bond appointment were from one of two sources. Someone who had their braces placed at another office, or a sibling who wants to torture their brother or sister.

 

Broken Appliances/Emergencies

Broken appliances are the most common form of an orthodontic emergency. Most of the diverse problems are addressed on our web page. Usually wax or cutting the wire with wire cutters will address most common problems. But for most common problems look at our web page.

Daily use of fluoride rinse is a good protection from decay that might occur if the home care is not up to expectations. Brushing at least 2x-3x a day is ideal. In the early stage of treatment, a daily salt and water rinse (1tsp of salt per 1/2 glass of water) will help the soft tissue to toughen up. In those cases where an ulcer may occur near the braces use a mix of Benadryl and Malox in equal proportions hold in the mouth for 1 minuet and then spit it out. This will help reduce the inflammation do this at most 3x’s per day.

On those occasions where emergencies may occur contact the office as soon as possible to allow us to view the problem and make any additional intervention.

 

Dr. Roland Nentwich, D.D.S., M.S

 

Hygiene Tips for Braces

Most children do not produce calculus (tartar). Thus, the importance of good brushing habits would entail the patient brushing for more than two minuets daily, “I advise the use of an egg timer, or electric tooth brush with a timer”. Then following up with a fluoride rinse, this can be done 1x-2x per day as to the incidence of cavities. The use of floss or water picks although helpful in most cases, for kids is unnecessary. For adults on the other hand, the process is a little more arduous. Most calculus build up is located behind the lower front teeth or lateral to the six year molar. With that thought in mind, I feel it is advantageous to use an electric tooth brush and toothpaste. Toothpaste containing baking soda seems the most effective, but there are so many variants out there predicated upon the conditions of ones teeth, I would follow the recommendation of your dentist. Here as an adult I would use either a water pick or some of the various interproximal utensils available on the market.

 

Dr. Roland Nentwich D.D.S., M.S.

What is Dentofacial Orthopedics, and Why Do I Need It?

Dentofacial-orthopedics is an orthodontic concept my profession is desperately trying to embrace, with some limited success. In essence the term relates to creating an effective balance between the jaws, teeth, and the soft tissue drape. It is not just a matter of creating nice little models of the teeth that appear to interdigitate properly. The term requires that we establish the best possible relationship between the upper and lower jaw. We must determine if there is sufficient space available for the tongue. From here we evaluate how the jaw inter-relationship reflects upon the functioning airway. Once all of this has been established it is imperative we provide the best possible aesthetic relationship of the teeth to the soft tissue. What is the appearance of the smile, what is the lip support being provided, and how do the teeth function relative to one another for a comfortable/ functional bite.

 

Dr. Roland Nentwich D.D.S., M.S.

Invisalign: Dentist vs. Orthodontist

The advances made by Invisalign over the last five years have been nothing short of remarkable. When Invisalign first came on the scene in 2007 it was little more than a fascinating quaint idea on broadening the availability of orthodontics to a broader range of patients. The additional bonus of this type of care could be delivered by a general dentist. They have now elevated the capability of this product to almost mimic that achieved by traditional braces, and for certain procedures it is superior to the traditional treatments. Here in lies the present-day problem.

In order to appropriately treat even mildly complicated orthodontic cases, one requires a deeper understanding of orthodontic concepts then just straightened teeth. Invisalign case treatment is determined by the lab (who has no greater understanding of dental biology than the average consumer). The training of an orthodontist is presented with entails, mechanics and dynamics of tooth movement, bone biology, the physics of forces, force vectors, and the implications when acted upon in the oral environment. Much time and energy is spent understanding what is most effective in any given circumstance. One must also have a deep understanding of the anatomy associated with the bones, teeth, and underlying bone. Many orthodontic programs require 3 additional years of training after one has completed their requirements for dental school. This often entails anywhere from 7-10 additional years in training.

The reason for this required knowledge is to address any of the problems that may be encountered in a given case. My reasons for not embracing Invisalign before was due to the material not achieving the results I had come to expect in my cases. But as stated before, the new attachment designs have enhanced the product enough where it can handle a much broader range of dental malocclusions. This is where the additional training provided within an orthodontic residency becomes valuable. Once a case is set up by a technician it is my responsibility to make the necessary changes so the desired movements can be achieved. This will often require between 2-5 modifications. This is done with the realization that there may be additional appliances required at the end of treatment to achieve and maintain the desired results. This is not to diminish the skills of my colleagues but merely to point out that what one does not know, one does not know. This makes it advisable if you wish to move teeth, you are still best served by an expert.

 

Dr. Roland Nentwich D.D.S., M.S.

Advantages of Lingual Braces

Today there is an increasing demand for pleasing aesthetics. This is not only in regard to the finished product from an aesthetic procedure (plastic surgery, orthodontics, aesthetic dentistry), but is often preferred while the procedure itself is being performed. Thus in the field of orthodontics aesthetic appliances have become in demand. The forms of those aesthetic appliances are as followed; Invisalign, porcelain or clear brackets, veneers or crowns, and lingual braces.

As with all things there are pros and cons to each one of these procedures.  I will attempt to provide a clear view of what they might be:

Invisalign

Pros: Very well marketed, simple, less visible than traditional braces

Cons: Must be worn 24 hours a day with attachments necessary to move teeth, can hardly be considered invisible, has been proven to achieve the predicted result 41% of the time, requires a high degree of patient cooperation

Veneers and Crowns

Pros:  Allows for aesthetic correction in a relatively short period of time (3 to 5 weeks)

Cons: Invasive, requiring some requiring some reduction of the natural tooth in order to correct tooth position, encroachment on periodontium often occurs leading to potential problems down the road

Porcelain or clear brackets

Pros: Not as visible as metal brackets, provides greater control for tooth movement for the orthodontist

Cons: Visible

Lingual Braces

Pros: Invisible appliance, as brackets are located behind the teeth, eliminates the possibility of white marks on the facial surface of the teeth, provides complete control for the orthodontist in treating the malocclusion

Cons: Some irritation to the tongue, accommodated with two to three weeks, requires slightly more meticulous care and cleaning

Its been my experience, that in the right circumstances, lingual braces provides the best treatment appliance available in orthodontics today. This is in terms of both the ending aesthetics, tooth position, appearance, as well as treatment mechanics superior to the traditional braces used today. It was with this thought in mind that I felt it incumbent upon me to introduce the use of lingual braces to the Tufts orthodontic residency. The use of that appliance in this program has been ongoing now for a three-year period.