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Orthodontics/Active Retainer Treatment

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I have been undergoing minor ortho treatment to correct shifting issues with my lower teeth that have developed over time due to over crowding. I was seeking treatment that would reverse the "backward shift" and "straightening" of my bottom front 3 teeth. Since I'm 50 and this was a minor adjustment for purely aesthetic reasons  I was only interested in treatment that would involve the least intrusive means while still seeing results in a reasonable time frame. So we decided on an active retainer and at that initial consultation I stressed that I was willing to wear the retainer 24/7, and that whatever it took to fast track this treatment in a safe manner I was not only game for, but would insist. We were in complete agreement to to the prescribed treatment as he explained that because of my commitment to always wear said retainer, the treatment could be drastically reduced --from 6-8 months instead of up to a year. Fast forward 8 months and while there has been significant movement, it has been much slower than anticipated and on top of this I was just informed that the "8 visit" my initial payment covered was completed now I would be charged for any additional treatments. Under normal circumstances I would not have a problem w/ this, however, throughout the process I had been concerned by the seemingly conservative approach he seemed to be taking when adjusting the retainer. There wasn't a visit that I did not voice my concerns asking "are you sure that's tight enough" "there seems to be hardly any pressure, I think it could use more adjustment". I can honestly say that although I persisted and questioned this approach there was never an adjustment visit that resulted in any pain or even mild discomfort afterward. The retainer would just pop in with ease. It just doesn't seem reasonable that not only did I not receive the "fast track" treatment that I signed up for but now I am expected to PAY for these extended visits. Before I approach him with my concerns, I wanted to reach out to a professional to get a grasp of how best to deal with this situation and if there is in deed any measure of validity to my concerns.

Answer
Hello Eddie,

I am asking all the readers to give me about 5-7 days to answer a question as i am in full time private practice, do volunteer work, try to write, and more. Thank you for your question , and rest assured what you are experiencing is extremely common.

As always let me say...What I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise,  or any form of  treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should  only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Okay… having said  that…  your  questions focused on changes in the alignment of your lower incisor teeth and related issues in conjunction with orthodontic treatment..  You  wrote:

" I have been undergoing minor ortho treatment to correct shifting issues with my lower teeth   "


Allow me to address you situation in the following manner:

# 1 Contributing factors to this condition.
# 2 Current Treatment Strategy
# 3 Options


#1
Eddie, if you look at your contemporary friends and coworkers, you will find that lower incisor shifting is one of the most common conditions. It is thought that as one ages one of the contributing factors is in fact the slow continued forward growth of the lower jaw  causing it to advance horizontally forwards. It advances forwards at a higher rate than the upper jaw, and in so doing causes the lower front incisors to slam up against the insides of the overlapping upper incisors. This causes these lower incisors, which have very small roots and limited stability, to tip backwards, often overlap, and experience an overall collapse so to speak.   There are of course other potential contributing factors including loss of bone support around the roots of the incisors due to periodontal disease, traumatic occlusion due to cross- bites dysfunctional habits such as biting on pencils, and more.

Other factors can also come into play, as explained in #3 below. A discrepancy in the size of your upper and lower jaw could be giving you a slightly relatively forward positioned or "pro-gnathic" mandible. It is not clear whether you have a deep vertical overbite, but this condition also is often concurrent with lower incisor crowding. At your age Eddie, many of my patients have had dental treatment involving bridges, dental implants, or restoring decayed teeth with crowns, on-lays, etc. Such restorative procedures likewise can affect stability and alignments of lower incisors.

#2
The treatment you have described so far, including the appliance used is an eminently reasonable solution. Recall, responding to your desire to have the least invasive approach used, the use of a removable active appliance is ideal. As you state, there were profound results, but there still apparently remain a few additional corrections which you would like to have done. The fact is, the doctor may need to employ additional treatment modalities which go beyond the " least intrusive means ". It is impossible for a clinician to be able to predict with compete assurance that an appliance will be able to deliver 100% of the desired result. Sometimes such treatment works out; at other times it does not.

#3
The additional options you have at this point include additional Hawley style of aligners, possible the use of clear aligners, or applying classic brackets ( braces) to the lower teeth. Before a decision is made, I would recommend that you ask the doctor to perform what is called an anterior Bolton Analysis of the upper and lower front teeth. By measuring the collective widths of the upper six teeth canine to canine and then comparing this to the analogous lower canine to canine measurement, a ration can be calculated. This is the Bolton ratio. It will provide insight into whether the crowding may in part be attributable to a tooth size discrepancy.  Sometimes slight proximal reduction in the widths of the lower incisors may be needed to align them and help ensure long term stability.

It has been my experience that many of my patients have slightly small undersized upper lateral incisors, If this is the case, lower crowding may in part be an expression of compensation for an upper/ lower Bolton Ration Discrepancy. Ask you doctor to better explain this to you either with digital or plaster models in front of you during the consultation.

Summary :

Eddie, I do not have enough information to give you a definitive recommendation. If you bite allows it, consider allowing the doctor to provide you with say 8 to 10 lower brackets over a short period of time to align the teeth. It will give the doctor the flexibility and control which no removable appliance can provide.

Also, the fact that you have treatment needs that exceed the capabilities of the current appliance, it would not appear unreasonable for the doctor to assess additional fees for these additional services.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com  

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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