Are Dental Braces the Right Choice to Straighten Your Child’s Teeth and Provide a Healthy Mouth?

Part 1

Insights every parent wished they had before their child started orthodontic therapy

Many parents face this important dental health decision: should their teen or pre-teen have dental braces to improve their bite or smile? For those who can afford it, it’s almost a rite of passage for their child to have their teeth straightened by the local orthodontist. With the internet increasing the access to health information, those interested can now read professional level information to help decide whether it’s prudent to continue that tradition.[1]

When considering braces, the not-so-obvious question to ask is, how successful are they? If they are initially successful, how long did it take for teeth, gums, bite or sensitivity problems to become evident? While once a broadly accepted dental recommendation, a closer look at results of braces merits some scrutiny.

A perusal of the professional research shows there’s a dearth of proof that orthodontic braces yields lasting benefits or prevents negative positioning changes.[2] In fact, recent research has found that:

As is common during medical and surgical consultations, likely and potential outcomes and consequences of dental braces should be reviewed.  Many orthodontists will transfer the decision on how to best prevent the negative changes to teeth positions from themselves to their patients or parents of patients. Regardless whether that’s based on their training, their office policy or for medical-legal reasons, if you’re going to be asked to make that decision, be prepared.

A parent should refrain from making an impulsive, unilateral or under-informed decision. It’s best to start the conversation during the initial consultation. Ask the orthodontist and general dentist “Are you confident that the treatment you’re proposing is likely to yield stable, healthy and long lasting dental results?”

An alternative to traditional braces is Arch Reformulation Therapy (ART) with periodontal aligners.[5] ART is a recently developed disruptive innovation to help those who have bone, bite, gum, spacing, crowding or a number of other dental maladies.[6] Not appropriate for pre-teens, it’s an option many parents who prefer long term results might find appealing.

Before initiating dental braces, ponder these five thoughts:

1) If at the end of active therapy my child’s teeth are in positions where they’re likely to remain stable, why would they ever need to have a permanent glued-to-the-teeth splint?

Periodontal aligners have two unique measures of success: the health of the gums and the ability of the teeth to stay put. Once re-positioned teeth are on their way to being stabilized, there’s rarely a need for a permanent splint.

Let’s see some results from ART (Arch Reformulation Therapy):

avulsed teeth were successfully save by a dentist in PA
dark yellow teeth were caused by a baseball accident

Caption: 1a- The patient in the photo had dental braces as a teen. Based on his and his dentist’s recollections, it’s unlikely that a stable result was ever achieved. Four years later at age 21, he agreed to have Arch Reformulation Therapy (ART).

treatment is superior to traditional porcelain veneers
excellent healthy and affordable correction of dark yellow teeth

Caption: 1b- Based on the health of his gums, this same patient in photo 1a was declared to have successfully completed the active portion of arch reformulation. He was now ready for the full time retainer phase. When teeth positions and the bite are stable, and the gum health is excellent, there would never be a need for a glued-to-the-teeth retainer. These results are typical and what one should expect from ART.

2) If my child’s teeth were unlikely to remain stable, why would an orthodontist stop braces therapy? Why would a patient be told they were ready and given retainers if their mouth wasn’t ready for them?

Those questions are best answered by the treating orthodontist or general dentist, but let’s get a better understanding with another example.

instability from orthodontic treatment led to her dental braces relapse
Slightly unhealthy gums can be misleading. Problems arose when dental braces did not adequately resolve her occlusal disease.

2a- This woman completed dental braces a few years before these photos were taken. Her teeth weren’t stable when the orthodontic therapy was declared finished. New problems arose post-treatment. Without prudent intervention, the problematic positioning of her teeth coupled with an unstable bite would continue to act as a negative impact to her dental health.

2b- Same patient. The blue lines make it easier to visualize that a number of teeth are oriented in asymmetric and undesirable directions. Left uncorrected, her dental issues (e.g., exposed roots, gaps, flaring) would increase and become more serious.

2c- Same patient. A side view shows adjacent teeth with vastly different angulations. The flaring was caused by strong undesirable forces from her bottom teeth. Until corrected, these bad forces will continue to have an adverse effect on the bone which supports the teeth, too.

2d- Same patient. Yellow arrows point to the splint glued to the backs of her top four front teeth which failed to prevent the teeth from shifting. The size of the growing gap is easily visible in photo 2e.

2e- Same patient. The green arrow shows the gap caused by her teeth shifting. Undesirable movements from unstable and poor teeth positions led to these problems. The professional permanent splint was unsuccessful.

3) Pre-teens and teenagers who’ve had dental braces or clear orthodontic aligners are more likely to have receding gums.[7] As a result, they will be more likely to require professional gum treatment with a periodontist or general when they get older. The topic of one’s gum health is an integral component of every ART consultation, but is infrequently discussed during a braces consultation.

3a- This 19 year old finished one year of dental braces a few years earlier. The blue arrows point to the inflamed and irritated gums which were healthy before the start of his orthodontic treatment. The purple arrow points towards the exposed portion of the tooth root no longer covered by gum. As we can see, a lot of protective and healthy bone was lost during his routine braces care.

3b- Same patient. The tongue view of the backs of his bottom front teeth. The yellow arrow points to unwanted tooth movements so fierce they’ve severed the splint. The orange arrow points to where the next break will be, where destabilizing forces have stretched and frayed the splint. The white arrows point to the buildup of dental plaque, stain and calculus (dental tartar); the magnitudes of which are exacerbated by the presence of a permanent splint.

4) Sometimes a splint is secured to teeth which are unlikely to become stable. When that happens, placing the permanent splint often coalesces and amplifies their collective bad bite forces. That will often lead to dental problems which will require attention and correction.

4a- The blue arrow is pointing to a “splint bubble” which has been re-glued by his orthodontist on more than one occasion. This splint is not providing any dental benefit because it’s attempting to retain teeth that are in such unstable positions, they’re unmaintainable. Only a return to active dental therapy (ART is the preferred treatment option) will correct the shortcomings, stabilize his bite stable and allow his gums to achieve their optimum level of health.

5) There’s no consensus amongst orthodontists when or whether a permanent splint should be used. Three recent independent surveys of US[8], Swiss and[9] Malaysian orthodontists confirmed that a “Best Way” to keep teeth in place after braces treatment doesn’t exist.[10] Opinions are still scattered regarding best practices.

5a- This splint poses a serious oral hygiene challenge. Large amounts of dental plaque and calculus start to accumulate within days after each professional cleaning, leaving him with persistent bad breath.

5b- Same patient. The blue arrow in this close-up view points to a break at the center of the splint. Until proper corrective action is taken (ART is the preferred modality), there is a modest silver lining – he can now floss between those two teeth. When he asked his orthodontist how long it should remain in his mouth, he was told “as long as you want to have straight teeth.” The insinuation was that it should remain in place and likely not need any attention throughout his lifetime.

In most professional dental procedures (e.g., implants, crowns, bridges), leaving the gums healthy is an important variable to be considered when judging its success. For example, a crown placed on a single tooth would be deemed unsuccessful if the gums became irritated, created sensitivity or caused the loss of healthy bone. So unsuccessful in fact that corrective dental action would be warranted and recommended. That’s why a dental result which leaves the gums in good health is important and valued. Yet, out of 8 criteria used to determine if braces had a successful outcome, leaving the gums healthy is not one of them.

ART is presently the most dentally gentle solution for those with a gum, bite, bone or general sensitivity problem. Because it’s so natural, some will be tempted to refer to the arch reformulation process as holistic or organic. Since one of ART’s goals is to leave the gums in a healthy state, it is integrated throughout the entire process, resulting in both the bite and positioning of the teeth to be sufficiently stable so the results will last a long time.

So, what should a conscientious parent do?

As is often the case, it’s best to be proactive.

  • Before one initiates treatment, seek both an orthodontic and if available, an arch reformulation consultation.
  • Focus on the clinician’s results in the years after the care they provided was finished.
  • Appreciate the clinician’s philosophy and what steps they take to ensure that the gums will remain robust once care has concluded.

If the traditional metal dental braces or popular clear removable orthodontic aligner treatment has already started, let the treating clinician know that your goal is to have the gums and bite be made as stable and healthy as possible prior to starting the retainer phase.

 

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495021/

[2] http://www.ncbi.nlm.nih.gov/pubmed/6961816

[3] http://www.ncbi.nlm.nih.gov/pubmed/22308954

[4] http://www.ncbi.nlm.nih.gov/pubmed/18984397

[5] http://www.themanhattandentist.com/#!arch-reformulation/ykeke

[6] http://www.themanhattandentist.com/#!dental-professionals/p28gc

[7] http://www.ncbi.nlm.nih.gov/pubmed/18984397

[8] http://www.ncbi.nlm.nih.gov/pubmed/20152670

[9] http://www.ncbi.nlm.nih.gov/pubmed/24943474

[10]http://synapse.koreamed.org/search.php?where=aview&id=10.4041/kjod.2016.46.1.36&code=1123KJOD&vmode=PUBREADER

This Patient Saved $11,000 On Dental Treatment!

Will Save $50,000 In Dentistry Over His Lifetime With This Proven Alternative to Porcelain Veneers!

 

This 22 year old young man wanted a smile where his two yellow front teeth didn’t stand out. He also wanted dental results that would last.

Dental History:

As an eight year old, he had those two front teeth knocked out of his mouth by a high fly ball to the outfield during a baseball game. After the teeth were picked up from the grass, they were brought to the local dentist who did a great job putting them back in their sockets just a few hours later! Those chipped yellow teeth were repaired with root canals, fillings and professional teeth whitening on more than one occasion. As a 16 year old, he received approximately one year of dental braces therapy. While there may have been some benefits at one time from the orthodontic treatment, none were present by the time he was 22. Mild gum tissue and bite problems were cropping up, too.

  • Recent treatment recommendation:
    • Dental braces re-treatment
    • 2-4 crowns
    • 0-10 porcelain veneers
  • Treatment proposed, accepted and rendered:


Patient and General Background:

Prior to his initial visit, the most recent dental recommendations (e.g., braces re-treatment, 2-4 crowns, 0-10 porcelain veneers) by his Pennsylvania dentists might have been influenced by the results of his prior dentistry (e.g., whitening, bonded fillings, orthodontic aligners) over the past dozen or so years, which were either unsuccessful or lasted for a shorter time than the patient, his parents and doctors had hoped.

The patient presented four years after the conclusion of his clear orthodontic aligner braces therapy. As is common with those who’ve received orthodontics, his teeth and bite weren’t stable. Kaan and Madlena’s comprehensive review which evaluated the longevity of orthodontic care noted that teeth showed signs of being repositioned to less desirable locations post-treatment 70%-90% of the time.[1]

That’s another way to state that dental braces are successful 10%-30% once active care has concluded (e.g., brackets removed, last aligner). If non-braces dental considerations were considered (e.g., gum health, TMJ, fillings and crowns), the dental success rate would likely be well below that 10%-30% range. Although noted as consequences, not one study tabulated or tracked non-braces dental problems.  The publication of that significant review might have been the impetus for the American Dental Association’s (ADA) Code Maintenance Committee to revise the insurance definition of comprehensive braces treatment at their February 2013 meeting. The essential phrase present for many years “Optimal care requires the long term consideration of patient’s needs and periodic re-evaluation” was deleted.[2]

Slutzkey and Levin pointed out that the breadth of this patient’s recession was common in his age group (18-22 years old). When they compared those who had braces with those who didn’t, the increased incidence of their gum shrinkage causing roots to show ranged from 5x-8x.[3]  That’s why it’s understandable for a dentist or orthodontist to conclude a patient might not be a candidate for braces re-treatment, be prone to braces relapse and to factor the presence of a bad bite and bad gums when trying to place fillings which will last.

In contrast to the many articles which support the concept of re-treating root canals which have problems[4][5], there aren’t any studies which claim a high success rate for braces the second time around. Yu concluded there’s an “urgent need” for those studies to identify the most effective method for managing relapse, because one does not presently exist.[6]

Obtaining a stable result after the repositioning of teeth is vital. The phrase “braces relapse” is often inaccurately attributed to describe consequences from a patient whose orthodontic care failed to achieve a stable result. If a lasting result is not achieved, then there’s nothing to relapse from. If a lasting result is not obtained, Sadowsky and Saklos concluded that no type of retention can help.[7]  Littlewood and his co-authors were even more succinct when they stated there is currently insufficient evidence on which to base the clinical practice of orthodontic (“braces”) retention.”[8]


Arch Reformulation Therapy:

ART is a highly conservative treatment which improves the bone and gums which support the teeth. ART also improves the bite and posture of the teeth. This helps make the mouth as self-cleansing as possible (reduces plaque and stain buildup). The results from ART contrasts favorably when compared to braces. Bollen’s systemic review found that improved gum health should not be expected after dental braces.[9]

Should one be fortunate and obtain a stable braces result, a definitive way to maintain it does not presently exist. [10][11]

Some patients have conditions which would rule out receiving braces (e.g., TMJ pain, loose teeth, baby teeth) that are indications to initiate ART.

ART’s periodontal aligners are indistinguishable from orthodontic aligners. The difference is ART’s aligners are programmed to move the teeth based on a unique protocol.

ART has defined phases. Most of the movements occur during the active phase. A much smaller amount happens during each of the passive phases.

 

 

Initial anterior view: Day 1

Month 8: conclusion of ART Active Phase
(Periodontal aligners)
2 years into Passive Phase (retainers)

3 years into Passive Phase

4 years into Passive Therapy

Four years after orthodontic aligners

Four years after periodontal aligners

The Manhattan Method for teeth whitening helped to fix his yellow teeth dominated smile

 

Caption / comments:

The yellow line which bisects the top front two teeth shows the reduction of the midline asymmetry that was present at the onset, reduced at the end of active therapy and just about eliminated a couple of years into passive therapy.

The lavender arrows point to some of the gums which became healthier as the amount of exposed roots stayed the same or improved.

The orange arrows point to some secondary teeth which in addition to the two dark yellow ones, also responded nicely to the Manhattan Method of teeth whitening.

The green arrows point to the bonded fillings which fixed chips in the teeth are doing nicely, having lasted longer than prior fillings placed.

There are two key measurements which define the lifespan of a porcelain veneer. The first is how well does it fit? How well do the porcelain, cement and natural tooth meet each other where they touch? Second is the esthetics. How indistinguishable is each veneer from the natural tooth or veneer alongside it? Various features; color, shade, shape, luster, etc., are evaluated to gauge whether the teeth are as pleasing as they once were.

Multiple dental studies have determined that the fit of porcelain veneers can be expected to remain satisfactory for ten to fifteen years. However, the esthetic excellence of veneers has a shorter lifespan, usually only five to ten years.[12][13]

Therefore, it would not be far-fetched for this 22 year old to have porcelain veneers replaced three or more times throughout his life. His cost savings for not having all of those porcelain veneers placed would be in excess of $50,000. That’s another way to quantify the value of ART!



Conclusion:

The positive dental results (improved gum health and bite stability) are representative of what one should expect after ART. This patient’s prior dental braces experience (with orthodontic aligners) did not yield stable results. The instability negatively impacted his gum health and bite. As previously noted, based on findings by orthodontic researchers, their results would not be considered atypical or unexpected.

ART and dental braces have different goals. ART merits classification as a long term dental therapy. While gum health is one of the two criteria which measures the success of ART, gum health is not one of the eight criteria used by the American Board of Orthodontics Grading System to measure the success of braces therapy.[14][15][16][17][18]

ART has a definitive protocol to conclude therapy. Orthodontic researchers confirm a definitive “best way” to conclude dental braces therapy does not exist and there is no evidence that one ever has.

The ART retention methodology is unambiguous and integrated within the protocol. Not only is there no proven retention methodology for comprehensive dental braces, the selection of the retention option is often made by the patient, not the clinician.

The word most frequently used by patients to describe their mouths at the conclusion of ART is “stronger.”

The ADA’s committee in charge of dental codes acted correctly in 2013 when it revised the definition of dental braces. The present definition (2014) no longer leads patients, dentists and orthodontists to believe that braces will yield a lasting result, accurately reflecting the data widely reported by professional orthodontic researchers.

Elliot Davis, D.D.S.  TheManhattanDentist.com

 

[1] Kaan M, Madlena M. Retention and Relapse: Review of the Literature. Fogorv Sz. 2011 Dec;104(4):139-46.

[2] 2013 CDBP Code Maintenance Committee (CMC) Action Report; p. 97

[3] Slutzkey S, Levin L. Gingival recession in young adults: Occurrence, severity, and relationship to past orthodontic treatment and oral piercing. Am J Orthod Dentofacial Orthop. 2008 Nov;134(5):652-6. doi: 10.1016/j.ajodo.2007.02.054.

[4] Allen R, Newton C, Brown C. A statistical analysis of surgical and nonsurgical endodontic retreatment cases. J Endo. 1989 Jun;V.15,I(6),:261-6.

[5] Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of Nonsurgical Retreatment and Endodontic Surgery: A Systematic Review. J Endo. 2009 Jul;V35(7):930-7.

[6] Yu Y, Sun J, Lay W, Wu T, Koshy S, Z Shi. Interventions for managing relapse of the lower front teeth after orthodontic treatment. Cochrane Database Syst Rev. 2013 Sep 6;9:CD008734. doi: 10.1002/14651858.CD008734.pub2.

[7] Sadowsky C, Saklos E. Long-term assessment of orthodontic relapse. Am J Orthod. 1982 Dec;82(6):456-63.

[8] Littlewood SJ, Millett DT, Doubleday B. Orthodontic retention: a systematic review. J Orthod. 2006 Sep;33(3):205-12.

[9] Bollen AM1, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence.  J Am Dent Assoc. 2008 Apr;139(4):413-22.

[10] Valiathan M, Hughes E. Results of a survey-based study to identify common retention practices in the United States. Am J Orthod Dentofacial Orthop. 2010 Feb;137(2):170-7; discussion 177. doi: 10.1016/j.ajodo.2008.03.023.

[11] Lai CS, Grossen JM, Renkema AM, Bronkhorst E, Fudalej PS, Katsaros C. Orthodontic retention procedures in Switzerland. Swiss Dent J. 2014;124(6):655-61.

[12] Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. J of Adhesive Dent. 2004, 6(1):65-76.

[13] Alfuriji S, Alhazmi N, Alhamlan N, Al-Ehaideb A, Alruwaithi M, Alkatheeri N and Geevarghese A. The Effect of Orthodontic Therapy on Periodontal Health: A Review of the Literature. Int J Dent. 2014; 2014: 585048. PMC4060421

[14] Casko J, Vaden J, Kokich VG, Damone J, James R, Cangialosi T, Riolo M, Owens S Jr, Bills E. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop. 1998 Nov;114(5):589-99.

[15] Grading System for Dental Casts and Panoramic Radiographs. The American Board of Orthodontics. rev. June 2012;1-22.

[16] Santiago J, Martínez C. Use of the Objective Grading System of the American Board of Orthodontics to Evaluate Treatment Outcomes at the Orthodontic Graduate Program Clinic, University of Puerto Rico, 2007-2008. PR Hlth Sci J.prhsj.2012; Vol 31:1.

[17] Song G, Baumrind S, Zhao Z, Ding Y, Bai Y, Wang L, He H, Shen G, Li W, Wu W, Ren C, Weng X, Geng Z, Xu T. Validation of the American Board of Orthodontics Objective Grading System for assessing the treatment outcomes of Chinese patients. Am J Orthod Dentofacial Orthop. 2013 Sep;144(3):391-7. doi: 10.1016/j.ajodo.2013.04.018.

[18] Kassas W, Al-Jewair T, Preston C, Tabbaa S. Assessment of Invisalign treatment outcomes using the ABO Model Grading System. J World Fed Orthodontists. Jun 2013;V2,I2:e61-4.

Arch Reformulation Therapy (“ART”): The Case Studies of Two Patients

Patient #1

Chief Concern:

This 22 year old male would like to have a smile where his two yellow front teeth don’t stand out.

Dental History:

As an eight year old, teeth #7, 8 were avulsed in a baseball accident and subsequently replanted by his dentist. Teeth #7, 8 were discolored and missing portions of their enamel, even though both had previously received appropriate dental treatment (composite restorations, whitening) on more than one occasion. As a 16 year old, he received approximately one year of orthodontic aligner therapy. While there may have been some benefits at one time from the orthodontics, none were present at age 22. Mild gingivitis and gingival recession were present, but no pockets probed beyond 3mm.

Recent treatment recommendation:

  • Traditional orthodontic retreatment
  • 2-4 full coverage ceramic restorations
  • 0-10 porcelain veneers

Treatment proposed, accepted and rendered:

  • Arch Reformulation Therapy (“ART”) with periodontal aligners
  • Manhattan Method for the teeth whitening of smiles whose teeth possess various shades
  • Direct composite restorations teeth #7, 8

Patient and General Background:

Prior to his initial visit, the most recent dental recommendations (e.g., traditional orthodontic retreatment, 2-4 full coverage ceramic restorations, 0-10 porcelain veneers) might have been influenced by the results of his prior dentistry (e.g., whitening, restorative, orthodontic aligner care) over the past dozen or so years which were either unsuccessful or lasted for a shorter time than the patient, his parents and doctor had hoped.

The patient presented four years after the conclusion of his orthodontic aligner therapy. As is common with those who’ve received orthodontic treatment, his dentition and occlusion were neither ideal nor stable. Kaan and Madlena’s comprehensive review which evaluated the longevity of orthodontic care noted that teeth showed signs of being repositioned to less desirable locations post-treatment 70%-90% of the time.[1]

That’s another way to state that orthodontic care is successful 10%-30% once active care has concluded (e.g., bracket debonding, last orthodontic aligner). If dental considerations were factored (e.g., periodontal health, TMD, impact upon direct and indirect restorations), the dental success rate would likely be well below that 10%-30% range. Although noted as consequences, not one study tabulated or tracked non-orthodontic dental problems.  The publication of that significant review might have been the impetus for the ADA Code Maintenance Committee to revise (unanimously, with one abstention) the CDT definition of comprehensive orthodontic treatment (D8070, D8080, D8090) at their February 2013 meeting. The essential phrase present for many years “Optimal care requires the long term consideration of patient’s needs and periodic re-evaluation” was deleted from the descriptor.[2]

Slutzkey and Levin pointed out that the breadth of this patient’s recession was common in his age group (18-22 years old). When they compared recipients of orthodontic therapy with non-recipients, the increased incidence of their gingival recession ranged from 500%-800%.[3]  That’s why it’s understandable for a clinician to conclude a patient might not be a candidate for orthodontic retreatment, be prone to orthodontic relapse and to factor the presence of his chronic malocclusion when attempting to maximize the longevity of the restorations.

In contrast to the multitude of articles which support the concept of endodontic retreatment[4][5], there aren’t any randomized controlled studies which purport a success rate for orthodontic retreatment. Yu concluded that there is an “urgent need” for those studies to identify the most effective method for managing relapse, because one does not presently exist.[6]

Obtaining a stable result after the repositioning of teeth is vital. The phrase orthodontic relapse is often inaccurately attributed to describe consequences from a patient whose orthodontic therapy failed to achieve a stable result. If a stable result is not achieved, then there’s nothing to relapse from. If a stable or soon to be stable result is not obtained, Sadowsky and Saklos concluded that no retention method could provide a lasting result.[7]  Littlewood and his co-authors were even more succinct when they stated “there is currently insufficient evidence on which to base the clinical practice of orthodontic retention.”[8]

Arch Reformulation Therapy:

ART is a dentally gentle protocol which uses periodontal aligners to modify the underlying osseous substructure and improve the health of the gingiva, which is one of the goals of treatment. Another goal is to improve the occlusion, teeth positions and axial inclinations which will help the oral cavity to maintain its stability and become more resistant to the accumulation of plaque and stain. The results from ART contrasts with those from orthodontic therapy, where Bollen’s systemic review determined periodontal improvement is not and should not be an expected outcome from comprehensive orthodontic treatment.[9]

Should one be fortunate and obtain a stable orthodontic result at the conclusion of care, a definitive protocol to maintain that excellent outcome does not presently exist. [10][11]

Patients who possess dental conditions which contraindicate their ability to receive traditional orthodontic or orthodontic aligner therapy exclusively (e.g., TMD, mobile teeth, primary teeth, teeth with poor crown root ratios, elective orthognathic therapy candidates, ankylosed teeth) possess traits which are indications to initiate ART.

ART designs and programs periodontal aligners, indistinguishable in appearance from orthodontic aligners, to achieve a greater range of and more predictable movements than can be accomplished with traditional non-surgical orthodontics, elective orthognathic surgical/implant-aided orthodontics, or orthodontic aligners.

ART has defined phases. The overwhelming majority of desired movements are accomplished during the active phase. Modest amounts of osseous reformulation continue during each of the passive phases.

Initial anterior view: Day 1

Month 8: conclusion of ART Active Phase
(Periodontal aligners)

2 years into Passive Phase (retainers)

3 years into Passive Phase

4 years into Passive Therapy

Four years after orthodontic aligners

Four years after periodontal aligners

Caption / comments:

The yellow line which bisects the maxillary central incisors shows the reduction of the midline asymmetry that was present at the onset, reduced at the end of active therapy and just about eliminated a couple of years into passive therapy.

The lavender arrows point to representative gingiva which became more healthful as the recession which was generalized stabilized or decreased.

The orange arrows point to teeth which responded positively to the Manhattan Method of teeth whitening.

 

Patient #2

Chief Concern:

This 25 year old woman would prefer to have dental treatment which does not include gingival graft surgeries or orthodontic treatment.

Dental History:

At age 12, she started four years of orthodontic therapy (palate expander, extraoral headgear, traditional orthodontics, etc.). Even though she was a conscientious and compliant patient, instability became rampant shortly after the completion of care. Her periodontal health was excellent prior to the orthodontic care. Gingival recession and root sensitivity started partway through her orthodontic treatment. Her gingival health continued to decline, increasing in breadth and severity throughout the remainder and after the conclusion of her orthodontics. Three years ago, at age 23, she had an epithelial and connective tissue graft in the mandibular anterior region. Her periodontist suggested additional grafting procedures to protect her roots and diminish their thermal sensitivity.

Recent treatment recommendation:

  • Traditional orthodontic retreatment
  • four gingival grafting surgeries
  • 0-6 porcelain veneers

Treatment proposed, accepted and rendered:

  • ART with periodontal aligners

Patient and General Background:

The patient presented ten years after the conclusion of her traditional orthodontic therapy and three years after her gingival grafting (recipient and donor site) surgeries. As is common with those who’ve received orthodontic treatment, her periodontal health and occlusion were neither ideal nor stable.

Prior to her initial visit, the most recent dental recommendations (e.g., traditional orthodontic retreatment, 0-6 porcelain veneers, four gingival grafting procedures) left her highly anxious.

It was a challenge for her to have confidence in the near-identical treatment plan proposed by the same orthodontist who rendered her prior unsuccessful care. She wanted to consider every option which would allow her to avoid the pain and discomfort which lingered for months following her prior gingival grafting surgery.

While many articles detail the issues which face patients and clinicians upon the cessation of orthodontic therapy (e.g., teeth which lack stability, periodontal manifestations which weren’t present at the onset, compromised occlusion, TMD), there has yet to be a single randomized controlled study which points to consistent improvement to the gingival health.[12] The continuing improvement of the periodontal health during and after the conclusion of ART is a unique and warmly appreciated benefit by patients and clinicians.

 

Patient #2

Initial anterior view: Day 1

Month 7+: conclusion of ART
[Active Phase – periodontal aligners]

1 year into Passive Phase (retainers)

3 years into Passive Phase

4 years into Passive Therapy

5 years into Passive Therapy

10 years post-traditional orthodontic care
3 years after gingival grafting surgery

5 years post-ART, 16 years post-orthodontics
9 years after gingival grafting surgery

Conclusion:

The positive dental results (improved periodontal health and occlusal stability) in these two individuals are representative of what one should expect after ART. These patients prior orthodontic experience – one with traditional orthodontics, one with orthodontic aligners; did not yield stable results. The instability negatively impacted their periodontal health and occlusion. Based on findings by orthodontic researchers, their results would not be considered atypical or unexpected.

ART and orthodontic therapy have different goals. ART merits classification as a long term dental therapy. While gingival health is one of the two criteria which measures the success of ART, periodontal health is not one of the eight criteria used by the American Board of Orthodontics Grading System for Dental Casts and Panoramic Radiographs to measure the success of an orthodontic therapy.[13][14][15][16][17]

ART can treat a number of patients non-surgically which would otherwise require elective orthognathic surgery in conjunction with pre- and post-surgery orthodontic treatment.

Mobile and ankylosed teeth are often indications to initiate ART. Teeth with those conditions are usually excluded from or serve to contraindicate orthodontics from consideration within a treatment plan.

ART has a definitive protocol to conclude therapy. Orthodontic researchers confirm a definitive “best way” to conclude orthodontic therapy does not exist and there is no evidence that one ever has.

The ART retention methodology is unambiguous and integrated within the protocol. Not only is there no proven retention methodology for comprehensive orthodontics, the selection of the retention option is often made by the patient, not the clinician.

The word most frequently used by patients to describe their mouths at the conclusion of ART is “stronger.”

The ADA Code Maintenance Committee acted correctly in 2013 when it revised the definition of comprehensive orthodontic therapy. The present (2014) descriptor does not insinuate that comprehensive orthodontics should be expected to yield a lasting result and more accurately reflects the data widely reported by orthodontic researchers.

[1] Kaan M, Madlena M. Retention and Relapse: Review of the Literature. Fogorv Sz. 2011 Dec;104(4):139-46.

[2] 2013 CDBP Code Maintenance Committee (CMC) Action Report; p. 97

[3] Slutzkey S, Levin L. Gingival recession in young adults: Occurrence, severity, and relationship to past orthodontic treatment and oral piercing. Am J Orthod Dentofacial Orthop. 2008 Nov;134(5):652-6. doi: 10.1016/j.ajodo.2007.02.054.

[4] Allen R, Newton C, Brown C. A statistical analysis of surgical and nonsurgical endodontic retreatment cases. J Endo. 1989 Jun;V.15,I(6),:261-6.

[5] Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of Nonsurgical Retreatment and Endodontic Surgery: A Systematic Review. J Endo. 2009 Jul;V35(7):930-7.

[6] Yu Y, Sun J, Lay W, Wu T, Koshy S, Z Shi. Interventions for managing relapse of the lower front teeth after orthodontic treatment. Cochrane Database Syst Rev. 2013 Sep 6;9:CD008734. doi: 10.1002/14651858.CD008734.pub2.

[7] Sadowsky C, Saklos E. Long-term assessment of orthodontic relapse. Am J Orthod. 1982 Dec;82(6):456-63.

[8] Littlewood SJ, Millett DT, Doubleday B. Orthodontic retention: a systematic review. J Orthod. 2006 Sep;33(3):205-12.

[9] Bollen AM1, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence.  J Am Dent Assoc. 2008 Apr;139(4):413-22.

[10] Valiathan M, Hughes E. Results of a survey-based study to identify common retention practices in the United States. Am J Orthod Dentofacial Orthop. 2010 Feb;137(2):170-7; discussion 177. doi: 10.1016/j.ajodo.2008.03.023.

[11] Lai CS, Grossen JM, Renkema AM, Bronkhorst E, Fudalej PS, Katsaros C. Orthodontic retention procedures in Switzerland. Swiss Dent J. 2014;124(6):655-61.

[12] Alfuriji S, Alhazmi N, Alhamlan N, Al-Ehaideb A, Alruwaithi M, Alkatheeri N and Geevarghese A. The Effect of Orthodontic Therapy on Periodontal Health: A Review of the Literature. Int J Dent. 2014; 2014: 585048. PMC4060421

[13] Casko J, Vaden J, Kokich VG, Damone J, James R, Cangialosi T, Riolo M, Owens S Jr, Bills E. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop. 1998 Nov;114(5):589-99.

[14] Grading System for Dental Casts and Panoramic Radiographs. The American Board of Orthodontics. rev. June 2012;1-22.

[15] Santiago J, Martínez C. Use of the Objective Grading System of the American Board of Orthodontics to Evaluate Treatment Outcomes at the Orthodontic Graduate Program Clinic, University of Puerto Rico, 2007-2008. PR Hlth Sci J.prhsj.2012; Vol 31:1.

[16] Song G, Baumrind S, Zhao Z, Ding Y, Bai Y, Wang L, He H, Shen G, Li W, Wu W, Ren C, Weng X, Geng Z, Xu T. Validation of the American Board of Orthodontics Objective Grading System for assessing the treatment outcomes of Chinese patients. Am J Orthod Dentofacial Orthop. 2013 Sep;144(3):391-7. doi: 10.1016/j.ajodo.2013.04.018.

[17] Kassas W, Al-Jewair T, Preston C, Tabbaa S. Assessment of Invisalign treatment outcomes using the ABO Model Grading System. J World Fed Orthodontists. Jun 2013;V2,I2:e61-4.

CDT Code Change Action Request Form

1.    
Requestor Information

Date Submitted:

October 28, 2015

Name:

Elliot Davis

Address (Line 1):

80 Fifth Avenue

Address (Line 2):

#1607

City:

New York

State:

NY

Zip Code

10011

Telephone:

(212) 645.9255

Email:

DrDavis@TheManhattanDentist.nyc

2.    
Does this request represent the official position of: a) a dental
organization or a recognized dental specialty; b) a third-party payer or
administrator; or c) the manufacturer/supplier of the product?

Yes  >

 

If Yes, Name:

 

No  >

x

3.    
Does the requestor or entity identified in item #1 or #2 receive any financial
benefit?

Yes  >

 

If Yes, describe:

 

No  >

x

4.    
Action

Add

x

Revise

 

Delete

 

Affected
Code (Revisions & Deletions)

 

5.    
Full text of requested action (Additions
& Revisions)

Nomenclature

Arch Reformulation Therapy (ART)

Descriptor

The utilization of sequential removable appliances (i.e.,
periodontal aligners) to improve the supporting structures of the dentition.

6.    
Rationale for this request (e.g., reasons why existing procedure code
is inadequate or no longer appropriate; description of technology inherent to
procedure; dental schools where taught).

Arch reformulation therapy (ART) is a dentally gentle non-surgical
methodology which uses sequential removable appliances (i.e., periodontal
aligners) to create new or enhance the existing osseous substructure that
supports the dentition and gingiva. ART can be used for a number of dental
maladies (e.g., periodontal disease, non-surgical elective orthognathic
therapy, TMD, chronic malocclusion).

Unlike comprehensive orthodontic therapy which this committee determined no longer merited classification as a long term dental remedy (February 2013)*, ART is designed to yield long term results. For additional information, please refer to the arch reformulation case studies (accompanying .pdf) as well as the additional videos
and tutorials at TheManhattanDentist.com which will be posted in January 2016.

The dental public is desirous of and yearning for non-surgical and non-aggressive solutions to common dental problems. Arch reformulation offers clinicians and patients a prudent, predictable and cost effective option to significantly improve their oral health.

* For reference purposes: At its February 2013 meeting, the CDBP Code Maintenance Committee modified the CDT Descriptor for comprehensive orthodontic therapy. The CMC voted without a dissenting vote (20 yes, 1 abstention) to delete the most vital sentence in the descriptor, one included for many years: “Optimal care requires long-term consideration of patient’s needs and periodic re-evaluation.”

In contrast to when verbiage is considered during a discussion and debate but not included, the removal of an essential aspect of a descriptor validates the inverse definition. The revised descriptor, which went into effect in January 2014, for code D8090 is unambiguous. The inverse to the portion of the descriptor states: “Optimal care neither requires the long-term consideration of the patient’s needs nor any periodic re-evaluation by the clinician who rendered care once treatment’s been completed.”

7.    
For Additions – a) current CDT Code used to report the proposed
procedure; b) description of the procedure or clinical condition; and c) scenario
describing the patient, materials, technique, etc.

a) D8090, D4273, D4999

b, c) Arch reformulation therapy utilizes sequential
periodontal aligners which are specifically designed to reformulate the
osseous substructure. The enhancement to both the quality and quantity of the
gingival health, as well as the improvement of the occlusion, confirm the positive
results. Continued improvement after the conclusion of active therapy confirms
the occlusion and periodontal health are likely to maintain their long term, stable
state.

 

8.    
Supporting documentation or literature: a) if protected by copyright,
written authorization to reprint and distribute must be provided; and b) all
material must be submitted in electronic format.

Material submitted?

Yes  >

x

Protected by
copyright?

Yes  >

 

Permission to reprint?

Yes  >

x

No  >

 

No  >

X

No  >

 

9.    
Additional Comment/Explanation:

Permission to reprint is limited as follows: These are my photos of my patients. The use of my photos is restricted to the CDBP Code Maintenance Committee’s evaluation of this request and may not be used for any reason beyond the evaluation process. Please limit the use of these photos to citation purposes only.

The photos are presented to help one appreciate the distinction between the goals for and results obtained with ART when compared to those associated with comprehensive orthodontic treatment and gingival grafting procedures.

 



 

Patient #1:        10 years after the completion of traditional orthodontic care

3 years after the periodontal grafting surgery in the mandibular anterior region

 



 

Patient
#1:        5 years after the completion of ART with periodontal aligners

9 years after the periodontal grafting surgery

16 years after traditional orthodontic care

 

The periodontist who performed the grafting surgery in the mandibular anterior region recommended that she receive four additional surgical grafting procedures. After ART, that periodontist revised his recommendations. He believes that there has been sufficient improvement to her periodontal health, coupled with
the elimination of thermal sensitivity, that there is no longer a need for any additional
grafting surgeries.

Based on the continued improvement to her oral health, her general practitioner dentist(GP) has reduced the number of recommend prophylaxes per year from four to two.

For the past few years, the GP has performed all of the periodic exams and oral prophylaxes. The GP does not believe the patient requires the care of a periodontist at this time.

 


Patient #2: 4 years after the conclusion of orthodontic treatment with orthodontic aligners



 

Patient
#2:        4 years after the conclusion of ART with periodontal aligners.

 

The improvement to his occlusion has helped stabilize the dentition. That has helped to increase the stability of his dental composite restorations, which have lasted significantly longer than those placed previously. While his oral hygiene habits have not changed significantly, the improvement to his periodontal health has been steady and appreciated by the patient and his dental team.