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.