Efficiency in Treatment: How Much Longer?

This podcast episode and blog is based on a question I get in many different ways from different people: How much longer?

Listen to the podcast here:

Before answering that question for each patient, orthodontists are trying to evaluate how that patient is counting time. Is it the least number of appointments? Does it matter how far apart those appointments are to the patient? Is it the least amount of time in orthodontics? Is it healthy results, even if not perfect, but in a time span they think is reasonable? Is it a certain number of trays? Does the patient prefer to scan in an app so they don’t have to make a trip to the office? Is it the time span until an ideal smile?

Here is the thing: Eight times out of 10, the limiting factor on the time span spent in braces is the patient’s own bone turnover. Two times out of 10, the limiting factor is how well the appliances (clear trays or braces) or the auxiliaries (elastics or springs) are taken care of and used when the patient isn’t at the office.

WOW! That’s crazy because that means it’s not the number of appointments, or adjustments, or how close together they are. This also means that the healthier your bone and body are, the better it responds to the orthodontic treatment. This is why keeping your teeth and appliances clean during treatment is so important. In a clean environment, your body can devote its energy and resources to remodeling your bone instead of fighting the bacteria that threaten infection with lots of food stuck on the teeth and gums.

The other part of it is making sure you are following the instructions prescribed by your orthodontist. Daily care of yourself and your appliances when you are outside the office is the biggest factor in your treatment.

So, what about asking for a larger adjustment or doubling up on elastics? There are a few patients that will ask if they can skip wires or come in sooner. They tell me, “No pain, no gain, Doc!” All the research studies (and my own experience) show that this will not actually cause the case to finish faster. If you change wires faster in the beginning, then you have made trips to the office to switch wires more frequently than needed, and ultimately end up sitting in a later wire a longer time. You are waiting on the bone and teeth to catch up to the wires. Also, too much force can cause damage to the tooth root or the gums and bone around the tooth – permanently.

(Pssst – pro tip: research shows it takes some wires 14-18 weeks to become “passive” or have no other tooth movement possible.)

Alright, what about doubling up on rubber bands? Each person is slightly different, but light continuous forces are the best approach to avoid damage to the teeth, bones and gums. That means if you double up the elastics without your orthodontist telling you to, you may actually cause harm to your teeth. As a general rule, it takes 6 hours for the body to recruit the right cells to remodel bone. Then the work begins after that.

So, if you are wearing an appliance or clear trays or elastics for 12 hours and then taking them off for 12 hours, here is what’s happening: You put on the clear trays or elastics, your body takes 6 hours to recruit cells to be able to move the teeth, and then moves the teeth for 6 hours. Then when elastics or trays are removed, the body recruits the cells to go in the opposite direction, and then spends the next 6 hours sending your teeth back to their original position. That’s why wearing something only half the time does not allow teeth to move significantly.

This is why waaaay back over a hundred years ago, the first orthodontists found ways to affix appliances to people’s teeth – so it would work!

So why would a patient want to stay in a tray longer than the average 7 days? If a couple teeth are lagging and “not tracking” and then you keep switching trays, the tooth that lagged a little at first, will stay in that position and not make any more progress. Say this happens at tray 5. You finish all 20 trays wearing each 7 days, but that one tooth is behind. You think, no big deal, just a couple trays to catch this tooth up. What ends up happening is that you have to get 16-20 trays again just for that one tooth! This is why it is more efficient to wear a few of your trays longer – even up to a month – to get all the teeth tracking before switching to the next set of trays. When you get a revision, and it’s 8 trays instead of 20, your future self will thank you for staying in those trays a few extra days instead of speeding through each tray in 7 or less days.

So, what about accelerating devices or procedures?

Vibrational devices have the most promise with medical doctors and dentists using vibration to facilitate bone healing. It definitely is helping on the bone healing part of bone turnover. More research is needed on actual acceleration by speeding bone remodeling with some bone being broken down for the tooth to move into that space.

Piezocision and light therapy came from med spa healing and some people swear it helps. The response has not been studied enough yet on light therapy to have good literature. Piezocision is not showing good results in the literature.

Then there is also perforating bone without augmentation and this is concerning. Teeth could actually be moved outside the bone housing because the bone is activated and soft. Long term these teeth are highly likely to be lost.

The PAOO, or Periodontally Assisted Osteogenic Orthodontics, procedure is perforating bone PLUS augmentation with bone grafting. This is the best of both worlds. Your bone gets activated and you get extra bone to expand the range teeth can be moved. In fact, Dr. Cooper just did a Facebook Live with the expert in PAOO, Dr. Brownfield! You can watch it here.

The periodontist has to do the bone activation and augmentation and works closely with your orthodontist for this procedure to be a success. In addition to gaining some bone, the orthodontic process is accelerated. This is the one situation where coming in for appointments more frequently will help your treatment progress quickly.

We hope this helps you have a fun, efficient orthodontic experience!

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