Interview: Teen treatments in aligner orthodontics
Dr Julia Haubrich is a member of the board of the German Association for Aligner Orthodontics and chair of its sixth scientific congress, which will take place in Cologne in Germany from 19 to 24 November 2020. She is also on the editorial board of the Journal of Aligner Orthodontics. She works in a private practice in Cologne. After her presentation at the EAS Spring Meeting, she kindly took the time to answer some questions.
Dr Haubrich, you focus on orthodontic treatments for teenagers. Is this only because it is your favourite topic or are there other reasons?
I love working with teenagers. I am not just talking about aligners; I mean, in general. I think it is a lot more fun and I also love the outcome, and the combination of the different treatments you have seen at the conference. Working with teenagers and children is actually the reason I wanted to become an orthodontist. Then, when aligner technology arrived, many adults came to be treated and I was a bit sad, because I wanted to have the kids back, so I focused on making it possible to treat kids with Invisalign, because they were whom I wanted to work with. I love to talk about teens, and I am sure that is the reason I was invited to talk at the EAS meeting.
Some of the cases you presented were of really young children. Is there a need to treat children who still have their primary teeth? Dr Sean Carlson mentioned in his presentation that he treats children to prevent future problems. Do you have the same goals in treating children?
What was interesting in Dr Carlson’s comments was that, in the US, they focus more on treating teenagers. In Europe and in Germany, we very often have a first-phase treatment with a functional appliance and then a second-phase treatment once most of the permanent teeth have erupted. I think that is what separates us from the doctors in the US, where most do not have a first treatment phase. As far as I know, the functional appliance is more something that is used in Europe.
There are both the functional appliance treatment and the aligner treatment. How many of your treatments are with functional appliances and how many are with aligners? Dr Carlson gave me his opinion on this question, and I’d like to know if you feel one treatment is better than the other or if you feel we still need both?
We absolutely do need both. Functional appliances are more for the morphology of the face—you can actually increase or decrease growth in a certain way. Influencing patients' growth is something you can only do once in a lifetime, when the patient is growing and is young. That is actually what Dr Carlson was talking about. He wants to prevent the “car accident” further up the road and therefore wants to take charge of the patient.
That is the reason we love to see our patients early on as well, because we can actually modify the growth. If we are working on a severe malocclusion case in need of surgery, we are probably not going to be able to change that, but there are cases where we can prevent surgery when we see the patient very early. For cases where there is not a lot of space, what happened in the past was that, because of that limited space, teeth were sometimes impacted and doctors had a tendency to do extractions. That is something that orthodontists did a lot 20 or 30 years ago, but we discovered that a patient’s profile was not very pleasing after extraction. It is not the profile that orthodontists want to have nowadays. In recent years, I have done only one extraction case in a child. We usually do not extract. We can use other techniques; we can widen the arch; we can also create the space with distalisation, as I showed in my presentation, to avoid extraction. If you have the opportunity to work with a patient quite early on and open the space, then you can prevent impactions of teeth and extractions later on.
In what direction do you see orthodontic treatments heading in the future?
It is going to be all digital and it is changing very, very fast. I still remember five years ago, when during courses, I would talk about scanners and people would look at me and would say it was expensive and they wouldn't see many advantages—they didn’t want to have one. When I ask now in a course how many people have a scanner, almost half of them do. It is changing very fast, because everybody sees the advantages of having one: it is an excellent tool to visualise treatment plans and goals with the patient, you can share the data easily; you can print models whenever you want—it is just a new generation in medicine and dentistry. It is going faster and faster and getting better and better.
Patients love to see their teeth on the screen, and if you can simulate the outcome, it makes them come back, they bring you new patients and the acceptance rate of a treatment increases.
You were telling me that, when aligner technology first arrived, many adult patients came to be treated. Do you feel it has increased the number of adults seeking treatment, treatment they might have avoided if it had been with fixed appliances?
Absolutely! It is the main reason for adults wanting to be treated, because if you ask them to wear buccal multibracket appliances, most would say no and many only accept treatment because the possibility of clear aligner treatment exists. The invisible alternative would be to use lingual appliances. Honestly, I have done very few lingual appliances and my experience as a practitioner was not a nice one—it was a real strain on my back as a result of the work position. I also saw some decalcifications with lingual appliances and patients with issues with talking, because it can be quite uncomfortable for the tongue. It was not uncommon to have patients coming to our office with lingual appliances, asking us to take them off and then continuing with aligners.
I see a huge advantage with aligners, and the technology is evolving. As Dr Cristina Viyuela told us during her presentation, in the beginning, we had some issues, there were some limits and there was no doubt that the fixed appliances we had been working with for years were easier for most of us. Now, however, aligner technology is getting better and better, and sharing the knowledge we receive makes it easier for all of us to learn and improve.
Any final thoughts or an important message you would like to convey?
I think that aligner technology or an aligner treatment, compared with a fixed treatment, offers many advantages, especially to young patients.
Apart from the aesthetic aspect, we do not have a lot of brushing issues, which can be a common problem with young patients with fixed appliances. With aligners, it is a lot easier to brush your teeth and therefore patients have a reduced risk for decalcification. There is no decalcification issue as there can be when debonding the brackets. Sport injuries can also be an issue when wearing fixed appliances and are avoided when wearing aligners, which can also be worn with a mouth guard. Many young patients play a wind instrument, and a fixed appliance can make this a difficult task. You can take your aligner off, which solves this problem. Aligners are also worn by people in the public eye such as television for example, because when they have to appear on camera, they can take the aligner off.
Whether you like it or not, it is going to be about aligner technology; there is no way you can avoid it.