Bonded (Permanent) Retainers- Pros and Cons

I was asked to weigh in on a facebook discussion about bonded retainers.  The opinions ranged from “why would you want to attach something to your teeth forever,” “They are hard to clean because you have to floss under them (or waterpik around them), ” “they promote tooth decay and periodontal disease because of plaque build- up (i.e  it is difficult cleaning around them) “ to “at least you can’t lose them” and “they keep the front teeth looking straight so you haven’t thrown your money out for the braces when everything moves.”

I loved this opinion:

“If it helps to hear a positive old-school retainer story: my kids have managed to not only NOT lose, but use their retainers for five years now. They can keep track of keys and wallets too. It's not a bad skill to develop and less risky than the permanent option.”

I also enjoyed reading this one:

“I sometimes wonder when orthodontists recommendations cross the line between good dental health and strictly cosmetics reasons. I probably could have used a permanent retainer, but the slight crookedness of my lower teeth has never had a bad impact on my dental health. I would want a second opinion and a very detailed explanation why a permanent retainer was necessary.”

Here is how I responded:

Teeth will move your whole life- from any force that is put on them. This includes over-bulked fillings that make the contact too tight, mouth habits (such as pencil biting, improper tongue posture, clenching your teeth), and aging (which causes the lower jaw to rotate forward "throwing" the lower front teeth against the upper front teeth.) Some orthodontists choose to "guarantee" the lower front teeth stay straight with respect to "each other" by bonding them together. This does not stop them from moving as a unit! It can also have other undesirable side effects (such as creating space between the upper front teeth, or pushing the lower jaw backwards causing clicking in the temperomandibular joints) in patients who clench their teeth. It is necessary to floss or waterpik the bonded retainer daily to prevent gum problems, and to have it checked every year to make sure that it is still bonded securely- otherwise you can get decay under it.

 "Invisalign" or "Essex" vaccuum formed retainers stretch-out over time so that they become less effective, and they prevent posterior teeth from settling fully into occlusion (i.e. they prevent your bite from working properly) when used long term.

 I still prefer removable hawley style retainers (with a shelf on the front of the top one for vertical control)- worn full time when the braces come off, and then just “at night” after the first year- at least til the patient stops growing. (I switch to an occlusal guard if the patient is a clencher.) If the braces were worn as an adult it is likely retainers will be needed at night forever.

#braces, #orthodonticretainers, #hawley retainers, #bonded retainers, #permanent retainers, #invisalign retainers", #essix retainers

I can fix that!

Orthodontists have many skills which are useful to straighten teeth.  These skills can also be used outside the office.

Recently my bottom refrigerator shelf split from using it to support heavy pots.  It seemed ridiculous to replace the refrigerator when the motor still worked.  After staring at the broken shelf for months I said to myself, “I can fix that.”  Using the method which my grandfather, Dr. Joseph Okun, used to repair dentures, and which my father, Dr. Stanley Okun, adapted to repair retainers, I set out to repair my refrigerator shelf.  I drilled holes on both sides of the crack, and sewed .012 ligature-wire across the crack.  On the top side of the shelf I flowed Triad Gel over the “stitches” to create a smooth surface, and light cured the gel.  Then I used cold cure acrylic on the underside of the shelf, to add strength to the repair.  I restored the support leg with .045 retainer wire and cold cure acrylic, the same way that I used to transfer copings when I still did general dentistry. Now my refrigerator shelf is as good as new!

How handy is your orthodontist?

The Danger of Undiagnosed Sleep Apnea, and Dental Treatment for Sleep Apnea

Once again, undiagnosed sleep apnea is in the news, as the cause of the September 29, 2016 Hoboken Commuter train crash.  It was also the cause of a New York City commuter train crash in 2013 and of freight train crashes in 2011 in Iowa, and in 2013 in Missouri. According to a CBSnews.com report on 11/21/16), “Metro-North started testing for sleep apnea after the 2013 crash. Metro-North’s screening program has found sleep apnea in 51 of its 438 engineers and trainees, spokesman Aaron Donovan said. They are undergoing treatment, he said. Now Federal regulators are urging railroads across the country to test train operators for obstructive sleep apnea.”

“Sleep apnea is especially troubling for the transportation industry because sufferers are repeatedly awakened and robbed of rest as their airway closes and their breathing stops, leading to dangerous daytime drowsiness. Studies have long concluded that people with the disorder have diminished performance in multiple areas during the daytime.

“You end up with an engineer who is so fatigued they’re dosing off, they’re falling asleep in these micro bursts and they often have no memory of it, and they’re operating a locomotive at the time, so they’re putting hundreds of people in danger,” (Sarah)Feinberg (of the Federal Railroad Administration) said.

“Airplane pilots with sleep apnea aren’t allowed to fly unless they’ve been successfully treated. Regulators are also pushing for bus and truck drivers to get tested.”

Treatment for sleep apnea may include:

Sleep hygiene measures such as: going to sleep the same time every night and getting up at the same time every morning in order to train your body when it should be sleeping, sleeping in a dark room, using the bedroom only for sleeping, and avoiding blue light from televisions, tablets and smart phones before bedtime.

Sleeping with a Continuous Positive Airway Pressure (CPAP) mask over the mouth and nose.  The air which blows into the mouth and nose keeps the airway open so that it doesn’t collapse when the airway muscles collapse during sleep.

Sleeping with a dental appliance which positions the lower jaw forward, so that the jaw position holds the airway open despite the collapse of the airway muscles during sleep.

In extreme cases there are surgeries which either cut away soft tissue or reposition bones to change the anatomy of the face and jaws, so that the airway is not obstructed during sleep.

All of these treatment options have side effects, but the consequences of leaving sleep apnea untreated are far more severe.  If you, or someone you know, is interested in treating their sleep apnea with a dental appliance, schedule a consultation appointment with Dr. Judith Okun to discuss your options and questions.

Yes, "It is your fault."

“It ain’t my fault”

Yesterday I heard Zara Larson, a singer who was on TV singing "it ain't my fault", a song about how it isn’t her fault if she falls for a man and can’t control her actions.  Every day we hear from politicians that the status quo is not their fault; it was caused by their predecessor. (Unless it was favorable, then they claim it for themselves.) We seem to live in a society of people who don’t make an effort to take responsibility (or make an effort to not take responsibility.)

Orthodontic treatment requires responsibility and effort by both the doctor and the patient. The orthodontist sets up the system, and the patient “drives” it.  I explain it to patients as if it is a car.  You can spend a lot of money on a car, but if you don’t put gas into it, it won’t drive; You can spend a lot of money for braces, and if you don’t put in your effort (wear elastics, eat in ways that won’t break your braces, and keep regular

appointments) your treatment will not progress.  It’s like saying that it is a two hour trip from here to Philadelphia, but you never turn on the car.  Two hours later you won’t be in Philadelphia.  Your case may take two years to complete if you follow directions, but you won’t have a complete result in two years if you don’t put in your effort.  The patient has to take responsibility and put in the effort to get that satisfactory result! Yes, “it is your fault” if you don’t. All of us are much happier when the result is amazing, so please take responsibility, and help make your smile spectacular.

Dr. Okun supports "Officer Phil"

Dr. Okun is proud to be one of the sponsors of the Officer Phil safety programs through the Rye Brook Police Department and the Bruno M. Ponterio Ridge Street School.  This educational program not only enables students in grades 1 through 4 to interact in a comfortable environment with their local police department, but it also provides them with an activity book to take home and share with their parents, to teach age-appropriate safety measures at home. There is a different activity book for each grade. Dr. Okun has been a supporter of this program since its inception three years ago.

It's so nice to be appreciated!

Recently, a new adult patient emailed me, saying: “Hello Dr. Okun, I just wanted to write a quick email and thank you so much for all the time you spent with me yesterday explaining the many different options for my treatment.  Your attention to me and my situation was nothing less than truly professional, thoughtful and caring.  I left your office feeling like you really cared about my teeth and situation and it was the best visit I ever had to a dentist.  I want you to know how much that meant to me and how truly appreciative I am.  Thank you from the bottom of my heart.  Kindest regards, Tim Boyd :-).” The same day, Gloria, another adult patient in my office, repeated to me what she told her general dentist's hygienist, that she had found a wonderful orthodontist. She told her, “Dr. Okun takes care of her patients; Dr. “X”,(the orthodontist to which her dentist referred her) only cares about the money.” A few weeks ago I received a letter from a father who was moving out of the country with his family before orthodontic treatment could be completed on his son.  He wrote, "Thank you for all of your help with "F"- I am only sorry we don't get the opportunity to send you "L", "M" and maybe even me! The pictures from March 2014 show just how far you have brought him."
I honestly do care about my patients; I'm glad that they notice. (Note: Tim gave permission to use his full name on the internet.)

Amazing Reviews

Samantha P posted a 5 star review on Yelp:
"I started my treatment with Dr. Okun 3 months ago and was immediately impressed with how thorough she is.  She takes a minimalist approach to your treatment and recommends treatment as if you were her kid. Her main interest is the longevity of your teeth. She is flexible with payment plans and scheduling appointments is very easy.  So far I am really enjoying working with her as my experience with my first orthodontist was less than desirable."


Anonymous from Old Greenwich, CT, and Paula G, each rated Dr. Okun with 5 stars on Google Maps:

"Dr. Okun is very thorough always taking time to explain everything to my children and me. She's experienced and very skilled and a wonderful Orthdontist. We highly recommend her practice."

"Dr. Okun always takes the time to explain everything to both my children and myself. I can say this both as a parent and a patient. She is always friendly and honest and the results are wonderful. I recommend her for all of your orthodontic needs."

"Invisalign" Retainers forever; a new solution

Multiple conversations with local dentists are coming to the same conclusion: Invisalign may make the front teeth look straight, but it doesn’t create great occlusions.  The smile may look nice, but the bite doesn’t work.

Recently the patient pictured above came in requesting that I order more Invisalign retainers for her. (She was not  returning to the treating orthodontist because she had moved.)  She had been wearing Invisalign retainers for many years and was happy with how her teeth looked.  She knew that she needed to wear retainers the rest of her life to keep her teeth straight. Orthodontically the result was less than satisfactory.  The top teeth overlapped the bottom teeth over 75% in the front (they should only overlap 1-2mm), and unless the patient postured her lower jaw forward, the front teeth could not meet like scissors to cut food. In addition, the gum was “creeping down” on the back teeth so that the roots stuck out.  This loss of periodontal attachment is frequently seen in patients that grind their teeth or wear flexible retainers (like Invisalign and Essex retainers) long term. The loss of attachment is accelerated when there is also a little bit of inflammation in the gums (from not brushing effectively and not flossing every day.) I suggested that we change her retention appliance.  Rigid retainers would minimize the rate that the gum- coverage of the roots would be lost in the future. An occlusal guard would give the patient a comfortable place to bite, at least at night when she was wearing it. We decided to make an occlusal guard for the top teeth (a rigid piece of plastic which fits on the top teeth, but is adjusted to touch all of the bottom teeth when the teeth are closed) and a Hawley retainer for the bottom teeth (an orthodontic retainer with a front wire to keep the front teeth aligned with the hard plastic which sits on the tongue side of the teeth).

The result was astounding.  At the visit that the occlusal guard was delivered the patient commented on how comfortable her bite felt, and that her face felt so much more relaxed than it did without the guard.  The muscles in her face did not have to work so hard when the teeth were closed on the guard because the bite against the plastic was balanced from "right to left" and "front to back".  This never happened when she closed her teeth.  She assured me that she would wear the lower retainer and upper guard every night forever, not only because she wanted to guarantee that the teeth stayed straight, but because they made her face feel so much better.

I know that patients will continue to ask for aligner treatment like invisalign, and I know that the results may not always be satisfactory.  But as the case above demonstrates, there is a long term solution for these patients which will retain tooth alignment, preserve the bones and gums that hold these teeth in the mouth (i.e.  Keep the periodontal attachment), and allow the chewing muscles to relax 1/3 of the rest of their life (i.e. 8 hours out of every 24.) Once again, a patient has left my office happy with her treatment.