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Difficult Case Types, Part 1: A Discussion of Adult Short-Term Orthodontics

Difficult Case Types, Part 1: A Discussion of Adult Short-Term Orthodontics

Six Month Braces for adults.

Originally posted on Dentistry Today.

INTRODUCTION
Short-term orthodontics (STO) has exploded in popularity during the past 10 years. Adults are discovering that they are able to straighten their anterior teeth cosmetically without undergoing 2 years of bite-changing orthodontics, and are enthusiastically seeking out this treatment.
Since I first wrote about “Adult 6-Month Orthodontics” in 1999 for Dentistry Today,1 Ryan Swain (Six Month Smiles) and other general dentists and some orthodontists, have been teaching STO in the United States, Europe, and Australia to enthusiastic audiences. There is good reason for this—orthodontists have not supported a strong case for routinely prescribing 2-year orthodontics with a Class I molar occlusion as its focus. Moreover, the evidence in the literature for the benefits of moving molars already in functional occlusion (except, for example, correction of a posterior edge-edge bite causing attrition) is underwhelming.
Adults do not generally seek orthodontic treatment and wear braces mainly for their molars, and 2-year treatment for profile change is not generally possible nonsurgically in the adult patient. When it is done, profile changes are difficult to retain. Although visits must be longer for STO and retention protocol more stringent, it is a great new service that is bringing many back to dentistry. As Dr. Gordon Christensen stated, “I feel certain that may more people would have orthodontic therapy if it could be simplified and made more acceptable to them as adults….I congratulate you for your innovative and thoughtful approach to the subject” (Dr. Gordon Christensen, personal correspondence in writing, January 4, 2000 and January 29, 2004). A general practice performing this treatment will experience a boon to its periodontic, endodontic, and restorative services, in addition to its bleaching and veneer offerings, as a healthy mouth precedes the healthy smile in treatment planning. This is truly a valuable service to the public.

Orthodontist Jack Sheridan2 pioneered interproximal reduction in the 1970s and promoted chief complaint orthodontics for years. His criteria was: (a) the occlusion is functional and the patient eats comfortably; (b) the patient’s chief complaint is crowded anterior teeth; (c) the crowding can be resolved without expansion and usually air-rotor stripping; (d) treatment time should be minimal, preferably about 6 months; (e) patients understand nighttime retainer wear may be permanent; and (f) patients understand that treatment is aesthetic only in nature (Dr. Jack Sheridan, personal correspondence in writing, June 5, 1997).

The cosmetic dentistry revolution has brought STO to the forefront, and it has become a field all its own. A wide array of problems can be dealt with in a different way when the focus is cosmetic. “Camouflage treatment” can be performed on Class III skeletal patients who decline orthognathic surgery by tipping mandibular incisors into a Class I incisor relation. Slight tipping of maxillary molars can be done in lieu of palatal surgery for the posterior edge to edge bite. Anterior crossbites can be corrected through lower incisor extractions if the patient’s profile is acceptable. As with many difficult cases, there often exist various solutions. With any new treatment approach, though, there also exist certain caveats, areas to watch out for, and pitfalls to avoid.

This article will be a review some of the most difficult cases I have seen during the past 20 years of performing STO on a wide variety of case types. Although there are traditional orthodontists and general dentists who would see this as an opportunity to categorically criticize STO, it is my hope instead that they seek to better understand the treatment, and to realize that it has a place in an array of cosmetic treatment options. Someday, they too may want to consider offering accelerated orthodontic treatment in adult cases that are strictly cosmetic, as it can be a superior and less invasive service than crowning or veneering crowded teeth. It should also be noted that many of the difficulties in the cases presented might have occurred with a longer treatment period.

 

CASE TYPE I: BRUXERS
Severe bruxers who do not wear their nightguard often experience relapse after orthodontics. The patient in Figure 1 underwent STO for anterior space closure and achieved a nice aesthetic and occlusal result. However, retention for bruxers hinges on strict adherence to retainer wear as well as diligent nightguard use. As new abfractions are evident in the recall photo, he did not comply.

Throughout a period of 14 years post-treatment, the patient’s vertical dimension of occlusion (VDO) decreased. Two crowns were done to cover fluorosis. Although the protrusion and diastema did not significantly relapse, the deep bite returned (Figure 2). Though this may also occur in 2-year orthodontic cases, I more thoroughly emphasize strict adherence to nightguard use indefinitely in these cases. I inform bruxers that orthodontics is of minimal or no benefit if they are not prepared for a lifelong commitment to retention. Despite some relapse, he is still a satisfied patient in our practice 14 years later and fully understands the responsibility of retention lies with him through wearing his nightguard-Hawley combination at night.

Figure 1. Preoperative: Before with diastema and deep bite from bruxing. Figure 2. Postoperative: The 14-year recall after 6-month short-term orthodontics (STO). The patient did not wear his nightguard.
Figure 3. Preoperative: Clencher before STO. Figure 4. Postoperative: Clencher, splinted.

Similar to case 1, this patient was splinted and still experienced some relapse of her VDO at recall because of bruxism and limited nightguard wear. However, her alignment was maintained (Figures 3 and 4).

Figure 5 shows another patient who is a severe bruxer with flat plane occlusion. He experienced buccal migration of his upper first bicuspids post completion due to no nightguard wear. This occurred before postorthodontic settling took place, and articulating paper showed these bicuspids more heavily in occlusion than his molars. When he bruxed laterally, the buccal bone (which had not yet solidified) did not resist buccal tipping from the lateral forces on these teeth during parafunction.
Rarely is every tooth in complete occlusion postorthodontics, even with comprehensive treatment. Bruxers and clenchers usually experience more rapid post-treatment settling with more complete interdigitation than nonbruxers. But when the patient is a severe bruxer, selective migration may occur, especially if this is a flat plane occlusion with no cusps. This patient was rebracketed for 2 months before having a complete occlusion equilibration at the day of debracketing. Nightguard wear was strictly emphasized and the final result was stable.

 

CASE TYPE II: OBSESSIVE COMPULSIVE DISORDER TYPE COSMETIC PATIENTS
Another case type to watch for is the cosmetic patient who wants to dictate the treatment plan. While it is tempting to want to “please” a cosmetic patient, as it is an elective procedure after all, forging into a new area or performing a procedure with which you have less experience means less predictability in the final result. Doing this on patients who have exacting personalities and have a specific end result in mind further increases the risks involved. As with the bruxer category, patients like this can be red flags in cosmetic dentistry. These patients often start out with enthusiasm and seem to grasp the nuances of cosmetic dentistry, understanding the details of smile design. We may feel on the same page as these individuals who share our love for cosmetic excellence, and this makes dentistry fun. But when enthusiasm morphs into unrealistic expectations of perfection, and the patient cannot fully understand that there are limitations, difficulties may arise. Do we always know exactly what end result can and cannot be achieved? Are computer simulations really honest predictors of the end result, and should we depend on them to be accurate in every case? In a perfect world, we could predict all contingencies as well as the final result. But unless one has done every possible case type on every possible personality type with the various biologic limitations, there is no way anyone can predict the myriad of possibilities which may arise in every cosmetic case.

 

Case 1
This first case involves a simple level and alignment type orthodontic case with a slight open bite (Figure 6). Toward the end of treatment, though, the patient decided she also wanted anterior bonding to change her basic tooth shape from round to square. She brought in close-up photos of a famous American supermodel, and wanted her teeth to resemble this model’s smile. These teeth are square, slightly flared forward, and appear wider at the incisal than at the height of contour, usually the widest part of the tooth. When the patient presented for treatment, there was no indication her preferences were so specific. At this point in treatment, we are “married” to our patient, and separation is unfulfilling for both patient and dentist. After treatment, retention and incisal bonding were combined with a composite-Ribbond splint (Figure 7).3

Figure 5. Preoperative: Bruxer with flat plane
occlusion.
Figure 6. Preoperative: STO with open bite.
Figure 7. Postoperative (after STO): Patient requested long square teeth like a famous supermodel she admired. Figure 8. Preoperative (before STO): Patient recently completed Invisalign treatment in another office.
Figure 9. Postoperative to short-term lingual orthodontics with custom requests. Patient wanted his centrals to be longer and a bit more protrusive and brought in a photograph of a famous actor’s teeth to copy. Figure 10. Preoperative: before STO.

The splint helps to support more durable lengthening of the incisal edges, often done with porcelain veneers. While the orthodontics went smoothly, the final step of aesthetic bonding and recontouring was tedious and difficult.

Case 2
This patient had not long before completed Invisalign treatment elsewhere with acceptable results, but had very specific requests and a particular mental picture of how he wanted his teeth aligned and shaped. I was hesitant to take the case, as his alignment was already fairly good (Figure 8). A chief complaint list was made at the initial consult and twice reviewed with the patient. He chose lingual braces, the most difficult to control. He was advised that we may need to do some finishing with labial brackets in the final weeks. During treatment, his requests grew even more specific and he brought numerous hand-drawn sketches and a picture of a famous American actor’s smile to copy. More frequent visits were required, but the teeth were aligned in 4 months to his specifications, like this actor’s smile, with the upper centrals slightly protruding and longer (Figure 9). The patient completed treatment very happy with the result, but it is still risky to accept this case type knowing the patient has such a specific result in mind.

Case 3
This patient had become addicted to cosmetic surgery at a young age. At the consult, he expressed his dissatisfaction with his plastic surgeon despite what seemed were good results. Because his occlusion, crowding, and tooth morphology were so unaesthetic, it seemed that significant aesthetic improvement would not be difficult (Figure 10). However, the patient had numerous specific demands, including exact measurements for the lateral incisor veneers done after Figure 11. The final results were excellent but, again, the process difficult due to specific requests.

Figure 11. After STO, but before porcelain veneers on teeth Nos. 7 and 10. Figure 12. The patient had central incisors extracted at a young age, before conventional 2-year orthodontics.
Figure 13. After distalizing lateral incisors. Figure 14. After retreatment with laterals brought back to mesial and 4 splinted crowns.

 

CASE TYPE III: PATIENT ALTERS TREATMENT PLAN
To what extent do we try to please the patient? Figure 12 shows a patient who had orthodontics at age 13 years. Due to protrusive maxillary central incisors, the orthodontist decided to extract them and move laterals into the centrals’ position. With relapse, the spacing and recession is highly conspicuous. A simple treatment plan was given to consolidate the space through space closure and to provide 4 splinted crowns. When treatment began, however, the patient decided he wanted to re-establish the space for the missing central incisors to have a natural complement of teeth. As this was a patient in his 40s, the bone was not malleable. When space was established and a temporary bridge placed (Figure 13), there was slight overjet. Although I have before left overjet to provide space for a maxillary lingual splint without patient objection, this particular patient was not comfortable with his new incisor position forward. He felt that his maxillary incisal edges were noticeable, at times touching on his lower lip, although there was no deep bite. I referred him to a board-certified prosthodontist who felt there was nothing wrong with the bridge and that he could not improve significantly on the result. After a hiatus, the decision was made to retreat the case (at no change) and follow the original plan; consolidate the incisor space, and place splinted crowns. The end result satisfied the patient, and was more aesthetic, but the circuitous route there was difficult and spanned 4.5 years (Figure 14).

Bruxers, patients with obsessive compulsive disorder, and patients who alter their treatment plan represent challenging cases even when one is prepared for them and has treated similar cases previously. This is because no 2 orthodontic cases are ever identical when one considers the complete aesthetic, biologic, and interpersonal picture. We can only diligently try to consider all contingencies.

 

CLOSING COMMENTS
Treating such a variety of cases makes aesthetic orthodontics fascinating. Specialty orthodontic training often has a different focus which does not always encompass the adjunctive cosmetic dimension and adult psychological aspect central to success in some of these adult cosmetic cases. Furthermore, patients do not always afford us the 2 years of treatment time often needed to cross-refer across specialties and follow the traditional channels from decades past. As we listen more to our patients, the future of adult orthodontics is finally evolving, becoming a distinct area and more integrated with cosmetic dentistry.

In part 2 of this article, I will discuss transfer cases, improper use of enamel reproximation, cases with special retention needs, temporomandibular disorder sequelae, large tongues, problem profiles, and multidisciplinary cases that have unique challenges which fall out of the norm of traditional orthodontic cases.


References

  1. Georgaklis CC. Six-month adult aesthetic orthodontic treatment. Dent Today. 1999;18:110-113.
  2. Sheridan JJ, Ledoux PM. Air-rotor stripping and proximal sealants. An SEM evaluation. J Clin Orthod. 1989;23:790-794.
  3. Georgaklis CC. Anterior retention with a reinforced composite resin splint after cosmetic orthodontic treatment.
  4. ‘;. 2002;21:54-57.
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Wearing Braces Back to School

Wearing Braces Back to School

It’s that time of year again when students of all ages are going back to school. Children start a new grade and adults may be beginning a new career path. In either situation, the first day of school can be nerve-wracking. This feeling can intensify if you recently were told you needed braces. But don’t let that stop you from enjoying your first day back to school! Dr. Georgaklis offers many alternative options to help you feel more confident. And he has even revolutionized the practice with his Rapid Braces method — most patients can be treated in just six months.

Here are two options for hiding those braces from your new friends at school:

Clear Braces:

The most cost effective way of hiding your braces is with clear braces. Dr. Georgaklis recommends clear braces to many patients because they are cost effective and provide great results in a short period of time. Some patients would rather consider clear retainers like Invisalign, but these don’t use the same force as real braces do. They sit over your teeth, instead of attached to them, which makes them less effective and require more treatment time.

 

Lingual Braces:

Lingual braces, otherwise known as “invisible braces,” are braces attached to the inside of your tooth (tongue side) — hidden from view! This option is popular amongst adults who want straight teeth but don’t want to deal with braces. Once un place, these braces work just like regular ones. These are a better option than Invisalign because Dr. G will have full control over teeth movement and maintenance. Plus, they don’t need to be replaces like the retainers for Invisalign do.

Dr. G works with every patient on a personal basis. He will meet with you for an initial consultation to hear your concerns, talk about budget and other options. Whether you’re going back to school, starting a new job or just afraid to have braces, Dr. G will make sure you feel confident in his hands! Contact us today to get started on your new smile!

 

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Invisalign Alternatives

Keep a Clear Smile When You Go Back to School

It’s that time of year again when students of all ages are going back to school. Children start a new grade and adults may be beginning a new career path. In either situation, the first day of school can be nerve-wracking. This feeling can intensify if you recently were told you needed braces. But don’t let that stop you from enjoying your first day back to school! Dr. Georgaklis offers many alternative options to help you feel more confident. And he has even revolutionized the practice with his Rapid Braces method — most patients can be treated in just six months.

Here at Rapid Braces, we offer a variety of options aimed to match the customers direct needs. Dr Georgaklis specializes in fitting the customer with not only a fast option, but a cosmetically appealing one. We understand that Invisalign is not cut out for everyone’s budget or natural mold. The expert staff at Rapid Braces offer a variety of options that give the patient the power to select a method that works with their budget and ideal time frame.  We offer lingual (behind the teeth braces), along with the option of clear front braces with invisible brackets and wires.

Lingual Braces 

Lingual braces, are behind the teeth braces, meaning that the brackets, wires and cement are placed on the tongue side of your mouth leaving your smile untouched. This option is popular amongst adults who want straight teeth but don’t want to show off their braces. Lingual, ‘incognito,’ braces do not require the timely maintenance and management of  a series of plastic retainers like Invisalign, and are even said to be more discrete. Once in place, these braces work just like regular ones. These are a better option than Invisalign because Dr. G will have full control over teeth movement and maintenance. Plus, they don’t need to be replaces like the retainers for Invisalign do.

 

Clear Braces 

Cleveland Circle Dental Associates offer a clear braces option, where the brackets and wires are see through and subtle. This option is much more affordable than Invisalign, and can be completed at a faster rate. Dr. Georgaklis recommends clear braces to many patients because they are cost effective and provide great results in a short period of time. Some patients would rather consider clear retainers like Invisalign, but these don’t use the same force as real braces do. They sit over your teeth, instead of attached to them, which makes them less effective and require more treatment time.

Dr. G works with every patient on a personal basis. He will meet with you for an initial consultation to hear your concerns, talk about budget and other options. Whether you’re going back to school, starting a new job or just afraid to have braces, Dr. G will make sure you feel confident in his hands! Contact us today to get started on your new smile!

 

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Clear Orthodontics Options for Adults

clear orthodontics brookline

At Rapid Braces, we treat many patients who want straight teeth but can’t stand the idea of being seen wearing braces. These patients are most often adults who missed out on visiting an orthodontist when they were younger. Wearing traditional braces can make anyone feel uncomfortable in social situations and long treatment times can be difficult to manage.

Luckily there are new orthodontic treatment methods for adults looking for straight teeth today. Rapid Braces offers clear braces alternatives that are easy to keep hidden. Our 6 Month Braces treatment is one of the fastest ways to straighten your teeth available. The expert staff at Rapid Braces understands that many of our patients have busy schedules and do our best to be accommodating. The Rapid Braces 6 Month Braces treatment has been completed in 6 months or less by more than 90% of our patients.

Clear Braces for Adults

There are a number of braces options to choose from at Rapid Braces. Clear braces have clear bands and brackets so they will almost be invisible on top of your teeth. Clear braces are put on by an orthodontist the same way as traditional braces but blend in with your teeth while they are worn. Another popular choice among Brookline orthodontic patients are lingual braces. Lingual braces aren’t transparent like clear braces but they are put behind the teeth so they can only be seen by an orthodontist. Lingual braces position on the inside of your teeth offers great control over how your teeth are aligned.

The best way to get straight teeth in 6 months or less at Rapid Braces is to schedule a consultation. Dr. G can get a good look at how your teeth are aligned at the consultation and present a plan for orthodontic treatment. After the initial meeting you can take your time to decide whether adult orthodontic treatment at Rapid Braces is right for you.

Schedule a Brookline Orthodontic Consultation Today

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Braces for Adults

A bright and straight smile can help anyone feel more confident in their appearance. Many individuals are able to undergo orthodontic treatment when they are younger. Starting orthodontic treatment at an earlier age is a great way to get a perfect smile for life but for some people that isn’t an option. 65% of adults do not have well-aligned front teeth. At Rapid Braces in Brookline, however, we use a number of different adult cosmetic orthodontic treatment techniques that make it easier for adults to get braces.

braces for adults

Rapid Braces offers a number of braces treatment options so adults can undergo their treatment discretely. Wearing braces makes many individuals feel very subconscious to the point that they will avoid social interactions. We have clear braces, lingual braces and invisalign treatments available so you can get a perfect smile without having to worry about showing off your teeth. Clear braces use clear brackets and bands so they blend in with your teeth. Lingual braces are put behind the teeth instead of in front so they cannot be seen. Invisalign utilizes clear plastic alignment plates that are worn over the teeth and must be remade every so often for further teeth straightening.

Another advantage that undergoing adult cosmetic orthodontic treatment at Rapid Braces has is our speedy treatment time. Dr. Georgaklis is able to complete 90% of his patients’ cases within 6 months using his Rapid Braces technique. He does this by putting an emphasis on the finished result. Doing this allows him to save precious time on the entire treatment and have his patients leave his office with perfect smiles faster. Treatment time is a big reason why many adults do not undergo orthodontic treatment and Rapid Braces is aiming to change that.

Schedule an appointment at Rapid Braces to learn more about how we’re making braces for adults easier than ever. We understand the obstacles that get in the way of adults starting cosmetic orthodontic treatment. With our expert staff, getting your braces treatment complete in 6 months or less is a real possibility. Check out the 6 month braces case photos here to see the results that our orthodontic work can get.

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Aesthetically Pleasing Options to Straighten Your Teeth

boston 6 month braces

Today, more and more adults are turning to orthodontic treatment for a perfect smile. Braces are becoming increasingly popular and countless individuals are realizing their dreams of having straight teeth. Patients are happy to learn that a number of different braces options have been developed that won’t leave them trying to hide their face. The days of getting your mouth taken over a clunky metal apparatus are over. After completing treatment patients almost always report back to their orthodontists with stories of renewed self-confidence and no longer being afraid to show their faces in social situations. The following is a list of the aesthetically pleasing braces options available with Rapid Braces in Brookline.

Invisalign:
A system of custom aligner trays are used to complete the invisalign treatment. The trays are put on over the teeth and move the teeth little by little to straighten them out. As your treatment progresses new trays will be made to continue the straightening. Invisalign trays are clear as well so you will be able to keep on smiling without metal brackets in your mouth.

Clear Braces:
Clear braces are a cost-effective and flexible braces option. These braces use clear brackets so that your braces won’t stand out. Patients can feel comfortable showing their smile while they undergo treatment with clear braces. Clear braces also move teeth with a bit more force than invisalign making them ideal for more difficult cases.

Lingual Braces:
With lingual braces the brackets and wires are placed on the inside of the teeth. They will remain hidden on the inside of your mouth for the duration of your treatment. Many patients report that their friends had no idea they were receiving orthodontic treatment while they were wearing lingual braces.

As you can see, there are a number of different aesthetically pleasing options to get straighter teeth. Each treatment option is perfect for a different type of case. Dr. Georgaklis and his expert staff have years of experience giving patients perfect smiles in the Boston area. Call our office today to learn more about all of our braces treatment options.

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Are Invisalign Braces Good For Me?

invisalign braces brookline

The Invisalign system uses clear plastic aligners to give patients straight teeth without having to deal with clunky metal brackets. Many patients are interested avoiding the self-consciousness that individuals feel when they have braces. Invisalign will work to straighten out crooked teeth while still allowing you to show off your smile to the world. It is important for patients to remember a few key points when deciding if they are a good fit for Invisalign.

You have a less severe orthodontic case

The Invisalign system works exceptionally well when treating orthodontic cases that are less severe. Invisalign helps space out overly crowded teeth, close gaps between teeth and align crooked teeth. By focusing on these issues, our expert team at Rapid Braces can give you a perfect smile.

You can stay diligent

Patients must stay committed during their Invisalign treatment in order to achieve the best results. The clear aligners can be removed at anytime and occasionally patients will neglect keeping the aligner in place. It is essential that you wear the aligners as often as possible. Try not to forget to put them back in after finishing a meal.

You are an older teen or adult

Older patients love the fact that you can be undergoing Invisalign treatment to get a better smile is very subtle. It is possible to complete the entire treatment with hardly anyone realizing. Patients are able to smile with confidence while wearing the aligners.

At Rapid Braces we have years of experience giving patients straight teeth. We understand that patients want to get braces treatment over with quickly and 90% of the cases we begin are finished in 6 months or less. We offer the invisalign system as well as a number of other types of braces to give patients the perfect smile.

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The 6 Month Clear Braces Solution

After beginning traditional braces treatment many individuals will try their hardest to hide their smile. Having all that metal and different colored bands in their mouth makes them feel like everybody is looking. Because of this, a number of patients will choose not to undergo treatment and miss the opportunity for straighter teeth. At Rapid Braces in Brookline we offer treatments designed to keep your oral care as discrete as possible. Clear braces are an effective way to get a perfect smile.

With clear braces you won’t have to deal with unsightly metal braces taking over your mouth for a few years. Clear braces are recommended for many patients due to their low cost and history of providing great results. They still use the same amount of force as regular braces but the brackets are clear so that they blend in with your teeth. Your smile will still be just as bright after getting your invisible braces put in. The transparent material that the brackets are made of won’t give you anything to hide.

6 month clear braces brookline

Pros to clear braces:

  • Much less noticeable than metal braces
  • Teeth are moved faster than invisalign retainers

Patients who get clear braces at Rapid Braces can get the 6 month clear braces treatment. Dr. G has been using the Rapid Braces technique for almost 20 years and 90% of his patients are able to complete treatment in 6 months or less. Getting straight teeth is the number one reason patients choose to get braces and Dr. G understands how important a perfect smile is. He approaches his treatment with a focus on dental cosmetics and will do whatever he can to ensure his patients leave with a perfect smile.

Many competitors claim that they are able to give patients straight teeth in 6 months or less but Dr. G is the only one with numbers to back it up. Rapid Braces has put a focus on offering perfect smiles in 6 months or less and is able to finish treatment with 90% of his patients in that timeframe. Get in touch with Rapid Braces to find out how you can get straighter teeth fast.

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