Orthodontics

The Magic of Orthodontics

The first article in this series on “Smile Design” provided an overview of the many facets involved in creating “smiles by design” and the many ways of interpreting what is both normal and ideal. When you communicate your desire for an improved or enhanced smile to your dentist, he or she will discuss their role as your diagnostician, artist, and scientist. You and your dentist will work together to develop the best course of action for your individual and particular situation. The second article in the series discussed porcelain laminate veneers as a way of enhancing your aesthetics when the situation is right for them to work their magic.The third article in this series discusses the role of orthodontics, moving the teeth into better position. Orthodontics is a sub-specialty of dentistry that is devoted to the study and treatment of malocclusions (improper bites). Improper bites may result from tooth irregularity or positioning, disproportionate jaw relationships, or both. The word orthodontics is derived from the Greek language (ortho) meaning straight and (odont) meaning tooth. Today, orthodontics means tooth movement and possibly much more...Orthodontic treatment may focus on improving poor positioning of teeth and bite relations or, may even influence the way the face shapes and forms over time. Orthodontic treatment can be carried out for purely cosmetic reasons, improving the general appearance of a person's teeth and face. In addition, treatment may be necessary to functionally improve the bite (occlusion). Often both goals can be accomplished simultaneously.One of the most important and fundamental considerations in smile design is the position of the teeth themselves; how do they actually fit into the framework of the face and jaws and how do the upper and lower jaws relate to each other. By analogy, before renovating or building a house it is important to consider whether the foundation is not only sound, but in the right position.

Orthodontics — A Unique Contribution to Smile Design

A pre-requisite to smile design is the proper positioning and alignment of the teeth. Only orthodontic treatment can move teeth into better position. Consider the following two outcomes of this unique contribution:

Create a new smile — by orthodontic treatment alone.
Improve the position and biting function of the teeth; to achieve a more complete aesthetic transformation — by a “team” approach in which other dental specialties work their magic.

Rules of the Game — Where to Start

Take the time to have a proper evaluation of your dental situation and learn what options are available and best for you. A good place to start is with your general dentist. Most dentists who practice “Smile Design/Cosmetic Dentistry” also tend to work in teams.

Try to use the right treatment approach the first time so as not to cut corners. This may well involve developing a trusting relationship with your dentist who knows who to contact. The combined knowledge, skill and judgment of an experienced dental professional team will allow the development of a personalized plan — what the right options are for you to create a long lasting new or enhanced smile. This approach may take some time, but don't be in a hurry — smile design for life takes time. As the saying goes “Rome wasn't built in a day.”

What is an Orthodontist?

An orthodontist is a dentist who has taken advanced specialty training in several areas. Some general dentists also practice orthodontic treatment, having taken varying degrees of advanced training in this specialty area. The most important part is understanding that form and function go hand in hand. The position of teeth dictates how your teeth work together and affects the way you look and smile. Simply put, when things look right, they probably are right. Orthodontics requires an understanding of the “mechanics” of how to move teeth in to the right position through three operating principles:

Development: The growth and development of the teeth and jaws.
Alignment: The alignment of teeth within the dental arches or jaws.
Occlusion: The bite or how teeth come together and function in harmony with the jaw joints

Orthodontic Diagnosis

Being trained in growth and development, an orthodontist will determine the ideal age to evaluate and treat a young growing patient. Growth can play an important role in the design of the treatment plan and orthodontic mechanics (tooth movement) itself. Growth can actually be assessed and sometimes modified through orthodontic treatment and can be an important ally to an aesthetic, functional and stable result. Since growth is complete in adults, a different approach to treatment is needed.

Before a problem can be fixed, there must be a clear understanding of how and why the teeth came to be in their present position. As with most things, this takes careful assessment or “diagnosis.” Dental and medical histories are necessary to ascertain whether you are healthy enough to undergo orthodontic treatment. Detailed records will also be needed including:

Impressions to make molds of your teeth and the way they meet, are known simply as study models.
Articulated models — these study models can be placed in a machine called an articulator which replicates jaw movement for study purposes.
Specialized radiographs (x-rays) of the teeth and the relationship of the jaws.
Photographs of your smile and position of the teeth.
Computer imaging.

All the above records are necessary in order to “image and imagine” what is possible related to your particular bite. These records help your orthodontist to determine the best plan of action to provide not only the best esthetics, but also functional improvement, ultimately to protect your dental health for a lifetime.

Records are also necessary to understand how to stabilize the teeth to prevent the possibility of the teeth moving back or relapsing after movement with orthodontic treatment.

How and Why Do Teeth Move?

Orthodontic appliances, commonly known as “braces” describe the small brackets that are placed on teeth through which little flexible wires are threaded. These small wires place light forces on the teeth, as the wires tend to straighten themselves to their undistorted forms, moving the teeth with them. The reason the teeth move is due to the magical properties of the periodontal ligament (attaches the tooth to the bone). Since the periodontal ligament is elastic — teeth are not set in the bone like pillars in concrete — there is micro-movement of the teeth all the time. Since these tissues are living, they are constantly changing and “remodeling.” When a light and controlled force is placed on a tooth on the “tension” or pulling side, new bone, ligament and cementum are formed. On the pressure side, cells will remove bone and ligament to allow the tooth to move. It is analogous to a hot knife moving through a stick of butter; it melts on one side and coalesces on the opposite side as the knife moves through the butter.

A Stable End Result

Overall, goals of orthodontic treatment are esthetics, function, health, and stability, all of which must be taken into consideration. The diagnosis of tooth position discrepancies and bite issues, including why your teeth are “where they are,” is fundamental. It is equally imperative to determine where they should be, the method to moving your teeth and how stable the result will be once the treatment has been completed (stabilization and retention). That's another reason that an orthodontist or a dentist who has advanced training and experience in orthodontics is so critical to your treatment plan.

Appliance Options

When considering orthodontic appliances, there are several options. The “gold standard” in orthodontic treatment has been the orthodontic band for posterior teeth and the bonded bracket for anterior teeth [Figure 1]. For people who wish to have the most esthetic appliances, “clear” brackets are an alternative option [Figure 2]. Clear brackets are less visible, but are more susceptible to breakage. Consequently, clear brackets must be cared for during treatment by avoiding excessively hard foods or extreme contact e.g., during sports. Both these types, traditional and clear brackets, are known as fixed appliances, because they can't be taken out by you, the patient.

Another approach to treatment involves the use of clear aligners to reposition teeth [Figure 3]. This is useful in situations which are generally milder in nature. After very careful assessment, a series of computer generated clear plastic trays are made to move the mal-aligned teeth. The clear aligners, each one a little different than the preceding one, progressively move the teeth into better alignment. This is the most modern choice of removable appliances.

With any orthodontic appliance, typically simple movements may take a matter of months, while complex movements may take months to two or three years.

Overall, the fixed appliances (brackets — metal or clear) are the ones of choice in more complex/comprehensive cases because they enable the orthodontist to accomplish desired three dimensional tooth movements, in the most efficient and predictable manner [Figures 4-7].

Removable appliances, clear aligners, are generally better for simpler or tipping movements of teeth, in “2D” (two dimensions) and which can be accomplished “invisibly” with little or no esthetic compromise. Consequently, in either situation treatment time is kept to the minimum necessary to realign the teeth. Either way diagnosis is the most important factor in choosing the right kind of appliances to do the job.

Figure 4 : A pre-treatment photograph showing the patient smiling with the spaces present between the anterior (front) teeth.

Figure 6: A pre-treatment photograph showing the need for orthodontic treatment to close the spaces between the maxillary (upper jaw) anterior (front) teeth.

Figure 5 : A post-treatment photograph showing the final result obtained from orthodontic treatment.

Figure 7: A post-treatment photograph showing the orthodontic result after the closing of the anterior (front) spaces.

Orthodontic X-rays

A radiographic (x-ray) analysis for orthodontic purposes is a critical tool in the formation of an individual treatment plan and vital to understanding your particular malocclusion (bite problem). A panoramic radiograph reveals dental, bone and skull conditions in younger patients. A more detailed full-mouth series of individual radiographs is critical in adult orthodontics where conditions of the teeth and bone have changed with age.

A cephalometric radiograph (head x-ray), a specialized orthodontic radiograph provides information about the relationship of the upper and lower jaws to each other, the relationship of the teeth to the individual jaws and their combined relationship to the cranium (skull). In the younger individuals who are growing, the cephalometric radiograph is a useful part of the orthodontic records by providing information regarding the direction in which growth is moving. Consequently, it assists in treatment planning decisions such as whether or not to remove teeth where there are too many. Cephalometric radiographs also help determine the timing of treatment and the design of the “mechano-therapy.” As the name implies, this term refers to the actual mechanics of how to move the teeth, where and how to place forces — more to follow on this fascinating topic.

Figure 1: An example of metal braces used with light orthodontic wires during full-banded orthodontic treatment.

Figure 2: An example of clear orthodontic braces with light orthodontic wires during full-banded orthodontic treatment.

Figure 3: An example of clear orthodontic aligners used to move teeth in the most esthetic manner possible.

The Team Approach

Rome was neither built in a day, nor could Rome have been designed and built by one person. Dental “teams” consisting of other dental specialties work and study together. They know how the other team members think; each is in tune with the expertise and experience of each other. Orthodontics will allow the teeth and jaws containing them to line up more functionally and aesthetically; (the architect and contractor put the foundations in the right position). The general dentists and other specialists, (subcontractors) each then apply their own special skills to complete the task. Here-in lies the strength of a team approach to smile design and proper management. In more complicated situations requiring a team approach (including replacement of missing teeth with dental implants) other dental professionals may be involved both in planning and in treatment.

The team members often include:

General Dentist: A general dentist is in a unique position. Depending upon the skill, training, experience and comfort level, a general dentist can practice any area of dentistry. Many “generalists” specialize in restorative or cosmetic dentistry; reshaping or restoring the teeth themselves, with veneers, crowns or other means. A general dentist may also perform orthodontic treatment including the use of braces or clear aligners.
Prosthodontist: Specialist in advanced tooth replacement and bite problems.
Periodontist: Specialist in the diagnosis and treatment of the supporting structures of the teeth (bone, connecting ligament and gum tissues); to enhance periodontal tissues — the “curtains” around the teeth.
Oral Surgeon: Specialist in oral (mouth) and maxillofacial (face and jaw) surgery — when “orthognathic” surgery (ortho – straight, gnathic – jaw) is needed to place the jaw bones (the foundations) into a proper relationship to each other to achieve proper biting relations and function in conjunction with orthodontic treatment.

Orthodontic treatment is an ingenious scientific discovery which has allowed the dental profession to accurately and precisely move teeth into not only improved aesthetic alignment, but also improved functional position. Harnessing the body's innate abilities by which tissues normally “remodel” themselves to maintain a steady state, has allowed “smile designers” the many options described above. The end result; the ability to move teeth into improved position is an incredible contribution to a lifetime of dental health with a great smile.

TheOptimalSmile