If you haven’t had your teeth straightened yourself, you probably know someone who has. Orthodontics is the dental specialization of straightening crooked and misaligned teeth – which is one of the most common undesirable conditions in humans – to improve their appearance and function. But what causes teeth to not develop properly in their correct positions, and function as they should? One of the most common causes is genetics. The children of parents from two different cultures may develop teeth that are too large or too small for their head, resulting in an abnormal function and appearance of their dentition.
While crooked or misaligned teeth do not usually cause physical harm, the often undesirable appearance can lead to negative psychological issues. The ability to eat may also be affected by teeth that do not occlude (meet) correctly.
Although it is usually orthodontists who specialize in straightening teeth, some general dentists and pediatric dentists with an interest in this area may also perform this type of treatment.
The most usual path to follow when seeking orthodontic therapy is to first consult a general dentist regarding the issue, who will determine whether referral to an orthodontist is required. If orthodontic therapy is needed, your orthodontist will develop a treatment plan. You should then discuss your plan with your general dentist.
In general, orthodontic therapy should be applied at an early age, and the best results are quickly achievable during puberty. Although repositioning teeth is much more difficult in adulthood, it can and should be done if required.
In contrast to most other dental treatments, orthodontic therapy usually requires a large time commitment. Treatment often takes months to years, typically around 18-24 months. Patients are usually required to wear some form of device that gradually moves the teeth into the correct position. These devices can be temporarily fixed, removable, or both, and can be highly visible or close to invisible. While you can express your opinion regarding the type of device used, your practitioner will suggest the most appropriate method for correcting your condition.
As teeth are moved through light force over time, there is some discomfort to be expected during orthodontic therapy. When a tooth is moved, it slowly degenerates the supporting bone on the side where pressure is being applied, and the bone grows to fill the resulting space on the opposite side. Performing this procedure too quickly can result in great discomfort and damage to the teeth and bones.
Your orthodontist will know how much pressure to apply to safely achieve the desired result. Minor discomfort is common during orthodontic therapy, especially right after the device has been tightened, and for a short period afterwards.
Some cases of crooked or misaligned teeth cannot be corrected through orthodontic treatment alone. Surgery is required in these cases, either in place of or followed by orthodontic therapy. Your orthodontist will refer you to an appropriate oral and maxillofacial surgeon if this is the case. It is also advisable to obtain a second opinion when surgery is recommended.
Millions of people’s lives have been improved through orthodontic treatment, allowing them to chew food without difficulty, and perhaps more importantly, feel much better about themselves.
What You Feel or See: Symptoms, signs, and conditions related to orthodontic treatment
- Crooked Front and/or Back Teeth
Most people have misaligned teeth to some degree, but having teeth that are crooked beyond what is considered normal can bother some people. How much teeth are misaligned can vary significantly – from barely noticeable to appearing as though treatment is hopeless. However, almost any case of tooth misalignment can be corrected with orthodontic therapy. In some situations, the teeth may be too small or large, which often requires surgical correction in addition to orthodontic treatment.
- Malocclusion
Sometimes the teeth develop incorrectly, preventing the front or back teeth from meeting correctly when the jaws close. Many habits such as thumb/finger sucking, pipe smoking, tongue biting or sucking, and many others can also lead to malocclusion (poor bite). In addition to correcting a poor bite, your orthodontist will also be able to identify the habits that have caused your malocclusion and suggest ways you can stop them. Surgery may also be required if the condition is particularly bad.
- Crossbite
Sometimes, some or all teeth are in a crossbite, resulting in the front teeth closing behind the back teeth when the jaw is closed. Orthodontic therapy can usually treat this condition, but sometimes surgery may also be required.
- Spaces Between Teeth
Spaces or gaps between teeth can vary from small enough to be hardly noticeable to so large they could accommodate another tooth. As with most conditions requiring orthodontic treatment, spaces between the teeth are not usually harmful, but their unsightly appearance is what causes most patients to seek treatment. Smaller gaps can often be corrected without orthodontic therapy through other means such as bonding or crowns. In cases where gaps are extremely large, treatment may involve extracting one or more teeth and replacing them with a full or partial denture.
- Midline of Teeth is Noticeably Left or Right to the Midline of the Face
Teeth that have developed incorrectly in the jaws can be misaligned and nonsymmetrical with the face. The nose is often incorrectly used to determine if teeth are aligned correctly, and most people’s teeth deviate one way or another from the nose. To determine true symmetry, the correct midline of the teeth is halfway between the centers of the pupils of the eyes when looking straight forward. Misaligned teeth are not physiologically significant, but their potentially unsightly appearance can cause psychological harm to a patient. Orthodontic therapy is usually the most successful method of treating this condition, but surgery may be required in some extreme cases.
- Spaces Where One or More Teeth Didn’t Develop
Some genetic defects can cause some teeth to not erupt or develop, resulting in spaces between the teeth. Carefully positioned radiographs (x-rays) are required to determine if the missing tooth is actually missing or has simply yet to erupt. Sometimes, teeth do not erupt because they are blocked by other teeth. These teeth can often be surgically stimulated, leading to appropriate eruption without the need for orthodontic therapy. If teeth are missing or unable to erupt, the spaces can be filled using a fixed or removable prosthesis, or implants followed by crowns. However, the most logical solution is to orthodontically move the existing teeth, removing the need for artificial replacements.
- Teeth Slant Downwards to the Left or Right
Many conditions such as genetics and thumb sucking can cause teeth to develop or become misaligned. The correct alignment of the front teeth is parallel to the center of both pupils when looking forward. Teeth that are aligned differently often appear abnormal and unsightly. Once a general dentist or specialist has determined the condition will not continue to worsen, the following methods can be used to correct the appearance:
- Incisal contouring – carefully smoothing or grinding the teeth to change their length or other contour.
- Orthodontically moving the teeth
- Placing veneers
- Placing crowns
While orthodontic movement or recontouring the teeth are the most preferred methods, some extreme cases may require surgery.
- Gums Show Excessively When Smiling
Many conditions can cause the gums to show too much when smiling. These include medications that lead to gum overgrowth, lips that lift too high when smiling, a larger than normal maxilla (upper jaw), or gums that do not shrink at the normal rate during adolescence and adulthood. Treatments for gums that show excessively when smiling include:
- Surgically removing some of the gum tissue to expose more tooth structure
- Orthodontically moving teeth back into the gums and bone, followed by surgically removing excess gums
- Orthognathic surgery to move the whole of the upper jaw (maxilla) forward, resulting in the removal of the excess gum on display
- Natural Teeth Not Displayed When Smiling
There are several conditions that can prevent the teeth from being displayed when smiling. The most common of these are extremely excessive wearing of the teeth from bruxism or jaw clenching, an inadequately developed maxilla (upper jaw) which keeps the upper teeth hidden behind the upper lip, or a naturally long upper lip that hides the upper teeth when smiling. Treatments include:
- Building up the upper jaw through orthognathic surgery
- Crowns or other forms of prosthesis to extend the teeth
- Orthodontically pulling the upper teeth and bone down to ensure the teeth display when smiling
- Upper Teeth Too Far Back, Upper Jaw Appears Underdeveloped
This can be an overdeveloped lower jaw or an underdeveloped upper jaw. The most suitable treatment for a truly underdeveloped jaw (retrognathia) is orthodontically repositioning the teeth into a preferable position in the bone (alveolus), followed by orthognathic surgery to move the entire jaw.
- Lower Teeth are Too Far Forward
This condition, commonly known as ‘lantern jaw’, is usually successfully corrected through surgery to reposition the jaw backward, which corrects the relationship of the jaws. Orthodontic therapy may or may not also be required to move the teeth into their correct position.
- Primary Teeth Remain, Permanent Teeth Have Not Erupted
Baby (primary) teeth can remain in the mouth and serve well for many years, or their roots may resorb (degenerate) on their own, resulting in the need for extraction. Primary teeth that are functioning well without issue should be left to remain in the mouth until the roots degenerate naturally. If the roots have resorbed, the teeth should be extracted and orthodontic therapy applied to fill the resulting space, or an implant placed followed by a crown, or a fixed or removable prosthesis (bridge) should be placed. If the remaining primary teeth are preventing permanent teeth from erupting, they should be removed to make space for the permanent teeth to erupt.
- Primary Teeth are Crooked
While orthodontic therapy can be performed on primary teeth, it is usually delayed until the permanent teeth have developed, except for extreme cases where crooked primary teeth may affect the correct development of permanent teeth. In cases where there are both primary and permanent teeth in the mouth (mixed dentition), minor orthodontic therapy known as interceptive orthodontics can be applied to move the teeth slightly. Such treatment reduces the need for more major orthodontics in later life.
What your orthodontist, general dentist, or pediatric dentist can do
There are many ways of moving teeth that require repositioning. Each method has its advocates and critics, and the best method for repositioning teeth remains a highly controversial subject throughout dentistry. Orthodontic patients should not worry about such disagreements, and only concern themselves with receiving treatment that safely moves their teeth to achieve straight teeth and/or a correct bite within a reasonable amount of time.
- Orthodontic Treatment
The most often used methods for repositioning teeth include:
- Metal wires and bands placed onto teeth allow light force to be accurately applied to the visible part of teeth (crowns) above the gumline. Over time, this minor pressure moves the teeth into the desired position. Although one of the oldest and best ways to reposition teeth, the metal wires and bands are generally unsightly and require spaces to be made between the teeth. However, this method is only temporary until adequate repositioning has occurred, and the spaces are closed afterwards.
- Ceramic or bonded plastic brackets placed onto teeth are a more modern method of repositioning teeth. This method involves using acid to etch the surface of the teeth and using plastic cement to bond the brackets in place onto the roughened surface. While the appearance of brackets is better than that of metal wires and bands, a considerable amount of debris is left on the tooth after removal, which must be carefully removed after treatment has been completed.
- Invisible brackets can sometimes be placed to apply the necessary force without needing to use unsightly metal wires bands, or brackets. Not all cases can be treated using this method, but if reasons such as your vocation require that metal bands are not on display, you should consult your dentist about this form of treatment.
- Removable orthodontic devices such as a retainer can be used for some minor repositioning of teeth. Some cases require both fixed and removable appliances to accomplish the desired result, and other cases require the patient to wear a removable appliance for some time after a fixed device has been removed.
Advantages of orthodontic therapy
The significant improvement in appearance after orthodontic treatment and the resulting increase in self-acceptance can’t be measured, but it is incredibly important. As self-esteem is generally at its lowest during adolescence, an improvement in appearance as a result of successful orthodontic therapy can have a positive lifelong effect on a patient. Although not usually significant, the ability to chew food may also increase. Teeth that are extremely crooked or misaligned can affect physiology, which is improved after orthodontic treatment.
Disadvantages of orthodontic therapy
In addition to experiencing some discomfort, there is usually a large time investment required for most orthodontic procedures. During treatment, the appearance of a smile is disturbed by the wires, bands, brackets, elastics, and other devices that must be worn for months or years, and the cost of orthodontic therapy can be significant. Cleaning teeth properly can also be difficult when orthodontic appliances are fixed to them.
Risks of orthodontic therapy
There are usually very few risks present when orthodontic treatment is carefully applied to a healthy patient. Cleaning teeth with fixed orthodontic appliances can be difficult, and food debris can become trapped against the teeth by removable orthodontic devices – both of which can increase the risk of developing dental caries (tooth decay). However, meticulous oral care can drastically reduce this risk. Occasionally, orthodontically-induced tooth movement can lead to death of the dental pulp (nerve), requiring endodontic treatment. While occurring only very infrequently, tooth movement can also cause part of the tooth root to resorb (degenerate), also requiring endodontic (root canal) treatment.
Alternatives to orthodontic therapy
Few alternatives are available if most of all of the teeth are misaligned, other than doing nothing and living with the condition. Crowns or veneers can be used to recontour teeth if only a few teeth are minimally affected. Badly affected teeth may be extracted and replaced with a fixed or removable prosthesis. However, this option costs as much as or more than orthodontic therapy.
Cost of orthodontic treatment
The cost of orthodontically repositioning all teeth is comparable to that of purchasing a large television.
Result of Nontreatment
The most obvious result is the continued appearance of misaligned or crooked teeth, whereas the less obvious but potentially more impactful result is psychological damage and reduced self-esteem caused by their continued unsightly appearance. Additionally, reduced chewing ability may remain, which may worsen.
- Interceptive Orthodontics
A dentist will be able to tell if a child’s teeth may not develop correctly, and will usually warn parents that minor orthodontic therapy may be required to reduce the need for major orthodontic therapy in later life.
Advantages of interceptive orthodontics
Minor interceptive orthodontic therapy can prevent issues from occurring later, while also reducing potential discomfort and saving time and money.
Disadvantages of interceptive orthodontics
The cost and inconvenience of interceptive orthodontic treatment are present to the child’s family, and the results cannot be completely predicted until the procedure has been completed.
Risks of interceptive orthodontics
Similar risks associated with orthodontic treatment are present but to a much lesser extent.
Alternatives to interceptive orthodontics
One alternative is to wait and see if the child’s teeth develop normally. However, if inadequate development is indicated, interceptive orthodontic therapy is highly recommended to reduce future problems.
Cost of interceptive orthodontics
Interceptive orthodontic therapy incurs a much lower cost than full orthodontic treatment as the required procedures are less comprehensive. Travel costs may also be reduced as many general dentists may perform the necessary procedures.
Result of Nontreatment
The child’s teeth will develop incorrectly if interceptive orthodontic treatment is not performed, resulting in the need for full orthodontic therapy in later life, which will be more difficult and costly to perform.
Orthodontic therapy is perhaps one of the most impactful types of dentistry on a patient’s self-esteem. The resulting appearance of a beautiful smile can have a lifelong positive effect, whereas failure to correct misaligned or crooked teeth can produce negative psychological effects. Orthodontic therapy is most often performed by an orthodontic specialist and is usually readily available at a reasonably moderate cost with very few risks. Such therapy should be applied at the earliest stage possible to reduce risks and improve appearance. However, while much more difficult to perform, orthodontic treatment is possible during the later stages of life.