I have had several very different opinions on how my child's orthodontic problem should be treated. How can this happen?
The most plausible explanation of why parents receive varying opinions has to do with the difference in final treatment goals of the orthodontists. If an orthodontist’s treatment goals are for straight teeth only, then almost any treatment plan with today’s appliances can give “straight teeth.” In fact, dentists sometimes advertise they can do orthodontics and give straight front teeth in six months. Dr. Rust has established what he thinks are several important treatment goals that should be common to all patients. These are his treatment goals in his practice and the treatment goals he emphasizes when he teaches restorative dentists and orthodontic graduate residents.
- Upper and lower front teeth properly positioned on their bony bases: The parameters of the positions have been long defined in orthodontic literature.
- The upper and lower jaw properly positioned to each other in all planes of space: Corrections in this area are brought about in growing patients by orthopedic appliances or in some cases in non-growing patients by orthognathic surgery.
- A functional occlusion that is in harmony with the teeth, muscles, and temporomandibular joint: The tenants of a functional occlusion are well described in current dental textbooks that deal with occlusion.
- A good soft tissue profile and enhanced smile esthetics which include the vertical position of the upper and lower teeth in relation to the gingiva and lips.
The above list of goals serves as a road map for the orthodontist in developing a treatment plan. Ignoring any one of these goals thus allows for significant difference in treatment approaches. There should be no controversy in modern orthodontics that all of the above should be part of an orthodontist’s treatment goals. The commitment of an orthodontist to obtain these goals will automatically lead him to a treatment plan that is much different than an orthodontist whose goal is only “straight teeth.”
I have heard from friends that extractions of permanent teeth are not necessary in today's orthodontic treatment. Is this true?
This impression is totally unwarranted and misleading but unfortunately has been promoted in part by some members of the orthodontic specialty and other dental professionals. There are many excellent evidence-based clinical studies which show that some patients require extraction of permanent teeth in order to obtain an esthetic, functional and stable result.
Members of the specialty have often promoted non-extraction treatment because they felt extraction treatment harmed the soft tissue profile. In fact, the best studies and current orthodontic literature show that extraction of teeth in many cases is necessary in order to obtain the best esthetic result and at the same time enhance long-term stability. Also, some members of the specialty believe a non-extraction approach is always better and less invasive. This is also untrue since it is sometimes less invasive to treat in an extraction approach to eliminate excessive expansion that would potentially place the patient's teeth in periodontal jeopardy. The orthodontist should work within the confines of established biological parameters and not the latest marketing tactics to increase "sales."
Extraction or non-extraction of teeth should never be considered a treatment goal. Extraction or non-extraction are simply treatment modalities that the orthodontist can use to obtain the best final result. It is obvious that some practitioners do not adhere to evidence-based diagnosis and treatment guidelines. The patient’s specific orthodontic problems should always dictate treatment and not the orthodontist’s non-scientific “philosophy” of treatment or marketing schemes.
Why is growth important to an orthodontist?
One of our goals in orthodontic treatment should be the correction of any skeletal disharmony. In a growing patient, many skeletal disharmonies can be corrected with the use of a variety of orthopedic appliances, i.e. headgears, palatal expanders, and mandibular anterior repositioning appliances. These appliances only work through growth.
Once growth is complete, then significant skeletal problems must be corrected through orthognathic surgery. Growth studies show that the average girl enters her pubertal spurt of facial growth around age 10-1/2, and it lasts until approximately age 12-1/2. Boys, however, begin their pubertal spurt of facial growth around age 12-1/2; and instead of two years, this growth spurt lasts three years. Seeing patients earlier during skeletal growth could eliminate a more difficult skeletal problem later.
The old adage, "Wait for all the permanent teeth to erupt before seeing the orthodontist" is incorect. It can be particularly disastrous in girls since they may not have all their permanent teeth until the age of 12-13 at which time no facial growth remains to correct any skeletal problem present. Again, it is better to see someone too early when growth modification can be initiated as opposed to seeing someone too late when the growth spurt is complete.
Why do some patients' orthodontic treatment time take longer than the original anticipated treatment time?
All orthodontists try to estimate at the beginning of treatment the amount of time the patient’s particular problem should be treated orthodontically. There are, however, many variables that can make this estimate of treatment time exactly that, an estimate. For instance, broken orthodontic appointments will lead to increased treatment time since the tooth movement may not be progressing properly.
Other problems such as aberrant growth that may occur during treatment, slow dental eruption of teeth, chronic missing of appointments or extended times between adjustments, complexity of the case and possible lack of growth that was anticipated can affect treatment time. Certainly, it does not behoove an orthodontist to keep a patient in treatment longer than the anticipated treatment time, but the patient and parents must realize that the orthodontist is trying to obtain the best result possible even though treatment time may be longer than anticipated.
What do retainers do, and how long are they worn?
When orthodontic appliances are removed, the patient can actually feel that their teeth are slightly loose. Studies have shown it takes 9-12 months for the bone around the teeth that have been moved orthodontically to mature. During that time, the retainers prevent movement of the teeth which is why it is important for the patient to wear the retainers as prescribed.
Recently published long-term studies have shown that lower front teeth tend to shift with increasing age and can be considered part of the aging process. In fact, 70% of a large group of patients many years out of treatment with removal of their lower retainer demonstrated some irregularity of the lower front teeth. The protocol suggested by this study is that we tell all of our patients that their direct bonded lower retainer should be kept on permanently if they wish optimum stability of their lower front teeth. In Dr. Rust's practice, we routinely use a direct bonded lower retainer which cannot be removed since we feel removable retainers are too easily lost or broken and certainly wouldn’t be worn for an extended period of time.
In our practice, the maxillary retainer in most cases is removable, and the regimen is to wear the upper retainer every night the first year out of braces followed by every other night the second year out of braces. After that time, the patient can choose to wear the upper retainer two or three nights a week. However, this is an option. The upper teeth are much more stable and in general do not require permanent retention. After orthodontic appliances are removed, we see our patients twice a year for the first two years and then once a year to approximately the age of 19.
Why do some children go through an early phase of treatment?
There are some early orthodontic problems such as crossbites, ectopic eruption of teeth, early loss of deciduous teeth, and the correction of certain habits that are best done at an early age to make orthodontic treatment at a later time easier. This type of treatment is often called “interceptive orthodontics.” A classic problem is the crossbite of the back teeth that is caused by a narrow upper arch. In our practice, we feel these should be corrected at approximately age 7 or 8. Quite often, the referring dentist or pediatric dentist can perform these procedures, and we refer the patient back to them for treatment. We then place the patient on orthodontic recall and continue to follow their facial and dental development while updating the referring dentist on the patient's status.
It has been shown in the literature that many types of multi phases of treatment do not eliminate the need for orthodontic treatment in the future or, in fact, make future treatment better or less expensive. For instance, early phases of orthodontic treatment to “develop the upper and lower arches to prevent extraction of permanent teeth later” have been shown in numerous controlled studies not to accomplish arch development but to lead to significant relapse later. Two-stage treatment should never be the norm for all patients.
Two-stage treatment is, however, indicated when there is a significant skeletal discrepancy such as a retrusive lower jaw. An orthopedic appliance is used in the first stage to correct the retrusive lower jaw, and the second stage of treatment is directed at aligning and perfecting the occlusion.
Can orthodontics be done on adults, and what is the oldest age a person can have orthodontic treatment?
The biological mechanism that allows orthodontic appliances to move teeth in children is usually present throughout life in all people; thus, there is no age limit as to when orthodontic tooth movement can be brought about. In fact, in our practice, we have performed orthodontic treatment on patients 70 and older. The time to move teeth orthodontically is slightly lengthened with increasing age but not dramatically. We must remember that adults do not have facial growth; therefore, any significant skeletal discrepancy has to be corrected through orthognathic surgery.
I have heard that some people have surgery during orthodontic treatment. Why is this necessary?
One of our objectives in orthodontic and orthopedic treatment is to obtain a good skeletal pattern in which the upper and lower jaw are properly oriented in all planes of space. This can be done in many cases with orthopedic appliances. However, in non-growing patients, the orthopedic appliances used in growth modification are ineffective. Also, there are certain skeletal patterns that cannot be controlled effectively by orthopedic appliances, i.e., protrusive lower jaws. Many of these cases then require orthognathic surgery to normalize the skeletal pattern. In Dr. Rust's practice, we have treated over 500 patients who have had orthognathic surgery incorporated into their orthodontic treatment plans. Dr. Rust works closely with the oral and maxillofacial surgeons throughout the area from the treatment planning phase to completion of treatment to ensure an excellent result. In some cases, other dental professionals (prosthodontists, periodontists) can be brought into the treatment process to optimize the dental results of the patient.
Some orthodontists advertise that they use a certain orthodontic bracket or appliance. Are some better than others? What's the deal?
This is an unfortunate occurrence in the specialty of orthodontics since the implication is that a particular bracket, wire or appliance assures a superior final result. Claims made by practitioners and dental manufacturers are often exaggerated and intentionally misleading. Orthodontic appliances only enable the orthodontist to reach his final treatment goals. It is only through comprehensive diagnosis and treatment planning along with a thorough knowledge of biomechanics that an excellent result can be obtained. The appliances are nothing more than a means to the end.
Dr. Rust uses many different appliances in his practice. The appliance chosen for each patient’s problem is the appliance that will give the most predictable and best result and has been proven by evidence-based clinical studies to be effective.
Why is a good bite important?
A good bite or occlusion, how the upper and lower teeth meet, can be important in many patients, particularly those patients who undergo parafunctional movements, i.e., clenching or grinding. It is known that at the age of 12 approximately 18% of 12-year-olds undergo parafunctional movements; and at the age of 50, approximately 60% undergo parafunctional movements. Patients can place loads of 150 to 500 pounds per square inch on back teeth during parafunctional movements. If the teeth are not positioned properly in harmony with the muscles and temporomandibular joints, the destructive forces of these movements are magnified. It is our belief that since we cannot identify who will undergo parafunctional movements in the future or who will be susceptible to temporomandibular joint problems that every patient deserves to have a good functional occlusion as part of the orthodontist's goals.