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Orthodontics and Dentofacial Orthopedics
What is it, and when to first see a specialist

Orthodontics patient

Orthodontics and Dentofacial Orthopedics

Choosing the ideal professional to serve your family can be a difficult task. Most of us feel that we can recognize the potential for rapport with a doctor based upon his or her expressed values and “bed-side manner.” However, when it comes to the technical aspects of specific services required, we often lack sufficient understanding of the field to determine with whom we should seek treatment. In order to shed some light on this topic, I have written the following paragraphs. My wish is that the information contained helps you to make the most appropriate choice for yourself or your family.
Keith B. Wong, DDS, MS

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What is an Orthodontist?
Orthodontics and Dentofacial Orthopedics is one of the nine specialties recognized by the American Dental Association. An orthodontist is a dental specialist who has graduated from dental school and has been selected for and completed at least two years additional training in an accredited post-graduate residency in orthodontics.

Orthodontists focus solely on correcting misaligned teeth and jaws using appliances such as traditional braces or Invisalign and do not perform restorative or cosmetic dental procedures (“fillings, crowns, implants, or laminates”). Graduate orthodontic training includes a comprehensive didactic education relating to the diagnosis, prevention, interception, and correction of malocclusion (misalignment of teeth), but most importantly, an orthodontic residency focuses upon the clinical practice of orthodontics through the diagnosis and treatment of patients, and the critical analysis of treatment outcomes.

The importance of clinical experience in graduate training cannot be overstated because general dental education in the United States rarely includes the opportunity to treat an orthodontic patient. While attending the School of Dentistry at the University of Michigan (a leading program with a comprehensive curriculum), I was unable to even observe one active orthodontic patient during my four years of general dental training. The reasons for this situation include the lack of sufficient numbers of orthodontic patients to be treated by undergraduate dental students and the sheer amount of other clinical training necessary (restorative dentistry, cosmetic dentistry, implant dentistry, fixed and removable prosthodontics, pedodontics, periodontics, endodontics, oral surgery, dental radiology, dental pathology, etc.)

The clinical training of orthodontic residency and the private practice experience of completing over three thousand orthodontic cases have led me to an understanding of numerous orthodontic approaches and appliances, but more importantly, have allowed me to establish a personal philosophy of diagnosis and treatment which I would like to share with you.

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My Orthodontic and Dentofacial Philosophy
Often, there are a number of ways to straighten the teeth of any given patient using many various appliances (traditional braces, clear braces, Invisalign, and so on). Achieving an excellent orthodontic result, however, requires looking beyond the mouth and seeing beyond the near-term. In order to discuss my approach to diagnosis and treatment I will present four general areas of consideration that influence the final plan of treatment: The face, the teeth, dentofacial health and stability of the final occlusion, and the preferences of the patient.

The Face

“Orthodontics” means straight teeth and “Dentofacial Orthopedics” relates to the correct alignment of the hard and soft tissue structures of the face. My diagnostic approach to the straightening of teeth begins with the face. Consider that a beautiful smile is seen when happy or pleased, the well-aligned teeth even more often, but the face is seen at all times. Therefore, all treatment options must be evaluated in relation to how they may affect the patient’s facial aesthetics from all angles and with respect to future age-related changes. While this aspect of diagnosis is highlighted in cases in which the extraction of permanent teeth or the repositioning of bone through oral surgery is considered, it is a significant factor in all orthodontic cases.

Moreover, the current positions of the teeth, and all potential positions to where the teeth may be moved orthodontically, are subject to the positions and influence of the jaws, alveolar bone (bone around the teeth), tongue, lips, facial muscles, and gums. The upper and lower teeth can be looked at as passengers with finite room to move within the local alveolar bone and gums, which are in turn passengers on the upper jaw (maxilla) and lower jaw (mandible). Because of the intimate and subtle relationship of all the structures of the dentofacial complex, it is crucial that every case be evaluated in a comprehensive manner, even in seemingly “easy” cases.

Many cases of what seem to be simple dental misalignment have underlying imbalances within the bones and/or soft tissue that influence what treatments should or should not be considered. When these underlying imbalances are not acknowledged in the treatment plan, negative consequences may occur affecting facial esthetics, periodontal health, or stability of the orthodontic result. On the other hand, an experienced orthodontist can also recognize those cases that can be treated ideally with a limited or “partial” treatment plan that results in less time and less cost.

Excellent diagnosis requires consideration of all dentofacial structures, in three spacial dimensions, plus the fourth dimension of time. For example, proper timing of treatment is very important in cases where the patient is a growing child. In some cases, for instance, interceptive treatment that takes advantage of lower jaw growth can correct significant “overbites” before physical and emotional stress is experienced. For adults, consideration of the effects of future aging on facial aesthetics, as well as the impact of tooth and bone movement upon the relationships of soft and hard tissue, now and in the future, is important in the determination of ideal treatment goals.

The Teeth

The specific nature of how the teeth are misaligned is an obvious factor in diagnosis, but the final corrected positions of the teeth are equally important to the treatment plan. For instance, to plan for ideal aesthetics requires addressing such issues as tooth shape, tooth size, smile arc (to provide a smile that is natural-looking rather than artificial), and proper incisor angulation. In addition, aesthetic concerns include how much tooth and gum show upon smiling and how much of the front teeth show when not smiling (repose), as well as how those teeth reflect light to the eye of the viewer. Moreover, the functional positions of the teeth as they contact and move are very important to the health and condition of the teeth, their supporting structures, jaw joint (TMJ), and chewing muscles. As you might expect, moving the teeth is the part of the plan that is most related to the biomechanical aspect of treatment.

Dentofacial Health and Stability of the Occlusion

The final corrected positions of the teeth must also take into consideration the long-term health and stability of the periodontium (supporting gums and bone), the functional dentofacial structures (temporomandibular joint, or jaw joint, and the chewing muscles), and the teeth themselves. As mentioned above, the teeth can be seen to be passengers within the periodontium with a limited range of displacement before such issues as gingival recession or lack of bony support for the teeth may arise. On the other hand, if the upper and lower teeth are well-aligned within their supporting tissues but not well aligned to each other, a dysfunctional relationship of the teeth will result (malocclusion). In such cases, the possibility of excessive wearing of the teeth and/or disturbances within the jaw joint and chewing muscles may increase, especially if a tooth-grinding habit (bruxism) develops.

Preferences of the Patient

Finally, consideration of what each patient desires as a treatment goal versus what he or she finds acceptable as an orthodontic treatment may be the most influential factor. In order to serve each patient well, the orthodontist needs to master multiple approaches, know the strengths and limitations of each approach relative to that particular situation, and be willing and able to communicate with the patient in such a way that there is a level of understanding sufficient to make an ideal choice.

Also, it has been my experience that the adult patient may have an intuitive awareness with respect to changes in facial aesthetics that will result from treatment. Therefore, I closely attend to any such thoughts from a patient and incorporate these thoughts into the treatment plan. However, I have been consulted by many adults for whom I did not recommend treatment, or have recommended limited treatment that does not impact the facial balance. In such cases, the patient has presented with concerns regarding the appearance of the dentition; but to bring that dentition to ideal occlusion would result in a detriment to facial aesthetics. This is not the norm for an adult seeking orthodontic care, but when it does occur I am obliged to recommend limited or no treatment if I feel, when considering the face as a whole, that the result will be unsatisfactory.

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When to Visit an Orthodontist
The American Association of Orthodontists recommends that children first see an orthodontist at age seven. This is due to the fact that the first permanent molars (the “6-year” molars) and some of the permanent incisors will have erupted; if not, a developmental issue may be indicated. It is important that the progress of the unerupted permanent teeth between the molars and incisors be evaluated because eruption in this area is sequential (and sometimes complex) and, many times, simple recognition and recommendation by the orthodontist of the strategic removal of a primary (“baby”) tooth can avert significant misalignments of permanent teeth. Although orthodontic treatment is generally not indicated at this age, it is very helpful to assess the development of the dentition and the facial bones in order to determine whether your child would benefit from the interceptive correction of any imbalances before they become more pronounced. Early correction of developmental issues (usually starting around the age of 9) leads to more successful, less invasive treatment once the permanent teeth erupt; in some cases, there is, as a result, no need for comprehensive treatment. Given that most orthodontists offer complimentary consultations and many developmental issues are subtle and not visible to the naked eye, it is highly recommended that all children are screened by an orthodontist. Fortunately, there are several qualified and experienced orthodontists in the Seattle area. I encourage you to arrange for an examination of your child by one or more of these professionals.

For adults, it is recommended that an orthodontist is seen when there is a question regarding the alignment of teeth or the stability of occlusion (bite). The breaking of teeth when chewing, for example, may indicate that orthodontic treatment is warranted. A consultation with a qualified orthodontist is an opportunity to have your questions answered and gain a comprehensive understanding of your tooth alignment relative to your bite, smile, gums, bones, and face (presently and as you age in the future). Moreover, if treatment is indicated, you will be able to compare the available options and choose that which is most ideal.

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I hope that this brief guide to orthodontics and dentofacial orthopedics has been of aid to you in choosing the best course for yourself, or your child. If you would like more information, please contact our office by telephone, 206-812-4494; email, contact@drkeithbwongseattle.com; or through the form provided on our Contact page.

Sincerely,
Keith B. Wong, DDS, MS

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