Introduction to Orthodontics and Dentofacial Orthopedics
Choosing the ideal professional to serve you or your family can be a difficult task. Most of us feel 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 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 issue, I’ve written a few words on the topics at left.
My hope is that this guide to orthodontics and dentofacial orthopedics aids you in choosing the best course for yourself or your child. If you would like additional information, please contact our office by telephone, 206-812-4494; email, email@example.com; or via the form provided on our contact page.
Keith B. Wong, DDS, MS
Specialist in Orthodontics
How an Orthodontist Differs from a Dentist: Orthodontics and dentofacial orthopedics
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 subsequently been selected for and completed a two to three year accredited post-graduate residency in the specialty. Only graduates from such residencies may refer to themselves as orthodontists in the United States.
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 (e.g., fillings, crowns, implants, laminates). Graduate orthodontic training includes a comprehensive didactic education relating to the diagnosis, prevention, interception, and correction of malocclusion (misalignment of teeth) within the context of the facial musculoskeletal system. Training, therefore, covers guidance and correction of facial skeletal formation, i.e., dentofacialorthopedics. An orthodontist is uniquely qualified to assess facial formation of the growing child or aging adult and provide interceptive treatment designed to influence that formation to improve appearance, occlusion, and oral health. An orthodontic residency focuses exclusively 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 an 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 to prepare a student to function as a primary care dentist.
Through the clinical training of an orthodontic residency and private practice experience of completing over 4,000 orthodontic cases, I have not only gained an understanding of numerous orthodontic and dentofacial orthopedic approaches and appliances, but more importantly, have established a personal philosophy of diagnosis and treatment—a philosophy I share with you in the next section.
My Orthodontic and Dentofacial Philosophy: Factors that inform treatment planning
Often, there are a number of ways to straighten the teeth of any given patient using many and various appliances (traditional braces, clear braces, Invisalign, and so on). Achieving an excellent orthodontic result, however, requires looking beyond the teeth and seeing past the near-term. In order to discuss my approach to diagnosis and treatment, I will present four general areas of consideration that influence a final treatment plan; the face, the teeth, the dentofacial health and stability of the final occlusion, and the preferences of the patient.
“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 only when happy or pleased, the well-aligned teeth 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 for which extraction of permanent teeth or the repositioning of bone through oral surgery is considered, it is a significant factor in all orthodontic treatment planning.
Even a seemingly “easy” case requires comprehensive evaluation given that current tooth positions, and all potential positions to which teeth may be moved, are subject to the positions/influence of the jaws, alveolar bone (bone around the teeth), tongue, lips, facial muscles, and gums. The upper and lower teeth can be considered 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). This intimate and subtle relationship of all structures of the dentofacial complex must be considered from both functional and aesthetic standpoints.
Many cases of what appear to be simple dental misalignment have underlying imbalances within the bones and/or soft tissue that determine which treatments should or should not be considered. When such imbalances are unacknowledged in the treatment plan, negative consequences may occur—affecting facial aesthetics, periodontal health, or stability of the orthodontic result. An experienced orthodontist should be aware of and evaluate all such imbalances before proceeding to treatment. Interestingly, cases that appear complex, due to extensive crowding or spacing, may, in contrast, be assessed as requiring limited or “partial” treatment if no underlying imbalances are present.
Additionally, 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, e.g., 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 relationships of soft and hard tissue, now and in the future, are important in the determination of ideal treatment goals.
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 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 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, 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. Each of these factors influences treatment planning, choice of appliances, and advisability of surgical procedures.
Preferences of the Patient
Finally, consideration of what the 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 the presenting situation, and be willing and able to communicate with the patient such that a level of understanding sufficient to make an informed choice ensues.
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. In contrast, 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.
When to Visit an Orthodontist: Children and adults
The American Association of Orthodontists recommends that all children be examined by an orthodontist at age seven. At this age, the first permanent molars and some permanent incisors will have erupted and the budding occlusion and dentofacial relationships should be evaluated. If first molars have yet to erupt, an examination is recommended to assess any developmental issue. In either case, it is important that progress of the unerupted permanent teeth, and particularly those between molars and incisors, be evaluated since eruption in the cuspid/bi-cuspid area is sequential and, often, simple recognition and recommendation by the orthodontist of strategic removal of a primary (“baby”) tooth can avert significant misalignment 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 facial bones in order to determine whether the child would benefit from interceptive correction of any imbalances before they become pronounced. Early correction of developmental issues (usually starting around age 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 invisible 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, including myself. 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 be seen whenever there are questions concerning smile aesthetics, tooth alignment, and/or the stability of occlusion (bite). In addition to cosmetic issues, the adult patient may experience accelerated wear or breakage of teeth due to misalignment. A thorough and responsible primary care dentist will screen for issues related to malocclusion and refer the patient to an orthodontist for evaluation to determine if tooth movement, rather than tooth removal, sculpting, or simply whitening, will best alleviate the issue in the context of long term health. 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 questions answered and gain a comprehensive understanding of tooth alignment relative to bite, smile, gums, bones, and face (presently and over time) and to learn of available options before committing to either no treatment or to changes in the teeth themselves. As stated above, orthodontic examinations are performed free of charge by most practitioners; consequently, if questions arise, I encourage you to seek one or more such examinations from reputable orthodontic specialists.
What Patients Say
“I am very gratified to have Dr. Wong as a colleague. As a surgeon, I have been fortunate to collaborate with Dr. Wong on hundreds of cases, from the most complex surgical orthodontic cases to the post-treatment extraction of “wisdom teeth” after braces. In each instance, Dr. Wong’s diagnostic expertise, clinical excellence, and effective communication have resulted in the highest quality of orthodontic care and patient (and parent) satisfaction. Moreover, his humility, keen mind, and generosity of spirit make him a valued member of the dental community.”
—William A. Schiro, DDS, Oral and Maxillofacial Surgeon
“I love coming to see Dr. Wong! He is so knowledgeable and such an excellent orthodontist, which I appreciate as a dental professional. But more than that, he is such a kind and loving person. He just gives off a happy energy that makes everyone else happy. He and the entire staff have created an atmosphere that is so inviting and welcoming. I highly recommend that everyone see Dr. Wong.”