My Orthodontic and Dentofacial Philosophy: Factors that inform treatment planning

Often, there are several ways to simply straighten the teeth of any given patient using 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. 

My approach to diagnosis and treatment planning includes four primary areas:
The face, teeth, dentofacial health and stability of the occlusion, and, importantly, preferences of the patient.

The Face

Consider that the beautiful smile is seen only when happy or pleased, the well-aligned teeth are seen more often, but the face is seen at all times. My diagnostic approach to orthodontics begins with the face. “Orthodontics” means straight teeth, and “Dentofacial Orthopedics” relates to the correct alignment of the hard and soft tissue structures of the face. Orthodontists are trained and expected to consider both simultaneously; therefore, all treatment options must be evaluated in relation to how they will impact the patient’s facial aesthetics from all angles and with respect to future age-related changes. While this aspect of diagnosis is apparent in cases for which extraction of permanent teeth or repositioning of bone through oral surgery is considered, it is a significant factor in all orthodontic treatment planning, including cases that may be assessed by a non-orthodontist as “simple.” In addition, these considerations take on special significance in early childhood interceptive treatment and complex aesthetic cases involving restorative dentistry.

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 that 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, both now and in the future, is important when determining ideal treatment goals.

The Teeth

The specific nature of how the teeth are misaligned is an obvious factor in diagnosis, but the final positions of the teeth and their effect upon the face 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. 

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 between the teeth will result (malocclusion).  In such cases, the possibility of excessive wear and deterioration 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. 

On the other hand, I have been consulted by many adults for whom I have recommended no or limited treatment because of the likely impact on facial balance.  In such cases, the patient typically has concerns regarding the appearance of the dentition, but bringing that dentition to ideal occlusion would be detrimental to facial aesthetics. While this is not the norm for an adult seeking orthodontic care, 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.

Young children and youths may or may not have opinions or desires when seeking treatment. It is my role to anticipate the aesthetic outcome for the face as it matures and the stability and health of the teeth over a lifetime when advising parents and teens on appropriate treatments and modalities.