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.
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 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 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. 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.