Treatment Philosophy

Functional Problems

Functional problems that affect the alignment of teeth and could require orthodontic care include: finger habits, thumb sucking, tongue thrusting, or lower lip entrapment. When the upper teeth stick out too much the lower lip will become trapped. Some oral habits cause the gum tissue to thin and abrade. Crowding can become so severe that infection could become a functional problem, as can lip and cheek biting. Spacing can allow food to be trapped and cause gum disease. The most common problem is that teeth don’t meet properly when biting down. Under-developed jaws can result in “cross-bites” which make for an improper bite; and the same is true for open bites where all teeth don’t touch equally. Tongue thrusting, which is generally associated with open bites and speech problems, can cause the teeth to stick out too much.

Best time to confer: Functional problems should be examined as soon as they are detected. See your family dentist, or an orthodontic specialist right away.

Growth Problems

True growth problems can develop when either the upper or the lower jaw is allowed to outgrow the other. This can result in such a large “overbite” (buck teeth) that the patient has a retrusive lower jaw or an “underbite” with a prognathic mandible . Lateral problems, for example, cross-bites, where the upper jaw is too narrow to fit the lower jaw, occur rather frequently; in these cases, the side teeth don’t meet properly, function will be impaired, and often these teeth show exaggerated wear. There can even be a negative impact on speech.

Best time to confer: Growth spurts are individualized physiologic events, and optimal treatment results are obtained while taking place simultaneously with “good growth.” See an orthodontist before age nine so that he/she can individually determine the optimal timing for the treatment of any growth problems.

Tooth Alignment Problems

1st Stage – Symmetry and Arch Length

In the normal course of tooth development, the upper and lower four front teeth (incisors) and first permanent molars generally erupt between age 5 – 7. Little else takes place until the primary canines and molars (side teeth) fall out and are replaced by permanent teeth, typically by age 9-11. Principle concerns are adequate space and symmetry; the mid-lines should be lined up.

Best time to confer: Once permanent incisors erupt, a Mixed Dentition Analysis can he performed which will tell us whether there will be enough space for all teeth; symmetry can then he evaluated as well.

2nd Stage – Tooth-to-tooth Alignment

If the first stage occurs normally, the second should be just a matter of the side teeth erupting into proper biting relationship with the teeth in the opposite arch. There might be some further space regaining; but this will usually be minor, allowing treatment, if necessary, to be simple and help keep the cost at a minimum.

Best time to start orthodontics: There is tremendous advantage in starting before the last lower primary tooth is lost, and even by the time it gets loose. Contact an orthodontist for any questions you might have.

Case example:

Animated Gif or QuickTime Movie

The Proper Placement of Teeth

Apart from chewing, the teeth are also essential for providing a nice smile. Even when the lips are closed, the teeth play a role in providing support for the lips.  While many people who have crowding have so many teeth that it is difficult to maintain lip closure – due to the procumbency of the teeth, the progressive loss of facial fullness accompanies the removal of teeth. Regrettably, so does the process of aging; and these looks can be confused. A balance has to be found that provides a nicely full smile – one that allows the lips to be comfortably closed at rest.  After all, the lips play an essential role in the long term stability of the placement of the teeth.

For years, orthodontists responded to the condition of crowding by having teeth removed: extraction. When you remove teeth for orthodontics, it is usually a side tooth: a premolar. Closing space will usually result in the front teeth being positioned off to the side of the extraction. In order to keep this in balance, it is common to remove paired teeth on opposite sides of the mouth. Suddenly, the plan involves the removal of two teeth in the upper arch and/or the lower. Premolars are usually about 7mm wide; this generally means that the correction of a crowding problem will be accomplished by the removal of 14-17mm of space. Extractions are essential in many cases, but they should be used sparingly and strategically.

We approach the removal of teeth in the context of a “gradient of anchorage.” That is, the more crowded the bite, and the more full the facial profile, the more likely it is that teeth will need to be removed in order attain and esthetic result that will be stable and functional. In fact, there are strategies that have a greater effect on facial fullness than others, and strategies that facilitate the relief of crowding that might be more specific to one part of the mouth than others. If teeth are going to be removed, an individualized plan should be developed for specific patients with specific needs.

Severe Crowding – serial extraction

If you do not have sufficient space, tooth-to-tooth alignment might not be possible without the removal of some amount of tooth mass. Widening the arch by simply tipping teeth has been shown to not be stable. There are cases where it can be determined by tooth size that there is a profound shortage of space and all of the teeth will not possibly fit into the dental arch. In those situations, the prudent choice is the sequential removal of teeth. Typically, baby teeth are removed with the expectation that certain permanent teeth will erupt early; and their removal will allow most – if not all space – to close naturally. This can significantly shorten the duration of treatment, as well as its complexity, and greatly reduce its cost. The animation below demonstrates such a case; note the lack of complete space closure in the lower arch at the end of stage 5. Braces were used for eleven months to finish this closure and make the roots parallel.

Serial Extraction Animation

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Transverse Problems:

Before Dr. Andrew Haas brought orthopedic expansion into vogue (and unfortunately in some offices today), it was thought that the solution to all crowding problems was extraction – the removal of teeth. Orthopedic expansion involves the delivery of a sufficient force level (in a very painless way) to separate the suture in the palate, allowing for needed growth in the midface. Broader smiles are provided, and the widened width spells a profound increase in the circumference of the dental arch, allowing for the aesthetic placement of previously crowded teeth.

Breadth of smile and ability to align crowded teeth without extractions are among the benefits of properly performed orthopedic expansion.

Special Problems: multidisciplinary treatments

Periodontial Support

Sometimes tooth alignment causes gum infection or makes difficult the healing of “periodontal” conditions. These cases need to be approached by an orthodontist and a periodontist, or a family dentist who does periodontic treatment. They can tell you when and if treatment should start.

Prosthodontic Collaboration and Post-Traumatic Repair

When teeth are missing, traumatically evulsed (knocked-out) , poorly formed, decayed or broken down, it is important that they be repositioned for restoration. Orthodontics can be instrumental in preparing the mouth for crowns, bridges, dentures or implants. These cases may require collaboration with other dental specialists.

Temporomandibular Dysfunction, “TMD”

Orthodontists manipulate occlusions on a daily basis, routinely treating many of the problems that result in jaw noise, discomfort and dysfunction. Confer with your family dentist for a referral.

Congenital Defects

Cleft lip and palate, plus various facial syndromes, are typically recognized at birth. Generally, the pediatrician will refer these to teams which include orthodontists. Call the Northern Michigan Cleft Palate Clinic at (231) 922-9538, where Dr. Northway is a staff member.