Placing Braces Before and After

Different types of orthodontic cases require different treatment approaches.

For example, for some patients that present with severe crowding as their chief concern, extractions of permanent teeth may be the only valuable treatment option. For other people, however, widening of the dental arches and interproximal reduction can avoid the necessity for extractions.

Orthodontic treatment is suitable for patients of all ages who are looking to improve their smile.

In this particular article I will discuss the specific diagnosis and treatment of a couple of cases that were treated with metal braces. 

Types of Orthodontic Cases

When we as dentists aim to improve the smile of our patients there are several questions that we need to ask ourselves before we initiate orthodontic treatment. 

These are just some of the questions that may arise depending on the individual case:

• What is the type of case that I am dealing with? 
• Is it a skeletal Class I malocclusion with crowding or am I perhaps dealing with a combination of skeletal and dental malocclusion? 
• Am I dealing with an actively growing patient or an adult? 
• Am I able to implement growth modification treatment and/or expansion of the upper jaw with a contemporary orthodontic appliance, or would a combination of orthodontics and surgery be the better option? 

The orthodontic diagnosis and clinical orthodontics are extremely important and are the principal focus of our orthodontic courses.

Every orthodontist and dentist who practices orthodontics knows that crowding of the front teeth and especially blocked out canines are usually the chief concern of our patients. Some clinicians achieve amazing results with braces, others with removable clear aligners. 

The type of appliance does not really matter. It has to be chosen based on the specific needs of the clinical case and the preference of the person sitting in the dental chair. The end result should be pleasing dental esthetics and a stable bite that will be able to serve the patient well for the rest of his/her life.

There is something that we clinicians need to understand before we begin treatment – that it is vital to be clear and honest about how long treatment time will be, as most teenagers and adults will start to complain when they pass 18 months of treatment. 

We must make it clear that treatment with fixed braces can be in the range between 12 and 36 months. It really depends on the severity of the malocclusion, velocity of tooth movement, which is specific to the patient. It also depends on patient cooperation – a patient that skips every other appointment should not be surprised that the treatment lasts longer.

Case 1: Overview and Treatment

The first patient that we will discuss is 12-years-old and presents with a posterior crossbite, anterior open bite and crowding of both upper and lower teeth. 

The crowding could be classified as severe in the upper arch and mild for the lower teeth. The severe crowding in the maxilla was the reason for the abnormal position of the canines and especially the right one which was completely blocked out of the arch.

In order to confirm the skeletal diagnosis, an analysis of a lateral cephalometric x-ray was performed which revealed a mild Skeletal Class III with average vertical dimension. The frontal intraoral pictures reveal bilateral posterior crossbite and oral hygiene that needs improvement. 

I personally have noticed that a lot of teenagers who lack confidence in their dental appearance tend to neglect brushing their teeth. However, their motivation improves significantly once they see an improvement in the alignment of their teeth.

In order for the clinician to develop the right treatment strategy in cases with posterior crossbite, we need to bear in mind that posterior expansion leads to a drop of the palatal cusps on the upper molars, which can significantly worsen the overbite. 

In cases with increased lower anterior facial height, a bonded expander that covers the occlusal surfaces of the posterior teeth is definitely a good approach. We need to bear in mind that opening of the bite and worsening of the overbite leads to backwards rotation of the mandible and worsening of the molar relations. That means that the relationship between overjet and overbite will be affected.

Intermaxillary elastics are always implemented in order for us to achieve good interdigitation between the upper and lower teeth. 

I personally implement them to heavy stainless steel working archwires because that gives me thе chance to preserve the torque and reduces the unwanted side-effects of the rubber bands. 

The last photos reveal the result of the maxillary expansion and braces treatment.

Case 2: Overview and Treatment

The second teenager is 14 years of age, interested in resolving the crowding in the upper arch and obtaining a new smile.  

The initial pictures reveal crowding in the upper arch that is asymmetric and had to be resolved with extractions of upper first premolars. The patient was not confident when smiling and wanted me to straighten her upper teeth and improve the smile esthetics.

In orthodontics, extractions of permanent teeth are often implemented when we deal with an asymmetrical bite and lack of space in the arches. Patients of all ages that present with Class II div 1 malocclusion can be treated with extraction of upper first premolars. 

Before we refer the patient for extraction, we need to be sure whether the non-extraction approach is not the best treatment option. Every clinician has a different opinion on that topic and it is based on his/her training, experience and appliance preference.

Our goal when upper premolars are extracted is to resolve the crowding and obtain normal overjet and overbite. 

The canines relations should be Class 1 while the molars should be in Class 2 relations. Sometimes there is initial upper and lower midlines deviation that has to be addressed during the space closure. Our goal is for the dental midlines to match the facial midline. 

Last but not least we are interested in the improvement of the smile esthetics. Ideally we should obtain a consonant smile with normal buccal corridors for optimal esthetics. 

We need to bear in mind that extractions can alter the soft tissue profile and the prominence of the lips. For this reason we as clinicians need to plan the anchorage requirements of the case and be very precise in the biomechanics that we implement throughout the course of treatment.

Conclusion

Orthodontics for teenagers and adult orthodontics are based on orthodontic diagnosis, treatment planning and execution of the treatment. It is our goal to teach you as a dentist the most reliable treatment protocols and procedures that you can implement into your clinical practice in order to treat your own patients comfortably. 

You can check out both our online orthodontic courses and live events if you feel that we can bring value to your practice.

FAQ:

How to choose the appropriate approach when working with teenagers?

This depends on the severity of their case and what they want to achieve with the treatment.

Can you use only aligners for treatment?

It depends on the case of the individual patient and we as orthodontists need to discuss the best approach with them. Sometimes classic metal braces are the better option.

How can I improve patient – doctor confidence when talking about braces?

Be honest about how long the treatment is going to take.