Class II before (age 6)

Age 12 after treatment

ClassIII

Class III deformities yield a "prognathic", or "strong chin" appearance.  This could be caused by over development of the lower jaw, or by underdevelopment of the upper jaw . This profile is not usually considered attractive on women, however it can be an asset to men, depending on the image they wish to project.  It is associated with the "tough guy" or "bulldog" image projected by the 1940's movies, and gives a singularly masculine appearance that we associate with football players today.  As with class II occlusions, this profile is associated with functional and esthetic problems.  Since the lower incisors are located in front of the upper incisors, they too can erupt to unattractive lengths.  This profile can be associated with a "smooth cheekbone" appearance and a tendency not to show the upper front teeth when talking or even when smiling.  Biting can be a real problem for these people in extreme cases, because while class I and II profiles can stick their lower jaws out further to bite off a piece of food, it is impossible for the class III profile to draw his lower jaw any further back to make the front teeth meet.

What is all that "equipment" that the patient wears during treatment?

Orthodontists use lots of complicated wires, jack screws, elsatics and "retainer-like" appliances to accomplish their orthodontic/orthopedic goals.  If you have specific questions regarding the purposes of things like headgear, bionators, palatal expansion devices and various other stuff that looks like it was invented by someone in Dracula's dungeons, the best thing to do is to corner your orthodontist and ask why you or your child needs it.  He or she knows your child's needs specifically and can speak directly to your concerns.  If this is not possible, click on the icon to the right to proceed to a site that goes into the technical reasons for these devices.  This link brings you to an internal page at the site with a good navigation bar that allows you to go directly to your point of interest.

The developmental deformities

Developmental deformities treated by orthodontists are caused by environmental factors such as thumb sucking and lip habits, as well as by other physical errors such as an inability to breath through the nose due to sinus and allergy problems, or the failure of some of the teeth to develop.  These deformities are often associated with narrow upper arches, and/or an open anterior bite such as that seen in the image of the thumb sucking habit below.  This category also includes crowded, crooked teeth since in this case there is a discrepancy between the size of the teeth and the space available in the dental arches to accommodate them.  Of course, all these problems often occur in combination and there is frequently no neat division between them  in any given case.  Therefore, every case is unique and must be handled with completely different treatment plans.  

Thumb sucking

Thumb sucking is a habit that will generally subside on its own.  By the time the child is in grade school, he or she wants to stop because it has already become a social liability.  If stopped by age 6 or 7, even the open bite pictured above will revert back to normal.  Upon occasion, a child will want to stop, but be unable to break the habit.  Under these circumstances, it can be helpful to insert a fixed (not removable) habit breaking device as a "reminder" not to put the thumb into the mouth.  These work well provided that the child wants to stop the habit.  If the habit persists past the age of 12, the skeletal deformity you see above can persist for the rest of that person's life. 

Mouth breathing

The normal development of the oral structures depends upon the ability of the child to breath through the nose without obstruction, especially at night.  This does NOT mean that if your child gets an occasional cold and can't breath through his nose he will grow up with oral abnormalities.  However, chronic obstruction of the nasal airway due to deviated septum, persistent allergies or other anatomic abnormality will tend to cause the roof of the mouth (the hard palate) to rise and the back upper right and left teeth to collapse toward each other.  We call this condition a constricted arch.  The teeth are arranged in arches. 

The picture on the right is a model of a constricted arch.  The model on the left has a more normal arch form.  A patient with the teeth on the right will have a smile that shows mostly the two prominent front teeth, with the others in shadow.  The one on the left shows a normally shaped archform resulting in a broader smile   

Crowded and missing teeth

Nature tries to fit the teeth into the space available.  The teeth always end up in their most stable position within the dental arch, whether they are crowded, or have extra space between them.  Stability is the name of the game.  There is always a balance between the various forces that affect any given tooth, as well as the amount and position of bone available, that helps determine where that tooth is most stable.   If a dentist tries simply to move the teeth into better looking positions, Nature may move them right back where they started.  This is why an orthodontist must play certain tricks to make sure the local forces affecting each tooth will cancel each other out after treatment so that the tooth will stay put once it is moved.  

This is why the orthodontist must usually treat both upper and lower teeth, even if only the appearance of the top teeth are of concern to the patient.  Unless the position of the lower teeth coincide with the position of the uppers, the biting forces produced by the ill fitting lowers will create instabilities that will move the uppers back into crooked positions over time.  This is also the reason that the orthodontist will order the extraction of some teeth.  The extra room created by the removal of these teeth changes the stability equation in favor of the preferred new tooth positions.

Adult Orthodontics

There are lots of reasons that many of us grew up with teeth we consider crooked and ugly. Perhaps our parents could not afford the braces, or perhaps we refused treatment because we were, well, kids.   For whatever reason, lots of us wish we could now have what we didn't get when we were youngsters.  

Well, it's not just for kids any more!  The decision that an adult makes to have their teeth straightened is not much different than the decision he or she makes to begin repairing and caring for the teeth that they have neglected over the course of their lives.  It is surprising just how many people are correcting their congenital and developmental deformities in adulthood.  With a little care on your part, you can have "perfect teeth" all your life too.  (Read my article on Why so many people have such nice teeth.)  

And why not?  It might cost three to five thousand dollars over a span of about three to five years.  It seems like a lot of money, but it is paid over a long contract period and the payments are really much less burdensome than a car payment.  But while you will be making car payments all your life, orthodontics is a one shot deal.  Once it's done, with a little care on your part, (and perhaps a lower bonded wire retainer) it stays that way and won't rust out in the New England weather.  How much is it worth to be able to smile during an entire lifetime?  What is the value of the quality of your own life?  

Adult orthodontics is somewhat different than children's orthodontics.  This is because with adults, unlike children, the bone is not always in a state of flux, and it takes somewhat longer to move the teeth.  But they do move, and results like the one above are common.  My wife had adult orthodontics when she was 40, and she's been happy with the results ever since (I won't say how long, so don't ask).  

Combined Orthodontic/Surgical cases

No matter how good the orthodontist is, he or she cannot move teeth anywhere the bone will not follow.  In instances of extreme deformity, where an adult's lower jaw is hopelessly inadequate (Class II) to correct with orthodontics alone, or in many cases of lower jaw prognathism (Class III), and frequently in cases of anterior open bite (where only the upper and lower back teeth make contact), it becomes necessary to combine the orthodontist's skills with that of an oral surgeon to affect a cure.  This sort of multidisciplinary approach is becoming more and more common throughout all branches of medicine, and just as I refer to all sorts of specialists in the course of my general practice, an orthodontist makes use of surgeons as well as other specialists on a routine basis.  

One of the largest advantages of surgery combined with orthodontic treatment is the marked improvement most patients have in their facial appearance after treatment.  Andy Gump and Bulldog profiles are reversed overnight. Patients have quick relief from long standing functional disabilities as well.  Those who could not chew their food can now eat without difficulty.  Patients who could not close their lips around their front teeth now can.  Even though I, as a general dentist am not directly involved with this form of treatment, I find these cases to be the most rewarding because the immense improvement in these patients' lives began with a visit to my office.

A word about Invisalign®

Sometimes called "invisible braces", Invisalign has become a very popular innovation in straightening teeth.  This technique uses a series of thin plastic trays to move the teeth gradually from their initial undesirable position to the final finished straightened position. These trays are designed and manufactured using computerized assisted design techniques.  The trays have indents for each tooth.   The indent for each tooth that is to be moved is in a slightly different place in each succeeding tray, so that a gradual movement of the teeth is brought about. 

This technique can be quite effective in some cases, and it is quite popular with patients because the trays are nearly invisible so most observers will not be able to tell that the patient is in "braces".  If an orthodontist has suggested that you go into an invisalign treatment plan, then you will probably be quite pleased with the process, and most likely with the results.  There are, however a number of hidden "snakes in this garden" and the prospective patient should be aware of these when considering treatment. The following information has been gleaned from conversations with a number of board certified orthodontists who use this technique in their practices.

Invisalign works best when it is used to close unwanted spaces, and for minor crowding situations.  It is not useful for the congenital skeletal malocclusions discussed above (especially Class II and Class III).  While it may successfully intrude teeth (push them into the gums), It is not generally successful at extruding them.  It is useful in all instances in which teeth can be tilted into position, but it cannot move them bodily (that is to say keeping the roots parallel, as can be done with brackets and wires).  It is also very difficult to torque teeth (twist them).  

If your case requires that the dentist find more room for a substantially crowded dentition, Invisalign is not good at closing spaces created by extracting teeth. (This would require bodily movement.)   Space may sometimes be gained by "expanding the arch", but this technique can lead to overly tilted teeth which may be unstable after treatment, since Invisalign provides no way to "finish" the alignment of the roots.

Can a general dentist do invisalign?

As long as your orthodontics is diagnosed and treated by a properly trained orthodontist, then if he or she suggests Invisalign, you can be assured of good results.  No matter what happens during treatment, these specialists are trained to use other standard orthodontic techniques to supplement the Invisalign.

Unfortunately, not all dentists offering Invisalign have extensive training in diagnosing and treating orthodontic cases.  Some of the cases that these dentists will accept for Invisalign treatment may yield disappointing results.  Here's why:

The procedure for doing an Invisalign case involves simply taking impressions and sending models of the teeth to the Invisalign lab where the lab technicians essentially create a treatment plan using these models alone.  In general, no diagnostic cephalometric x-rays are submitted to the lab.  Any treatment planning associated with the position of the tooth roots and the underlying bony structure of the skull must be done by the dentist himself prior to submission of the models.  While some general dentists may have acquired this training during their careers, a majority have not.  If the dentist has not properly vetted the case, he WILL receive back a set of trays in spite of the fact that the case is not appropriate for the Invisalign technique.  The patient is assured of proper treatment planning only in the office of a board certified orthodontist.