Discussion Guidelines for Orthodontic Treatment Decisions

Communication is a key factor in a smooth running practice. Yet in a busy practice, we often find that a way to communicate information to patients is not always at our fingertips. For many of us in practice, we are challenged with a way to quickly communicate information to patients at the moment you need it.

For orthodontic treatment, there are often questions that arise in the general practice that team members would be very capable of managing if they had a reference to guide them. The following is a discussion guide that can be used in part or in its entirety for communicating some frequently asked questions or discussing common orthodontic issues when making an orthodontic referral. You can copy and paste it into a word processing program and save it. Then you can use whatever part of this hand out applies for individual patients, edit it to better portray your philosophy, print it for patients to take home, place it as a reference on your website, add your logo, or use it for team training. It is meant to start the process of the referral discussion with some initial information sharing. Following up with your orthodontist, you can together confirm what you both believe to be the best treatment option of your patient.

Orthodontic Treatment FAQ

Will I need extractions?

Extraction of primary or permanent teeth has long been an option to consider as part of an orthodontic treatment plan. Removing teeth creates space quickly to open an eruption pathway for crowded teeth. Extraction can make future alignment of teeth (room to straighten teeth) and bite correction possible by moving teeth into the gap created by the extraction. Extractions can also result in moving the remaining teeth to improved bone structure and better function with the face and lips.

A possible benefit to an extraction treatment plan is the time in braces may be reduced for an individual patient compared to the treatment option when teeth are not removed. The finished result may be easier for the patient to complete because additional appliances like expanders are not required. However, when teeth are removed there may be some differences in the final result that must be accepted as a compromise. Your child may not be a good candidate for extractions when considering their facial profile as well as their bone and jaw structure.

How will expansion help?

Crowded teeth are often the result of a jaw-size and tooth-size difference. When teeth are crowded we often find that the upper jaw width is narrow. During an orthodontic examination, measurements are made to evaluate the jaw size so a comparison can be made to normal jaw width.

Just as with decisions about extractions, there are several considerations to be made when selecting an expander as a treatment option. Expansion develops the jaw size to open space for crowded teeth to erupt. Like building a house, expansion prepares the space for the teeth to move into. Selecting an expansion treatment plan is indicated when the goal is to avoid extracting permanent teeth or the patient is not a good candidate for an extraction treatment plan. Expansion can correct the narrow jaw and reduce crowding with the added benefit of “filling out” the smile. Expansion ideally is done early (age 8-10) to get the best response from the jaw growth and provide the space before crowded teeth are ready to erupt. Early expansion using primary teeth as anchors is more ideal than using permanent teeth after they have erupted. When using an upper expander, a partner appliance or wire is used in the lower arch to keep the molars coordinated.

Treating without extractions can be an important goal to achieve an ideal bite and facial balance; however, it can result in a two-step or an extended treatment time to develop the space needed to align teeth properly.

Is headgear still used?

Headgear treatment can offer benefits to achieving a successful orthodontic result and have been used for many years. New technology advancements are now providing alternatives to some but not all types of headgear in orthodontic treatment. The advantages of headgear alternatives can be significant and important to understand when making treatment decisions.

• Some headgears can still provide a very important benefit during orthodontic treatment.
• Some headgear is designed to modify how the jaw grows so the fit and function of the bite is improved.
• During growth, a headgear can boost the growth of one jaw compared to the other jaw.
• Headgear can also slow the growth of one jaw to allow the other jaw to “catch up.”
• Headgear can also help hold groups of teeth in place while other teeth are moved with braces to the ideal position.

With proper use, headgear can help achieve a better result. The challenge most patients have is the time commitment to successful headgear wear. Headgear requires a significant time commitment from the patient and can require an average of 12 hours daily to achieve the expected results.  

Can I use clear removable aligner therapy?

The options for orthodontic treatment for teens and adults have expanded to include clear aligner therapy. In the more than 15 years since it was first developed, clear aligner therapy can be selected as a successful treatment alternative to braces in a wide variety of cases. For many patients, the option of clear aligner therapy makes the difference in agreeing to orthodontic treatment.

Removable aligners can be combined with many of the support systems we use with braces. This can include elastic wear and anchorage appliances. Those patients who do choose removable aligner therapy must agree to take on a stronger commitment and accountability for the success of their treatment. Aligners are removable and will not move teeth without adequate wear time, so this is a serious consideration when making a treatment decision. Many but not all types of treatment can be accomplished with removable clear aligners when patient cooperation is established.

What is a TAD?

TAD stands for “temporary anchorage device.” A TAD is a small bone anchor. It is placed temporarily in an area of bone away from the teeth and out of view when smiling. As the word “anchor” implies, a TAD is a solid, unmoving support point. With pressure, teeth will always move, so a TAD is used when we need something that will not move at all.

Once placed we can use a TAD to hold (anchor) a tooth in place and move other teeth around it. We can use it to keep teeth from drifting, or we can use it to pull other teeth closer to it. A TAD can also aid in leveling bone so both right and left sides are even. A TAD can replace the need for headgear or other devices that provide anchorage that a patient is required to wear to be effective. A small TAD can be much easier for a patient to tolerate than additional appliance wear.

Is elastic wear part of braces?

Teeth are moved with several types of forces that create pressure. Some forces come from wires placed in the braces. Some forces come from elastics that tie the wire to the braces. Several forms of elastics help to pull or push teeth along the wire at a specific rate and direction. The orthodontic team places all these forces during orthodontic treatment visits.

Elastics that a patient is required to place have a different but very important focus. These treatment elastics are placed by the patient, often from one area on the upper arch to a different area on the lower arch. The focus may change during the treatment progress. Treatment elastics can guide how the jaw grows during treatment, making the difference in a good bite finish. The elastics can make the tooth movement more efficient and effective. Overall treatment elastics create a force that is essential to achieving the planned finish.

Treatment of impacted teeth

An impacted tooth describes a tooth that is no longer able to erupt into the mouth on its own and has the potential to damage other neighboring teeth. Treatment of an impacted tooth (teeth) involves the combined teamwork of the orthodontist and the surgeon.

There are two common ways to treat an impacted tooth and will vary based on the position in the mouth. When a tooth is impacted on the palate (roof of the mouth), there are two approaches. In one approach, the surgeon removes the bone surrounding the crown of the impacted tooth. A brace is bonded to the crown and a barrier material is placed to keep the gum tissue from growing back over the tooth. It is like a small window for the tooth to follow. One benefit of this exposure plan is that no active orthodontic treatment is needed during the wait for eruption. A contraindication is if the impacted tooth position may be damaging another permanent tooth. 

A second procedure involves placing a brace with a small gold chain on the impacted tooth crown and closing the tissue back in place. Orthodontic appliances are placed to use active traction on the chain to guide the tooth into the proper pathway of eruption. This approach is used when an impacted tooth is damaging other teeth and needs to be directed away. Although a slow process, saving a natural tooth is important for long-term function and appearance.

Treatment of missing teeth

Treatment of missing teeth is an issue that can arise in many families. The missing teeth can be related to a genetic cause, a traumatic loss from injury, or breakdown from decay or infection. Each case of missing teeth will have unique characteristics based on the specific tooth that is missing.

Several things are considered when determining how to replace any missing teeth. Esthetic concerns will be different for a missing front tooth than for a missing back tooth. We can determine if there is enough space and bone available to support a replacement tooth. We will discuss the option to replace the missing tooth with a natural tooth or if an implant is a more ideal option. Most important is that we will work with an experienced team of specialists to provide a final result you can enjoy for a lifetime.

(Click this link for more orthodontic articles by Dr. Donna Stenberg.)

Donna J. Stenberg D.D.S., M.S., P.A., Spear Visiting Faculty and Contributing Author. djstenbergdds@gmail.com