Orthodontic Treatment

Who Is an Orthodontist?

Orthodontists are dental professionals who, after completing a five-year dental school program, have successfully completed a 4–6 year orthodontic specialty or doctoral training program and conducted a scientific thesis in the field of orthodontics. They are specialists in the application of functional jaw orthopedics, extraoral appliances, and fixed orthodontic (braces) treatments. Orthodontic treatments must be performed exclusively by orthodontists.

The term orthodontics originates from Latin, where “ortho” means straight and “donti” means tooth; therefore, orthodontics literally means “straight teeth.”. Orthodontics is a branch of dentistry concerned with the supervision, guidance, and correction of dentofacial (jaw and facial) structures in growing or adult individuals. It focuses on correcting irregularities by guiding tooth movement and modifying the relationships between teeth, jaws, and facial bones through controlled force application.

 Scope of Orthodontics

1.       Diagnosis, prevention, interception, and treatment of malocclusions.

2.       Design, application, and monitoring of functional and corrective orthodontic appliances.

3.       Guidance of teeth and supporting tissues to achieve ideal functional, physiological, and aesthetic relationships between facial and cranial structures.

 Why Do Orthodontic Disorders Occur?

1. Genetic factors:

In individuals with skeletal discrepancies, missing teeth, maxillary constriction, or dental crowding, the presence of similar anomalies in family members is significant.

2. Ear, nose, and throat (ENT) problems:

Conditions such as nasal septum deviation, adenoid hypertrophy, and mouth breathing can negatively affect jaw development.

3. Parafunctional habits:

Habits such as thumb sucking, cheek sucking, prolonged pacifier use, and tongue sucking—if not discontinued in a timely manner—can adversely affect jaw growth. Children with such habits should be closely monitored, and the habits should be eliminated as early as possible.

4. Early tooth loss:

Premature extraction of primary teeth due to caries without the placement of space maintainers may cause adjacent teeth to drift into the extraction space, leading to loss of space for the erupting permanent teeth. This may result in crowding and eruption problems.

 Common Orthodontic Disorders

Anterior open bite:

A condition in which posterior teeth are in contact while the upper and lower anterior teeth do not overlap, leaving a vertical gap between them.

Crossbite:

Normally, upper teeth should overlap the lower teeth. When this relationship is reversed, the condition is referred to as a crossbite.

Crowding:

Insufficient space within a dental arch or a specific region to allow proper alignment of the teeth.

Spacing (Diastema):

The presence of spaces between adjacent teeth, most commonly observed between the maxillary central incisors. Diastema is considered normal during the primary dentition stage.

Ectopic eruption:

Abnormal eruption of a tooth in a position other than its normal anatomical location.

Impacted tooth:

A tooth that fails to erupt and remains embedded within the jawbone, usually due to lack of space.

Lip incompetence:

Inability of the lips to adequately cover the teeth when the mandible is in a relaxed position.

Deep bite:

In ideal occlusion, the maxillary incisors should overlap the mandibular incisors by approximately 2–3 mm or one-third of the crown height of the lower incisors. Excessive overlap is referred to as a deep overbite.

Increased overjet:

An excessive horizontal distance between the maxillary and mandibular incisors when the teeth are in occlusion.

Rotation:

A condition in which a tooth is rotated around its long axis within the alveolar socket.

Transposition:

A positional anomaly in which two teeth erupt in each other’s normal positions.

Why Is Orthodontic Treatment Necessary?

Most patients seek orthodontic treatment primarily to improve their facial appearance and smile aesthetics. Orthodontic treatment enhances self-confidence by providing aesthetic benefits. However, many orthodontic problems also have significant implications for oral health. Crowded teeth are more difficult to clean, increasing the risk of dental caries and periodontal disease. Malocclusions may cause abnormal tooth wear. Orthodontic disorders can also lead to temporomandibular joint disorders, as well as head and facial pain. Anterior open bite or spacing between anterior teeth may impair proper sound articulation, resulting in speech difficulties.

Types of Orthodontic Treatments

Orthodontic treatments are classified into four main categories:

1. Preventive orthodontic treatments

2. Interceptive orthodontic treatments

3. Corrective orthodontic treatments

4. Retention (stabilization) therapy

What Is the Ideal Age for Orthodontic Treatment?

In general, the ideal age for the treatment of dental irregularities is between 10 and 12 years, when the transition from primary to permanent dentition is nearly complete and the eruption of canine teeth occurs. However, in cases involving jaw-related problems and the elimination of harmful oral habits, early intervention is of great importance. Therefore, an orthodontic examination is recommended around 6–7 years of age, when fissure sealants (protective materials applied to the chewing surfaces of teeth to prevent caries) are typically placed.

Can Adults Receive Orthodontic Treatment?

Yes, adults can also undergo orthodontic treatment comfortably. Contrary to common belief, teeth can be moved at any age provided that the periodontal tissues are healthy. However, since early-detected anomalies offer a wider range of treatment options, early orthodontic evaluation of occlusion is highly recommended.

How Long Does Orthodontic Treatment Take?

Active orthodontic treatment typically lasts approximately 1.5 to 2 years. However, the duration may vary depending on the treatment modality, the patient’s age, and the level of patient compliance.

What Are Orthodontic Appliances?

The selection of orthodontic appliances depends on the type of malocclusion and the individual’s growth pattern. For this purpose, various removable and fixed appliances—applied intraorally and extraorally—are used in cases with skeletal discrepancies. For minor tooth movements, removable appliances may be sufficient. In cases without skeletal problems and with dental crowding only, fixed orthodontic treatments are generally preferred.

Fixed Orthodontic Treatment Options

Fixed orthodontic treatments are indicated in cases where there is no skeletal discrepancy or where skeletal correction is not feasible, but varying degrees of dental crowding are present. Fixed orthodontic treatments (dental corrections) are initiated after the eruption of all permanent teeth.

Brackets bonded to the teeth contain slots into which highly elastic or pre-bent flexible archwires are placed and ligated. These archwires guide the teeth toward their ideal positions. Springs and elastics may also be used as part of fixed orthodontic treatment.

Aesthetic Brackets

Many adult patients are hesitant to undergo orthodontic treatment due to the visible appearance of orthodontic appliances. Some may choose tooth extraction or porcelain crowns, which involve tooth reduction, as an alternative. However, orthodontic treatment preserves the natural tooth structure and provides a more aesthetic and biologically favorable outcome.

To address aesthetic concerns, tooth-colored ceramic brackets are used instead of metal brackets. These brackets have increased acceptance among adult patients, although their cost is relatively higher.

Precautions During Fixed Orthodontic Treatment

During the first week, temporary sores may develop on the inner cheeks, lips, or tongue. These usually resolve within 1–2 weeks as the patient adapts. Orthodontic wax may be used for protection.

Hard foods (such as green almonds, plums, apples, carrots, nuts, and chips) should be avoided. Sticky foods (gum, gummy candies) and carbonated beverages should not be consumed. Sandwiches and similar foods should not be bitten into directly but broken into pieces.

These foods may cause bracket debonding or wire breakage, leading to prolonged treatment duration.

Treatments with Removable Appliances

This treatment approach is typically applied before permanent dentition, during the primary or mixed dentition stages. The aim is to guide growth and development, ensure proper eruption of teeth within the dental arches, and establish correct dimensional relationships between the jaws.

Functional Appliances

Functional appliances are used during growth and development to guide jaw growth in cases of mandibular or maxillary deficiency or excess.

Extraoral Appliances

Appliances such as chin cups and headgear provide external support to increase or restrict jaw growth as required.

How Do Teeth Move During Orthodontic Treatment?

Orthodontic treatment is a biological process, and orthodontic tooth movement is a physiological phenomenon. When light, continuous pressure is applied to a tooth via fixed or removable appliances, the tooth moves within the alveolar bone. Bone resorption occurs on the pressure side, while new bone formation takes place on the opposite side. This coordinated process is known as bone remodeling, allowing the tooth to stabilize in its new position.

Who Is Not Suitable for Orthodontic Treatment?

Orthodontic appliances may not be suitable in certain medical conditions. In patients with blood disorders such as leukemia or hemophilia, special medical precautions are required prior to extractions. Orthodontic wires may be problematic in patients with recurrent aphthous ulcers. Orthodontic treatment options may also be limited in individuals with intellectual disabilities.

Decision-Making for Tooth Extraction in Orthodontics

If there is insufficient space to properly align the teeth, orthodontists may create space through tooth extraction or alternative space-gaining methods. Orthodontic treatments may therefore be extraction-based or non-extraction-based. The decision is made by the orthodontist, with facial aesthetics being one of the most important considerations. Extraction treatments may allow retrusion of the lips, while non-extraction treatments may result in lip protrusion.

Retention Phase

After orthodontic treatment, teeth tend to relapse to their original positions. To prevent this, teeth must be maintained in their corrected positions until bone and surrounding tissues fully adapt. Removable or fixed retainers are used for this purpose.

Removable retainers should be worn as instructed, potentially from 3 months up to 2 years or longer.

Fixed retainers (lingual retainers) consist of a thin wire bonded to the inner (lingual) surfaces of the teeth. The duration of retention is determined by the orthodontist based on the initial condition.

Orthognathic Surgery

Orthognathic surgery refers to surgical procedures performed to correct jaw and facial skeletal discrepancies and restore normal function. When developmental discrepancies of the jaws cannot be adequately treated with orthodontics alone, orthognathic surgery may be required. Depending on the condition, the jaws may be repositioned forward, backward, vertically, or laterally.

Oral and Dental Care During Orthodontic Treatment

·         Teeth should be brushed after every meal and snack.

·         Interdental and bracket areas should be cleaned at least once daily.

·         A fluoride mouth rinse should be used before bedtime.

·         Oral irrigators are beneficial.

·         Regular dental check-ups and orthodontic appointments must be maintained.

·         All removable and functional appliances should be worn as prescribed.

·         Hard and sticky foods should be avoided.

·         These measures help prevent caries, reduce appliance damage, and enhance treatment effectiveness.

Discomforts and Risks

·         Mild pain is common at the beginning of treatment and usually subsides within 3–4 days.

·         Temporary tooth mobility may occur and is normal.

·         Poor oral hygiene may result in permanent stains, caries, and periodontal disease.

·         Rarely, root resorption may occur.

·         Temporomandibular joint discomfort may develop.

·         Growth changes during or after treatment may positively or negatively affect outcomes.

Clear Aligner (Wire-Free) Orthodontic Treatment

With technologies such as Invisalign®, clear aligners allow correction of dental crowding without traditional braces. A series of custom-designed transparent aligners is changed every 1–2 weeks to gradually move teeth into the desired position. Aligners are nearly invisible, removable during meals, comfortable, and do not cause irritation. Suitability is determined by the orthodontist.

Lingual Orthodontics (Hidden Braces)

In lingual orthodontics, brackets are bonded to the inner (tongue-facing) surfaces of the teeth, making them invisible externally. Due to the anatomical variability of lingual surfaces, brackets are positioned using laboratory-based techniques and transferred using custom trays.

Recent advances allow laser scanning and fabrication of fully customized lingual brackets. Lingual orthodontics requires greater precision and expertise and has both advantages and limitations compared to conventional orthodontics.