Smile

- It is aesthetically pleasing to show a lot of tooth (even some gum) when you are young
- The upper front teeth should follow the contour of the lower lip
- The upper front teeth should not be straight across or in a reverse smile line
- A reverse smile line is when the upper front teeth appear to curve away from the lower lip contour
- The soft tissue of the face, including the upper lip, decends with age & in some older people upper teeth don't show

 

Occlusal Plane

- The occlusal plane is a line across the occlusion
- The occlusal plane should be parallel to a line between the eyes (inter-pupillary line)
- If the occlusal plane is slightly tipped one can improve / mask it by bonding the front teeth on a slant
- If the occlusal plane is significantly tipped, upper and lower jaw surgery is required to fix it
- Upper jaw surgery is called a Le Forte I osteotomy
- Lower jaw surgery is called BSSO (Bilateral Sagittal Split Osteotomy)

 

Centre Lines

- It is more important aesthetically to keep the upper dental centre-line in the middle of the face
- We would accept a lower centre-line which is a little bit off due to lower jaw assymmetry or L to R tooth size discrepancies
- If the lower centre-line is more than 3mm we usually recommend jaw surgery to correct this
- It is aesthetically important to make the centre-line between the upper front teeth (the connector) vertical and not slanted
- Studies have shown that as long a the connector is vertical a centre-line discrepancy of up to 2-3 mm is not distracting

 

Inadequate display of Upper teeth

- We like young people to show at least the full upper incisor when smiling (even some gum)
- On talking (saying EMMA) with a serious face, the upper front teeth should ideally show at least 3 mm
- As we age the lips and cheeks descend and progressively less of the upper teeth are visible on talking and smiling

 

Excessive display of gum

- This can be because the upper jaw has grown down too much
- This can be because of a short upper lip
- If the gum is nice and pink and healthy this can be acceptable
- Young people with gummy smiles often have perfect smiles as older people
- The upper lip and soft tissue around the mouth descends with age

 

Concave profile (young person)

- This is when the upper and lower lips are behind a line connecting the tip of the nose and most forward point on the chin
- This is indicative of a prominent chin and retrusive teeth and lips

 

Concave profile (adult)

- This is when the upper & lower lips are behind a line connecting a point halfway along the lower border of the nose and the most forward point on the chin
- This is indicative of a prominent chin and retrusive teeth and lips

 

Convex profile (young person)

- This is when the upper & lower lips are ahead of a line connecting the tip of the nose and most forward point on the chin
- This is indicative of an underdeveloped lower jaw or chin

 

Convex profile (adult)

- This is when the upper & lower lips are ahead of a line connecting a point halfway along the lower border of the nose and the most forward point on the chin
- This is indicative of an underdeveloped lower jaw or chin

 

Paranasal depression

- This is usually associated with an upper jaw which has grown too little
- Correcting this involves either a Le Forte I osteotomy to advance the upper jaw or onlay grafting or injectable fillers
- Onlay grafting is not very commonly done but is a surgical option
- Injectable fillers need to be repeated every few years but can be a useful aesthetic option

 

Naso-labial angle

- This is the angle between the lower border of the nose and the upper lip
- In Causasoid male profiles this angle is usually most aesthetically pleasing at about 90-100 degrees
- In Causasoid female profiles this angle is usually most aesthetically pleasing at about 100-120 degrees in women
- In Mongoloid (Chinese and Japanese) & Negroid profiles this angle is usually most aesthetically pleasing at less than 90 degrees

 

Class I malocclusion

- The upper incisors, canines, premolars or molars biting correctly relative to the lower teeth

 

Class II malocclusion

The upper incisors, canines, premolars or molars are more forward relative to the correct bite with the lower teeth

 

Class III malocclusion

The upper incisors, canines, premolars or molars are more backward relative to the correct bite with the lower teeth

 

Class I skeletal pattern

- The upper and lower jaws are growing or have grown at the same rate horizontally
- Skeletal class I patients can have class I, II or III type malocclusions

 

Class II skeletal pattern

- The lower jaw is growing or has grown slower than the 'normal' upper jaw
- Sometimes it is the upper jaw which is growing or has grown faster than the 'normal' lower jaw

 

Class III skeletal pattern

- The lower jaw is growing or has grown faster than the 'normal' upper jaw
- Sometimes it is the upper jaw which is growing or has grown slower that the upper jaw

 

Skeletal Deep Bite

- This is associated with a square face, a deep bite, powerful jaw muscles and bruxing
- This is also called Brachyfacial or Hypodivergent
- There is usually an associated short lower face height

 

Skeletal Open Bite

- This is associated with a longer, narrow face, an open bite, weak jaw muscles and mouth breathing
- This is also called Dolichofacial or Hyperdivergent
- There is usually an associated increased lower face height

 

Dento-alveolar deficiency

- This is when the tooth bearing part of the lower jaw is retrusive but the chin is prominent
- In these patients the lower face height is usually decreased (this nose to chin height decreases further with age)
- Correcting this involves a BSSO to advance the lower dentition with opening rotation into a correct bite
- At the same operation a reduction genioplasty is necessary to shift the chin back so that it is not too prominent
- This combination of surgical procedures obtains the correct lower lip fullness and the correct lip-chin-throat angle

 

Lip-chin-throat angle

- If this angle is too obtuse the chin is receding
- If this angle is too acute the chin is too prominent

 

Unilateral Condylar Hyperplasia

- This is when one side of the lower jaw has grown more than the other
- UCH is thought be caused by an early bump to the jaw during early childhood
- This trauma causes more cartilage to be formed during on the side that got more injured
- This increased amount of cartilage then forms more bone on that side than the other
- Unfortunately, this usually gets worse with growth
- This assymmetric growth will sometimes continue for a number of years after the end of general body growth
- If the assymmetry is a functional or aesthetic problem then upper and lower jaw surgery may be recommended later

 

BSSO - end of growth

- Surgical repositioning of the lower jaw may be necessary at the end of growth (Bilateral Sagittal Split Osteotomy)
- However, patients may choose to not do this operation and rather live with an imperfect bite and / or an imperfect bite
- Patients choosing not to do jaw surgery will need more retainer wear over the years because the bite will be less stable
- Impacted wisdom teeth can usually be removed at the same operation
- See Treatment information Surgical Orthodontics

 

BSSO

- Surgical repositioning of the lower jaw may be necessary (Bilateral Sagittal Split Osteotomy)
- However, patients may choose to not do this operation and rather live with an imperfect bite and / or an imperfect bite
- Patients choosing not to do jaw surgery will need more retainer wear over the years because the bite will be less stable
- Impacted wisdom teeth can usually be removed at the same operation
- See Treatment information Surgical Orthodontics

 

Le Forte 1 - end of growth

- Surgical repositioning of the upper jaw may be necessary at the end of growth
- However, patients may choose to not do this operation and rather live with an imperfect bite and / or an imperfect bite
- Patients choosing not to do jaw surgery will need more retainer wear over the years because the bite will be less stable
- Impacted wisdom teeth can usually be removed at the same operation
- See Treatment information Surgical Orthodontics

 

Le Forte 1

- Surgical repositioning of the upper jaw may be recommended after 12-15 months of orthodontics
- This upper jaw surgery can improve the display of upper teeth by making them more or less prominent
- A Le Forte I osteotomy can shift the upper jaw forward, upwards or downwards
- However, patients may choose to not do this operation and rather live with an imperfect bite and / or an imperfect bite
- Impacted wisdom teeth can usually be removed at the same operation
- Patients choosing not to do jaw surgery will need more retainer wear over the years because the bite will be less stable
- See Treatment information Surgical Orthodontics

 

Genioplasty

- This is a surgical procedure to enhance the shape of the chin and is often done at the same time as BSSO or Le Forte 1
- A reduction genioplasty corrects a chin which is too prominent
- An advancement genioplasty corrects a chin which is too short
- The genioplasty can also increase or decrease the height of the chin as necessary for the ideal aesthetics

 

Diastema

- This is a gap between the upper front teeth due to an incorrectly inserted maxillary midline labial frenum
- This frenum is the piece of mucosa which attaches the upper lip to between the top front teeth
- This should not be attached between the teeth but rather a few mm away from the gum between the teeth
- This may require a frenectomy to be performed during or after treatment - to be reassessed

 

Frenectomy

- This is when the piece of mucosa (frenum) which attaches the lip to the upper jaw is attached incorrectly
- This should not be attached between the teeth but rather a few mm away from the gum between the teeth
- Frenectomies are usually done when necessary during treatment or sometimes later when the wisdom teeth are removed
- We want to see the patient about 5-10 days after the frenectomy to activate for space closure (if there is a diastema)

 

PAOO

- Periodontally Accelerated Osteogenic Orthodontics is an excellent but expensive surgical procedure (about R60 000)
- PAOO stimulates bone formation around the roots of the teeth and allows the teeth to move much faster
- Patient to book a consultation with Dr Andreas Siebold (tel: 011 486 1630) and get a date for the PAOO procedure
- Braces are placed 1 week before the PAOO
- Orthodontic appointments usually every 2-3 weeks are necessary to make use of the fast tooth movement

 

TADS

- Temporary anchorage devices (bone screws or miniplates) may be recommended during treatment
- These are usually inserted by a MFOS surgeon or a Periodontist
- The cost of TADS is additional and not included in the orthodontic treatment

 

TMJ

R&L temporo-mandibular joints have opening / closing clicks / pain

 

Bruxing

- Lower incisor edges are worn from grinding or clenching the teeth (usually while sleeping)
- All habits depend on the sensation elicited by the habit to trigger that part of the brain causing the habit action to start
- Intermittent retainer wear will be recommended after treatment to 'confuse' the habit by continually altering the sensation
- The Temporomandibular joints are not supposed to be loaded for more than 17 minutes per day
- Grinders and clenchers will typically do this destructive habit for many hours a day (usually while sleeping)
- Bruxing which is not managed may lead to TMD. Click here to learn more about TMD. 

 

Headache

- Headaches may be triggered by TMJ problems but orthodontic treatment will not necessarily cure the headache
- So orthodontics is not recommended for headaches unless you want straight teeth

 

Tongue-scraper

- This is recommended to all patients to scrape the decomposing dead cells, plaque and mucous off your tongue each morning
- This debris causes halitosis and tooth decay and is not efficiently or effectively removed with a toothbrush

 

Sinusitis

- Most sinusitis is caused by GERD - We recommend that you avoid carbohydrates at night
- Carbohydrates cause small intestinal bacterial overgrowth, gas production and acid reflux

 

Throat Inflamed ? GERD

- Gastroesophageal reflux disorder is suspected because the throat is inflamed - avoid eating carbohydrates after lunch-time
- Carbohydrates cause small intestinal bacterial overgrowth, gas production and acid reflux

 

Throat and tonsils ? GERD

- Gastroesophageal reflux disorder is suspected because the throat is inflamed - avoid eating carbohydrates after lunch-time
- Carbohydrates cause small intestinal bacterial overgrowth, gas production and acid reflux

 

Mouth breather

- For an hour a day hold a pen between the lips forcing yourself to breath through the nose
- This is to train yourself to keep the lips together and avoid mouth-breathing which is very unhealthy
- Click here for more information on the problems with mouth-breathing

 

Tongue-press-swallow

- 4 x per day dissolve then swallow using a Xylitol peppermint eg Smint against your palate with your tongue
- Concentrate on allowing no contact between the tongue and teeth - this trains you to swallow correctly
- Swallowing incorrectly causes severe orthodontic problems (one swallows about 2500 times per day)

 

Thumb / finger sucking

- Thumb sucking is very bad for the teeth - a dummy is preferred because it can be thrown away
- Only when people want to stop sucking their thumb can we help them
- This is not age-appropriate behaviour - offering to buy a dummy which is less harmful could be a reminder of this
- The patient must be aware that it is unhygienic unless the hands are washed and the nails scrubbed before sucking
- Hopefully the hassle of cleaning hands and the awareness of the "dirty habit" will help stop the habit
- Wrap non-elastic gauze bandage loosely around the elbow at night so that keeping the elbow bent is uncomfortable

 

Pontic

- A false tooth (pontic) will be placed on the braces during treatment where there is a missing front tooth
- We will glue the false tooth into the gap after the braces are placed (when there is sufficient space)
- This false tooth called a (pontic) is a temporary measure during orthodontics
- This pontic will usually remain until your dentist can make a Maryland bridge after treatment
- Your dentist will manage the Maryland bridge until about age 18 when an implant or a permanent bridge can be made

 

Reshaping teeth

- This is a routine procedure performed to a greater or lesser extent on nearly every patient
- It is called interdental odontoplasty or stripping when performed to improve the contact points between the teeth
- It is called morphologic odontoplasty when performed to improve the general shape of the teeth
- It is often performed on teeth that are too triangular to eliminate dark triangles between the necks of the teeth
- A significant amount of space is often created by this procedure, often eliminating the need for tooth extraction

 

Diagnostic composite buildups

- During treatment some teeth may be built up with a tooth coloured material to an ideal shape (no charge)
- After treatment your dentist will either maintain these composite buildups, redoing them every few years as necessary
- Alternatively, your dentist may decide to place porcelain veneers or crowns

 

Overbite (vertical overlap)

- The ideal amount of vertical overlap of the front teeth is about 2mm
- We intentionally make this more if we can in class III problems

 

Overjet (horizontal overlap)

- The ideal amount of horizontal overlap of the tip of the top teeth over the bottom teeth is 2mm
- The part just behind he tip of the top tooth contacts the lower incisors
 

 

RC- IC discrepancy

- This is where the bite of comfort (IC) doesn't coincide with the best fit in the TM joint (RC) resulting in 2 different bites
- IC (maximum intercuspation) is where the teeth fit best - in this bite of comfort the jaw joint is in the incorrect position
- RC (retruded contact) where the TM joint is in the 'home' position but the teeth don't fit together nicely
- Patients must learn how to check their own bite in RC
- This is done by biting on back teeth with the tip of the tongue far back on palate and the head tipped backwards
- This RC-IC discrepancy is sometimes very difficult to detect and may only be discovered after some months of treatment
- This can sometimes lead to a different treatment plan being recommended if it is only discovered during treatment
- For example a patient who has an RC-IC discrepancy of more than 3 mm may need jaw surgery at the end of growth
- Jaw surgery is a choice and some patients choose to rather live with an imperfect bite and or profile

 

Edge-to-edge bite

- This is when biting edges of the upper front teeth bite directly onto the biting edges of the lower front teeth
- This is unfavourable and leads to excessive wear of the incisor edges
- An edge to edge malocclusion prevents normal incisor guidance during chewing

 

Incisor guidance

- With the correct vertical overlap of the front teeth, the back teeth will be protected from contact when protruding the lower jaw slightly
- This is thought to be necessary for correct chewing patterns and TM joint function

 

Bolton discrepancy

- This is when the lower 6 front teeth are relatively too large for the upper 6 front teeth
- In such cases the upper teeth can be made larger with composite buildups during treatment & with crowns or veneers later
- Alternatively, the lower teeth can be made smaller with tooth reshaping
- Another option is to extract a single lower incisor to make up for the fact that the lower incisors are relatively too large

 

Canine guidance

- If one slides the lower jaw slightly to the right or left only the upper and lower canines should touch
- This is thought to be necessary for correct chewing patterns and TM joint function

 

Buccal crossbite

- This is when an U premolar or molar is displaced towards the cheek or its opposing tooth is displaced towards the tongue
- This displacement is so great that the inside cusp of the U tooth is biting outside the outside cusp of the L tooth

 

Posterior crossbite

- This is when the upper back teeth bite inside the lower back teeth instead of being slightly wider than them
- Crossbites disallow normal muscle sequencing during chewing and can lead to TM joint problems

 

Dental Deep Bite

- The vertical overlap between the front teeth is excessive
- This is usually associated with a bruxing habit

 

Anterior crossbite

- This is when the any of the upper front teeth bite behind the lower front teeth instead of slightly ahead of them
- Crossbites disallow normal muscle sequencing during chewing and can lead to TM joint problems

 

Anterior Open Bite

- The upper front teeth do not overlap the lower front teeth
- This is associated with a tongue-thrusting habit

 

Lateral Open Bite

This is when the back teeth are separated when the front teeth are biting - usually caused by a lateral tongue thrust

 

Lateral tongue thrust

This is when the tongue is pushed between the back teeth during swallowing instead of up against the palate

 

Frontal tongue thrust

This is when the tongue is pushed forward between the front teeth during swallowing instead of up against the palate

 

Attached gingiva

- The same type of thick pink gum which covers the hard palate should also form a collar around every tooth
- When the gum around the teeth is thin, this leads to recession especially if brushing is too aggressive or not good enough
- We may recommend that a periodontist does a gum graft from the palate, usually after the teeth are aligned

 

Thin Biotype

- This is when there is less bone around the roots of the teeth than is ideal
- Perfect oral hygiene with flossing & not smoking is essential to prevent the bone and gums receding and the teeth becoming loose
- We may need to refer this problem to a periodontist if it becomes worse

 

Gingivitis

- The gums around the teeth should be pink - red gums are a sign of infection from the bacteria in plaque
- The gums should make sharp thin points between the teeth - swollen and rounded gums are a sign of infection (gingivitis)
- Overgrowth of the gum due to plaque (gingival hyperplasia) - this may need to be cut back with laser during treatment
- Gingivitis will usually cause the gums to bleed on flossing
- Gums are tough - one week of excellent brushing and flossing should make them healthy again

 

Periodontal disease

- Incorrect brushing and flossing over the years has caused the bone support of the teeth to be eroded
- Regular deep scaling and root planing every 2-3 months during orthodontic treatment is the mininum treatment required
- This regular deep scaling and root planing where recessary should continue indefinitely
- In some cases the most ideal treatment is PAOO because this gives the bone and gum the best chance of good health

 

Geographic tongue

- This is a relatively common, harmless condition of unknown cause
- The tongue has changing (migrating) areas of inflammation of the tongue with the loss of tongue papillae
- These reddish areas have a map-like appearance and sometimes there is a burning sensation
- There is no predictable treatment or cure but may be triggered or worsened by certain foods
- RInsing with salt water (1 teaspoon of salt in a cup of warm water) may help prevent infection
- Antihistamines or topical anaesthetics may give temporary relief

 

Decalcification

- This usually manifests as white marks in the tooth enamel near the gum margin from poor or imperfect brushing
- The acid generated by the plaque leaches the Calcium out of the tooth and makes it rough and weak.
- This decalcified enamel retains plaque more easily and over time becomes a cavity
- With excellent brushing and flossing these areas can remineralise and become stronger but the white mark remains
- To remove the white mark the dentist would need to do a tooth-coloured composite or glass ionomer filling

Rationale for treatment

- Orthodontic treatment has long term functional benefits for the occlusion, the temporomandibular joint and the periodontal structures
- Well aligned teeth are easier to brush and floss properly resulting in fewer cavities over the years
- The occlusal forces are better distributed when there is a harmonious relationship between the teeth and the temporomandibular joint
- Teeth which are upright are less likely to develop periodontal pockets and bone loss which are features of periodontal disease

 

Decreased Lower Face Height (LFH)

- The tooth-bearing part of the lower jaw is underdeveloped and overclosed
- The lower face height is too short and this becomes shorter with age
- So the distance from chin to nose is too short and gets shorter with age
- Jaw surgery can correct this
- In most cases lower jaw surgery (BSSO with opening rotation) can resolve the problem
- In some cases both the BSSO and upper jaw surgery (Le Forte I with downgraft or downsliding advancement) are needed

 

Increased Lower Face Height (LFH)

- The lower jaw has grown too much vertically
- The lower face height is increased
- So the distance from chin to nose is too long and that makes it difficult to keep the mouth closed
- Jaw surgery can correct this
- In most cases both lower and upper jaw surgery are needed
- These operations are called BSSO with closing rotation (lower jaw) & Le Forte I with vertical impaction (upper jaw)

 

How to wear retainers

Retention appliances should be worn as follows:

  • For the first week: Full time, except when eating, drinking and brushing
  • For the second week: Afternoons & nights
  • Thereafter for the first year: sleeping hours at night
  • From the second year: every second night
  • It is very important to keep checking the retainers and to wear them as necessary for the rest of your life, whenever they start feeling tight
  • Should your retainer break it is very important to contact us to arrange for a new one to be made


CLEANING OF RETAINERS

  • Wash retainers in cold water using soap or diluted
  • Sunlight liquid Sterident can also be used but only with cold water

 

Minor apthous ulcer

- About 20% of the population are affected and ulcers usually recur 3-6 times per year
- The cause is not completely understood, but involves a T cell-mediated immune response triggered by a variety of factors.
- Different individuals have different triggers, which may include nutritional deficiencies, local trauma, stress, hormonal influences, allergies, genetic predisposition or other factors.
- These ulcers usually last about 2 weeks regardless of what treatment is attempted
- The patient usually notices them after about 1 week when they are most painful
- Rinsing with a teaspoon of salt in a glass of warm water at least twice a day will help to prevent bacterial infection
- Some people find Kenalog in orabase applied topically to be useful

 

SYNERGY

- This is our preferred labial (outside braces) appliance
- Depending on how we engage the bracket it can be made active or passive
- When all 3 wings of the bracket are engaged the bracket is active and will not slide easily along the archwire
- When only the middle wing is engaged the bracket is passive and will slide easily along the archwire
- This is called differential resistance and allows us to allow some teeth to move faster than others

 

EMPOWER

- This is a tooth-coloured bracket with a matt silver Nickel-titanium clip
- We find this to be the best tooth-coloured bracket because it does not discolour as most other types do

 

LINGUAL

- In this approach the bracket is placed behind the teeth in the upper jaw
- Lingual in the lower jaw is uncomfortable and inefficient and we do not ever do lower lingual
- Instead tooth-coloured brackets on the front 6 teeth in the lower is usually recommended
- We used to use the lingual approach in most of our patients until about 8 years ago
- Technological advances in outside braces makes them superior now in most cases

One of the reasons to choose Invisalign treatment is because it is a less invasive approach to straightening teeth. 

- In this approach a new clear aligner called Invisalign is provided each week which moves the teeth 0,25 mm per week ie. 1mm per month
- Recent advances have made Invisalign superior to normal braces in many cases
- A higher level of patient motivation, cooperation and self-discipline is required
- The major problem with Invisalign is the USD 2600 extra cost involved

 

Canine substitution

- This is when the lateral incisors are missing and we reshape the canines to look like lateral incisors
- In the near and long term, natural teeth look better in the front of the mouth
- Implants are better at the back of the mouth because over time the gum and bone recedes exposing the neck of the crown on the implant
- Reshaping and composite buildups of the upper 4's to look like canines - implants will be placed in the upper first premolar position at about age 18 years
- The alterative approach is creating space for the upper lateral incisors and placing false teeth there, which is less aesthetically pleasing long term and more of a nuisance for the patient

 

Canine expose and bond

- This is when the canines are impacted and need to be surgically exposed and bonded
- This surgical exposure and bonding is usually done by a MFOS (Maxillo-Facial and Oral Surgeon)
- This is usually done under general anaesthetic
- Some dentists will do this exposure themselves, sometimes under local anaesthetic if the canines are not too deep
- If the canines are superficial with only some gum covering them, we can do this exposure in the chair using a laser
- It can sometimes take a year or more to bring difficult canines down
 

 

Unfavourably impacted canines

- Sometimes when the surgeon surgically exposes the canines they detect unfavourably impacted canines
- Unfavourable impactions are when the canine is ankylosed (fused to the bone), or touching the roots of the upper incisors
- Bringing down canines which are touching the incisor roots has a high risk of damaging the incisor roots by root resorption
- It is better to remove unfavourably impacted canines rather than risk damaging the incisor roots
- Ankylosed canines should be removed
- It is not possible to accurately predict whether or not a canine is ankylosed
- Sometimes when tapping the tooth with a mirror handle it has a ringing sound different to a tooth which is not ankylosed
- If the canine doesn't move we know it is ankylosed and needs to be surgically removed at a 2nd operation

Root resorption

- This is when the roots of the teeth are resorbed by the body and become shorter or narrower
- Root resorption often occurs spontaneously for unknown reasons
- Upper lateral incisor roots are often resorbed by the follicle of the erupting permanent canines if there is insufficient space
- Root resorption often occurs
- Thin and curved root tips sometimes become shorter during treatment but this is very rarely a problem

 

Ectopically erupting canines

- This is when the permanent canines are not erupting below the baby canines
- The follicle is the tissue surrounding the crown of the erupting permanent canines
- The cells of the follicle normally resorb the roots of the baby teeth to make them fall out
- If the follicle is touching the roots of the permanent teeth, permanent roots can be damaged by this process
- Creating space usually allows the ectopically erupting canines to move into a more favourable position

 

Premolar substitution

- This is when the canines are missing and we choose to move the premolars into the canine position
- Depending on the smile line, an implant in the canine area may develop an unattractive gum margin, sometimes years later
- The premolar is then intruded to create a canine-like higher gum contour
- The crown of the premolar is reshaped to resemble a canine by reducing the inside cusp
- The more visible outside cusp is built up with composite to resemble a canine
- The dentist may later recommend a crown or a veneer on the premolar to make a more perfect canine shape
- If this is done an implant is placed in the premolar area

 

Opening rotation of the maxillo-mandibular complex

- This is when a Le Forte I and BSSO osteotomies are performed together to increase lower face height (LFH)
- The Le Forte I can be downgrafted using a iliac crest (hip) bone graft or
- The Le Forte I advancement is at a downward sliding angle to increase the upper jaw height
- The simultaneous surgical opening rotation of the lower jaw (BSSO) completes the increase in LFH
- This procedure is particularly useful when one doesn't wish to increase the chin prominence

 

Nail biting

- Nail biting is extremely damaging to the teeth
- Nail biters tend to break their braces much more often than normal
- The patient must be aware that it is unhygienic unless the hands are washed and the nails scrubbed before nail biting
- Hopefully the hassle of cleaning hands and the awareness of the "dirty habit" will help stop the habit

 

Leeway space

- This is the difference in size betweeen the larger baby molars (E's) and the smaller 2nd premolars (5's)
- If one starts braces immediately after these baby molars are removed we get to use this extra space
- This space is normally lost due to mesial drift
- Mesial drift is the natural tendency for back teeth to drift forward if there is space

 

Mouth Breathers


There are a number of problems with habitual mouth-breathing (see below) but the problems relating directly to teeth are as follows:
 

  • Teeth lie in what is called the NEUTRAL ZONE where the average pressure from the tongue and lips are equal. Often patients with open bites have their lips apart and this contributes to relapse, since the teeth are pushed forward and apart.
     
  • As soon as the lips part, the tongue drops down from the palate. The tongue in fact forms and supports the shape of the palate but in mouth-breathers the tongue isn’t supporting the palate so the cheek muscles push the back teeth inwards, creating a narrow upper arch and high palate.
     
  • Mouth breathers tip their heads backwards, to maintain an open airway and this is thought to contribute to the development of the malocclusions associated with the Long Face Syndrome and Adenoidal Facies appearance.

    An essential exercise for mouth breathers is called LIP-PEN where for an hour a day, while watching TV or reading you hold a pen (sideways) between your lips to ensure nose-breathing and strengthen the lip muscles.
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