Wednesday, February 14, 2018

Why would I need Braces for relatively straight teeth?

My teeth look straight, why do I need braces?


The trend in current general dentistry seems to be not to send patients to the Orthodontist unless their teeth are incredibly crooked or unsightly.  Unfortunately for patients, severe crowding is only a symptom of some other problem that was evident much earlier and may have been correctible (preventing crowding) much earlier and with less effort and certainly with more stable results.  Even worse, teeth in poor function sometimes can look very normal to the untrained eyes and yet be very detrimental to teeth.  Even straight teeth may need braces but unless a trained Orthodontist evaluates your bite, you may not know until it is too late.  And dentists just are not trained to the same level as specialists when it comes to functional development of the bite a as whole.  General dental offices are focused on the trees, not the forest as a whole.  Hygienists are trained even less; they are experts at cleaning the teeth but are not trained in facial development or early dental development to the level as a doctor or Orthodontist yet many times this may be the only professional that sees you at the check up for more than a minute.  Without a referral to an Orthodontic specialist, you may never know what they also cannot see.


“Even straight teeth may need braces but unless a trained Orthodontist evaluates your bite, you may not know until it is too late.”


For the purpose of brevity I will focus on one main type of a malocclusion Orthodontists see regularly that requires braces despite have teeth that appear straight: what we term the Class II Division II malocclusion.  This malocclusion is characterized by upper front teeth leaning backward blocking the lower teeth back.  This leads to crowding in the lower arch, a deepbite (where the lower teeth deflect off the upper teeth and keep erupting up toward (and sometimes into) the palate, heavy occlusion on front teeth and sometimes a retruded lower jaw.  An example of the Class II Division II malocclusion is shown below:


Note the backward tipped upper incisors and their effect on the lower teeth.  From age 6 to 12, these patient’s will grow into ideal overjet if we simply round out the upper arch and upright the incisors.  Without treatment, the bite continues to deepen and the lower jaw is dislocated distally (backward).


Since the lower jaw cannot come forward, these patients function backward into “Class II” malocclusion (the lines in the above photo should line up with each other but the lower jaw is pushed backward).  This leads to severe wear on front teeth as it dislocates the condyles to the back of the joint space increasing the chance of eventual chronic TMD/headaches.



Class II can be worse on one side; again the lines above should be coincident but as you can see the lower jaw is pushed backward not allowing the jaw to occlude or bite forward.


When the patient does bring her lower jaw forward into the center of her joint space (aligning the lines drawn in the two earlier pictures), the front teeth occlude too ealry (holding  the back teeth apart) causing the lower jaw to push backward (Class II); this hinders the actual growth of the mandible leaving patinet with a retruded chin (see below).


So the next question is:

What can this “Class II Division II malocclusion” lead to if left un-corrected?

Below you will see examples of patients with this malocclusion that were never treated and now have come to have their respective teeth corrected. 

Case 1.


This patient is in his mid-forties and after a lifetime of heavy contact due to backward tip of upper front teeth and over-eruption of lower teeth, he has experienced severe wear which has worn down through the enamel and well into his dentin.  It may take 10 to 20 years to get through the enamel, but once the opposing teeth reach the softer inner dentin of the tooth, the wear becomes very rapid sometimes reducing the tooth all the way to the gumline.  As is the case with this patient, we must restore the position of teeth to the correct angles and levels in preparation for full porcelain veneers.  At the current positions, there is no room to place veneers; they would simply break apart within the first week.


After 14mo in braces, the teeth have been “leveled” to the correct position and upper teeth have been uprighted outward to the correct angles.  Space is now available for porcelain restoration.


After braces and porcelain veneers; total treatment time 18mo.

Case 2.

Patient presents with severe long-term wear, through his enamel, due to lingual (backward) tipped upper incisors and a lifetime of functioning on his front teeth.  Note the “scrunched” face from a persistently decreasing vertical facial height.
Braces were used to re-open his bite, increase lower facial height and provide space for restorations.  The upper incisors were also uprighted to their correct angle (v. leaning backward into the bite).


Braces have been removed and restorations placed by his general dentist.  Occlusion is now restored with improved esthetics however the greater change is in the increase facial height making this patient look years younger even after nearly two years of treatment.


Now returning to the younger patient first pictured in profile at the beginning of this article, we can see that early correction of the backward tipped upper incisors allows the lower jaw to grow forward and the teeth to erupt into ideal function for a lifetime of normal occlusion:


Initial Photos with Class II occlusion and severe mandibular hypoplasia (note retruded mandible).  Early treatment was performed around age 8 to upright backward tipping (erupting) upper incisors and to expand the upper jaw to prevent constriction backward of the lower jaw.


Following early treatment to enhance mandibular growth and open space for permanent teeth and final alignment.  Note the marked improvement of the lower jaw years after the correction and the ideal fit of the teeth.
How can you tell your child may need braces despite having relatively straight teeth?
1.    See an Orthodontic Specialist; initial exams are almost always free and a specialist will be able to tell you very quickly whether treatment is recommended, why and most importantly, when to begin for the best outcome.
2.    Don’t just look straight at the teeth, look at your child’s profile when they are not paying attention to you; if the lower jaw is recessed significantly, you should see an Orthodontist (even if your dentist has not said anything; remember it is the Orthodontist that is trained to identify and correct the developing malocclusion.  Waiting can lead to more severe problems, possible loss of permanent teeth due to crowding, wear of teeth and even TMD/joint pain later in life.
3.    Look at your child’s teeth, if the upper front teeth are leaning back, your child needs to be seen by an Orthodontist.  You will also likely see crowding of the lower teeth and, as the your child gets older, the lower teeth will grow up and contact the palate behind the front teeth.
4.    If your child’s lower teeth are in front of the upper teeth you can figure treatment is needed and needed early; you should see the Orthodontist to discuss timing and options.
Remember that in these days of corporate advertising, false promises from clear aligners and television campaigns that stress looks without even mentioning function (that is a whole different article in itself!), function is far more important in the long run and teeth that are in ideal function always produce a great smile; unfortunately a “good looking smile” does not equate to ideal function.  Only a trained Orthodontist is going to have the years of experience and knowledge to give you a consistently great treatment plan and provide the most ideal outcome every time.
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at 


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