Contemporary Orthodontics & Dentofacial Orthopedics
James
R. Waters,
DDS, MSD , PA
Board Certified Treatment for Children, Teens and
Adults
Why am I having to re-treat my previous
braces?
Everyone has heard about teeth moving following a course of
braces; either immediately following correction or later following the
retention period. It is easy to think
there was a problem somewhere that has led to this later movement such as
improper treatment, removing braces too early or not wearing the retainer long
enough.
Assuming true braces (and not an inferior clear aligner
treatment), there are many reasons we see movement of the teeth following
alignment and correction of a malocclusion.
Looking beyond the simple causes such as not wearing retainers or not
finishing treatment to completion (leaving the teeth fitting poorly in an
unstable position), we must realize that teeth are in a growing and changing
environment. A recent article by a
well-known and respected Orthodontist points out that no one expects a crown to
last forever; filings have to be replaced just as gingival tissue continues to
change as we age possibly requiring grafting or replacement of teeth.
“no one expects a crown to last forever; fillings have to be replaced
just as gingival tissue continues to change as we age possibly requiring
grafting or replacement of teeth.”
In fact, no other doctor (whether it be a Dermatologist or
Cardiologist) expects a static patient as we age; Orthodontists should know how
to predict changes and realize there may be future refinements along the way to
maintain the best occlusion as we age thus providing reasonable expectations and
an opportunity for patients to have a beautiful and functional smile for a
lifetime.
First, we must recognize that our teeth ultimately stabilize
within a natural but unique equilibrium to each individual. Muscles act on the teeth from the outside
(the cheeks) and from the inside (the tongue), habits affect muscles (tongue
thrust, chewing on cheeks), breathing and airways affect muscles (mouth
breathing, seasonal/chronic allergies, sleep apnea), the underlying
relationship and size of jaws to each other and relative to the cumulative size
of the teeth, etc., etc. As
Orthodontists, it is our training and responsibility to place the teeth in the
best alignment with each other, with the jaw bones, with the opposing occlusion
and over the long axis of the roots and we must take into consideration the
timing of when certain aspects of a near-perfect occlusion must be
accomplished. Much has been discussed
both in offices and online between friends/bloggers about “Phase Treatment” but
most people miss the bigger picture.
“… teeth ultimately stabilize within a natural but unique equilibrium
to each individual.”
Treatment can be broken down into several Phases:
There is the time during growth when the jaw size can be
manipulated to either restore deficiencies in size through palatal expansion
(with a fixed expander, not a removable retainer that only tips teeth) and by
altering the early forces affecting jaw development between ages 6 and 10. This is why early treatment (Phase I) may be recommended for some
patients since the size of the bone will affect how the teeth (whose sizes are
fixed) will fit in each arch. Early
treatment also allows us to change the relationship of the jaws to one another;
after all if the lower jaw is half a tooth forward relative to the upper after
growth subsides, then no matter what we do in the future the lower teeth will
be too far forward leading to latent crowding of the lower incisors, spacing in
the upper incisors or severe wear of the incisors (not to mention increased
prevalence of TMD). Early treatment,
when necessary, places the foundation of the teeth and future occlusion in a
more ideal relationship. This is the
reason for fewer extractions in modern orthodontics and how cases previously
treated with surgery can now be controlled or even corrected with early
appliances.
“Early treatment, when necessary, places the foundation of the teeth
and future occlusion in a more ideal relationship.”
The next time to consider is the completion of the permanent
dentition, usually from age 11 to 13.
This is the traditional time for braces when actual alignment and
fitting of the teeth takes place usually termed Phase II. Assuming the jaws
are correct in size versus the size of teeth and the upper to lower jaw
relationship is correct, then the teeth will generally fit well and any
correction will be stable. If the
equilibrium or balance is disrupted during the eruption of teeth (even if the
jaws are corrected), we can still have problems; consider losing a baby molar
too early and the space closes before the next tooth can erupt. Or consider when a permanent tooth doesn’t
push the baby teeth out and “deflects” sideways (then the adjacent teeth
collapse around the shifted tooth and so forth). Braces are used to correct these issues and
align teeth into an ideal occlusion. If
the teeth are too far off due to poor foundations/jaw relationships, then we
have to consider removal of permanent teeth to gain space or even surgery to
re-set jaw positions.
Retention
following braces should do several things.
First, it allows the Orthodontist to hold the correction as bone
re-forms solid around the roots of previously moved teeth. Second it allows the teeth to “settle” into a
tighter occlusion when retained with typical wire and acrylic retainers (clear
aligners prevent this settling which is why I only use them as temporary
retainers for patients’ special occasions).
Third, it allows us to slowly, with control, walk the patient down from
full retention to night-time retention and down to occasional wear while
monitoring stability and any remaining growth.
I typically watch all patients for 2 years following removal of
appliances; wear of the removable retainers is 6mo full-time, 6mo PM only and
then 6 to 12mo 3Pm/week down to 1PM/wk.
After that I base further wear on stability and growth during the first
2 years.
So can teeth still move? Does it happen everytime? How much is normal?
All great questions but we as Orthodontists must resist a
definitive answer. It is safe to say
that a patient that has been treated on a life-long plan starting with early
intervention (or simple evaluation if development is good from the beginning)
followed by alignment of teeth as an adolescent which is then retained properly
as teeth are allowed to settle will have the most stable bite possible for that
individual patient. Muscle forces,
breathing obstructions, tongue activity and adverse (to the teeth) growth will
all still act on the occlusion and alignment but the better the fit and foundation, the more stable to resist long-term
forces.
After years however, we can expect that the equilibrium may
change leading to a late cascade of forces that can move otherwise stabilized
teeth. If movement is slight, simple
refinement can be performed with limited appliances or even clear aligners
(assuming compliance did not contribute to movement). If movement is more significant, it might
favor a more in-depth evaluation of the jaw relationships or tooth sizes which
may suggest a different course of correction (extraction of teeth due to a
tooth to bone size discrepancy or more definitive treatment to move roots with
true braces if clear aligners were initially employed). Patients can lose supporting tissue/bone over
time which allows muscles to shift what would have otherwise been solid teeth;
teeth can be lost or loosened from trauma affecting the forces on adjacent
teeth and so forth.
The point is that your teeth are a part of a living and
changing system, just as your skin, your circulatory system and your muscular
system. We all will change as we age and
it is unreasonable for either the Orthodontist of the patient to expect these
natural changes won’t have an effect on our teeth in some way, sometimes to the
point of wanting to refine a previously corrected bite. This should not deter one from treating just
because they did not go through any early efforts to align jaws; instead it
should help to set expectations and guide long-terms efforts to maintain (and
refine as necessary) a great smile throughout life. If both the patient and Orthodontist work
together for a long-term goal, there is no reason every patient should not be happy
with their smile no matter what changes may occur.
“your teeth are a part of a living and changing system … we all will
change as we age and it is unreasonable … to expect these natural changes won’t
have an effect on our teeth in some way”
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.
Dr. Waters and his wife of 20 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
BracesAustin.com.
Central Austin
1814 W. 35th
Street
Austin, TX 78703
(512) 451-6457
Steiner Ranch
4302 N. Quinlan Park
Austin, TX 78732
(512) 266-8585
BracesAustin.com
No comments:
Post a Comment