WRITTEN BY Katie Graber, DDS
In other words, for the rest of this year and 2007 and beyond, what can an orthodontist offer to your patients? In dental school, we all learned that our main purpose as dental health care professionals was to fight the two diseases of dentistry - dental caries and periodontal disease. As a practicing dentist, one quickly learns that this is only a small portion of the practice. Many times we are focusing on long-term patient management, rehabilitation of deteriorated occlusions, and restoration of dental esthetics. The challenges of management of dental trauma, congenital absence of teeth, and tooth size asymmetries are important considerations in comprehensive treatment planning.
So, as dentistry has expanded in focus, has orthodontics? The easy answer is yes, but how has orthodontics changed and what does it mean for today’s dental practitioner?
Now, more than ever before, the orthodontist can be (and is) a part of the comprehensive dental care for patients of all ages. We’ll focus on three areas - orthodontic appliances, interdisciplinary esthetic dental care, and communication technology.
➊ New technology incorporated into the design of orthodontic appliances makes routine treatment outcomes better.
In the last 30 years, there have been major advances in the field of orthodontics. These have included bonding teeth vs. banding, advanced metallurgy of wires, and, more recently, low-friction/low-force appliances and temporary anchorage devices. Appliances have been bonded to teeth since the early 1970s. Metallurgy advances began in the late 1970s and took another jump in the late 1990s. Since the millennium, worldwide use of low-friction appliances and temporary anchorage devices has grown.
Low-friction appliances allow the orthodontist to move teeth with less force than traditional orthodontic brackets. Lighter forces often mean less discomfort and faster tooth movement. In coordination with the advanced metallurgy (nickel titanium wires with shape memory), appointment intervals can often be longer as well. This provides for less intrusion on our patients’ busy schedules and adds to their convenience while maximizing their treatment benefit. With these technological advances, orthodontic appliances have also become much smaller and more esthetic.
Temporary anchorage devices (a.k.a. TADs, mini-implants, micro-implants) have provided the dental team with more possibilities. These implants are placed to aid in the orthodontic movement of teeth or reinforcement of orthodontic anchorage requirements. In addition, they can assist in orthodontic intrusion with results formerly only possible with orthognathic surgery. These small temporary implants are currently in wide use in Europe and Asia. Indeed, much of the basic and clinical research has come from Korea and Europe. American orthodontists are just now utilizing TADs in practice as only recently has the FDA approved them for use in the U.S.
➋ In recent years, esthetic dentistry has become a large part of the general dental practice. As our society becomes more sensitized to appearance, patients have become more conscious of the benefits of a beautiful smile. While some patients can be treated with simple dental procedures, preprosthetic orthodontics can often improve appearance and emergence of dental restorations. The positioning of root structure, bony architecture, and repositioning of several teeth can improve path of draw for bridges or implant placement. Coordinated treatment can also improve the overall esthetics and stability of dental restorations with minimal sacrifice of the structural, functional, and biologic aspects of the dentition. Proper diagnosis and interdisciplinary planning is needed. In some cases where minor tooth movement is needed, preprosthetic orthodontic treatment can be completed with removable clear aligners.
The orthodontist can also assist in management of dental trauma. Long-term outcome of avulsed teeth is highly dependent on the condition of replantation or site management after the trauma. If the tooth is replanted, there are several possible outcomes. Only one of these is continued normal development. Others include ankylosis, loss, external resorption, and internal resorption with the attendant potential of endodontic therapy. Unfortunately, many times the tooth that experiences trauma is an anterior tooth. This, combined with the likelihood that the avulsed tooth occurs when the patient is young, poses long-term management problems. The orthodontist can assist in treatment. If the tooth has a coronal fracture that extends too far apically for adequate care, the orthodontist can extrude the tooth for restoration. If the tooth has root fracture in the coronal third, the orthodontist can extrude the tooth for temporization (and the maintenance of bone in the site should the tooth be lost and need a dental implant).
Additionally, the orthodontist can help manage congenitally missing teeth. Missing teeth can pose occlusal and esthetic problems, as well as bony structure problems. Restorations can be a challenge to the restorative dentist and the surgeon. Potential problems include too little (narrow) space for surgical placement in the alveolar crest, convergence of adjacent tooth roots, inadequate ridge thickness, and patient age. The restorative dentist, oral surgeon, and orthodontist can work cooperatively to diagnose and plan for the eventual placement of implant prostheses. With orthodontic repositioning, the adjacent structures can be positioned to maximize final restorative outcomes, simply with root divergence or in combination with additional esthetic dental restorative work. If the patient is too young, sometimes primary teeth can be positioned and temporarily “restored” during the growth phase of the patient to provide good esthetics through the teen years. If these primary teeth are lost, there is adequate bone height, root divergence, and intraoral space for dental implant placement.
Teeth come in all shapes and sizes - and usually are not in the perfect proportions patients see on television or in print! Unfortunately, sometimes these tooth shapes and sizes are different in the same individual, providing asymmetrical smile esthetics. The dental team, working in an interdisciplinary fashion, can plan for the best esthetic outcome with a combination of orthodontic tooth movement and root positioning for emergence profile and periodontal gingival recontouring (either gingivectomy or grafting), as well as veneers/composite build-ups. Symmetry in gingival contour and restoration are optimized with a combined diagnostic and treatment approach to each individual patient.
➌ Technology can aid in communication within the interdisciplinary dental team. Many dental offices now rely on their computer system for voice-activated charting, scanning of tooth structure for restoration, digital dental photography, and much more. The wide use of the computer and the Internet has opened a wonderful channel for communication within the dental team. Whereas with most cases it is still necessary to meet with the interdisciplinary team, there are many times when online communication can be equally effective. Online services can provide the dental team with mutual records access and instant e-mail communication. Each dental team member is assigned a password that allows access to the records of their patients. This allows the sharing of dental radiographs, photographs, and remote discussion of comprehensive patient care, which in turn improves communication and patient service and reduces the need for multiple sets of “records.” In addition, the patient can be brought in to the discussions through the electronic sharing of their digital records.
As dental professionals, we strive for excellence in the care of our patients. This is an exciting time to be a dentist. Technological advances in orthodontic appliances and communication technology, coupled with increased use of interdisciplinary diagnosis and treatment, have improved the quality of care. When we work as a coordinated team, our specialized skills and knowledge coupled with these advances can combine for the best diagnosis and comprehensive treatment planning for our patients.
Orthodontist, what have you done for me lately? The answer for most of us is not what has happened in the past, but rather what we can do now and in the future for our patients by working as a team together with the orthodontist.
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