Orthodontics: How You Start Finishing at the Beginning and Reduce the Stress at the End for You and Your Patient

© 2018 Dr Chris Baker

LEFT: Patient "Miss A" (see below for case explanation), displaying a right lateral openbite and forward tongue.  © 2018 Dr Chris Baker

Patient "Miss A", with evidence of mouthbreathing and a forward tongue. © 2018 Dr Chris Baker

Funny how we call detailing the tooth alignment and the bite, “finishing”.  Funny because it all starts from diagnosis. Actually it starts at the initial examination. What we do at the beginning makes our finishing time longer or shorter.

• Identifying the existing risks, discrepancies, malpositions, and adverse trajectories of erupting or unerupted teeth begins your finishing.
• Making them part of your written treatment plan information for the parent/patient puts you all on the same page, reducing surprises and disappointments later.
• When you work these out, discover, document, and add the concerns to the treatment plan, and review with the parents/patient BEFORE you start, you will feel better, they will feel better, and even though the challenges are there for all of you, there is a better chance of working together with the realities.

Think about the facts yielded by the patient’s medical history and status, dental history and status, and current findings, skeletal, dental, airway, function.  Your level of awareness and utilization of these facts will help you from level and aligning to finishing stages of treatment.

Here are three examples of finishing challenges that can become overwhelming, and how you can know of the facts, and handle the challenges better, from the start:

Facts and challenges like:

Patient Miss A may need lengthy and difficult anterior bite closure - how do you know?.

• Signs and symptoms of airway and breathing limitations (bedwetting, ADD/ADHD, mouthbreathing, snoring, bruxism/grinding, enlarged tonsils, enlarged adenoids, dense turbinates and more).
• Vertical or dolichofacial growth and muscle patterns
• Forward and low tongue position, tongue habits, forward tongue swallow, difficulty with sibilant sounds and even generalized spacing between teeth
• Short sub-lingual frenum, which makes the tongue stay low and forward
• History of or current finger, thumb or pacifier habit
• Deficient overbite
• Protrusive incisors

Treatment during or throughout the ortho treatment, not just during what we call finishing may include:
    - ENT referral and treatments
    - Tongue exercises that you prescribe
    - Sublingual frenectomy
    - Habit treatment
    - Bite turbos, posterior biteplate, or other posterior intrusion therapies
    - UAW or other molar positioning and incisor extrusion where appropriate
    - TAD anchorage with posterior intrusion
    - Lower full coverage splint following ortho treatment

And look at the concern typed onto the treatment plan for this patient, just above the signature line for the parent/patient:

Concern –  Airway issues, habits and adverse tongue positions all contribute to adverse growth and continued adverse forces on teeth, with or without orthodontic treatment. Adam’s growth is vertical, which is made worse by mouth-breathing and low tongue position.

This may predispose him to an openbite. All treatment will be directed to improving these adversities, but longterm stability is lessened and risk of relapse is greater, depending on the success of the airway treatment, tongue position improvement and habit cessation.

OR

Vertical growth patterns are difficult to correct, and when corrected, often relapse, with a return of the open bite (space between upper and lower incisors, when the patient is biting on the posterior teeth.) 

Even in the best-case scenario, openbites may relapse.  Beginning treatment as soon as is feasible may help in longer-term stability.  Compliance with elastic wear, if indicated, is important.  All treatment is directed to improving the openbite pattern with as much stability as possible.

Annie’s tongue position is low and forward, and probably is contributing to the spacing of her teeth.  Tongue training may be helpful, including CM circle and ball on retainers, and wear of her retainers as directed, will be critical, because the teeth often exhibit connective tissue memory/relapse without excellent retainer wear, due to the tendency of the tongue to remain forward and low throughout life.

Patient  Mr. B may have later excessive mandibular growth, “outgrowing” your orthodontic treatment that attained a beautiful Class I, and the patient ends up Class III with open bite tendency.  How do you know?

• The patient has more than 4 total clinical deviations from the norm toward Class III, between Porion Location, Ramus-Xi position, Cranial Deflection and Molar Position.
• The patient presents with Angle Class I occlusion or Super Class I occlusion
• The patient has a brachyfacial growth and muscle pattern.
• The patient is skeletal Class III.

A patient and his mother presented for a recall orthodontic evaluation, and the mom said her dentist had asked her why we took the braces off, when he had 0 overbite and 0 overjet.  A review of his final photographs at orthodontic completion showed a Class I occlusion with 3 mm overbite and 3 mm overjet.  Indeed that was not the case any longer. 

​His treatment plan had listed the concern of possible excessive mandibular growth.  He had a chin sling for nighttime wear prescribed for wear with his retainers, which had not been worn.  Don’t we dislike these concerns expressing themselves in reality? 

But - we don’t make the growth, and we are pleased to stress the concern at the diagnostic and retainer delivery stage.  The patient compliance may not work to advantage.  We hate that, of course.

Treatment during or throughout the original active phase, not just during what we call finishing may include:
    - Class III Correctors - Motion or D2 appliances
    - Chin Sling or Facemask wear
    - Posterior intrusion therapies
Communication of growth progress to the parent is critical, throughout treatment.  Keep them in the reality loop!

Patient Miss C may have difficulty attaining and maintaining adequate canine and/or posterior overbite.  How do you know?

• Low and adverse tongue position
• Narrow palate, result of low tongue and cheek muscles strong without tongue balance
• possibly Class III tendency

Treatment during the active phase of orthodontics may include:
    - Tongue exercises
    - Blue Grass or other beads in palate
    - Castillo-Morales circle in palate
    - Crib on appliances
    - Expansion therapy

We could similarly lay out the signs of future TMJD, of lack of eruption of an ectopic tooth, adding 2-3 years to a treatment time, of the complete dependence on the patient’s compliance if the occlusion is to be corrected, and on and on…

So, before you even consider putting appliances into a patient’s mouth, consider the findings - all of them.  Do excellent diagnostics.  Get all the information - about medical, airway and breathing, dental, skeletal, growth and finally dental findings.  THEN put it together in a comprehensive treatment plan that you can share with the parent /patient, giving them the information they need to make good informed decisions about the treatment.

Then, pay the closest attention to your bracket placement. Bracket placement, though impossible to do perfectly, can make huge differences in finishing needs.

Keep everyone — parents, patient, your chart — in the loop. Be honest and open with the progress, OR LACK THEREOF. This will help you throughout the treatment. Your finishing will be more predictable, and could be a lot less surprising, a lot less difficult, and a lot less stressful for all.

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Patient "Mr B" (case discussion above), displaying zero overbite, zero overjet and excessive mandibular growth. © 2018 Dr Chris Baker

Patient "Miss C" (see above for case discussion) displaying an adverse tongue position. © 2018 Dr Chris Baker

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