Bite, face and jaws

Question 1

I have crooked teeth, but I don't want to have my bite corrected. Is that possible?

Accepted Answer

If a patient only wants their teeth straightened, without correcting the bite, this is possible, as long as there is no risk to the health of the teeth. However, in some cases crooked teeth are directly linked to a bite problem, which means it is not always possible to align them without at least partly correcting the bite. This needs to be confirmed by a detailed orthodontic analysis.

Question 2

I have protruding teeth. Can they be moved back?

Accepted Answer

Protruding (sticking-out) teeth can be the result of the whole dental arch sitting too far forward, or of just the front teeth doing so. This can affect one or both jaws and is often linked to abnormal jaw development and a bite problem. People with this problem often find it difficult to close their lips. To move the teeth back, space has to be created for them to move into – this can be done by taking out teeth (for example wisdom teeth or premolars) or by using any existing gaps between the side teeth.

Question 3

Can a deep bite or an open bite be corrected with braces?

Accepted Answer

We have a deep bite when the upper front teeth overlap more than 1/3 of the lower front teeth when the back teeth are clenched together. This problem may be due to abnormal development of the jaws, misalignment of the teeth or a combination of factors. A deep bite caused by the jaws can be corrected while the patient is still growing – by moving the teeth, we can generally guide jaw growth in the right direction. In patients who have finished growing, the jaw problem can be corrected surgically, or the teeth can be moved so that they mask the problem. A deep bite at the level of the teeth can be corrected with braces. It isn't one of the easiest problems to treat, but it is completely solvable. We have an open bite when, with the back teeth clenched together, one or more front teeth don't make contact (they seem to hang without touching). Like a deep bite, an open bite can be skeletal or dental. A skeletal problem most often needs an additional device to correct it – for example, a facebow (headgear) or mini-implants for anchorage, or sometimes surgery in adults. A dental open bite can also be treated with an extraoral appliance, mini-implants or intermaxillary elastics, worn together with braces.

Question 4

Can a deep bite be corrected with aligners?

Accepted Answer

Clear aligners can move teeth in all directions, but in some cases these movements are achieved with varying degrees of success. Correcting a deep bite by moving the lower front teeth downwards is a more difficult movement for aligners, but it is possible. That said, aligner treatment methods are constantly developing, and there are no longer any movements that can't be achieved.

Question 5

Can an open bite be corrected with aligners?

Accepted Answer

Clear aligners deal with an open bite very well. The thickness of the aligner material between the teeth has an additional effect of gently pressing the back teeth in (intrusion), which helps to correct an open bite. In the front or side teeth, where the tongue sometimes pushes in between the teeth and contributes to the open bite, the aligner acts as a barrier for the tongue and helps the problem resolve more easily.

Question 6

Can a crossbite be corrected with braces or aligners?

Accepted Answer

Normally the upper teeth overlap the lower ones, and the upper dental arch is the wider of the two. We have a crossbite when one tooth or a group of teeth have swapped position – a lower tooth sits further out than an upper one. It can affect the front or the side teeth and, like any bite problem, it can be at the level of the teeth or of the jaws. A crossbite caused by the jaws most often means that the upper jaw is narrow and needs to be widened. This is usually done with an appliance other than braces or aligners, which may be a removable or a fixed expander. Once the narrow jaw has been widened, treatment can continue with braces or aligners to align the teeth. When only one or a few teeth are in crossbite and the jaws are in a normal relationship, the problem can be corrected with braces or aligners, and sometimes by wearing elastics hooked onto the teeth involved – a cross elastic.

Question 7

Will my face change if my teeth are straightened?

Accepted Answer

A small change in the position of individual teeth doesn't have a significant effect on the appearance of the face. Still, depending on the treatment method and the way space is found to straighten crooked teeth, some change can be expected. For example, a canine in crossbite on one side makes the lower lip stick out asymmetrically on that side, and treatment restores the symmetry of the soft tissues.

Question 8

Will my face change if my bite is corrected?

Accepted Answer

The position of the lips and cheeks, which shapes how our face looks, depends on the position of the teeth directly behind them. For example, if the upper teeth tilt forward a lot, this will make the lips protrude. Sometimes the lips even close with difficulty, or the patient keeps their mouth open. If these teeth are moved back as part of orthodontic treatment, the lips will follow them. The same is true of the opposite situation – teeth that sit too far back lead to lips that sit back, and correcting the teeth changes the appearance of the lips. An underbite (reverse bite) of the front teeth shows in the face as a prominent chin and lower lip and a retruding upper lip, because with this problem the upper teeth sit behind the lower ones. Correcting the bite will change the lips too.

Question 9

What does ‘camouflage’ treatment mean?

Accepted Answer

Camouflage treatment, as the name suggests, involves moving the teeth in a way that masks a mismatch between the jaws. It's done in adult patients, when we can't rely on bone growth to correct the bite and surgical treatment of the abnormally developed jaws isn't absolutely necessary, or the patient has declined it as an option.

Question 10

Which orthodontic cases are complex and which aren't?

Accepted Answer

Numerous indices have been proposed to help orthodontists classify how complex their cases are. Most classifications rate as difficult the cases that need correction of overjet (the upper front teeth sitting forward of the lower front teeth), an underbite of the front teeth, impacted teeth, an open bite in the side teeth, and treatment of patients who have missing teeth. Crossbites in growing patients, and deep and open bites at the front, are easier to resolve. Cases with no bite problem are easy – rotated teeth, high canines. Treatment in children and adolescents is easier and quicker than in adults.

Question 11

Can braces fix facial asymmetry?

Accepted Answer

In growing patients, correcting a wrong tooth position – for example, a crossbite – can permanently correct facial asymmetry. Once jaw growth has finished, this asymmetry usually doesn't change when the teeth are aligned. There are orthopaedic and surgical methods of correction that can work together with orthodontic ones. Also, sometimes facial asymmetry, even in adults, may not come from the jaws at all but from misaligned teeth that force the lower jaw to slide to one side. In that case, correcting the teeth also corrects the problem in the face.

Question 12

Can braces change how my nasolabial folds (smile lines) look?

Accepted Answer

Nasolabial folds are creases in the skin that mark the edge of the upper lip, starting from the nose. They can be more or less pronounced, and this is an inherited facial feature. The position of the teeth affects how far forward the upper and lower lips sit. If the teeth sit further forward, the lips are pushed forward too and the nasolabial folds are smoothed out. If the orthodontic treatment plan involves moving the patient's teeth backwards, the nasolabial folds can be expected to deepen and become more noticeable.

Question 13

I have pain in my jaw joint. Will orthodontic treatment fix it?

Accepted Answer

The temporomandibular joint is the movable joint that connects the lower jaw to the base of the skull. A number of epidemiological studies show that problems with this joint occur in 60%–70% of the population. Despite this high percentage, only one in four patients reports a problem. These are usually women, but it is thought that men are simply less likely to seek help, rather than the problem mainly affecting women. Jaw joint pain can have a wide variety of causes. Some of them are: injury, inflammation, degenerative disease, clenching and grinding of the teeth, incorrect contacts between the teeth, a poorly adapted restoration in the mouth such as a bridge, poor general health, an unhealthy diet, nervous tension, stress, depression and nervous disorders. Temporomandibular joint disorders are described as multifactorial – that is, they have more than one cause acting at the same time. Orthodontic treatment can correct incorrect contacts between the teeth, but if this is only part of the cause of the discomfort and pain, it won't be enough to resolve the problem.

Question 14

Can orthodontic treatment cause me pain or problems with my jaw joint?

Accepted Answer

Jaw joint problems appear most often in adults between the ages of 20 and 40. This is the age at which many people decide to start orthodontic treatment, so sometimes the two simply happen at the same time. Sometimes orthodontic tooth movement can turn out to be a trigger for the condition, but bear in mind that the problem is multifactorial and needs a combination of causes to develop. The most common cause found in jaw joint pain and problems is bruxism (clenching and grinding of the teeth). This pathological reflex should not be underestimated.

Question 15

Which specialists should I see for a jaw joint problem?

Accepted Answer

The specialists who can help with a jaw joint problem are an oral surgeon, a gnathologist (prosthodontist), an orthodontist and sometimes a neurologist, if nervous tension and stress are part of the problem.

Question 16

Is there a link between my bite and poor posture?

Accepted Answer

Patients who breathe through their mouth tend to have a characteristic posture, hunched with the head tilted forward. This helps them take in air more easily. In this posture, the chin stays pressed down and its forward growth is restricted. That is why mouth breathing is also characterised by a lower jaw that lags behind in its growth. A correlation has been found between a crossbite on the side teeth and scoliosis (an S-shaped curve of the spine). If both conditions are found at the same time, the recommendation is to start widening the jaws straight away.

Question 17

I've had bite raisers fitted. How long will I have them?

Accepted Answer

When the initial bite or the position of the teeth doesn't leave enough room to fit lower braces because of where the upper teeth sit (for example, with a deep bite at the front), we use bite stops, also called bite raisers. They stop the upper teeth from touching the lower braces when you close your mouth, which could otherwise make the braces come off. Bite raisers can be placed on the upper or lower back teeth and are usually made of a material in a different colour from the natural tooth, so that they can be clearly seen when they are removed. They are bonded directly onto the tooth without damaging its structure and are then ground down until they are even on both sides. Once they are in place, you'll notice that when you close your mouth your front teeth don't touch, while your back teeth meet something hard – and this takes some getting used to. The feeling is a little unsettling at first, and it takes about a week to get used to it. Eating changes during this period too – small, grain-like foods such as lentils or peas aren't recommended, as they can be hard to chew properly. The most common question patients ask straight after their bite raisers are fitted is: ‘When are we taking them off?’ The most accurate answer is: ‘When they are no longer needed.’ How long they are worn depends on the individual case and can range from 2-3 months to 7-8 months or more .

Question 18

My teeth have moved forward during treatment with braces. Will they go back?

Accepted Answer

In the early stages of treatment with braces, we use thin, very flexible archwires. The first teeth to respond by moving are the front teeth, because they have smaller roots and need less force to move. The direction in which teeth move most easily is forwards, because that's where the resistance is lowest, so the initial expansion of the dental arch is from front to back. As treatment progresses and we move on to the next archwires, they start to shape the arch at the sides too, and the arch then widens sideways as well. This creates room for the front teeth to be moved further back. And of course, the forward movement of the front teeth can be controlled and limited if it isn't part of the treatment plan.

Question 19

I feel I've been clenching my teeth more since I got braces. Is that normal?

Accepted Answer

Unconscious clenching of the teeth (bruxism), whether at night or during the day, can be triggered by many factors. Sometimes patients tell us they were already clenching before treatment started; sometimes we find signs of clenching and grinding in someone who has no idea they have this problem. Usually, the discomfort teeth feel with braces makes people stop any clenching or grinding they did before. However, placing cement on the teeth together with the braces acts as a trigger and causes clenching, even in patients who have never clenched before. Aligners also cause clenching in the first few months of treatment, because the material between the teeth raises the bite. Generally speaking, any material placed between the back teeth can trigger bruxism. The clenching stops once the material is removed or once you get used to it.

Question 20

When I take my aligners out to eat, it feels as if my back teeth don't meet. Is that normal?

Accepted Answer

Aligners are made of a hard, clear material about 1 mm thick and cover the teeth on all sides. This means that when your aligners are in, you're biting together not on your teeth but on the aligners. It feels as if something high has been placed on your teeth. This awkward feeling gradually fades during treatment, and after about 3 months your teeth feel less comfortable without the aligners than with them. The reason is that the teeth shift and adapt to the aligners, making room for them in the mouth. So when we take them out, at some point it feels as if something is missing. This is a temporary change in the position of the back teeth, caused by wearing aligners for a long time. After treatment ends, the contacts between the back teeth are gradually restored.

Question 21

The way my teeth meet changes every few weeks. Is that normal?

Accepted Answer

Orthodontic treatment is started in order to move the teeth into a better position or to correct a misaligned bite. Moving the teeth changes the way they meet. While the teeth are settling into place, you may feel different contacts, with different pressure, on the left and right. If you have a lot of discomfort, you should of course tell your orthodontist. Although these complaints are to be expected, we can relieve them by selectively and temporarily building up certain teeth to improve the contacts during treatment.

Question 22

What are inter-arch elastics used for?

Accepted Answer

Inter-arch (intermaxillary) elastics are an additional way of moving a particular group of teeth. They get their name from the fact that they attach to the upper and lower braces at the same time. They can be placed in many different ways, and the way they are placed determines the effect they have. If an elastic runs between the lower back braces and the upper front braces, it is probably being used to correct the bite in the front-to-back direction. If it is hooked onto opposing upper and lower teeth, the force from the elastic acts vertically and draws the teeth down – to correct an open bite, for example.

Question 23

Will I definitely have to wear elastics if I have braces?

Accepted Answer

Wearing elastics is not a compulsory part of treatment with braces, but it is very often part of the plan for moving the teeth, both with braces and with aligners. Whether you will need to wear inter-arch elastics is decided when your treatment is planned, and you should know this before you start.

Question 24

My orthodontist says I have to wear elastics with my braces all the time. Will they still work if I only wear them at night?

Accepted Answer

Elastics have their strongest effect during the day, when we are active and talking. This stretches the elastics dynamically, which increases the force applied to the teeth and helps to correct the bite. At night, while we sleep, the elastics mainly hold the position that has already been achieved, but they don't apply the same level of active pressure. If the elastics are being used to correct a specific problem with the position of the teeth, rather than simply as a supporting element, they must be worn all the time . Even short breaks of a few hours can lead to a significant loss of effect and slow down your progress. Wearing them constantly makes them as effective as possible and gets you to the results you want sooner.

Question 25

Is there anything I can use instead of elastics?

Accepted Answer

Elastics can be placed in many different ways, on braces or with aligners, and can move teeth in different directions. There are inter-arch elastics – ones that connect the upper and lower teeth and are active (they stretch) when you open your mouth – and there are also elastics that work within a single dental arch. They can pull the teeth front to back, vertically and sideways. There are alternative appliances that can be used instead of elastics – a Class II corrector, mini-screws, a Herbst appliance, headgear and others.

Question 26

The centre line of my lower teeth doesn't line up with my upper teeth. Will this be corrected?

Accepted Answer

The centre lines of the upper and lower teeth should line up with the middle of the face. The upper midline can be off-centre because of uneven crowding of the teeth or a shifted bite. The lower midline can be off-centre in relation to the middle of the face because the lower jaw has developed asymmetrically, or again because of crowding or an incorrect bite. In general, when the cause of an off-centre midline lies in an asymmetry of the jaw, moving the teeth may not be able to disguise the problem, because the cause lies in the underlying bones. If the problem is due to displaced teeth or a shifted bite, the centre line can in all likelihood be corrected with orthodontic treatment alone. An unequal number of teeth on the left and right – whether inherited or because a tooth that couldn't be saved was extracted in the past – can also make it impossible to centre the teeth. In some cases the midlines are off because the teeth on the left and right are different sizes – for example, when one upper lateral incisor is smaller than usual, which is often inherited.

Question 27

Can the tooth my elastic is hooked onto become crooked from the pull of the elastic?

Accepted Answer

The elastics we give patients, with instructions on how to put them in and take them out themselves, are an aid to moving the teeth alongside braces and aligners. When we hook an elastic onto braces, as well as movement in the desired direction we can also get side effects, such as the teeth concerned rotating or being pulled outwards (extruded). To minimise these side effects, elastics are worn when the archwires are a suitably large size and the teeth the elastic is hooked onto are held firmly by the archwire; alternatively, the elastic can be hooked onto an extra hook instead of a bracket. Of course, depending on why elastics are needed, there are also cases where they are started right at the beginning of treatment with braces, while the archwires are still thin.

Question 28

Can aligners correct an underbite?

Accepted Answer

Aligners are the most modern orthodontic appliance, and today they can correct all orthodontic problems. If treating the underbite (reverse bite) requires extracting teeth, for example, aligners can still be used to achieve the final result.

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