How hygienists can provide support for the
movement by Ann-Marie C. DePalma, CDA, RDH, MEd, FAADH As defined by Wilkins, orthodontics is the area of
dentistry concerned with the diagnosis,
supervision, guidance, and treatment of the
growing and mature dentofacial structures – including conditions that require movement of the
teeth – and the treatment of malrelationships and malformations of the craniofacial complex. As dental hygienists, we are familiar with Dr.
Edward Angle's classifications of occlusal
relationships. Dr. Angle is considered the "father of
modern orthodontics," who designed a
classification system in the late 1890s to early
1900s based on the first molar as the key to occlusion. As a review, normal occlusion is
considered when the mesiobuccal cusp of the
maxillary first molar occludes with the buccal
groove of the mandibular first molar. Deviations
from this norm are considered malocclusions. Class I malocculsion has normal molar relationships
present, but other teeth may be crowded, rotated,
or have excess spacing. In Class II malocclusion,
the maxillary first molar is forward of the normal
molar relationship so that the mesiobuccal cusp of
the maxillary first molar is mesial to the buccal groove of the mandibular first molar. Class II
malocclusions are further divided into Division 1
and Division 2. With Division 1, the maxillary
incisors are protruding, while in Division 2 the
maxillary central incisors retrude and the lateral
incisors protrude. Class III malocclusions present with the mesiobuccal cusp of the maxillary first
molar distal to the buccal groove of the mandibular
first molar. Additionally, occlusal discrepancies
including anterior or posterior open bites,
increased overbite and overjet, crossbites, and
diastemas may be present. Hereditary, acquired, or habitual factors are also
involved. Teeth that are in malocclusion are hard to
clean and maintain and can lead to periodontal
disease, caries, or tooth loss. Orthodontic problems
can cause abnormal wear patterns, speech and
chewing difficulties, and possible temporomandibular joint disturbances. The
American Academy of Orthodontics recommends
that every child receive an orthodontic evaluation
by age seven. Early interventional treatments use
the patient's growth and development and can
make any corrective treatment faster and easier. Adults can also receive orthodontic treatment, and
there are a variety of treatment options available.
This article reviews the basics of orthodontic
treatment and investigates current alternate
modalities. What causes tooth movement? Orthodontic tooth movement is the result of
pressure applied to the teeth by orthodontic
appliances. The pressure is transmitted down the
clinical crown to the root and periodontal ligament
and alveolar bone. Slow, continuous forces work
best, while excessive forces destroy the periodontium and may cause root resorption. Basic
orthodontic concepts involve pressure exerted on
the tooth in the direction of desired movement,
which squeezes the periodontal ligament and
results in compression. The bone surface
contacting the ligament begins to resorb due to the activation of osteoclasts. On the opposite side of the movement, the
periodontal ligament is stretched and activation of
osteoblasts occurs. The osteoblasts create new
alveolar bone where the tooth was once located.
Once active pressure and movement is stopped, the
bone regenerates and fills in the area, allowing the tooth to become secure and the periodontal
ligament to reattach normally. Orthodontic
appliances are designed to create this movement
and can be removable or fixed, placed buccally,
lingually or both, and can be metal, ceramic, or
plastic. The patient's clinical situation and needs, along with the orthodontist's preferences,
determine type(s) of appliances. Advancements in treatment Over the past few decades, advancements in
technology have contributed to a variety of new
materials and techniques in orthodontic care. Many
of the new materials make it easier for patients and
professionals to maintain healthy gingiva and tooth
structure during orthodontic treatment. NASA has been instrumental in these
developments, including the development of heat-
activated nickel titanium alloy wires and plastics. At
room temperature, NiTi (nickel titanium) wires are
very flexible. As they warm to body temperature,
they become active and move teeth to the shape of the wire. These wires maintain their shape for
extended periods of time. One new technology system involves the self-
ligating bracket. Several companies, including
Ormco (Damon System), Dentsply GAC (In-Ovation),
3M Unitek (Smartclips), and Ortho Organizers
(Carriere System) use these self-ligating
attachments. Self-ligating braces and brackets use a permanently installed moveable component that
entraps the archwire. Self-ligators are often referred
to as "speed braces." Self-ligating bands and
brackets eliminate the need for plastic ties or wire
ligatures to hold the archwire in place. Traditional
ligatures tend to become bioflim traps, thus complicating treatment. Manufacturers of self-
ligating bands and brackets claim that there is less
friction between the arch wire and bracket, they
require less frequent office visits, and they are
easier to clean and more comfortable for patients
than traditional bands and brackets. Manufacturers produce both metal and ceramic
(clear) models depending on the patient's needs
and clinician's preferences. Treatment time,
outcome, and patient satisfaction have been rated
higher than traditional brackets and bands through
various product manufacturers. Another innovation in orthodontics is the use of
removable aligners, including Invisalign (Align
Technologies), ClearCorrect (ClearCorrect, Inc.),
Triple Play (Ortho Organizers, Inc.), and Simpli5
(AOA Orthodontic Laboratory). In preparing these
aligners, each manufacturer has proprietary software that provides patient-specific case
planning. The results of the data obtained via
impressions, photographs, and other information
determines how many aligners (trays) are made on
a case specific basis (each manufacturer may
require different orthodontic records to be sent). Movement occurs through the series of trays
designed to cover each arch completely. Each
aligner, which resembles a whitening tray, is worn
approximately 20 to 22 hours per day for two to
three week intervals before the next set of aligners
is inserted. However, patient compliance is an important factor; in order for proper alignment to
occur, the patient must be willing to wear the trays
for the designated time, removing only at meals.
Total treatment time varies from six months to two
years and depends on the experience of the dentist
in achieving the desired results. Aligner design depends heavily on the
practitioner's clinical judgment and experience.
Determining the need for any interproximal
reduction (IPR) or attachments (composite
materials attached to specific teeth to increase
aligner retention and movement) is also included in the overall treatment plan. The aligners are
constructed of a thermoplastic resin material and
do not contain bisphenol A. Depending on the
brand used, manufacturers claim high success rates
and the ability to orthodontically correct a variety of
problems. However, some patients and situations may not be ideal candidates for aligner treatment.
The most common candidate for aligner treatment
is an adult with orthodontic relapse or minor
discrepancies who is concerned about esthetics.
Additionally, Align Technology has a line
specifically for teenagers called Invisalign Teen that targets 13- to 19-year-olds. Clear braces (ceramic or plastic) are another
alternative to traditional metal ones. These can be
traditional brackets and bands or the self-ligating
orthodontic appliances. Clear elastic ligature ties
used for traditional bands/brackets allow for a less
conspicuous appearance. However, clear braces have been reported to have a higher rate of friction
and can be more brittle than metal counterparts,
although this has only been reported in literature.
This brittleness can make removing the appliances
difficult. In a process used by OraMetrix's SureSmile,
computerized robotic arms bend archwires into
desired shapes based on 3-D imaging. Using a
specially designed OralScanner, the orthodontist
records digital models of patients to visualize
treatment results and map tooth movement to achieve final results. The orthodontist chooses the
bands/brackets and archwire, and the robotic arms
create the shape of the wire as needed in the
treatment process. The company claims that the
treatment time is less than traditional orthodontics
and that the patient experiences fewer adjustments and less discomfort. However, the OralScanner is a
cone beam computed tomography (CBCT) unit, and
although CBCT is optimum in certain circumstances,
there is concern about the amount of radiation
patients are exposed to. Several new areas of orthodontic appliances are
currently being investigated. For less difficult cases
involving only the six maxillary or mandibular
anterior teeth, a spring aligner may be an option.
These aligners resemble traditional orthodontic
retainers but contain high tensile strength alloy wires that provide force through springs. "Smart
brackets" contain a microchip capable of
measuring forces applied to the bracket/tooth
interface. The goal of smart brackets is to reduce
the duration of orthodontic therapies while setting
the appropriate forces within nonharmful ranges. At this time, smart brackets are investigative only. TADs (temporary anchorage devices) are titanium-
alloy mini-screws (also known as microimplants)
that serve as anchors for moving specific teeth in
the most predictable manner possible. TADs have
been in use in orthodontics since 1983. Oral
surgeons and orthopedists used them prior to that. TADs allow orthodontists to move teeth without
moving adjacent teeth and without cumbersome
appliances such as headgear. Patient compliance is
minimal since the TAD is anchored into the bone,
and movement devices (chains or appliances) are
orthodontically attached. Insertion and removal of TADs are often painless, and are done with only a
topical gel applied in the orthodontist's office. From a hygiene perspective, there are a variety of
home care and professional products available to
maintain the orthodontic patient. For the patient,
there are manual orthodontic toothbrushes
designed with a "V" cut design that allows the
brush to fit over the orthodontic bracket and wires. Power brushes, including the Sonicare Flexcare and
Flexcare for Kids, Oral-B Triumph, and Arm &
Hammer Spinbrush, offer patients an alternative to
manual brushing and have been found to remove
biofilm better than manual brushing in a variety of
situations. The use of oral irrigators, such as the WaterPik
Water Flosser, adds another dimension to the
orthodontic patient's home care routine.
Interdental cleaners, including Superfloss, Oral-B
Hummingbird, and WaterPik Power Flosser, are also
great alternatives. The Platypus Flosser fits under the arch wire due to its innovative design by a
hygienist to help her orthodontic patients. Other
adjuncts include Oral-B Floss Picks, Sunstar/Butler
Floss Threaders, Eez-Thru Flossers, Thornton 3-in-1
Floss, and GUM Soft-Picks. A variety of interproximal
brushes, end-tuft brushes, and sulca brushes all help orthodontic patients maintain a biofilm-free
mouth. Dental professionals can offer patients
remineralization products, including MI Paste (GC
America), Clinpro 5000 (3M ESPE), NovaMin, and
SensiStat, to treat areas of decalcification that may
occur during orthodontic treatment. Retainer Brite
can be used to clean retainers or other removable hard acrylic appliances. Premier's 2pro Total Access
prophy angles are a patented dual action cup and
tip that can help gain easier access around
orthodontic appliances. The prophy cup can be
removed to reveal a tip that can fit easily under
wires. Treatment can be costly Orthodontic treatment in any form may present cost
issues for patients. Patients may or may not have
insurance coverage. Many insurers cover children
up to age 19, whereas only select insurers/
employers cover adult orthodontics. Plans also
have a lifetime orthodontic maximum ranging from $1,000 to $2,500. Depending on the type(s) of
appliances and the severity of the case, orthodontic
charges can range from $1,000 to $8,000. Patients
often experience sticker shock when it comes to
discussing the finances. However, dental
professionals can work with outside credit agencies such as CareCredit or Chase Financial.
Many offices offer in-house financing with no
interest for several months. Hygienists should be
familiar with the office policy regarding payment
options. Hygienists play a critical role in the orthodontic
process by providing support, encouragement, and
education. Orthodontics has changed considerably
in the last few decades. New and easier treatments
that make moving teeth and creating a healthy,
happy smile for a lifetime for many children and adults are available or coming soon.
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