“All I want is to straighten my teeth. Why are you sending me from room to room to see so many specialists?”
“I feel like I’m a ball being passed around ! ”
“Do you guys know what you are doing?”
“Tell me exactly, which one of you is in charge of my case?”
Most people think of orthodontics as straightening teeth in children and the occasional adult, to create a beautiful smile. In reality, orthodontics is not a separate and distinct dental discipline. It is a very integral part of dentistry. True, in the majority of cases, orthodontics is the last stage of the overall dental rehabilitation plan as primary health takes priority over cosmetic procedures. Still, there is an increasing proportion of patients, young and old, who needs a multi-disciplinary approach to achieving their treatment goals.
“Can’t eat, can’t bite and can’t smile.”
In all cases, the orthodontist aims to bring the teeth into an arrangement that is both aesthetically pleasing, and functionally sound, stabile and easy to clean. In multi-disciplinary management, the objectives of treatment are :-
- 1. Intercept existing disease or potential problems
- 2. Establish a functionally sound and stable occlusion (“the bite”) goal
- 3. Restore maximum function the remaining teeth
- 4. Stabilise and prevent further deterioration of oral health and function
- 5. Improve aesthetics of the teeth, smile and face
As you can see, function always take precedence over aesthetics. Getting you from Point A (your present oral state) to Point B (the goal) will involve input and treatment by a team of specialists.
You, the patient is the key person in the team. You are a player on the team, not just the ball being passed around towards the goalpost. What you want and in which order will guide the rest of the team players towards building the final treatment plan.
The dental disciplines most commonly involved in multi-disciplinary orthodontic management are :-
- 1. Prosthodontics – replacement of missing teeth, restoration of decayed and damaged teeth
- 2. Periodontics – management of gum disease and supporting bone structure of the teeth
- 3. Oral maxillofacial surgery – surgical removal of teeth, infections, tumours and re-alignment to jaws and facial skeleton
- 4. Pedodontics – children dentistry, management of handicapped patients
- 5. Geriodontics – management of older patients with compromised dental, oral, mental and general health
- 6. Endodontics – root canal treatment to save badly decayed or broken teeth.
In these combinations, orthodontics is involved in the re-alignment of crooked teeth as well as intercepting jaw growth and teeth eruption problems.
Time. Money. Pain.
Periodontics + Oral surgery + Orthodontics
Anthony is an active young teenager, a mental age 3 year old boy in a 13 year old body entering into puberty. He also has a hole-in-heart condition that is partially repaired.
His mother is concerned about Anthony’s prominent upper incisors sticking out and the crowded lower teeth which are hard for her to clean since Anthony cannot manage his own toothbrushing. She also feels that the prominent front teeth draws further attention to Anthony’s mental disability. Anthony himself also does not like his teeth and often tries to press them inwards himself. His pedodontist is also concerned that his prominent incisors may be easily knocked out of the mouth should Anthony fall face down.
His orthodontist organised a treatment planning session jointly with the pedodontist, oral maxillofacial surgeon, Anthony and his mother. The Team decided on building up Anthony’s motivation, trust and compliance with a simple removable brace for the first few months before proceeding onto full fixed braces including removing 4 adult teeth under general anaesthesia and antibiotic cover. It was also agreed that Anthony should be treated with ideal dental goals of a normal child, and if needs be, these goals would be adjusted down to suit Anthony’s motivation and tolerance.
In the beginning, Anthony refused to even sit on the dental chair, cried and yanked the removable brace out of his mouth. Gradually, Anthony learnt to trust his “uncles and aunts” and could sit still with his mouth open for up to half an hour. Eventually, he managed to cope with extractions under local anaesthesia and 2 years of full fixed braces. The only change to the original dental plan was to allow the front teeth to still show a little rather then put him through an extra year of wearing braces. Retainers were bonded and these are regularly reviewed by his pedodontist.
Periodontics + Orthodontics + Prosthodontics
Janice had lost many of her back teeth to gum disease over the years. As a result, her bite had collapsed, front teeth were overloaded and splayed forwards. She was referred by her periodontist to to the orthodontist and prosthodontist to see if anything could be done. Together, the Team quickly establish the treatment goals and management for Janice. The long term goal was to allow for Janice to transit from dental extractions to prosthetic replacement with minimal down time, loss of function and aesthetics should gum disease progress. The short term goals were to re-establish her bite, strengthen the mobile teeth through splinting them together, improved aesthetics and make it easier for Janice to clean her teeth.
After removing 3 very mobile teeth and over 2 years of orthodontics, the re-grouped teeth were splinted together with fixed retainers by her periodontist. Denture-retainers were made to temporarily replace the missing teeth and stabilise the rest. An implant plan has already been drawn up by the prosthodontist and is held off temporarily as Janice preferred to hold on to her natural teeth for as long as possible.
The Game Plan
So exactly who is in charge of your case? Everyone has a part to play in forming the total management plan. Invariably, it is the last person left carrying the baby, that is to say, the dentist who is doing the finishing stages of your treatment. He or she could be the periodontist who will be managing you gums problems for many years to come; or even the pedodontist who will continue to look after a cerebral palsy patient into his adulthood.
Just like a basket ball game, the state of your oral health is dynamic and constantly changing. Your teeth and gums may not respond as predicted. Teeth may refuse to budge despite braces. Infection may smoulder on or flare up. New dental materials, technology and skills may arrive.
For multi-disciplinary orthodontics to succeed, all the team members including the patient need to be in constant communication. It is not about the patient being treated by a series of different dental specialists, it is about specialists working in tandem with each other concurrently.