Introduction

Orthodontics is a specialised branch of dental medicine that discovers and treats dental and jaw-related abnormalities. The main indications are to improve oral function, aesthetics and general dental health. Corrected alignment of the teeth not only enhances the aesthetics but also contributes to function, speech and overall well-being of dental health. The main aim of the orthodontic treatment is to encourage the eruption and alignment of displaced or impacted teeth, remove any trauma from occlusion (contact between teeth) and/or displaced teeth, and improve facial and dental aesthetics by aligning and levelling teeth. Thus, establishing mutually protected occlusion, within a stable soft tissue environment and eliminating functional problems including temporomandibular dysfunction. Factors such as age, severity of the condition, underlying medical conditions, and patients’ cooperation influence the choice of orthodontic appliances and treatment approach. This review aims to provide an overview of how orthodontics is tailored to address specific dental needs, providing optimal oral health and a beautiful smile.

Are crooked teeth genetic?

Genetics can be the reason for crooked or malalignment, but it does not always be the case. Conditions like overbites, underbites, open bites, spacing, or crowding can be due to genetic traits or bad dental habits. For example, the small lower jaw can sometimes be because of an overbite (excessive overlapping of front teeth) and tongue thrusting. Malocclusions are a treatable condition and any patient can get a symmetrical and natural-looking smile.

Certain habits and behaviours are the main culprits of dental malocclusions. They are: 

• Mouth breathing
• Thumb or finger sucking
• Prolonged pacifier use
• Poor oral hygiene
• Poor nutrition

Common dental conditions addressed by orthodontics

The orthodontic treatment goes beyond simply straightening of teeth. Aesthetic improvement and correction of dental anomalies are the main reasons for orthodontic treatment. Besides those aesthetic-psychological motives, there is a need for treatment of dental alveolar abnormalities for preventive reasons. Orthodontic treatments comprise a large proportion of dental treatment and in most cases, they are carried out during adolescence and early adulthood to solve dento-maxillary problems.^1,2

Malocclusions

Malocclusion is a craniofacial (involving bones of the face and skull) growth and development disorder that leads to functional problems with esthetic impact and psychological implications in children and adults. This is considered a public health concern and the third most frequent oral disorder after caries and gum problems.^3,4 The aesthetic impact of malocclusion greatly influences biopsychosocial development, but little attention has been given to its association with normative values of treatment needs.⁵ Malocclusions, or bad bites, occur when the upper and lower jaws don't fit together properly in a closed position. 

This can lead to several problems:

• Difficulty chewing and speaking
• Increased risk of tooth decay and gum disease
• Jaw pain and discomfort
• Uneven wear and tear on teeth
• Facial asymmetry 

There are different types of malocclusions, each requiring a specific treatment approach:

Crowding

This is the most common alignment issue, known as crowding. Generally, it occurs in individuals who don’t have enough space in their jaw to accommodate all the teeth to erupt normally. It can also lead to crooked smiles, difficulty cleaning, susceptibility to infection, tooth decay, cavities, and tooth loss.

Spacing

Spacing refers to gaps between teeth that can happen anywhere inside an oral cavity. It may be the consequence of some bad habits acquired in childhood, like thumb sucking or tongue thrusting. Other causes are missing teeth, small teeth, or a large jawbone.

Overbite and open bite

Normally, upper teeth slightly overlap lower teeth horizontally and vertically.  An open bite is a dental abnormality seen when severely misaligned teeth leave an opening in the mouth even when completely closed. It can be anterior (in front teeth) or posterior (in back teeth). The consequences of this bad bite are speech impediments, jaw pain, halitosis, sleep apnea, uneven teeth wear, TMJ disorder, and more.

Angle’s Class I, II, and III malocclusions

The Angle’s classifications categorise different jaw relationships based on the alignment of the front teeth and how much the lower jaw protrudes relative to the upper jaw.  Statistics show that teeth proclination is the severe type of dental problem seen in 33.7 % of children which is similar to the studies conducted in south India by Prasad et al., Nataraja rao et al., and Das et al.^6,7,8 Heidi Kerosuo et al., study concluded that early orthodontic treatment has better long-term stability than delayed orthodontic treatment.⁹

Impacted teeth

Teeth that are unable to erupt completely into their proper position within the jawbone are called impacted teeth. This can be due to a lack of space, misalignment, or abnormal jaw development. Orthodontics plays a crucial role in creating space for impacted teeth to erupt or assisting in surgical exposure for proper positioning.

Midline discrepancies

Common midline diastema refers to a gap between the upper front teeth, particularly central incisors, which is usually an aesthetic concern among the people affected by this condition.

TMJ disorder and dysfunction

Its wide range of applications is not just restricted to correcting malocclusion but also widely used in TMJ disorder likely bruxism. Occlusal orthodontic devices, and soft and hard night guards are initial management measures. 

Timing of orthodontic treatment

In most cases, timing to begin the orthodontic treatment is right at the stage of dental development.

• Deciduous dentition: Orthodontic treatment is not indicated for the primary dentition, but crossbites that cause a displacement on closing can be treated successfully at this stage
• Mixed dentition: Treatments at the mixed dentition stage involve the extraction of deciduous teeth for correcting the anterior or posterior crossbite and/or growth modification
• Early permanent dentition: The right time to begin fixed orthodontic treatment is at the early permanent dentition stage
• Adult dentition: Except for growth modification, other common orthodontic treatments can be undertaken in adulthood. After the morphological growth has stopped, this is the right stage to start the orthognathic surgery

Orthodontic appliances for specific conditions

Braces

In the absence of a skeletal discrepancy, the malaligned teeth can be treated by creating or closing the space using fixed orthodontic appliances. Humans have benefited greatly from orthodontics, undoubtedly a blessing for those whose teeth are misaligned. Orthodontic braces were historically associated with teenagers. But now adults are also seen preferring braces. Regardless of the age of an individual, the braces can work in the same way but the treatment time can greatly vary according to the patient’s age and growth of the jaw. The fixed orthodontic braces help f in treating overbite reduction, overjet reduction, overcrowding, space closures and dental malocclusions.^10,11 

Fixed braces consist of brackets affixed to each tooth and an archwire which connects the brackets. The brackets are usually made of metal, ceramic, plastic, self-ligating brackets, or a clear synthetic material which is less noticeable to the naked eye.¹² Orthodontic braces have been adapted and modified to make them more convenient for adults. They can move the teeth in all directions and the forces are applied by archwires or auxiliaries through these attachments.

Fixed appliances can:

• Change the mesiodistal angle of teeth
• Change the buccolingual inclination of teeth
• Rotate teeth
• Bodily move teeth

Headgear

Extraoral appliances have been used for dental and skeletal changes and anchorage reinforcement. Growth modifications can be done with the help of these appliances, by inhibiting or redirecting the growth.^13,14

Different types of headgear are, 

• Kloehn headgear, cervical strap, neck strap
• Straight pull headgear
• High pull headgear
• Vertical pull headgear
• ‘J’ hook headgear to the archwires

Headgear is the device with extra oral support and delivers forces intraorally. They can be used for treating class II and class III malocclusions.^15,16 The headgear can also be used with fixed appliances, functional appliances, removable appliances for:

• Retraction of the anterior teeth
• Distalisation of molars
• Distalisation of the dental arch
• Anchorage reinforcement
• Distalisation of the jaw
• Growth modification
• To treat vertical maxillary excess
• To treat open bites

Retainers

Aesthetic achievement and occlusion are not the final steps of an orthodontic treatment. When the original malocclusion has been treated with braces, it is essential that the teeth do not revert to the original misalignment. A retainer is used to ensure the teeth are properly aligned and stabilised.¹⁷ The ever-popular passive Hawley removable appliances¹⁸ are credible in maintaining the desired occlusion. Other modifications are removable wrap-around appliances,¹⁹ translucent retainers, and vacuum-formed retainers.²⁰

Expanders

Maxillary deficits which are characterised by abnormally low maxillary growth are often accompanied by dental crowding, with a possibility of canine inclusion, crossbite, class II and III malocclusion. They are usually treated with rapid maxillary expansion (RME).^21,22 The rapid maxillary expansion can be carried out by RME hyrax appliance, leaf expander appliance and MARPE appliance. They help palatine suture open up and widen the palate with the various activation regimens of these appliances.^23,24,25,26

Aligners

The demand for esthetic treatment is increasing. More people are seeking alternatives to conventional fixed orthodontic braces. Clear aligners are an esthetic and comfortable option. They have gained immense popularity over the last decade.²⁷ The clear aligners are widely used in mild to moderate crowding cases, but with great caution can be exercised in complex cases. In 1999, the Invisalign system was introduced to treat mild malocclusion only, however, the development of different attachments and auxiliaries by CAD-CAM technology now enables the system to perform major tooth movements and treat more complex cases involving premolar extraction.^28,29 Obtaining periodontal health is easier in patients treated with clear aligners.³⁰

Summary

Orthodontics treatments offer a valuable tool for addressing a wide range of dental conditions. It promotes not only a beautiful smile but also maintains optimal oral health and function. The success of orthodontic treatment depends on the appliance and the dental condition. Maintaining oral hygiene throughout treatment is crucial to prevent cavities and gum disease. Regular adjustments and check-ups are essential to monitor progress and ensure optimal results. The results may vary with individuals so it must be carefully planned. Consulting with a qualified orthodontist allows for a personalised assessment of your specific condition, expected outcomes, and potential considerations for your unique case. Remember, a healthy and confident smile is just a consultation away.

FAQs

Is there any age limit for orthodontic treatment?

No, there is no age limit for braces. 

Do braces hurt?

Braces can create some pressure on the initial day, which may last for a day or a week. 

What is the duration of the braces?

Minor problems can be corrected in 6-8 months. Complex conditions can take up to 12-18 months.