What causes orthodontic problems

ORTHODONTICS; A guide to the perplexed


History of orthodontic 
What causes orthodontic problems?
Why carry out orthodontic treatment?
What does an orthodontist do?
How do braces work?
My teeth are straight, now what?
Who should carry out orthodontic treatment?

Tags: orthodontic;orthodontic problems; orthodontic treatment;orthodontist; braces ;My teeth are straight; orthodontic treatment;


ORTHODONTICS:  from the Greek- orthos- right, correct + odous odont- tooth.

The diagnosis and treatment of malpositions of the teeth.


History of orthodontic problems

Whilst the possibility of moving children's teeth by applying light pressures was known to the Romans, it was only in the mid-19th Century that Orthodontics started to take shape as a science based branch of Dentistry. The early writings of American and European dentists in the 1800’s described the use of various appliances for the straightening of teeth and even jaws, and some of these inventions are still in use today, albeit in a more sophisticated form.

What causes orthodontic problems?

What causes orthodontic problems


Whilst the exact mechanisms are uncertain, there can be no doubt that many of the elements that make up dento-facial structures are influenced by heredity. Children, after all, tend to look like their parents, who commonly try to identify family features in their offspring - "…he's got his mother's nose, his father's chin, grandpa's eyes and grandma's teeth". As a result of this genetic mixing  it will often occur that the parts don't fully match. The teeth, inherited from one parent, may not be the appropriate size to fit into the jaws, inherited from the other parent. This may lead to crowding and malposition of the teeth if they are relatively too large for the jaws or spacing if the teeth are too small.

Clefts of the lip and/or palate, which have a strong hereditary background, will have obvious effects on the teeth and jaws.

Abnormal function

Abnormalities of biting and chewing; swallowing; speech and mouth-breathing as opposed to nose-breathing, may all contribute to the development of orthodontic problems.


Sucking habits in childhood, in particular fingers or pacifiers, are often blamed for the protrusion of the upper front teeth. However, there is no firm evidence that such habits are, indeed, a major cause of orthodontic problems. Many children with sucking habits who stop at an early age can then develop a normal bite in the absence of other factors. It would seem that the longer the duration of the habit and the greater the intensity and pressure applied during sucking, the greater the likelihood of causing of an orthodontic problem.

Many orthodontic patients thrust their tongue forward, particularly during swallowing and speech. These tongue thrusts have a marked impact on the position of the front teeth as the tongue is a large muscle and the continuous pressure on the teeth, mainly during swallowing,  will move the teeth, usually forwards.

Dental disease

Early loss of baby teeth due to dental decay may cause unwanted movements of surrounding teeth and may complicate a pre-existing orthodontic problem or cause such a problem where none existed. In such a case it is important to seek advice on the need for a space maintainer to prevent such movements. Similarly,  the loss of permanent teeth due to decay or gum disease may turn a non-treatment situation into a treatment case. Ongoing dental care, both at home on a daily basis and at the dentist and hygienist on a regular basis, is essential, to ensure a healthy mouth.   

Dental anomalies

Congenital absence of teeth is not uncommon. Third molars or wisdom teeth, which only start to erupt at 18 years or more, are the most commonly absent teeth with upper side incisors, lower second bicuspids and lower incisors next. In fact any permanent tooth may be congenitally missing with consequent problems of excess space, although in an otherwise crowded mouth a missing tooth or two may be an advantage!

Extra teeth sometimes develop and they will tend to cause crowding.

Sometimes the shape or size of the teeth may be abnormal, either on a full mouth basis as part of a general condition, or affecting only a few teeth.

Developmental position of orthodontic problems

Teeth may develop in an abnormal position and then fail to erupt properly. This mainly affects upper cuspids (canines) which may end up trapped in the palate and require complex treatment to bring them into their correct position.


Trauma to teeth and/or jaws is regrettably common, particularly in boys in their boisterous teens. Jaw fractures can lead to disorganization of the occlusion (bite) and damage to the growth centres of the lower jaw which are situated in the joints in front of the ears. Trauma to teeth may result in their loss with consequent movement of the adjacent teeth.


Developmental position of orthodontic problems

Why carry out orthodontic treatment?

There are basically 3 reasons for carrying out orthodontic treatment and in any individual patient any or all may apply.


The usual complaint voiced by patients and their parents on their first visit  to the orthodontist is that they "don't like the way the teeth and/or jaws look"   At the same time,  there are those patients who are not at all bothered by the appearance of their teeth but are brought to the orthodontist solely as a result of parental concerns. Given the motivation and cooperation demanded from the patient to carry out successful orthodontic treatment, it is important for the orthodontist to listen to the patient as well as to the parent. Unlike most other dental treatments which are of short-term duration, orthodontic treatment typically is carried out over a period of several years and depends as much on the patient’s cooperation as on the orthodontist’s skill. An unwilling patient will not, generally, achieve a successful result


Usually associated with more severe jaw discrepancies in which there is a lack of full contact between the teeth, either front or back, resulting in a reduced ability to bite and chew. However every orthodontist will have seen patients with such malocclusions and yet able to bite and chew without trouble, which demonstrates the remarkable adaptability of the chewing mechanism.


Intuitively, one might think that very crowded teeth are more prone to dental and gum disease due to the difficulty in cleaning to the required standard because of overlapping teeth which trap food. However this has not been shown to be true in the majority of cases  - provided that the patient is given proper instruction on the use of a toothbrush, dental floss and a good mouthwash and is motivated to carry out a thorough mouth cleaning each morning and evening.


When is the right time to start orthodontic treatment?

Once again there are differing views on the appropriate timing of orthodontic treatment.  Some authorities suggest starting early, at 8-9 years, while others suggest waiting until all the baby teeth have changed over to permanent teeth, which is usually 11-14 years. There are many and varied considerations as to the correct timing for each individual child, but it is probably best to seek the advice of an orthodontist at the age of 8-9. If it turns out to be too soon, one can always wait.

What does an orthodontist do?


At the first visit to an orthodontist, the patient’s personal details are recorded and a comprehensive medical and dental history is taken. Emphasis is placed on finding out what the patient, adult or child, is hoping to achieve from the treatment. A clinical examination of the face and mouth follows and additional examinations will be requested. These may include: various X-rays, both of the teeth and of the jaws; CT scans, particularly to locate unerupted teeth; plaster models to allow measurements of tooth and jaw size to be made. Occasionally further consultation with other dental or medical specialists will be needed in order to obtain a comprehensive picture of treatment needs.


With all the relevant information to hand, the orthodontist can now make a diagnosis and fit a particular patient into the appropriate place on the spectrum of known orthodontic conditions.

Treatment planning of orthodontic problems

Having determined where the teeth and jaws are before treatment, it is now necessary to decide where they should, ideally, be after treatment. The journey between these two positions is the treatment. Research has indicated that there are certain relationships between teeth and jaws which are more aesthetic and more stable than others and it is towards these relationships that treatment is planned. However one must take into account that there are differences between ethnic groups in the norms of these relationships.


Some treatments need to change the relationship between the upper and lower jaws in order to establish a normal base for the straightening of the teeth. In a young, growing child this may be achieved by the use of various appliances which exert pressure on one or both jaws to try to modify and influence the direction and/or amount of jaw growth. This is more correctly called Dento-facial Orthopaedics. In an adult, significant changes in the jaws will usually require surgery.

Once the jaw relationship is corrected, the teeth can be straightened. The first consideration is the availability of sufficient space to achieve the planned correction. Space can be obtained in a number of ways: widening of the jaws, particularly the upper;  expanding the dental arch in a forward or backward direction, or both; narrowing teeth by removing a very thin layer of enamel so that each tooth requires less space in the arch and; finally, by removing permanent teeth. Determining which method of space gaining is appropriate for each case is a product of  the amount of space needed, where in the mouth it is needed, the state of health of the teeth and, to a large extent, the treatment philosophy used by the orthodontist. The argument over the removal of permanent teeth in orthodontic treatment has been going on for 100 years or more, with some saying "never" and others saying "almost always". As with such arguments the truth lies somewhere in the middle and each case must be considered on its own merits.


The range of orthodontic appliances now available is diverse. The usual fixed metal braces come in numerous shapes and sizes, each product having its supporters. If the results are good, it does not really matter if one uses brand X or brand Y.  For adults who are reluctant to show too much metal, there are now fixed white braces, made of plastic or porcelain, as well as clear plastic plates, computer designed and manufactured to carry out tooth alignment, which can be removed. The ultimate in invisible orthodontic treatment is now the lingual brace which is fixed on the inner surface of the teeth; this brace combines the advantages of fixed appliances with invisibility.

Additions to fixed appliances may be necessary for full correction of certain orthodontic problems. These may include: headgears with neckstraps or headcaps or, on rare occasions, both; removable plates, upper or lower,or both; chincups or face masks.

A new addition to the orthodontist’s toolbox is the temporary implant. These are small titanium screws that are screwed into the jaw bone, under local anaesthesia, acting as anchor points for tooth movement. Their use may often eliminate the need for external headgears. Unlike the implants used to replace missing teeth, these orthodontic implants are not locked into the jaw bone and can easily and painlessly be removed when no longer needed.

Elastic bands

The use of elastic bands in orthodontic treatment has a history going back over 100 years. They are a convenient way to apply the light pressures needed to move teeth and are easy to hook on to the braces as directed by the orthodontist.

How do braces work?

The pressures applied to the teeth by orthodontic appliances of any type are transmitted to the roots of the teeth and there they cause changes in the tissues that separate the roots from the jaw bone. These tissue changes cause a process of bone shrinkage on one side of the root and bone building on the other side, thus the tooth moves along with its surrounding bone. This process is caused by cells; cells need a blood supply and  therefore it is light forces that move teeth quickest. Heavy forces will damage the cells and the blood vessels and slow down the whole process.

Does the treatment hurt?

Fixing the braces to the teeth does not, generally, hurt although some pressure may be felt when the bands are pushed onto the teeth. As a reaction to the light orthodontic pressures teeth often become sensitive for a day or two but this wears off and can be controlled by an occasional pain killer, if needed. Removable plates are usually made with a plastic base which restricts the space for the tongue and may interfere with speech. Again this wears off after a day or two. Similar speech interference occurs after fitting lingual appliances. Research has shown that 95% of patients with lingual appliances can speak normally within 2 weeks of the brackets being fitted.

My teeth are straight, now what?

The completion of orthodontic treatment to the satisfaction of patient, parents and orthodontist, is often the start of the most difficult phase of the treatment process. On removing the braces, the teeth are very unstable and can very quickly move away from their ideal position. Therefore retainers are needed to hold the teeth in their post-treatment position. These may be removable plates or wires fixed behind the teeth. The use of the retainers according to the orthodontist’s instructions is an essential part of the treatment and must not be neglected. Even with fulltime retention over a period of years, changes are often noted. During the first year after the completion of treatment these changes can be considered to be reactions to the treatment. Beyond this, most changes are due to the normal process of growth and maturation which would have caused such movements even in the absence of orthodontic treatment. Perfect and permanent stability is rarely, if ever, achievable.

Who should carry out orthodontic treatment?

In most countries any licensed dentist is entitled to carry out any dental treatment, including orthodontics. However, given the complexity of diagnosis and treatment planning of orthodontic cases and the range of treatment options which are now available, it is advisable to turn to a properly trained and qualified orthodontist. Formal courses to train orthodontists are available at many Universities throughout the world and may take as long as 3-4 years. At the end of the course, students face stringest examinations that test their theoretical and practical knowledge. Those who pass these examinations are entitled to call themselves "Specialist". Some countries or states have specialist registers in all branches of Dentistry and these can usually be viewed at local or national health authority offices or websites. It is worth checking into qualifications before choosing an orthodontist although personal recommendations from satisfied former patients are also a valuable guide.

At the end of the treatment, the reward for all that hard work and perseverance on the part of the patient and the orthodontist will be an attractive smile, balanced facial features and the good feeling that comes with a job well done.


A short glossary of orthodontic terms, or 

“How to understand what the orthodontist is telling you”

Dental arch or arcade: The row of teeth on each jaw, upper and lower.

Dentition: All the teeth in the mouth. The deciduous dentition is all baby teeth, 20 in number, themixed dentition is some baby and some permanent and the permanent dentition is all permanent teeth, 32 in all, including the wisdom teeth.

Incisors: The front teeth, 2 on each side, one central and one lateral. Used for cutting food therefore have sharp edges.

Cuspids (canines): Also known as “eye-teeth”, pointed teeth similar to the sharp fangs of meat-eating animals such as the dog and the cat families.

Bicuspids (premolars): 2 in each quarter, used for grinding food before swallowing together with the molars.

Molars: 3 in each quarter, these are the only permanent teeth which do not replace a baby tooth. They come into the mouth at 6 years, 12 years and 18 years, approximately.

Maxilla: The upper jaw.

Mandible: The lower jaw.

Tempero-mandibular Joint (TMJ): 

The joint which connects the mandible to the skull on each side and on which the mandible pivots during chewing. The TMJ can be felt just in front of the ear when the mouth is opened and closed. The growth centres of the lower jaw are located in the joint.

Orthodontic bands:

 Stainless steel rings which are fitted to the teeth, usually the back molars, and to which wires and other accessories are attached.

Orthodontic brackets:

Small attachments, metal, porcelain or plastic which are glued directly to the teeth or attached to metal bands.

Bands and brackets are the means by which light forces are applied to the teeth using wires, springs and elastics


 Wires which are attached to bands within the mouth and which have a second wire outside the mouth to which a neckstrap or headcap is attached to pull on the teeth.

Functional appliance

: A removable or fixed appliance which uses the force of the muscles to apply pressure to the teeth and/or jaws in order to modify the direction and/or amount of growth. These are most effective in younger patients during their growth spurt, ages 9-14.


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