Orthodontics/braces

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Question
Hello my regular dentist has advised me to go see a orthodontist for braces. He said I have a class 3 malacclusion with a open bite. Can you tell me what are the options to treat that and the approximate time of treatment?

Answer
Class III
Class III  

Class III
Class III  
Hello Romain,

Thank you for your question. You present a clinical challenge which involves one of the most difficult types of situations to treat in all of Orthodontics.  

What I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Okay… having said that…  your questions focused on a Class III open bite situation and appropriate orthodontic treatment options.  You wrote:
  “ Hello, my regular dentist has advised me to go see a orthodontist for braces. He said I have a class 3 malocclusion with an open bite. Can you tell me what are the options to treat that and the approximate time of treatment?

Let me approach this question in separate steps. First of all the Class III situation reflects  a bite which is sometimes called a “shovel bite” or “under-bite” What you see in general is the lower incisor teeth protruding out in front of the upper incisors forming in effect a cross bite. ?  A Class III bite can be due to just dental reasons (tooth position anomaly), or skeletal reasons (jaw position/relationship anomaly), or a combination of both dental and skeletal anomalies.  Let us address ach of these.

If your Class III is due to dental reasons alone, this makes things much easer to treat, In effect your upper and lower jaws are properly proportionately sized and come together so that the foundation or bed work in which the teeth are embedded are in alignment. The upper anterior teeth themselves may be improperly retro-positioned and/or tipped backward while the lower anterior teeth are oppositely positioned and/or tipped too far anteriorly. A dental correction is generally far easier than a skeletal one.

If the Class III situation is due to a skeletal anomaly, that is a discrepancy in the coordinating architecture of the upper and lower jaws, three scenarios are possible. I have outlined in the attached images a normal skeletal architecture with the size and anterior-posterior position of the upper ad lower jaws labeled “OK”. In the following two images a protruding lower jaw Class III style profile is noted. Three possible skeletal conditions can be present. The upper jaw can be normal sized while the lower is excessively large and protruding; the lower jaw can be normal with a small undersized upper jaw, or finally a combination small upper and large lower jaw can create the classic Class III “under-bite” situation.

In cases of Class III bites and profiles due to only dental reasons, orthodontic correction by moving the teeth may be all that is needed. If there is a skeletal component that is causing the issue then the treatment is more complex. In growing individuals, orthopedic appliances such as head gear, reverse headgear, and other appliances can be helpful. The dental Class III contribution may be present in addition to the skeletal Class III circumstances. For adults or for more severe situations, skeletal anomaly correction warrants consideration of orthognathic surgery to help ensure more definitive correction. So, what are you supposed to do Romain? Well, I hope you have an appreciation on how difficult this situation is.

Your family dentist is correct in referring you to an Orthodontist for an evaluation. Your orthodontist in turn may refer you for an additional consultation with an oral surgeon. Oral surgery procedures may or may not be covered by whatever insurance coverage, if any, which you my have,  Treatment of these conditions without oral surgery can give you an improvement, but with limitations. Be sure to check with the orthodontist and oral surgeon for guidance regarding the limitations of treatment and what realistic expectations you should have with either surgical or non-surgical option.

Finally, the question of the additional open bite likewise can be due to dental or skeletal reasons. Patients who have had a history of chronic thumb sucking often present with an anterior opening between the upper and lower anterior incisors, This opening can be due to the flaring out of the teeth, or can be more profound and include actual slight deformation of the “alveolar bone” which comprises that part of the upper and lower jaws in which the teeth are embedded.  Therefore an “open bite” of the anterior teeth can be due to just dental causes or skeletal due to dental-alveolar deformation, or a combination of both.

An additional and far more profound cause of an open bite is called an anterior skeletal open bite, This may sound a little confusing, because it involves the posterior teeth hitting prematurely because of a mismatch in the architecture of the upper and lower jaws whereby the back teeth touch first and therefore prevent the front teeth from closing, Imagine for example propping your mouth open by transversely placing a pencil  ( crosswise ) into your mouth so that is points from left to right. Well, if you bite down on the pencil with your back teeth , then the front teeth obviously will not meet. Likewise, some patients have slightly deformed/shaped jaws so that the back molars likewise  touch early, simply without the pencil there,

Again, proper diagnosis of this complex condition is best left to specialists such as Oral Surgeons and Orthodontists.  Radiographs ( x-rays ) including possible cone beam imaging may be recommended by the doctors to fully document your needs.

This question Romaine takes in some of THE most difficult cases in all of orthodontics. The potential for relapse after treating a skeletal open bite is relatively high. Special measures to maintain the treated bite in retention so as to help minimize relapse will likely be recommended. Your Orthodontist will help guide you on this.

Romaine, I hope this answer has not been too long. My bottom line is to pick an experienced, board certified Orthodontist as well as his/her oral surgeon counterpart and proceed with diligence. Make sure everything is documented before you commit to a treatment plan, and that all options have been explained.,  An informed consent document should also be made available for your  review and signature.

Please write back if I can help answer any other concerns.  

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Paul Supan, DDS, MA, MPH

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First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

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American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

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Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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