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Orthodontics/Upper Midline Not Centred on Face!

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QUESTION: Hello Dr. Supan,


I am receiving orthodonitc treatment  for class I malocclusion and posterior crossbite on one side. I noticed that the centre of my top two front teeth/upper midline, does not  exactly line up with the centre of my nose/face. This was never mentioned to me by my orthodontist, nor was it sated in the consultation notes (even though the lower midline was noted to be off the upper., with no mention of the upper being off my face...). I brought this to the attention of the orthodontist;s office,  asking if he was aware of this and whether or not he planned to address it.  The ortho's assistant stated that he is aware but that it cannot be correct without extracting teeth and that they are only able to centre the lower arch to the top arch because my lower teeth had crowding, whereas my upper teeth did not have as much crowding.

I wonder how logical this reasoning is...my upper midline is not centred to my face by about 1mm, and it appears to need to be shifted 1mm towards the crossbite side in order for it to be centred to my face...why would it be necessary to extract teeth to correct this? Does this seem like more of a case of ignorance and poor treatment planning?

I understand that my issue may not be visibly noticeably to people right away, but that is aside the point to me.  I am not happy with my orthodontist failing to give me all of my options or  going over the outcomes/expectations with me..it wasn't until I brought it up that I was given what I believe to be a poor excuse/reasoning about why they cannot fix what appears to be a minor thing to fix.

Please advise.

Thank You.

ANSWER:
Hi Chila,

Below please find the completed question as per our earlier emails. Thank you for changing the answer to public for the benefit of the many readers of this website.

****************************************************************************************



Dear Chila,

Thank you for your question. The question of centering of dental midlines to the face is a very common concern. First let me again state, 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. No pre or post treatment records or photos were submitted.

Your wrote:

   “  I am receiving orthodonitc treatment for class I malocclusion and posterior crossbite on one side. I noticed that the centre of my top two front teeth/upper midline, does not  exactly line up with the centre of my nose/face. This was never mentioned to me by my orthodontist, nor was it sated in the consultation notes (even though the lower midline was noted to be off the upper., with no mention of the upper being off my face...). “  

If you have a posterior crossbite, it can be due to dental or skeletal, or a combination of these two factors. In either case, slight midline discrepancies are not unheard of and sometimes actually are more or less unavoidable. The reason for this is that a skeletal anomaly such as a long standing lower or upper jaw asymmetry may have been present and in fact may be related to the crossbite. You may in fact have a basically slightly asymmetrical face. Let me parse this up a bit.

If the upper jaw is narrow, then a one sided or bilateral cross-bite may occur.  In another scenario, picture  the lower jaw being affected by chronic repositioning to one side by a person always sleeping on one side of their face and pressing the jaw to one side.  This person may develop a slightly off set lower jaw. In fact, a growing child who always sleeps on one side of their face may well develop a slight asymmetrical face because of changes to the entire cranium. This is a very subtle change not apparent to most lay persons or patients. For the experienced clinician who has a careful eye, it is often easily seen. When first seeing patients for an initial examination, if I see an asymmetry, I may ask, “ do you sleep mainly on the left side of your face?” They often look surprised and say ..” why yes”.

The point being Chila, if you have a cross-bite, your face and bite may not have been very symmetrical to begin with, and a 1 mm discrepancy is actually for all practical purposed inconsequential.

Now you may say, well not to me.  Point well taken.  There has been published research (links below) where dentists and lay persons were tested on when they started to notice a midline discrepancy.  Article” Comparing the perception of dentists and lay people to altered dental esthetics.” By  Kokich VO Jr1, Kiyak HA, Shapiro PA. The Abstract is found in the link below, and I have excerpted a portion.

http://www.ncbi.nlm.nih.gov/pubmed/10825866

Basically,

“Forty images were randomized in a questionnaire and rated according to attractiveness by three groups: orthodontists, general dentists, and lay people; 300 questionnaires were distributed.

RESULTS:  

The response rate was 88.2% for orthodontists, 51.8% for general dentists, and 60.6% for lay people. The results demonstrated threshold levels of noticeable difference between the varying levels of discrepancy. A maxillary midline deviation of 4 mm was necessary before orthodontists rated it significantly less esthetic than the others. However, general dentists and lay people were unable to detect even a 4-mm midline deviation. “  

I think the take home message here Chila is that no one doubts the fact that the 1 mm midline discrepancy bothers you. However, taken in tot  broader context that you presented with a cross-bite and possible underlying facial, skeletal, and/or dental asymmetries, the  fact that you currently have a 1 mm offset is perhaps no as profound an issue as you may think. No one is saying you are wrong, rather it is more to offer an explanation on how most people interpret and perceive moderate midline discrepancies.

You also wrote:

" I brought this to the attention of the orthodontist’s office, asking if he was aware of this and whether or not he planned to address it.  The ortho's assistant stated that he is aware but that it cannot be correct without extracting teeth and that they are only able to centre the lower arch to the top arch because my lower teeth had crowding, whereas my upper teeth did not have as much crowding."  

I do not have the benefit of any records, but this seems quite plausible and reasonable. Sometimes certain dental issues can be resolved, but at the expense of something else. Extracting teeth, placing implants with smaller crowns, etc. are all options that can solve certain vexing orthodontic problems, but at what expense. What is the risk/benefit ration and is it in the interest of the patient to leave the existing issue alone, or to undertake draconian solutions however drastic.  Perhaps your orthodontist is in fact assessing the overall situation quite accurately and using his/her best clinical judgement to achieve a clinical result that is excellent, albeit not perfect, without invoking drastic solutions such as extractions.

You also wrote:

" I wonder how logical this reasoning is...my upper midline is not centred to my face by about 1mm, and it appears to need to be shifted 1mm towards the cross-bite side in order for it to be centred to my face...why would it be necessary to extract teeth to correct this? Does this seem like more of a case of ignorance and poor treatment planning? "  

Crossbites,  when coupled with facial, skeletal, and dental asymmetries present a complex constellation of issues. In addition, there are sometimes tooth size discrepancies to deal with even further complicating this situation. If you have but a 1 mm discrepancy, which is less than 1/25 of an inch, ask yourself if you really think most people would notice it. The research done by Kokich, and many others since then would suggest no.

You further wrote:

“ I understand that my issue may not be visibly noticeably to people right away, but that is aside the point to me.  I am not happy with my orthodontist failing to give me all of my options or  going over the outcomes/expectations with me..it wasn't until I brought it up that I was given what I believe to be a poor excuse/reasoning about why they cannot fix what appears to be a minor thing to fix. “  

Your point is well taken. Again, in defense of your orthodontist, treating any orthodontic case, particularly one involving a cross-bite, is not an exact science. You can go to say a  home improvement store and ask them to cut an 8 foot piece of wood for you into two identical 4 foot pieces. That is predictable and doable. Orthodontics, like much of medicine is NOT 100 % predictable, and everyone presents with a unique situation. In general, results are excellent, and a 1 mm discrepancy I would accept as being an acceptable, if not excellent result.  One needs to judge a treatment’s end result by what the doctor was tasked with treating in the beginning.  It could well be that he/she may have sought to finalize and harmonize the midlines, and in fact succeeded in doing so to a large degree, but simply was not able to bring them 100% perfectly spot on. Again, I would not consider this a shortcoming.

You wrote finally:

“Please advise”  

My advice would be to look at your pre and post treatment records. Ask yourself if the results you see are a significant improvement. I am certain it is. Also, and this is interesting, take a piece of floss and hold it vertically just touching your nose. Stare into a mirror so as to ensure that you are in fact bisecting your face. You may be surprised to actually find how asymmetrical the rest of your face actually is. The nose may be slightly deviated, as might be your chin.  Again, a lot of esthetic and orthodontic research has been done in this area. There have been many studies that took pictures faces from modeling agencies or beauty contest winners and then made three “composites. The picture of the face was bisected vertically and a composites of two left halves, two right halves, and the actual left and right half were assembled. Remarkable symmetrical discrepancies appeared even among so called “ models” and “beauty contest winners”

So Chila, have a careful look and tell me what you thin of your current orthodontic result. I would very much welcome a follow up question. I consider this a very interesting question.

I hope my comments have been helpful Chila. I am told the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your upcoming Doctor visits, and thank you for writing.

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. I also will sometimes consult with other doctors on complex questions. This of course takes time.  Your understanding is appreciated.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com


---------- FOLLOW-UP ----------

QUESTION: Dr. Supan,

I  cannot thank you enough for your well thought through and detailed response.
I always knew I had some facial asymmetries but I had thought that maybe
my teeth, if positioned where they should be, would help improve the look of this. I think my main issue now is that  my orthodontist did not discuss any of this
with me in the beginning, nor asked me what my expectations were and what he
could achieve. I feel I have little control, opinion, or input on the process.
Despite this, the result so far have been positive, aside from the minor issue
-- my teeth are fairly evenly shaped, and I am about halfway through, so at least there is that.

I suppose my other question out of curiosity would be why IPR could not be used in a case like this to get a centred midline? Also, is it only a crossbite that causes this discrepancy of the midlines to the face, and would this be fixable if it was not due to a crossbite?

The time and effort you have put into answering my question is great ,and I appreciate you helping to not only shed knowledge and insight on my perceived issue, but also to allow me to move towards feeling content about it.


I look forward to your reply.

ANSWER: Dear Chila,

Thank you for your kind comments.  It is always a pleasure to answer interesting questions like yours. The midline issue is in fact a very common manifestation, and it is a concern for some, and not for others.  My philosophy has always been that if it is a problem for the patient, then it is a problem that cannot be ignored. It needs to either be resolved if possible, or a better effort needs to be made to inform the patient about realistic expectations, limitations of treatment, and other mitigating factors.
Now to address your latest concerns.

You wrote:
I suppose my other question out of curiosity would be why IPR could not be used in a case like this to get a centred midline?


With a 1 mm discrepancy of the midline I suppose IPR is indeed an option. However, there are pros and cons. IPR does remove enamel that will never grow back. If excessive IPR is done then sometimes there can be thermal and other sensitivities. In your case a 1 mm discrepancy might be managed by reducing several adjacent teeth by < 0.5 mm.

If a single anterior incisor is chosen for IPR, a slight asymmetry in the tooth size may become noticeable for some, even though the upper and lower midlines are now aligned.  Reducing the size of the lateral AND central incisor might mitigate this concern regarding unbalanced incisor sizes.

The degree of horizontal overjet in the existing bite is another concern. In other words, if a small space is created for example to move the incisors from one side over in order to center the midlines. The front teeth will still need to be retracted or moved in mass collectively back towards the palate in order to now close the space which was created. It is generally not possible to move all the teeth on one side all forwards to close the space which was created by IPR and which in fact still exists  even though the incisors have been moved to align the upper and lower midlines.  Bonding a canine or premolar to close the created space is sometimes considered.

In summary, if the midline discrepancy is only 1 mm, many studies have demonstrated that it is not noticeable by most lay persons. Only when such a midline deviation approaches 4 mm does it become a concern. Given the IPR issues, only you can decide whether such an undertaking is really worth it for a 1 mm offset.

Chila, you had a second follow up question.

You wrote:
Also, is it only a crossbite that causes this discrepancy of the midlines to the face, and would this be fixable if it was not due to a crossbite?


A crossbite, and the issues which cause a crossbite such as skeletal maxillary width insufficiencies can be contributing factors to midline discrepancies. However, a midline discrepancy can certainly arise in the absence of a crossbite.

Imagine for example an asymmetric lower jaw where the left side of the jaw (body and/or ramus) is larger or smaller than the contralateral right side. This could lead to an upper/lower midline discrepancy. It is important to define “midline discrepancy” here.

Midline Discrepancy Types:

** Upper dental midline (where two upper central incisors contact) is not coincident with overall facial midline.

** Lower dental midline (where two upper central incisors contact) is not coincident with overall facial midline.

** Upper dental midline is not coincident with lower dental midline, even though upper, lower, or neither dental midline is coincident with the overall facial midline.

** Upper and lower dental midlines are coincident with one another, even though they are not coincident with the overall facial midline.

These “skewing” effects, be they dental, skeletal, or a combination of both, are sometimes difficult to treat.

When left vs right tooth size discrepancies exist then a second possible situation can arise where no crossbite necessarily exists, yet there is a midline discrepancy of some sort. Imagine for example Chila if you had a small, undersized upper lateral incisor. For purposes of illustration, let’s say the upper left lateral incisor is 5 mm in width, and the contralateral upper right lateral incisor is 9 mm in width. After orthodontic correction and closure of all spaces, there may be a midline discrepancy.

In many cases, the clinician sees this before treatment begins and  can advise the patient regarding bonding options to cosmetically restore the undersized tooth back to its normal size and width, thereby now matching the size of its contralateral partner, and thereby helping ensure little if any of a midline issue.

Chila, I don’t have a recommendation to give you on your small 1 mm midline discrepancy. Much of this is a matter of persona aesthetics, and in the final analysis it is up to you to decide what, if anything, you would like to undertake.  I hope you will follow this up with a comment letting readers know what you decided to do.  

Again, thank you for the follow up question. I hope my comments have been helpful Chila.  As you know, website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your upcoming Doctor visits and thank you for the follow up.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com  
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. 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. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.




---------- FOLLOW-UP ----------

QUESTION: UPDATE: I'd like to thank Dr. Supan again for his information presented. I recently had an appointment with the orthodontist and I brought up the mid-line issue. He was not too concerned about this and mentioned the possibility of nose and/or facial asymmetries as a cause. He described it as being off "by a hair." Basically, he did not find it to be a big issue and said there was nothing they could really do about it. I did not contest his view on this nor did I suggest what my further options/possibilities could be to correct this because I wondered myself how important it really is to "fix" what most would consider a minor issue. I am working towards learning to simply accept and live with the many little physical quirks I have. Good luck to anyone else who may be going through similar!

Answer




Dear Chila,

Thank you again for writing. There has been a terrible delay in answering your question because I have actually talked to a Board Certified Dermatologist who is well versed in aesthetics about your question.  Again, pardon my inclusion of the following disclaimer which I know you have now seen many times .

Chila, what I write here are only my opinions based on limited information. Any comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  As you know Chila, 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.

Now, in your latest follow up question you asked several things. Let me parse the question into three more easily digestible parts.  You  wrote:

#1
QUESTION: UPDATE: I'd like to thank Dr. Supan again for his information presented. I recently had an appointment with the orthodontist and I brought up the mid-line issue. He was not too concerned about this and mentioned the possibility of nose and/or facial asymmetries as a cause. He described it as being off "by a hair." Basically, he did not find it to be a big issue and said there was nothing they could really do about it.

From the many submissions and in reviewing what you wrote, I think Chila you have been the recipient of some really excellent dental care. You live in Ontario, and Canada has some of the world’s premier dental care. The University of Toronto is considered leading edge, and their Orthodontic program for many years was headed by a leading pioneer in the field of Orthodontics namely Dr. Donald G Woodside. Sadly he recently passed.

http://v1.theglobeandmail.com/servlet/story/Deaths.20130727.93325102/BDAStory/BD  

In any case, what I am saying is that you live in an area where it is probably difficult to in fact find Orthodontic treatment which is not first rate. I am not saying every Orthodontist in Ontario delivers excellent care, but I would venture to say that across the board it is pretty darn good.

Facial asymmetries, as described in an earlier reply to you,  are not uncommon. The BBC in fact had an excellent program on the human face. You may enjoy watching it on Youtube. I have included several links below.

https://en.wikipedia.org/wiki/The_Human_Face  

http://www.imdb.com/title/tt0280262/  

Basically Chila, at this point indeed trust your Orthodontist when he says that correction has been done to the best extent possible. If not all asymmetries have been corrected, then they in all likelihood are simply beyond practical correction.

I spoke with my Dermatologist friend. There are patients she has had who while blessed with  perfect skin and a perfect complexion, nevertheless may still find fault with themselves. Patients like this often have a condition known as body dysmorphia.

https://en.wikipedia.org/wiki/Body_dysmorphic_disorder  

I think you are in fact very wise to have accepted your already excellent Orthodontic result and to not dwell on what may in fact be trivial matters.  This is so nicely reflected in your comments in the following section #2.

#2
I did not contest his view on this nor did I suggest what my further options/possibilities could be to correct this because I wondered myself how important it really is to "fix" what most would consider a minor issue.

You know Chila, try this little test.  Take a picture of yourself. Enlarge it to say 8x10 inches (this is 200 by 250 mm for our metric readers) . Show this picture to say 10 friends. Ask them do comment on your hair, eyes, skin, chin, ears, and smile. I will bet that not a single person will comment about the midline. As I alluded to earlier, research has demonstrated that discrepancies have to well nigh approach 4 mm before a lay person finds them noticeable.  Now Chila, don’t show them the picture and say. “  hey do you think my eyes are a little saggy or my smile is a little off? “  That is prejudicing a person, and in all likelihood they will try to be agreeable and concur with any of your comments.

#3
I am working towards learning to simply accept and live with the many little physical quirks I have. Good luck to anyone else who may be going through similar!

Well Chila, to this I would again say…have a look at the pre-treatment and post-treatment records. No doubt there will be a profound difference. Here is a quotation to think about:

“   Normal people... believe that if it ain't broke, don't fix it. Engineers believe that if it ain't broke, it doesn't have enough features yet.  “  (  Scott Adams  )

At this point Chila, I believe you are very wise to accept and appreciate what you have been able to achieve through Orthodontic treatment.  As Confucious never said….”It is not worth worrying about things not worth worrying about “.

So Chila, it is 2016, go forth and enjoy your smile. Wear your retainers, and maintain the alignments which you have achieved.  Also, do watch that BBC series on the beauty of the face. I think you will find you are probably blessed to be at the high end of the bell curve when it comes to facial aesthetics.
I hope my comments have been helpful. As you know Chila,  the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your retainers,  and thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. 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. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.

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Paul Supan, DDS, MA, MPH

Expertise

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.

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

Publications
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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