One of topics asked about most often is dental crowding; patients very often say that their teeth are overlapping and they want treatment to straighten out this dental crowding. In the majority of cases dental crowding is related to other problems. As such, in each case it is crucial that ALL of the problems are assessed, not just the crowding. If time is not taken to carry out an initial analysis in meticulous detail, the patient and orthodontist may find themselves in a very unpleasant situation with further complications arising.
When it comes to treating dental crowding as part of a malocclusion, many factors must be taken into consideration:
1. The type of malocclusion the patient has, in addition to the crowding (if they have a crossbite, an open bite, etc.).
2. Inclination of the molars and premolars (rear sections of the mouth).
3. Inclination of the incisors (front sections of the mouth).
4. Periodontal condition, gum health and biotype (thin or thick gums).
5. Size and shape of the teeth.
6. The patient’s facial profile.
7. Other factors (caries, wear, etc.).
How do you ‘make space’ in order to solve dental crowding?
1. Expansion – making the dental arch larger.
The way to make the dental arch larger is by widening the rear sections (pushing them outwards) and inclining the front sections forward. This is the simplest way to create space, but it is limited as it depends on the gums and the alveolar bone in which the teeth are anchored. Some orthodontic techniques advocate a disproportionate expansion of the dental arches using self-ligating brackets. Personally I am not in favor of performing this type of expansion because of the clear risk to the health of the gums; if the orthodontist goes beyond the ‘healthy limit’ of expansion, very serious gum problems may arise, such as receding gums, bone loss or even the loss of a tooth.
In the orthodontic analysis we look at whether the front teeth can be inclined or not, and whether or not the rear teeth can be expanded. If the front teeth are already inclined very far forward, we cannot incline them further. And if the rear teeth are already very wide apart, we cannot expand them further. In such cases, alternative solutions to the case must be sought. In the following image the yellow arrows point to the lower incisors. On the left they are very inclined, but on the right they are not inclined so far forward and can therefore be inclined more in order to create space.
2. Tooth extractions.
In general, extractions are carried out when the crowding is very severe and the gums are very thin, not allowing for expansion; when the profile is very protruding (lips that stick out a lot); or when the goal is to neutralize or camouflage a malocclusion related to crowding (such as this class II camouflage treatment). Sometimes a decision is made to take advantage of the orthodontic treatment and extract a tooth that already has a problem with caries or unsuccessful root canal treatment.
Dental stripping involves shaving the points of contact between the teeth in a way that is minimally invasive. This creates space to allow for the alignment of the teeth. This procedure is limited to the enamel of the teeth, meaning that there are no side effects. Stripping is a method that is widely used, but it is very limited due to the fact that the enamel can only be shaved to a certain extent.
The procedure we favor most when it comes to severe crowding is the distalization of the molars, taking advantage of the space of the wisdom teeth and managing to create 4-5 mm each side on each arch (upper and lower). By using micro-screws it is possible to avoid the majority of tooth extractions relating to crowding, and to neutralize or camouflage problems that previously could only be treated with extractions.
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