Malocclusion
What is malocclusion? “Malocclusion” is a combination of the Latin words ‘mal’, meaning ‘bad‘, and ‘occlus’, which translates to ‘shut up‘. The literal translation sounds a bit rude but the term is really just a fancy way of saying “a bad bite.”
In dentistry, it references an abnormality of the occlusal plane. The ‘occlusal plane’ is an imaginary line that arches across your mouth and indicates where each tooth should be positioned and how they should fit together in order to maintain optimum health of the teeth and facial bone structure.
As an umbrella term, there are many different bite problems that fall under the category of malocclusion:
Overbite
An overbite is one of the more common types of malocclusion. It occurs when the upper teeth extend out past the lower teeth and overlap them when biting down. In cases where the upper teeth are extended out drastically, it is referred to as a ‘deep bite’.
On overbite causes the front teeth to repeatedly grind against each other while chewing, wearing them down over time and making them more susceptible to chipping and breaking. It can also have an impact on facial appearance by pushing the lips outward and creating an aged appearance.
Underbite
In direct contrast to an overbite, an underbite is when the lower teeth extend past the upper teeth and overlap them. This condition has many of the same issues as an overbite does but the lip protrusion tends to be more noticeable since it’s concentrated on the lower lip, which makes it appear more striking.
Speech problems are also associated with an underbite more than the other types of malocclusion.
Crossbite
As a combination of an overbite and an underbite, a crossbite consists of teeth overlapping in different areas of the mouth. A lower tooth could be overlapping an upper tooth while an upper tooth three spaces over will be overlapping a lower tooth. It creates an uneven look when smiling and it can cause damage to the teeth by causing them to grind together and wear down.
Openbite
One of the tougher malocclusion types to treat is an openbite, This bad bite is defined by the front teeth not meeting when then mouth is closed, leaving a gap between the upper teeth and the lower teeth. Surgery has been the traditional treatment method for an openbite but in some mild cases where the issue isn’t caused by a problem with the structure of the jaw bone, less invasive methods can be used. One study from 2007 indicated that a non-surgical method of gradually pushing the molars back was actually more effective than surgery.
Crowding
Having crowded teeth greatly effects the appearance of a smile but thankfully, it’s not as difficult to treat as some of the other types of malocclusion. This issue occurs when the teeth are pushed together too much, either due to having a narrow upper jaw, injury, or teeth that didn’t erupt correctly. While easier to correct, fixing an issue of crowding is often a long process that may involve extractions and braces although a type of surgery called PAOO is an option to help speed up bite correction. When the upper jaw is severely narrowed, S.A.R.P.E surgery may be needed as well.
Diastema
Being the complete opposite of crowding, diastema is characterized by larger than normal gaps between the teeth. This can occur for a number of reasons but regardless of the cause, this issue can typically be easily corrected using dental composites, braces, or crowns.
Transposition
The appearance of a smile affected by transposition is similar to that of one affected by crowding. Although the two conditions have similarities and may appear together, there are a couple differences. While crowding is when the teeth are pushed too close together, transposition occurs when a tooth erupts in the wrong space, typically in the same space as another tooth. It gives the appearance of overlapped and uneven teeth. The cause of transposition is often genetic and the treatment is fairly simple, consisting of extracting one of the teeth in the transposition or a premolar and then using braces to bring the teeth back into alignment.
Misplaced Midline
The midline is the line between the two front teeth. When the midline of the upper teeth doesn’t match up with the midline of the lower teeth, it’s referred to a misplaced midline. Although this issue is often purely cosmetic, it may cause wear to the front teeth in some cases because the upper and lower teeth don’t meet correctly when biting down. A misplaced midline is one of the more mild form of malocclusion and is most often treated with braces.
Rotation
Usually seen with crowding, a rotated tooth is one that erupted incorrectly and is not straight. It is extremely rare for a tooth to be completely rotated to the point where the back of the tooth is visible when smiling and instead, it’s more common for the side of the tooth to be visible to some extent. Braces are the main treatment for this bite issue.
Each type of malocclusion has a variety of appearances and how much the malocclusion affects the aesthetics of a smile is dependent on the severity. In order to determine the best treatment options, each case of malocclusion can be classified into three different categories of severity:
- Class I or Neutroclusion – The teeth are either crowded or gaped but the molars are in the correct position.
- Class II or Distoclusion -The issue is caused by the molars being in the correct spot but tilting back towards the jaw joint.
- Class III or Mesioclusion – The molars are pushed forward away from the direction of the jaw joint and don’t line up with the upper molars.
The classifications can get fairly complicated and there are divisions within the classifications. Additionally, more than one class of malocclusion can appear in a diagnosis because each angle and plane of a bite is taken into consideration. While the information of which class your particular case of malocclusion falls into may not be that useful to you or worth getting a headache to try to figure out, it does give your dentist an indication of what the treatment process will be like.
The Impact Of Malocclusion
From a dental health standpoint, untreated malocclusion leads to many problems. Someone who has a significant bite issue that does not get taken care of is more likely to need dentures in the future. Misaligned teeth are often harder to keep clean. A tooth brush isn’t able to effectively get into the odd angles between crooked teeth and flossing can be close to impossible to do correctly when the spaces between teeth aren’t straight or accessible.
Periodontal issues, including gingivitis and periodontitis, are commonly seen with malocclusion due to the difficulty with keeping maintaining oral hygiene. These are caused by plaque build up around the gums, causing the gums to become inflamed and bacteria to get trapped between them and the tooth. Over time, the bacteria chips away at the jaw bone and can eventually lead to tooth loss. However, these issues don’t solely affect the mouth or dental health. They have been known to have an effect on the health of the entire body and are linked to the formation and progression of diabetes and heart issues.
The strength of a tooth in a badly aligned bite slowly diminishes over time. Due to the not meeting correctly when biting down, pressure isn’t distributed evenly over the tooth. This causes wear to the enamel, which is the protective layer encasing the tooth, and gradually weakens the tooth’s ability to handle the pressure of chewing. Chipping or breaking a tooth is more likely to be experienced by someone with a bad bite. More worryingly, the combination of not being able to efficiently clean the teeth and having the enamel wear down creates the perfect situation for tooth decay. Chronic pain from increased sensitivity, more cavities appearing, and dental abscesses forming are all side effects of malocclusion.
A painful disorder called TMD, also known as TMJ, is another common side effect of a bad bite alignment. The temporomandibular joint is where the lower jaw connects to the rest of the skull. It is located right in front of the ear and if you place your hand on that spot, you can easily feel the joint moving when you open and close your mouth. This joint of arguably the most used joint in the entire body so it’s important to have it functioning properly.
A misaligned bite hinders the temporomandibular joint from moving the way it’s supposed to. Having a bite that is not correct often pushes the lower jaw in an awkward position and that causes strain on the joint. As a result, the joint swells and over time, may eventually become permanently damaged. The symptoms of TMD include pain that can extend from the area of the joint to the rest of the head and the neck, toothaches from the nerves around the joint being affected by the swelling, jaw locking or popping, and ringing in the ears. More often than not, correcting the bite issue will cause TMD to go away but if there has been enough damage to the joint, a surgery to remove fluid build up or to repair the disc in the joint may be needed. In extremely severe and rare cases of extensive damage, a full joint replacement may be needed but this isn’t a common treatment because it’s a major surgery that is considered a last resort option.
Overall, from a health perspective, leaving a case of malocclusion untreated is risky.
Yet, health is far from the only detrimental effect of malocclusion. Misaligned teeth have a large impact on appearance. In our society, we put a lot of stock in how we look. Hollywood is full of stars with perfectly straight and white teeth and that kind of smile has become ideal. Considering how much we use our smiles to communicate or convey emotion, having one that falls short of the ideal can greatly impact our self-confidence and ability to be comfortable in social situations. Having to worry about what someone will think about our teeth and consistently reminding ourselves to keep strictly to closed-lip smiles will greatly affect our social lives.
Possessing a smile that we can’t say we’re proud of negatively affects our self-esteem. A 2010 Brazilian study concluded that people, although only adolescents participated in the study, with malocclusion are generally dissatisfied with their smile. It’s not only the smile that is a source of anxiety for those with malocclusion but the overall facial appearance. A few types of malocclusion cause the lips to protrude, making the rest of the face appear sunken in and aged. When the jaw is not positioned correctly, it can also juts out at an angle that is not aesthetically pleasing and alters the appearance of the lower half of the face.
The impact of a bad bite and misaligned teeth is an issue that comes into play within the most important aspects of our lives. Our social relationships and our ability to form them can become hindered. If someone has a less than perfect smile, they’re less likely to show off that smile. The lack of smiling gives off an unfriendly vibe because it neglects a vital piece of communication that people use to indicate that they’re welcoming to the idea of being approached.
A recent study also found that those with a misaligned bite or visible dental issues have more trouble getting into romantic relationships. Our society has created a standard where an imperfect smile is considered less attractive and not smiling or presenting a misaligned smile negatively impacts the ability to attract romantic connections. Within that study, the researchers found that crowding was the type of malocclusion that was the biggest hindrance to having an attractive smile. A large gap between the two front teeth and having a smile that showed too much gum came in second.
Adult Bite Correction Myths
- “I’m too old for braces.”
- “Only surgery works for adults.”
- “It’s better to just get dentures or implants.”
These statements are common myths that surround the idea of adult bite correction. Without a doubt, more teenagers wear braces than adults. The reasoning behind this is that teeth move more easily in younger people because the jaw is still forming and hasn’t entirely fused yet. However, that doesn’t mean that adults are excluded from the process of bite correction, by any means.
The adult jaw is fully developed and as a result, bite correction is more difficult to achieve. The options are fewer but those options are highly effective and they don’t all include surgery. More and more adults are seeking out bite correction treatment and the demand has caused dentists and orthodontists to develop new strategies and procedures to accommodate those patients so the options are steadily increasing.
Many people assume that full teeth extraction and dentures are the best choice but the reasoning is a bit flawed. The process of getting dentures is quicker than most bite correction treatments and often cheaperbut it presents an entirely separate list of dental issues. Without the teeth in place, the jaw bone starts to reabsorb. Over time, a significant amount of bone disappears and this has a large impact on the appearance of the face because the structure supporting it is diminished. This also affects the strength of the bone, particularly in the lower jaw. As it loses density and becomes smaller, it becomes more prone to fracturing. Surgery to complete bone grafting in order to provide enough bone for the dentures to adhere to may be needed later on. While getting dentures may seem like a quick and relatively inexpensive fix to a bite problem, it simply creates more severe problems and pain in the long run.
Dental implants following full extraction are a step up from dentures because they preserve the bone structure. The preservation isn’t as good as would be with the natural teeth still in place but it’s more than what is seen with traditional dentures. However, the cost of a full mouth of dental implants often exceeds the cost of bite correction by a mile. The average cost for full dental implants is roughly $35,000, with the higher ranges reaching up to $90,000 or greater, without the dental office and possible bone grafting fees included. You’d be in a situation where you could pay a lot to have all your teeth removed and replaced with artificial ones or you could pay less for bite correction treatment and keep all your natural teeth, which is considered ideal in terms of oral health.
The adult bite correction myths are simply that -myths. There is no age limit for getting malocclusion treatment or correcting a smile. Surgery is an option but not the only one and dentures are far from a better alternative in the majority of cases. Although adult bite correction may require a longer process than would be needed for a teenager and there may be different challenges involved, it’s still entirely possible and highly recommended to improve oral health.
Bite Correction Treatments
Braces and Retainers
Everyone is familiar with braces or at least very least, have a vague idea of what they are. They’re the most common treatment for a bad bite and many teenagers have spent their high school years with the dreaded ‘train track’ smile. Within the recent decade, these pieces of teenage life have become more popular among adults. With smaller bracket designs, the choice of ceramic brackets, and the growing popularity of invisible aligners, they are not as noticeable as they used to be and the ‘train track’ image is not applicable anymore.
All types of braces, from the traditional metal to the clear plastic, work on the same basic concept of gentle pressure. By applying a light but constant pressure on the teeth, which will be more concentrated on the areas most in need of correction, braces slowly push teeth into alignment. A retainer, which can also be made of metal or clear plastic, is used after the treatment with braces has ended and serves to keep teeth from shifting back into their original positions. With adults, keeping realigned teeth in their new positions can be a little more of a challenge so a retainer may be needed indefinitely, although it usually won’t have to be worn all the time after the first six months to a year. Learn more about Adult Braces and Retainers.
Periodontally Accelerated Ostegenic Orthodontics (PAOO)
This treatment is a combination of surgery and braces that involves damaging the jawbone slightly to make it more pliable during the healing period. The main appeal of this treatment option is that it’s much quicker than regular braces. Due to the slight bone damage, the teeth move more easily and it cuts the bite correction time nearly in half. Another perk of choosing PAOO is that there is a lesser chance of the bite reverted back to being misaligned. Despite the jaw bone being injured during the surgery, bone grafting is a part of the procedure and the end result is a stronger jaw bone that is more likely to hold the teeth into their new position.
Veneers for Bite Correction
Although mostly known as a largely cosmetic procedure, getting veneers for bite correction is only useful for treating mild cases of malocclusion. The process involves grinding the front of the teeth down to fit a tooth-shaped piece of porcelain onto it. While they are highly aesthetically pleasing, the grinding needed to make them fit correctly does cause irreversible damage to the teeth and can be pricey. They’re good for a bite issue that is purely cosmetic but overall, they’re better suited for restoration.
However, new forms of veneers that are made specifically for bite correction have been developed in the last couple years. VENLAY® is a newer bite correction method that resembles traditional veneers but has been claimed to fix multiple types of malocclusion. Since the treatment is still relatively new, there is no way to verify the long term results or know how effective it truly is after a couple years but from the information currently available, it appears to be a promising treatment.
Surgery
When all else fails, surgery is a popular bite correction option. There are a few types of surgery that correct malocclusion and all of them involve breaking and re-positioning the upper or lower jaw to some extent. The surgeries are highly invasive but they typically are only associated with mild or moderate pain during the recovery period.
Surgery isn’t often the end of the bite correction treatment. Once the jaw is re-positioned, braces may be needed to then straighten out the teeth. It can be a very long process when taking the pre-surgery planning, the recovery time, and the time needed for the orthodontics treatment into consideration so surgery is a treatment reserved for the worst cases of malocclusion that can’t be treated by less invasive methods.
Cost of Bite Correction
A large reason that people postpone bite correction is the price tag that comes with it. The treatments for correcting malocclusion can be expensive and many of them do not fall under the coverage of most insurance companies.
Veneers are the most expensive bite correction treatment and since they are considered cosmetic, the cost has to be paid out of pocket. On the other hand, most braces and surgical options are typically covered, at least in part, due to that fact they correct an issue that will can lead to more costly problems in the future. However, invisible aligners and retainers are not as likely to be covered because there’s a less expensive option in the tradition metal versions. The exact price and amount of coverage will vary depending on the region and type of dental insurance. There may also be certain office fees that have to be paid out of pocket.
If the cost, even with insurance coverage, is outside of your budget, looking into a dental college may alleviate some of the financial burden. Some dental colleges offer services at a much cheaper price because it helps give the students experience and is a good teaching tool. In return for getting the treatments at a lower price, you have to agree to let students do examinations and possibly even the conduct the procedures while under supervision. Each dental college will have different programs available so the pricing and what kind of treatments they offer will vary greatly.
After Bite Correction
Restoration
Having the alignment of your bite corrected is a large step towards being satisfied with your smile but it may not fix the entire issue. Since misaligned teeth are harder to fully clean, they can become stained in parts and this will be more noticeable once they are straight. Using at-home or in-office teeth whiteners will fix the problem of discoloration and brighten up a smile. For extensive staining, veneers or lumineers are a great option and a more permanent solution than whitening treatments.
An abnormal bite can also cause teeth to become worn down. That kind of damage is not reversible and while straightening out your teeth will stop any additional wearing, it will not help correct the damage already done. Worn down teeth are not as strong as healthy teeth and are more likely to chip and break. When the wear is significant enough to cause worry, dental crowns are an option worth looking into. Although they are expensive, they not only give the teeth a better appearance but they also add strength and protect the tooth. It’s very uncommon for every tooth to be worn down by malocclusion so crowns do not need to be placed on every tooth.
Adult bite correction can be a difficult and long process, involving both straightening the teeth and repairing any damage left behind by malocclusion, but it’s well worth the time and effort. Not only will your oral health be greatly improved but your self-confidence and happiness with your appearance will increase tenfold. Although treatment can be expensive, the large variety of treatment options means that bite correction can be achieved within the limits of most budgets. The first and most important step is to get in and see a dentist or orthodontist so that you can begin your progress towards a happier smile.
Citations:
Alpern, M. C., DDS. (2012, October 1). The Piggyback Technique. Retrieved from http://www.orthodonticproductsonline.com/2012/10/the-piggyback-technique/
Binder, R. E., DMD. (2004, April 7). Correction of Posterior Crossbites: Diagnosis and Treatment. Pediatric Dentistry, 26(3), 266-272.
Borges, C., Peres, M., & Peres, K. (2010, December). Association between malocclusion and dissatisfaction with dental and gingival appearance: Study with Brazilian adolescents. Revista Brasileira De Epidemiologia, 13(4).
Complete Dental Implant Cost Guide. (n.d.). Retrieved from http://www.dentalimplantcostguide.com/
Ersoy, Ü Z., DDS. (2014, June 8). Principles of Cross-Bite Treatment [Scholarly project].
Flieger, S., Ziebura, T., Kleinheinz, J., & Wiechmann, D. (2012). A simplified approach to true molar intrusion. Head & Face Medicine, 8(1). doi:10.1186/1746-160x-8-30
Gkantidis, N., Simeon, P., & Topouzelis, N. (2007, May 31). Teeth spacing: Etiology and treatment. Hellenic Orthodontic Review, 10(2), 75-92.
Karacay, S., Yildirim, E., Bengi, O., & Okcu, K. (2014). Treatment of midline shift by asymmetric premaxillary distraction: A case report. Gulhane Medical Journal, 56(2), 1. doi:10.5455/gulhane.14564
Kuroda, S., & Kuroda, Y. (2005, May). Nonextraction Treatment of Upper Canine–Premolar Transposition in an Adult Patient. The Angle Orthodontist, 75(3), 472-477.
Ngan, P., DMD, & Fields, H. W., DDS. (1997). Open bite: A review of etiology and management. Pediatric Dentistry, 9(2), 91-98.
Pithon, M. M., Santos, C. R., Santos, N. D., Lima, S. O., Coqueiro, R. D., & Santos, R. L. (2016). Impact of malocclusion on affective/romantic relationships among young adults. The Angle Orthodontist, 86(4), 638-643. doi:10.2319/030915-146.1
Kuroda, S., Sakai, Y., Tamamura, N., Deguchi, T., & Takano-Yamamoto, T. (2007). Treatment of severe anterior open bite with skeletal anchorage in adults: Comparison with orthognathic surgery outcomes. American Journal of Orthodontics and Dentofacial Orthopedics, 132(5), 599-605. doi:10.1016/j.ajodo.2005.11.046
Lakkakula, R., Dr. (2014, July 17). Periodontally Accelerated Osteogenic Orthodontics.
Rizvi, H., Sikder, M., & Hossain, M. (2013). Orthodontic Treatment of Severe Crowding Malocclusion with Extraction of premolars. Bangladesh Journal of Orthodontics and Dentofacial Orthopedics, 2(2). doi:10.3329/bjodfo.v2i2.16161
Tanaka, E., Iwabe, T., & Kawai, N., et al (2005). An Adult Case of Skeletal Open Bite with a Large Lower Anterior Facial Height. Angle Orthodontist, 75(3), 465-471.
Underbite. (n.d.). Retrieved from http://www.dentalhealthmed.com/conditions/underbite.html
Understanding the 3 Class Types of Malocclusion. (n.d.). Retrieved from http://www.dentalfind.com/article/orthodontics/understanding-the-3-class-types-of-malocclusion
Watted, N., Abu-Hussein, M., Hussein, E., Proff, P., & Watted, A. (2015, November). A Dental Transposition: Literature Review and Clinical Management. Journal of Dental and Medical Sciences, 14(11).
Weiland, F. J., Bantleon, H., & Droschl, H. (1996). Evaluation of continuous arch and segmented arch leveling techniques in adult patients—a clinical study. American Journal of Orthodontics and Dentofacial Orthopedics, 110(6), 647-652. doi:10.1016/s0889-5406(96)80042-4
What is a VENLAY? (n.d.). Retrieved from https://www.faceliftdentistry.com/venlay/
Whitening: 5 Things to Know About Getting a Brighter Smile. (n.d.). Retrieved from http://www.mouthhealthy.org/en/az-topics/w/whitening