how modern technologies help to achieve the ideal result

Orthodontists' offices may not look like this yet, but the equipment there is still at the level of space technology. It helps to carefully plan treatment.

The smile is beautiful, but the teeth do not close completely, chewing is uncomfortable, and the jaw, when moving, crunches, clicks and hurts – such situations are not so rare after treatment by orthodontists. The patient usually comes to such consequences because the doctor did not plan the correction correctly. There are usually two reasons: either the clinic did not have good diagnostic equipment, or the doctor does not know how to work with it very well and did not take into account important nuances.

A thorough examination and planning are everything. If you see the overall picture and every nuance well, and have modeled the movement of the jaw and teeth in advance in a computer program, then everything often goes like clockwork, and the satisfied patient leaves with an excellent result. But if you act blindly, then the patient is likely to get serious problems, and it can be difficult to fix them. What's most offensive is that many of these problems do not begin immediately, but after some time.

Modern equipment gives the orthodontist simply cosmic opportunities to plan everything correctly. You just need to know your business well, be able to work with equipment and software, and not spare time for the patient.

Proper planning in orthodontics takes place in four stages:

Facial and photograph analysis.
Analysis of jaws and joints.
Digital planning of jaw movement.
Klincheck – planning the movement of teeth.

To make it clear and understandable, I will use practical examples.

Step #1: Analyze the face from the photo

As an example, I will give just such a case, when the result of the orthodontist's work is outwardly gorgeous… but “behind the scenes” there are many nuances. Look: this girl's smile is perfect, isn't it?

On the outside, the smile seems perfect, but, as they say, there are nuances.

It is obvious that the orthodontist tried. He managed to achieve the most aesthetic appearance. This is good, but the patient's temporomandibular joint began to click and hurt. It is beautiful, but what is the point if a new problem arose because of this beauty?

So, how should you act correctly in such a situation? First of all, take a photo protocol and analyze your face for symmetry. In general, there are no absolutely symmetrical people in nature. For example, women always have one mammary gland slightly larger than the other, and men have one testicle slightly lower. The same story with the face: the question is how strongly it is expressed, how it affects the teeth, jaw, and temporomandibular joints.

We conduct an analysis of the face for symmetry.

Facial symmetry is assessed in relation to the central line – the one that runs vertically in the photo. According to the photo protocol, the patient’s face is generally quite symmetrical, but the right half is about 4 mm wider than the left. And the orthodontist placed the teeth exactly in the center. Conclusion? Perfect does not mean good.

It is also important to pay attention to the slope of the occlusal plane. In the photo, this is the red line, it passes through the cutting edges and buccal tubercles of the teeth. It is important that it is parallel to the pupil line. If there is a slope, it must be corrected, because it greatly affects the distribution of the chewing load.

To better understand the essence of the problem with the tilt of the occlusal plane, you can imagine a cylinder with a piston. If the piston enters at an angle even slightly, it will not be able to move normally and will wear out heavily (as will the walls of the cylinder). Sooner or later, it will jam. Approximately the same thing happens with the jaws: the teeth wear out, and the temporomandibular joint experiences too much stress and gradually collapses.

We check how far the chin protrudes forward.

In a profile photo, it is important to evaluate how the line is located, which passes through two points: the glabella between the brow ridges and the point at the base of the nose. Determine how the gnathion point is located in relation to this line – the most protruding part of the chin. If this point and the chin protrude forward, then such a bite is called mesial (by the way, if it is very pronounced, then this is a very difficult thing to correct), and if they are pushed back – distal.

This patient has a harmonious profile. It is only slightly inclined to mesial bite. There is nothing wrong with this, but it should be taken into account when planning on CT.

Here you can see that the upper and lower teeth do not close quite symmetrically.

The smile in the photo looks harmonious and beautiful, but there is a minus. This is the deformation of the occlusal plane, that is, the teeth do not close quite evenly, which is clearly visible in the image on the left. There is another problem. It is not noticeable at first glance, but the orthodontist will see it right away. The teeth on the right are located more vertically, and on the left they are more inclined. This once again demonstrates that the doctor did not take into account the asymmetry of the face during treatment.

The patient also complained that her teeth did not close completely, and because of this it was uncomfortable to chew. Actually, that is what you can see in the photo.

At the same time, there is enough space on the jaw arches, their sizes correspond to the sizes of the teeth. And this is great.

Step 2: Analyze the teeth, jaws and joints

The patient's left lower jaw has “moved” back, hence the crunching problem. This is confirmed by the scan results. The muscles pull the jaw to the side, and as a result, there is a slight displacement of the lower teeth in relation to the upper ones:

The scans also show that the teeth do not close quite correctly.

A frontal CT scan showed that both the upper and lower jaws were wide enough for the teeth to be positioned opposite each other. There are severe cases where the patient has no alignment at all. But here everything is fine:

CT scan confirms that the jaw sizes are fine.

A CT scan can help see what's wrong with a patient's temporomandibular joints. This image shows the right joint on top and the left joint on the bottom:

CT scans show narrowing of the joint space.

So, what do we have here? The joint spaces are very narrow on both sides, especially on the left. There is no room for the articular disc (its thickness is normally 2 mm) in such a narrow space, and it is very important for the proper functioning of the joint. There are even places where the articular process of the lower jaw touches the bone. All this happened because the branch of the lower jaw on the right is slightly longer than on the left, and the muscles pull the left part back more strongly. This is like, for example, glasses with different temple lengths: the one that is shorter will press its side to the face more strongly.

The orthodontist’s task in this situation is to perform distraction, “pull” the left joint forward and thereby increase the joint space.

Here are some more calculations of the main angles and planes. I will not go into details, this is to show how much needs to be taken into account when making a treatment plan.

Step #3: Putting it all together and “positioning” the jaw correctly

This stage is probably the most interesting for any orthodontist. Because now we can combine the results of the photo protocol, scanning and CT, create a general picture and a correction plan. And at the same time move the patient's jaws and teeth in a special computer program.

To figure out what to move where, first of all, you need to take measurements and make calculations. This is how the width of the clearance in the temporomandibular joints is measured:

We measure the width of the joint spaces and figure out what to move where.

Here we see that the width of the joint space on the left at the edges is 1.8 and 1.5 mm, and in the central part – only 1.2 mm. This is very small. For comparison: on the right, the same size is 1.9 mm, and this is already much closer to the norm.

Next, right in the same computer program, in real time, we move the jaw to the correct position. This image shows how we have already “played” with the jaw and “cured” the virtual patient:

We corrected the position of the jaw in a computer program - now we need to correct it on the patient. — We corrected the position of the jaw in a computer program – now we need to correct it on the patient.

Do you see the difference between the images? There is one. Initially, the joint space width on the left (upper right image) was 1.2 mm, and we made it 2.2 mm (lower right image). Similarly, we “stretched” the right joint space to 2.1–2.2 mm (lower left image).

Now we need to transfer the results of this “computer treatment” into reality: correct the patient's teeth so that they remain beautiful, but the symptoms of crunching and pain disappear. Based on what is revealed in the photos and images, two correction options are possible:

Place overlays on the chewing teeth and increase the height of the chewing section.
Change the position of the teeth with the help of aligners (they are also called orthodontic caps), so that the jaw is then “tightened” after them.

In this case, the patient chose the option with aligners.

Step #4: Figure out where and how to move the teeth

The next stage is clinch check (setup), creating a virtual volumetric model of tooth movement. In a special computer program, you can move the teeth as needed. But you can't focus solely on beauty. In the previous stage, we aligned the jaw, and now we give the teeth certain positions taking into account its new position. This is generally the key idea: first, we correctly position the jaws, and only then the teeth.

As a result, the entire complex structure is correct – the entire dental apparatus. The teeth look beautiful and close correctly, the jaws are brought into the right position, the temporomandibular joints are “stretched”, the loads in them are distributed optimally, they no longer crunch, click or hurt.

The clinch looks like this (in this particular case, the Avantis program was used):

These images help you understand how to move your teeth correctly.

The output is the order of teeth movement. That is, if we explain it in simple terms, now we have a cartoon where each frame corresponds to a new, slightly changed position of the teeth. In fact, each frame is one small stage of correction, and separate aligners are made for it. The patient wears them for a certain time, and then we move on to the next “frame” and issue new aligners.

At the end of the last stage, the patient's teeth take their final correct position, and the orthodontist is left with a box with a bunch of aligners as a keepsake (by the way, I have an idea to give them to patients as a souvenir).

I'll tell you a little more about how useful a wedge can be, and I'll illustrate this with a very difficult case from practice. I had a patient with teeth like these, and it was completely unclear what to do with them:

Klincheck helps to find solutions even in such difficult situations.

The difficulty here is that the central teeth had to be moved back by 6 mm to get them into the correct position. This is impossible from a clinical point of view. The images show that the roots of this man's central incisors protrude significantly forward, practically hanging in the air. It is unclear how to tilt them back and insert them into the bone.

The arrows show that the tooth is practically hanging in the air, and it is unclear how to implant it into the bone.

Klinchek helped to understand what to do in such a situation. It was decided to remove the central incisors and put implants instead. There was no other way in this situation. The treatment plan is shown in this image:

This is how the correction scheme turned out to be complicated. And without the clinch check, nothing would have happened at all.

The red arrows show how we will move the teeth. The crosses are the teeth that need to be removed and replaced with implants. The blue rectangles are the places where the implants were planned to be installed. This process is not quick and complicated: the prosthetics alone took a year. But without the clinch check, it would not be clear at all what to do.

Let me repeat once again: before performing a wedge check, you always need to look at the position of the lower jaw and set it correctly. Here is this stage in this patient:

It was unclear from the CT scan what to do, but from the clinch check it was clear.

There is a strong contrast with the condition of the teeth: the temporomandibular joints are not that bad. Yes, the jaw was in a forced position for quite a long time, arthritis developed, but it only needed to be moved a little. After digital positioning of the jaw, it was still unclear what to do with the teeth. And after the clinch check, everything became clear.

These are the possibilities that modern equipment provides. No magic: only the achievements of technical progress and the desire of the doctor to do everything as it should be.

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