Altered Passive Eruption: Hard Tissue

Teeth are composed of two basic, visible parts—the root portion and the crown (enamel-covered) portion. The term crown does not refer to the type of tooth replacement fabricated by a dental laboratory. Rather, it is the part of the tooth that is normally seen when you speak.

The present-day esthetic dental philosophy, demonstrated by people who have beautiful teeth and smiles, shows that there must be a certain amount of enamel-covered tooth visible for an attractive smile. The ratio is about 1.6:1, length to width. Teeth that are shorter than this look progressively less attractive. They look short and stubby. If they are actually worn down from a clenching or grinding problem, this is a different type of problem. But it may not be that the teeth themselves are too short. It could be that there is not enough of the crown of the tooth that can be seen. The remainder that should be seen is covered with gum or gum and bone tissue. This is known as altered passive eruption. It is not entirely clear why this happens. It may become obvious as early as age 14. The teeth may have a pleasing color and be very straight, but they still leave something to be desired because they are too small and too much gum shows when you smile.

This can be a severe cosmetic problem when coupled with the type of lip line that frames the teeth. A low lip line will probably hide most or all of the gum covered part of the tooth, so there is less of a need to correct the defect. A medium or high lip line, especially a high lip line, will show all of the tooth and gum. As the lip line gets higher, the attractiveness of the smile goes down. The situation can be so severe that the patient will train his or her muscles to artificially hold the upper lip stiff or cover the mouth with a hand when smiling. In this way, the short teeth or the great expanse of gum tissue will be hidden from view. It can cause significant psychological problems.

The solution can be easy or complicated, depending on the exact nature of the problem. If there is only a small amount of gum tissue to be removed from a single tooth or multiple teeth, and there is a medium lip line, then the tissue is easily removed with a laser or electrosurgical cutting device. Scalpels and stitches are not needed in small cases. As more gum must be removed and more tooth is exposed, there may be some underlying bone that must be reshaped. Bone removal will be followed, about 2 months later, by the soft tissue removal mentioned earlier. The first surgery must heal long enough for the tissue to reach its final position before the second can be completed. Remember, you are looking at differences of several millimeters to a fraction of a millimeter that will cause the case to be a success or failure. A two-step procedure is better than a one-step procedure.

The biting edges (enamel and/or dentin) of one or more teeth may be reshaped if there is a need not only to lengthen the teeth but also to make it appear that they have actually been placed higher in the smile line. This is for top teeth, of course. If a great deal of tooth must be reshaped to accomplish the desired effect, root or dentin may be exposed, making the tooth sensitive. These teeth will need to be covered with porcelain veneers or crowns to achieve the proper esthetics. Even if only a little amount of tooth is reshaped, the veneers or crowns may be indicated to get the exact appearance you want. We will discuss this with you before you begin treatment. It is important that you know what is being done, how long it will take to complete, and what you will look like when it is finished,

We will make the veneers or crowns and reshape the teeth. We will determine what can be done. We may also do the soft tissue contouring. This is most common. For procedures that involve a reshaping of the bone, you may be referred to our periodontist. Since we will do the restorative treatment, we know exactly where the soft tissue should be. We are the cosmetic specialists. We will establish the final position of the gum line. In extreme cases, the problem will be corrected with a combination of the above-mentioned procedures and orthognathic surgery to reposition the jawbone and teeth. This can be done by our oral surgeon. With a comprehensive examination, we can tell you what is appropriate for you. You do not have to live with an unattractive smile because you have short-looking teeth due to showing too much gum tissue. These problems can be corrected. Let us know what you do not like about your smile or teeth. More than likely, the smile you now have can be made into something you will like to show off.

If you have any questions about altered passive eruption, please feel free to ask us!  

Hymeadow: (512) 250-5012

Jollyville: (512) 346-8424

West William Cannon: (512) 445-5721

A Beginner's Basics to Braces

How can orthodontics help you?
If your teeth are in poor alignment, you could be facing a functional or cosmetic problem. Orthodontics (braces) can eliminate that problem for you. One of the first things people notice about you is your smile and how your teeth look. You don't have to be a dentist to notice poorly positioned, crooked teeth. In today's culture, crooked teeth are not regarded as attractive or desirable. Most people, when asked, say that they would like to have straight teeth. Straight, white teeth are the cosmetic dental improvements patients most request.

Braces may also be suggested to correct a specific dental problem that only affects one or several teeth. This is not a cosmetic tooth repositioning, but rather a functional tooth movement. Occasionally, in order to properly finish an orthodontic case, the orthodontist may ask the dentist to adjust the enamel of some teeth or bond a resin to some teeth to improve the occlusion (bite alignment) or to enhance cosmetics. This will be discussed with you as soon as it becomes apparent.

When should you see an orthodontist?
The need for orthodontics is best discovered when you are young. A dentist will have a good indication of whether or not your teeth will be straight when he sees you as a child 6 to 8 years of age. Most treatment would not begin until a patient is 8 years old, although in some cases, orthodontics can be started earlier.

It is easier to direct the movement of teeth in a child. Early tooth guidance is a very important phase of orthodontic care, which can take place even though all the permanent teeth are not yet in place. Certain problems are much easier to correct at this stage of a "mixed dentition" of baby and permanent teeth. An average case can last from 18 to 24 months.

While orthodontic therapy is admittedly easier in the child patient, you are never too old to begin orthodontics. The number of adults seeking orthodontic treatment has risen dramatically during the past decade. As long as you have healthy bone support for your teeth, you can have orthodontic therapy. Most adult cases take 18 to 24 months to complete.
What are retainers?
Once braces are removed, it is usually necessary to wear a retainer. After your braces come off, your orthodontist will make a mold of your mouth and produce a set of retainers. This retainer will maintain the new tooth alignment until the teeth have had a chance to become firmly set in their new positions. This retainer may be either removable or fixed in place. Aside from a permanent bonded retainer, there are two other types that most people get.

A Hawley Retainer is made of acrylic and metal. The acrylic goes behind your teeth and up against your upper palate; the metal is in front of your teeth. This is the most reliable refinements that still need to be done to your teeth.

Orthodontic Toothbrush

An Essix Retainer is clear plastic and looks like an Invisalign aligner tray. Many people want this type of retainer, but it has its disadvantages. Many orthodontists feel that because it covers the biting surface of your teeth, they do not "settle" properly after treatment. For this reason, sometimes orthodontists give a patient both types of retainers: an Essix Retainer to wear during the day when they are people-facing, and a Hawley Retainer to wear at night when they are home sleeping.

No matter what type of retainer you get, the most important thing is to wear it exactly as the orthodontist tells you. Most people need to wear their retainers 24/7 for at least 6 months, then switch to wearing it only at night when sleeping. 

How do I keep clean teeth with braces on?
While orthodontic treatment is in the active phase, that is, while the braces are on your teeth, you must be very diligent about keeping your teeth clean. This will be more difficult than and somewhat different from cleaning your teeth without braces. You will be instructed in the use of any cleaning aids needed. These may include dental floss threaders, orthodontic toothbrushes, an oral irrigator to flush out debris, proper brushing habits, fluoride mouth-rinses, and periodontal aids. You must follow your proper oral self-care routine each night to prevent decay, decalcification of the teeth, and gum disease. You also should not use a whitening toothpaste when you have braces. It could cause you to have "two tone" teeth after the brackets are removed. Another thing to remember is that although a device like a Waterpik is great for gum stimulation and dislodging food, it is not a substitute for flossing. You still need to floss daily.

Fixed and Removable Orthodontics

The traditional and stereotypical movie, television, and commercial vision of orthodontic treatment is one of yards of metal wire tied down to teeth so covered with silver bands and brackets that the whites of the teeth are barely visible. With today's advanced dental technology, this picture is far from accurate.

Tooth Alignment:
Changes in tooth alignment can be accomplished in several different ways. When appropriate, upper and lower arch expanders can be used to increase the curvature of the tooth-bearing supporting structures. These expanders are usually cemented into place and are not able to be removed by the patient. The expanders are often a prelude to fixed metal bands. They can be cemented to the teeth as well as longitudinal arch wires and springs and still be used to move teeth.

The look:
Some time ago, the desire of patients to show less metal resulted in the development of bonded tooth-colored and clear brackets (as opposed to the metal bands that completely surround a tooth). These brackets cover only about 25% of the tooth surface and are bonded into place. The trade-off with the more esthetic bonded brackets is a higher percentage of dislodgement of the bracket, requiring additional office visits for repair and replacement. The wires and springs are changed periodically to accomplish the various stages of movement. The metal components stay in place until the tooth movement is finished. Some dental conditions mandate the use of this traditional orthodontic process.

Removable:

Tooth-colored Braces

It is not always necessary to use fixed devices to move teeth. Less aggressive tooth movement can additionally be done with patient-removable appliances. Some are made of a gum-colored pink acrylic material with metal wires and springs embedded in them. These are worn by the patient except when he or she is eating, brushing, and flossing. The metal and plastic appliances do not show as much metal so they are somewhat more acceptable. The trade-off with removable appliances is that they only work when they are in the patient's mouth, making proper patient compliance a big issue. If you do not wear them, the teeth will not move as planned. The metal and plastic appliances are used in what is called minor tooth movement. Many orthodontic cases are not appropriate for removable appliance therapy.

Invisalign:

Several years ago, a new type of removable appliance therapy was developed and patented. Align Technology has a product called Invisalign. Clear, thin plastic aligners (positioners) are sequentially placed to move the teeth in a precise fashion. The aligners are left in the mouth as much as possible and removed only for eating, drinking, and cleaning the teeth. Again, if you do not wear them, the teeth will not move. The aligners are almost invisible when in place and are extraordinarily acceptable esthetically. They are indicated for adults and patients older than 14 years who have all permanent teeth in including fully erupted second molars. They can be used to treat simple to fairly extensive misalignment problems. Most cases are completed in about 12 months. Research is still in progress to determine the limits of this process.

The doctor who will be performing the orthodontic treatment will take these different modalities into consideration and develop a treatment plan best suited to your needs. Age of the patient, number of teeth involved, and extent of movement are primary factors in the decision-making process. Please be sure to ask why or why not one technique rather than another was suggested.

If you have any questions about your orthodontic treatment, please feel free to ask us.