A & Ω of Orthodontics

When a patient sits down in my chair, the first question I ask myself is not what are the teeth like. It is what are the muscles doing.

It sounds like a strange inversion for an orthodontist. For a century, my profession has perfected the way we move teeth — wires, brackets, forces, anchorage. It has done that job very well. What we have not done nearly as well, as a profession, is understand the environment we deliver those moved teeth into.

Because teeth do not sit in thin air. They sit in a space bounded on one side by the tongue and on the other by the cheeks and lips. And those structures are not scenery. They are muscles that work, day and night, for a lifetime.

A calculation that changes the perspective

You swallow between six hundred and one thousand eight hundred times a day. Each swallow lasts about one second.

Do the multiplication: that is roughly fifteen to twenty minutes a day in which the tongue presses, in a concentrated way, on the palate and the teeth. Every day. Since the day you were born.

The orthodontic literature has established that the force threshold needed to move a tooth is surprisingly small — far below what intuition assumes. So the question is not whether fifteen minutes a day of concentrated force has an effect. Of course it does. The question is what shape that effect takes after twenty years, and in which direction.

And swallowing is only one of the situations in which the muscles are at work.

Where I look, and in what order

From my clinical experience — and I want to say openly that this is an estimate from practice, not a measurement from a study — the clinical weight of these situations looks roughly like this:

• Swallowing — about half of the problem. It is the only situation in which muscular force consistently reaches the biological threshold at which a tooth actually moves. It is the first thing I evaluate in every new patient.
• The rest position — about one fifth. Twenty-three hours a day of gentle force. It rarely moves a tooth on its own, but it decides where the tongue is at the moment the swallow arrives. It is the context that sets the direction.
• Habits — about one fifth, with clenching at the top. Mouth breathing, thumb sucking, lip biting, resting the chin in a hand at the desk. And, above them all, clenching.
• Speech — about one tenth, when it applies. Most patients need no intervention here. The ones who do reveal themselves in the first minutes of conversation.

Chewing does not appear with a weight of its own on my list, and I have a specific reason for that: it is the only muscular situation where my direct intervention does not change the outcome. Patients learn to chew according to the bite they have. I change the bite, and the chewing reorganises itself afterwards.

The most common habit nobody knows they have

Teeth should touch for around eighteen minutes a day — practically only during swallowing. The rest of the time they should sit slightly apart.

I can tell from across the room when that is not the case. I look at the volume of the masseter and temporal muscles. If someone's jaw musculature looks trained but the rest of the body does not, those muscles are training on something. And since nobody chews gum six hours a day, the conclusion is simple.

That gym is the clenching they do not know they are doing. Usually, within the next minute, the patient notices that at that very moment their teeth are pressed together. That observation is the first step of the treatment.

Alpha — where it all begins

The dento-maxillary apparatus of a four-year-old is a faithful recording of the muscular environment that produced it. The position of the tongue. The swallowing pattern. The way the child breathes. The habits.

A child who reaches the orthodontist at seven with a narrow palate, an open bite at the front and a retruded lower jaw is a child whose muscles have spent seven years working against healthy development.

The earlier the muscular patterns are corrected, the more the face can be reshaped by the very muscles that are reshaping it anyway. We are not building something artificial. We simply stop the force pulling in the wrong direction and let biology do its work.

Omega — where it is decided whether the result lasts

A case that looks beautiful on the day we remove the braces is not yet a successful case.

A case that looks beautiful and is supported by muscles retrained to maintain it — that is a successful case.

The difference between the two is invisible in a debonding photograph. And it is perfectly visible in a photograph taken five years later.

That is why, with me, treatment does not end when the teeth are straight. It ends when the muscular environment supports their position without being forced to.

What this means for you

If you are a patient, it means I will ask you things that seem to have nothing to do with teeth: how you sleep, whether you breathe through your nose, whether your head hurts in the morning, whether you ever catch yourself with your teeth pressed together.

These are not filler questions. They are the diagnosis.

And it means that part of the treatment belongs to you. Re-educating the swallow, the rest position, nasal breathing — these are things I cannot do in your place. I can teach them, check them, correct them. But the repetitions are yours.

It is the part of the treatment that does not show in the mirror the next day, and that decides what everything looks like ten years from now.

What you can check right now

The correct resting position of the face, which anyone can find:

• lips touching lightly, without effort;
• teeth a few millimetres apart;
• tongue resting up against the palate;
• breathing through the nose.

Every time you catch yourself outside it, return to it. Dozens of times a day at first. In time, it becomes the muscles' new habit — and then they work for you, not against you.

Biology first. Orthodontics after.