Orthodontics

Dental procedure
Overview
Reverse occlusion due to skeletal and dental malocclusion arch constriction.

Figure 1: A strong case of orthodontic need. This patient has moderately severe crowding in the upper dental arch (maxilla); mild crowding of the lower dental arch (mandible); maxillary arch constriction; teeth in cross-bite; misalignment; and periodontal concerns (note the receding gums on the upper central incisor and canine teeth). Fortunately, through a combination of orthodontic and periodontal treatment, this patient has a good prognosis for long-term dental health. The ideal treatment plan for this patient might involve tooth removal and possibly other surgical procedures. (Image courtesy Thomas J. Melcher, DDS, MS).

Patients who have crowded or rotated teeth, or a poor bite relationship between the upper and lower teeth (malocclusion) may benefit from orthodontic tooth movement (Figure 1). Crowding and misalignment of the teeth makes it difficult to keep them clean, and puts the patient at risk for tooth decay (caries) and gum disease. This is because wherever food accumulates, bacteria thrive; and bacteria cause tooth decay and gum disease.

Advanced gum disease (periodontitis) has been shown to contribute to cardiovascular disease (blood vessels of the heart), peripheral vascular disease (blood vessels of the body), poor control of diabetes, and the risk of stroke. It has also been implicated in pre-term childbirth and low birth-weight babies in certain populations.

Malocclusion can accelerate wear (attrition) on the teeth, and increase the likelihood of tooth fractures. It can also cause jaw joint (TMJ) pain and dysfunction (TMD), fatigue/pain in the chewing muscles (myalgia), gum recession (from off-axis forces on the teeth); and can be a contributing factor in improper nutrition.

Moving the teeth and influencing the growth and development of the jaws, such that they align properly and provide proper support for the lips and cheeks is what orthodontists do. Moving teeth orthodontically can be done with fixed braces, adjustable retainers the patient can remove, or rigid acrylic positioning trays (e.g. Invisalign®).

Influencing the growth and development of the jaw and facial bones may involve use of externally applied forces (e.g. headgear appliances), adjustable appliances that are worn in the mouth, dental implants positioned as temporary anchorage devices for orthodontic devices (TADs), palatal expansion devices, and other mechanisms.

The process
Panoramic dental X-ray for assessment of developmental status.

Figure 1a: A panoramic radiograph allows the dentist to assess a patient’s growth and development status, check for missing or extra teeth, and evaluate the teeth and bones of the facial area for disease processes.

Orthodontic tracings on a lateral cephalometric X-ray (radiograph).

Figure 1b: A cephalometric radiograph is a type of X-ray image showing the bones of the skull, mandible, and cervical spine, as well as the teeth. The orthodontist measures the relative position and angles of certain bones, and of the teeth to determine the extent and type of orthodontic treatment needed by the patient. (Image courtesy Thomas J. Melcher, DDS, MS).

Tooth movement is best accomplished with light forces applied to the teeth over as much time as is necessary to move them. It can take as little as a couple of months to move just a few teeth, or as much as a couple of years to move them all.

Some patients may require early orthodontic treatment to influence the growth and development of their jaws while they still have primary (baby) teeth. For some of these children, no orthodontic tooth movement will be necessary later. For others it will be.

Many times, orthodontic treatment begins while the patient is in their mixed dentition years (some primary and some permanent teeth are present), around the time of puberty. Other times, a patient is treated many years after their growth and development is complete—even into retirement years. Adult orthodontic treatment has become very popular as the Baby Boomer generation has aged.

Screening appointment

Regardless of the timing of orthodontic treatment, many aspects of the process are common to all patients. The first orthodontic visit is often a screening appointment, to assess at a high level whether orthodontic treatment would be appropriate for the patient, and when it should begin.

At this appointment, the orthodontist will look into the patient’s mouth, and evaluate the patient’s plaque control (oral hygiene), bite relationship, number of decayed, missing or filled (or otherwise restored) teeth, and the health of the gums (periodontal health). He or she will review the patient’s health history. A patient must be medically and dentally stable before orthodontic treatment is undertaken.

Diagnostic records appointment

If a patient is considered appropriate for orthodontic treatment, the next appointment is usually what is known as a diagnostic records appointment. Panoramic and cephalometric X-ray images (Figures 1a and 1b), and impressions of the teeth will be made. The impressions will be used to make stone cast replicas (diagnostic casts) of the teeth. Sometimes other X-ray images will be exposed to assess the patient’s development status. The dentist uses these to assess how much growth is likely to remain (if the patient is still growing).

The orthodontist will use all of the information gathered at the screening and diagnostic records appointments to measure tooth size relative to the length of the dental arches; and orientation and relative position of the bones of the face and lower jaw. He or she will determine how much tooth/ jaw movement needs to occur, and will develop a treatment plan for accomplishing the goals of orthodontic treatment given the patient’s unique needs.

Consultation appointment

The next appointment is often a consultation, in which the diagnostic findings are presented to the patient, a problem list is discussed, and the goals of orthodontic treatment are enumerated. The orthodontist will provide his/her recommendations for treating the patient, and will discuss the relevant timing and financial issues. If treatment is agreed upon, and if fixed braces are part of the orthodontic plan, elastic spacers (rubber bands) may be placed between the patient’s molar and bicuspid teeth to make room for orthodontic bands.

Banding appointment

Tooth colored orthodontic brackets, upper teeth; Metal brackets, lower teeth.

Options for fixed braces. This patient elected to have tooth-colored orthodontic brackets and arch wires on the upper teeth, and traditional metal orthodontic brackets and arch wires on the lower teeth. Ask your orthodontist if options like this may be available for your individual needs.

If fixed braces are to be placed, the next appointment is generally what us known as the banding appointment. At this appointment, the orthodontist places the bands, brackets and arch wires which make up the orthodontic hardware that moves the teeth, and treatment is underway.

Progress appointments

The patient will be seen at periodic intervals during orthodontic treatment to evaluate progress, and make adjustments/additions to the positioning appliances. Oral hygiene should be carefully monitored throughout treatment to verify that the teeth and gums remain healthy. Your orthodontist or general dentist may prescribe a fluoride gel supplement to further reduce the chance of developing cavities while in braces.

It is important to maintain excellent oral hygiene and to see your general dentist as often as necessary to keep the teeth and gums healthy while in braces.

It is not uncommon for the length of treatment time to be extended if the teeth are not moving as fast as estimated at the start of treatment. This is especially true if the patient is not complying with all of the orthodontist’s recommendations.

When the goals of orthodontic treatment have been met, the braces are removed and the patient enters the retention phase of treatment. In order to move teeth through the jaws, it is necessary to loosen the ligament attachments between the teeth and the jawbone, which is what orthodontic appliances do. Once moved, the teeth need to be held in place long enough for the ligaments to re-solidify. This is done with retainers.

Lower Hawley orthodontic retainer holds teeth following removal of braces.

A traditional removable Hawley retainer shown on the lower teeth. The small amount of inward rotation visible on the two central incisors may have been preventable with a fixed retainer.

Orthodontists commonly retain the lower front teeth with a fixed (bonded onto the teeth) retaining wire. The wire is not intended to be removed by the patient, and may be suggested as a long-term (ten or more years) means of holding those teeth in position. Frequently, the remaining teeth will be retained with some type of removable retainer (it is also possible for the lower front teeth to be held in place with a removable retainer).

Advantages and benefits

Orthodontic treatment:

  • Establishes a proper bite relationship between the upper and lower teeth and jawbones
  • Evenly distributes bite forces to minimize wear and the chance of cracking teeth
  • Improves accessibility for oral hygiene so that the patient can properly clean the teeth and gums
  • Provides proper support for the jaw joints
  • Provides proper balance of muscle contraction forces in the chewing muscles
  • May be accomplished by a variety of methods, depending on the individual’s needs
  • Produces cosmetically appealing smiles without the need to alter the teeth themselves (for example with veneers or crowns that must be maintained for the life of the patient).
Disadvantages and risks
  • Orthodontic treatment can be costly (although payment can often be spread out over the length of treatment).
  • The "instant gratification" of an attractive smile is not achievable with orthodontics.
  • Requires maintaining good nutrition habits and excellent oral hygiene.
  • Performing good oral hygiene while wearing fixed braces can be difficult.
  • Maintaining poor oral hygiene while wearing braces can lead to disastrous consequences involving tooth decay and gum disease.
  • Removable retainers (and Invisalign® aligners) can be lost, adding potential expenses to the treatment.
  • Applying too great of tooth movement forces to teeth or moving them too rapidly may cause the tooth roots to shorten (resorb). This may or may not be clinically significant. Occasionally, orthodontic tooth movement can lead to pulp death (necrosis), especially if the teeth are moved too quickly.
  • May require surgical procedures to be performed either prior to, during, or following the orthodontic treatment, to provide the best treatment result. Surgical procedures introduce risks of their own, including infection, bruising, bleeding, swelling and pain. Depending on the nature of the surgical procedure(s), there may be other risks.
Other care that may be needed

Sometimes orthodontic treatment is part of a larger, more comprehensive treatment plan. If your problem is especially complex, you may require additional procedures in addition to orthodontic treatment. These procedures (including diagnostic records such as X-ray images (radiographs) and casts of the teeth) may be billed against your dental (in some cases, medical) benefit instead of your orthodontic benefit. Jaw surgery (orthognathic surgery) is sometimes necessary to physically alter the length, shape, or position of the jawbones, and to achieve an ideal orthodontic result. Ideal orthodontic treatment of certain malocclusions often involves the removal (simple tooth extractions or surgical tooth extractions) of one to four teeth.

Other treatment options

For some adult patients, improving the appearance of the smile quickly is the primary goal. In these cases, crowns, bridges and/or veneers) may be an option that can provide excellent cosmetic results—as long as the patient understands the risks associated with altering the teeth, the cost involved, and the fact that the dental restorations may need to be replaced one or more times over the patient’s lifetime.

For patients with malocclusion (improper bite relationship), the teeth can sometimes be protected by the use of an occlusal guard. Bite forces which are concentrated on just a few teeth can sometimes be evenly distributed (equilibrated) by altering the shape of the biting surfaces of the teeth (occlusal adjustments).

What if I do nothing?
  • Not treating crowded dental arches with tipped and rotated teeth allows "food traps" to remain, and increases the risk of caries (tooth decay) and gum disease.
  • Poorly aligned teeth and/or jaws (malocclusion) lead to excessive wear (attrition) on those teeth which are most highly loaded, and increases the risk of tooth fractures.
  • Malocclusion increases forces on the temporomandibular (jaw) joints (TMJs), increasing the risk of developing pain and dysfunction (TMD) in them.
  • Malocclusion can lead to a tooth grinding habit (bruxism), as the patient (generally subconsciously) attempts to grind their teeth into a position where the majority of them touch evenly when the jaw muscles are at rest.
  • Crooked or poorly aligned teeth can make a patient self-conscious. Having an attractive smile can make a patient more self-confident.

Author: Thomas J. Greany, D.D.S.
Editor: Ken Lambrecht
This page was reviewed by members of our review board.

This page was last updated on July 7, 2015.

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Related pages on ToothIQ.com

Attrition
Attrition
Caries
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Casts
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Bridges
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Bruxism
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Cracked Teeth
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Crowns
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Dental Implants
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Diabetes
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Fluoride Treatments
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Malocclusion
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Myalgia
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Periodontal Disease
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Periodontal Surgery
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Photographs
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Poor Oral Hygiene
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Simple Tooth Extractions
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Surgical Tooth Extractions
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TMJ Disorders
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Veneers
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X-rays
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Background information

Centric relation: A historical and contemporary orthodontic perspective
Rinchuse, Donald J., DMD, MS, MDS, PhD and Kandasamy, Sanjivan, BDSc, BScDent, DocClinDen, MOrthRCS
The Journal of the American Dental Association
2006 137 (4): 494-501

Supplemental mandibular central incisor
Bhat M.
Journal of Indian Society of Pedod Prev Dent
2006 24 (5): 20-23

Treatment of a Patient With Metal Allergy After Orthognathic Surgery
Kitaura, Hideki, et al.
The Online Angle Orthodontist
2006 77 (5): 923-930

Effect of Nickel and Chromium on Gingival Tissues During Orthodontic Treatment: A Longitudinal Study
Ramadan, Ahmed Abdel-Fattah, MSD, PhD
World Journal of Orthodontics
2004 5 (3): 230-235

Orthodontic anchorage with specific fixtures: Related study analysis
Favero, L., MD, DDS, MS et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (1): 84-94

Periodontic and orthodontic treatment in adults
Ong, Marianne M.A., BDS, MS and Wang, Hom-Lay, DDS, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (4): 420-428

Relationship Between Dental Occlusion and Physical Fitness in an Elderly Population
Takayuki Yamaga, et al.
The Journals of Gerontology, Biological Sciences and Medical Sciences
2002 57: 616-620

Principles of biocompatibility for dental practitioners
Wataha, John C., DMD, PhD
The Journal of Prosthetic Dentistry
2001 86 (2): 203-209

Short-term effects of fiberotomy on relapse of anterior crowding
Taner, Tulin (Ugur), DDS, PD, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2000 118 (6): 617-623

Supernumerary Teeth—An Overview of Classification, Diagnosis and Management
Garvey, M. Therese B. Dent. Sc, D. Orth., M. Orth., M.Sc., FDS, et al.
Journal of the Canadian Dental Association
1999 65: 612-616

Retention and stability: A review of the literature
Blake, Marielle, BDent Sc, FDS(Orth), DOrth, MOrth, MRCDC and Bibby, Kathryn, BDS, MSc, FDS, DOrth, MRCDC
American Journal of Orthodontics & Dentofacial Orthopedics
1998 114 (3): 299-306

The decision to extract: Part 1—Interclinician agreement
Baumrind, Sheldon, DDS, MS, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1996 109 (3): 297-309

The decision to extract: Part II—Analysis of clinicians’ stated reasons for extraction
Baumrind, Sheldon, DDS, MS, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1996 109 (4): 393-402

A Guide to Understanding Hemifacial Microsomia
Fearon, Jeffrey, MD and Johnson, Carolyn, M. Ed.
Children’s Craniofacial Association web site
Last viewed: 9/23/2010
1993
Notes: Article published June 1993

An algorithm for ordering pretreatment orthodontic radiographs
Atchison, Kathryn A., DDS, MPH, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1992 102 (1): 29-44

Comparison of electrosurgery with conventional fiberotomies on rotational relapse and gingival tissue in the dog
Fricke, Laurie Lee, BS, DDS and Rankine, Christopher A.N., DDS, MMedSc
American Journal of Orthodontics & Dentofacial Orthopedics
1990 97 (5): 405-412

Aetna® Clinical Policy Bulletin: Temporomandibular Joint Syndrome (TMJ) and Temporomandibular Disorders (TMD)
Aetna Inc. web site
Last viewed: 9/23/2010
Editor’s notes: Clinical Policy Bulletin: Temporomandibular Joint Syndrome (TMJ) and Temporomandibular Disorders (TMD). Describes one major insurer’s position on the assessment and management of these disorders.

Bruxism/Teeth grinding
MayoClinic.com web site
Last viewed: 9/23/2010

Cadent OrthoCAD™ Home Page (www.orthocad.com)
Cadent Inc.
Cadent OrthoCAD web site
Last viewed: 9/24/2010
Editor’s notes: Manufacturer’s web site

Occlusion in the New Millennium: The Controversy Continues, Part 1 (PDF, 429K)
Spear, Frank, DDS, MSD
Spear Perspective—The art and science of exceptional esthetic and restorative dentistry
3 (2)
Editor’s notes: Great Lakes Orthodontics web site.

Occlusion in the New Millennium: The Controversy Continues, Part 2 (PDF, 112K)
Spear, Frank, DDS, MSD
Spear Perspective—The art and science of exceptional esthetic and restorative dentistry
3 (2)
Editor’s notes: Great Lakes Orthodontics web site.

The Politics and Science of Neuromuscular Dentistry 1965–1999; One Man Versus the Establishment—1965–1987
Jankelsion, Robert
Myotronics Australasia web site
Last viewed: 9/23/2010
Editor’s notes: Manufacturer’s web site

The TMJ Association
The TMJ Association web site
Last viewed: 9/23/2010

Information you may wish to read before making a decision on treatment

Evaluation of a software program for applying the American Board of Orthodontics objective grading system to digital casts
Hildebrand, Jed C., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2008 133 (2): 283-289

Twenty-year follow-up of patients with permanently bonded mandibular canine-to-canine retainers
Booth, Frederick A., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2008 133 (1): 70-76

A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment
Miller, Kevin B., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2007 131 (3): 302.e1-302.e9

An Overview of Invisalign® Treatment (PDF, 600K)
Josell, Stuart D., DMD, MDent Sc and Siegel, Steven M., DMD
University of Maryland Dental School
2007
Notes: Spring 2007, Continuing Education Course from The Baltimore College of Dental Surgery

Assessing the American Board of Orthodontics objective grading system: Digital vs. plaster dental casts
Okunami, Troy R., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2007 131 (1): 51-56

Dental health assessed more than 10 years after interproximal enamel reduction of mandibular anterior teeth
Zachrisson, Bjorn U., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2007 131 (2): 162-169

Electromyographic activity of the temporal and masseter muscles at different occlusal positions
Petrovic, D. and Horvat-Banic S.
Medicinski Pregled (Novi Sad)
2007 60: 134-139

Invisalign and Traditional Orthodontic Treatment Postretention Outcomes Compared Using the American Board of Orthodontics Objective Grading System
Kuncio, Daniel, et al.
The Online Angle Orthodontist
2007 77 (5): 864-869

Orthodontic Movement: Preliminary Results with Standard Branemark Implants
Merli, Mauro, MD, DDS, et al.
The International Journal of Periodontics & Restorative Dentistry
2007 27 (1): 43-49

The use of temporary anchorage devices for molar intrusion
Kravitz, Neal D., DMD, et al.
The Journal of the American Dental Association
2007 138 (1): 56-64

Unexpected complications of bonded mandibular lingual retainers
Katsaros, Christos, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2007 132 (6): 838-841

Esthetic management of the upper labial frenum: A novel frenectomy technique
Sukhchain, Bagga, BDS, et al.
Quintessence International
2006 37 (10): 819-823

Interdisciplinary management of anterior dental esthetics
Spear, Frank M., DDS, MSD, et al.
The Journal of the American Dental Association
2006 137 (2): 160-169

Is there an association between occlusion and periodontal destruction?
Harrel, Stephen K. DDS, et al.
The Journal of the American Dental Association
2006 137 (10): 1380-1392

Variations in orthodontic treatment planning decisions of Class II patients between virtual 3-dimensional models and traditional plaster study models
Whetten, Joshua L., et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2006 130 (4): 485-491

Clinical trials needed to answer questions about Invisalign
Turpin, David L.
American Journal of Orthodontics & Dentofacial Orthopedics
2005 127 (2): 157-158

Is occlusion becoming more confusing? A plea for simplicity
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2004 135 (6): 767-770

Comparison of measurements made on digital and plaster models
Santoro, Margherita, DDS, MA, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2003 124 (1): 101-105

Congenitally missing teeth: Orthodontic management in the adolescent patient
Kokich, Vincent O., DMD, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 121 (6): 594-595

Repositioning of the gingival margin by extrusion
Chay, Siew Han, BDS, MOrth, MOrth RCS (Edin) and Rabie, A. Bakr M., Cert. Ortho, MS, PhD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (1): 95-102

Now is the time to observe and treat dental occlusion
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2001 132 (1): 100-102

Management of space problems in the primary and mixed dentitions
Ngan, Peter, DMD, et al.
The Journal of the American Dental Association
1999 130 (9): 1330-1339

Stability of orthodontic treatment outcome: Follow-up until 10 years postretention
Al Yami, Essam A., DDS, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1999 115 (3): 300-304

The mandibular central incisor, an extraction option
Klein, Douglas J., DDS, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
1997 111 (3): 253-259

Abnormal occlusal conditions: a forgotten part of dentistry
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
1995 126 (12): 1667-1668

How occlusal forces change in implant patients: A clinical research report
Dario, Lawrence J. DMD, FACP, FICOI
The Journal of the American Dental Association
1995 126 (8): 1130-1133

The morphologic basis for the extraction decision in Class II, Division 1 malocclusions: A comparative study
Bishara, Samir E., BDS, DDS, DOrtho, MS, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1995 107 (2): 129-135

The functional impact of extraction and nonextraction treatments: A long-term comparison in patients with borderline, equally susceptible class II malocclusions
Beattie, John R., DDS, MSD, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
1994 105 (5): 444-449

The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects
Salama, Henry, DMD / Salama, Maurice, DMD
The International Journal of Periodontics & Restorative Dentistry
1993 13 (4): 313-333

Pain Control During Nonsurgical Periodontal Therapy
Kumar, Purnima S., BDS, MDS, PhD and Leblebicioglu, Binnaz, DDS, MS, PhD
Compendium of Continuing Education in Dentistry

Treating Bruxism and Clenching (Letter #1)
CLENCHING

The Journal of the American Dental Association
Editor’s notes: Editorial comment re: Dr. Christensen’s recommended treatments for bruxing- discusses mandibular rest and isokinetic stretching, used successfully for 40 years, by Dr. James H.Quinn, DDS.

Treating Bruxism and Clenching (Letter #2)
The Journal of the American Dental Association
Editor’s notes: Editorial comment re: Dr. Christensen’s recommended treatment for bruxing in young patients- discusses possible orthodontic complications from splint use in growing patients, by David J. Harnick, DDS, MSD (orthodontist).