The Smile Is Just the Start

Dr. Flavio Uribe, chair of orthodontics at the UConn School of Dental Medicine, explains how the benefits of correcting a child’s bite go well beyond the cosmetic, plus Courtney and Chris learn about some orthodontic options that weren’t options when they were kids.

(Dr. Flavio Uribe, Courtney Chandler, Chris DeFrancesco, February 2020)


Chris: A healthy smile is about more than a pretty face. Today on the Pulse, we bring in one of our experts in orthodontics to show us how a healthy smile can do wonders for your overall health.

This is the UConn Health pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful. With Courtney Chandler today, I’m Chris DeFrancesco. Whether it’s getting braces to correct an overbite or straighten teeth, improving your child’s smile can go a long way in his or her overall health. Here to explain that as Dr. Flavio Uribe, chair of the Division of Orthodontics at the UConn school of Dental Medicine. Dr. Uribe, thank you for joining us.

Dr. Uribe: Thank you so much, Chris, for inviting me this morning.

Chris: Now, sure, it’s nice to have an improved smile, but there are bigger health implications here than just cosmetics, right?

Dr. Uribe: Yes. What we’re really trying to do is fix malocclusions. And what are malocclusions? The word form “mal” is bad and occlusion is the way we bite, OK, so improper bite. So our job as orthodontists is not only to align the teeth, but to overall give a good bite that will be important for function overall, as we chew food, as we speak. Most of the time that we spend when we’re treating our patients is trying to achieve a good bite.

Chris: And what are some of the other implications that go along with correcting a bite in children? We’ll start with children.

Dr. Uribe: If we look at one situation that is very clear for a young kid, this kid could present what we call an anterior crossbite. So what that means, the bottom teeth are ahead or in front of the top teeth. And this could be detrimental to the health of the anterior teeth in the long term. And although you might not see this in the short term, as this kid becomes an adult, those teeth in the front might start wearing significantly up to a point where these teeth might have to get restored with a crown or a bridge. The tooth in some possibility could be lost too.

Another aspect that I think it’s important to consider that also has aesthetic connotations is the kid with those teeth are sticking out. So that kid that has teeth sticking out above and beyond the lips first, often they’re bullied at school for the aesthetic reasons.

And the other important thing is, because they cannot close their lips when they play sports, there might be instances where those kids might traumatize those front teeth. In this instance that trauma could create a lot of problems because that individual might lose the tooth with the trauma or might need a root canal. And so at the end, by having orthodontics, we could move that tooth to the proper place and achieve a good bite and prevent this from happening.

Courtney: So what could be done for a child who’s in danger of losing a tooth?

Dr. Uribe: For any kids that do have a trauma to the front teeth and they might lose that tooth, called evulsion, when that happens, we do here at UConn a very interesting approach that has been done in Europe and some other places in the world for a long time. We do here an interdisciplinary approach with Dr. Safavi in the endodontic department, we do a procedure that is called outer transplantation. In this procedure, we take teeth from the back, usually premolars, and in these kids, we implant them in the front for that lost tooth incisor.

So when we do this, the tooth is going to continue growing. This is typically at the age of 11, 12, and the bone and all these structures around the tooth are going to come down and create a more natural look for that tooth in the future. So, when we do not do this procedure, that bone’s not going to develop, and it’s harder for that restorative dentist  — for whoever is going to restore that tooth — to make that look more natural. So that’s actually that technique that we approach, that we use here.

Another reason that we do our transplantations for kids that might be missing some teeth and may be they’re missing more teeth on one side than the other. So we can sometimes pick, take one of those teeth that on one side that might be more than the other side and transplant it to the other side. So we’re able, we can even out the amount of teeth. And this, typically we do it at the age of like around 12, 13, because we want that there’s a little bit of a root still left that is forming in these individuals. But it doesn’t mean that we don’t do it in adult patient. We still can do outer transplantation in fully adults in some instances.

Courtney: So you mentioned that this isn’t a very common practice. Can you explain a little bit why? Is it because you’re merging two different disciplines?

Dr. Uribe: Yes, the possibility that we have here, like we have experts in many specialties, and one of those is, Dr. Safavi has done this on transplantation for, I would say, over 30 or more years. So he has a significant amount of expertise in this area. And I was in a meeting recently where an expert from Seattle that does this technique, a periodontist, was talking about the approach. And in this conference there were a lot of orthodontists from the Northeast of the United States attending the meeting, and they actually very curious to know where this approach could be done, who could they refer the patient to? And actually to this alternative, I told him that we’re kind of like one of those that have expertise, and they always can come here to UConn Health because we do have the expertise in this area.

Courtney: That’s great. And that’s the benefit of academic medicine, right?

Dr. Uribe: Yes, definitely, because we are always, trying to use those evidence-based approaches, sometimes trying new approaches, and as we try in academics to try to evolve and make things better than the way we used to do before.

Chris: Dr. Flavio Uribe from the UConn School of Dental Medicine, what would be some examples of why an adult may come to an orthodontist?

Dr. Uribe: What many times we see adult patients for is to be able to do what is called pre prosthetic orthodontics. Preprosthetic means before bridges, crowns, that’s prosthesis, any of those prosthesis. Often these adult patients have lost a tooth early on and the adjacent teeth start migrating to that spot where that tooth was before. So when they migrate the adjacent teeth, they start creating what is called collapsed occlusion. The upper teeth also might come down, so when they want to get up on a bridge and implant something to restore that tooth or other teeth, they might have lost, they’re going to find that there’s not enough space to put that implant or bridge in that area.

So as orthodontists we have to almost like undo time and put the teeth where they were before, so there’s enough space to be able to restore and properly what is called the space appropriation: We exactly locate the space where it needs to be so the implant can be placed in that spot. So that’s one of the other areas that we can help and work as a team here with other specialties such as the prosthodontist or the general dentist, in this, restoring a good bite, and of course, good aesthetics.

Courtney: Now, is there some sort of innovative treatment approach that’s not really common? Similar to the…

Dr. Uribe: Outer transplantation?

Courtney: Yes.

Dr. Uribe: Very good. Yes, we definitely have, we’re pioneers in this approach, that is the orthognathic surgery approach: “ortho,” correct alignment, and “gnathos,” jaws. So orthognathic means correct alignment of the jaws. These are for patients that have a significant facial deformity where orthodontics alone would not be able to align the jaws with a proper bite. So we work with a team of the oral surgeons here, and they are the ones who are responsible to align the jaws. And we as orthodontists work with them to align the teeth. We have this approach, it’s novel, and very few centers in the U S. use this technique, that is called the surgery first approach. So in this approach, we go directly to surgery to address the dental facial deformity from day one. Instead of what’s commonly done, of a surgical phase, that is having braces for about year and a half. And that typically makes the deformity actually more worse before it gets better. So instead of doing this, we go directly to address, many times that patient’s chief complaint, that is that deformity. And then we finish with braces. And typically a treatment time instead of being at the conventional two and a half to three years. We do it typically in one year, one year and a half. So definitely reducing the amount of time that the individual is in braces.

Also for this specific type of patients, we have developed this new approach. We’re combining surgery first, again, surgery from day one, and then using the Invisalign instead of conventional braces. We’re one of the pioneers in the world with this approach, and it’s actually pretty interesting because a lot of these adult patient might have had braces when they were early on. Their jaws kept on maybe growing and they now need to get orthognathic surgery, and often they don’t want to have braces. So we do give them this approach of having aligners. So we combine this early surgical intervention with aligners, and we have had some successful outcomes as we adopt this technique in the last few years that we have been doing this.

Chris: All right, and can we briefly talk about the difference between Invisalign, which you mentioned as part of this as an option, and the traditional braces?

Dr. Uribe: Yes, Invisalign is been in the market approximately for 20 years, and it has become very popular. The appliance has improved significantly over the last few years. We typically, we do use in our clinics Invisalign. and we typically have it more indicated for not so complex malocclusion. But as the appliance has evolved, we are dealing, we’re addressing more and more complex malocclusions. Sometimes with this appliance, it could be hard to refine the bite and sometimes the alignment, so sometimes we have to resort either to do braces from the beginning, if the complexity is that severe, or, in some instances we have to resort to start with Invisalign and then have short phase of braces to refine that occlusal in alignment of the teeth. But we definitely are seeing more and more interest, and we do provide that care here at UConn Health.

Courtney: Right. and I know for less complex cases, we can print, 3D print aligners in house.

Dr. Uribe: Yes, we do have our own in-house 3D printer and we’re able not only to print the aligners, but we can also do this to be able to have the retainers done in a fast manner. The clear retainers, we can provide them with a scan and then a printout.

So that’s also something that is becoming very popular in orthodontics, the ability to 3D print the teeth that we have scanned with our scanner.

Courtney: Dr. Uribe, so what do you love most about orthodontics?

Dr. Uribe: I will tell you that, what’s so interesting about orthodontics is, when you place on appliance or when you put a wire in, it’s kind of like, somewhat, to a certain extent, unpredicable: What are you going to see next visit? But you can like envision that result in that. And when the patient comes the next visit, it’s so exciting to see, “Hey, is this worked really exactly  how I planned.” So that’s the exciting, like the surprise factor there, I think it’s so exciting every time. And then when you see the changes, I think it’s just dramatic changes in how these kids also, we see them grow. There’s adults, see their smile changes and their bite improves. So all these things are important.

But I want to finish with a story that I think is interesting when we think about, until what age can you have braces?

So I’ll finish with this 80-year-old patient that I treated. She came in and she needed  some work, aesthetic work on the upper teeth, and she had some crowding on the bottom and they needed a little bit of space to do some crowns on the top. And she needed a brace on the bottom. We put the braces on the bottom, and I was refining her bite and trying to get the best outcome. And then she came one day and said, “You know, I need to take him off, OK? I’m done.”  I’m like, “Why are you done? What happened?” “Everything’s beautiful, everything’s perfect, and you know what? I have a date tomorrow, so I don’t want to have braces for my date tomorrow.”

So it’s very, very interesting. Yeah. Like what do you see in the, and again, there’s no limit in terms of age.

Courtney: Right, right. But going back to children, what is your message to parents, especially those who are thinking about their children and going to an orthodontist. What is your message to parents?

Dr. Uribe: I think my message is that the American Association of Orthodontics recommends to get children to get screened about  the age of 7, so we can monitor for any developing problems that might be there, such as missing teeth or those reverse bites or crossbites that might be there. It doesn’t mean that we’re going to be treating at that point, OK. We don’t treat all the patients that early, OK, but we want to make sure that we’re monitoring any problems that may be developing, and intervening at the right time.

Chris: Well, this has been terrific. And before we go, I just want to mention that the American Dental Association Foundation observes February as National Children’s Dental Health Month, and has designated the first Friday in February as “Give Kids a Smile Day.” That’s something Dr. Flavio Uribe from the UConn School of Dental Medicine certainly can help with. So, Dr. Uribe, thank you so much for joining us today.

Dr. Uribe: Thanks so much, Chris and Courtney, pleasure.

Chris: Courtney, thank you for playing radio with us today as well.

Courtney: Thank you for having me.

Chris: That’s our time for today. For Dr. Flavio Uribe and Courtney Chandler, I’m Chris DeFrancesco. Thanks for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.