I recently finished treatment on a patient who started with crowded, crooked teeth, a bad bite, and multiple crowns and restorations throughout her mouth. After two and a half years of treatment, I had accomplished all that I could with braces given the condition of her teeth. The crowding was resolved, the teeth aligned, and the bite corrected. I was pleased with the result. To my surprise however, the patient was still unhappy. She grabbed the plastic models of teeth that I have for patient consultations and said, “My teeth don’t look like this. I want a perfect smile when my braces come off.” Why can’t all finished orthodontic cases look perfect?

Many variables determine treatment outcome
The appearance of a smile at the end of orthodontic treatment is determined by many things. Some of them are in the hands of the orthodontist, some are determined by the patient, and some are dictated by good old Mother Nature. Here is how each of these variables affects your orthodontic result.

The skill and experience of your orthodontist is important
Your orthodontist influences how your smile will look by the treatment plan he selects, the techniques he uses to move your teeth, and his artistic “eye." Some key decisions include removing teeth or not, replacing missing teeth or closing the spaces, and working with the jaws where they are or having them surgically repositioned. Your doctor’s experience and skill will determine how the teeth are moved into their final positions. Last but not least, part of how your smile will look is preference. Is your orthodontist an artist? Does he pay attention to detail? Your orthodontist does play a major role in how good your smile will look at the end of treatment.

Your cooperation during treatment is critical
What you do as a patient also has direct influence on how your smile will look when the braces come off. Did you follow your doctor’s recommendation to have teeth pulled or your jaws surgically moved? Do you wear your rubber bands as instructed? Do you come to all of your appointments? Do you brush your teeth to prevent white marks on the enamel and swollen gums? Your orthodontist may have the best treatment plan in the world and be an amazing clinician, but he can’t do it alone. For the best result, you’ll need to take responsibility and give 100% too or you’ll be disappointed.

Your result is also affected by your biology
Even if you and your orthodontist do everything “by the book,” there are still some things that neither of you can control. One of these is your body’s response to the treatment (the biology). Your treatment plan may be perfect and you may wear your elastics like a champ, but there are times when the teeth don’t cooperate. Sometimes your muscles and habits work against the forces provided by the braces (i.e. clenching and grinding). Other times teeth are fused to the bone and can’t be moved (anykylosis). Less than ideal jaw growth can also prevent an ideal outcome (I recently had a patient who grew 8 inches during treatment and he was a junior in high school). These are just a few examples of how nature can thwart the best laid plans of both doctor and patient.

You can't chose your parents (or change your DNA)
One last area that doesn’t fit perfectly into either the patient or Mother Nature columns is the shape and size of your teeth and jaws. You might have been born with short teeth but like the look of long ones. You might prefer a strong chin but got your mother’s instead. You may have had perfect teeth at one time but now have crowns, bridges, or even be missing some teeth. All of these variables will affect your final result. While it is possible to perform full mouth reconstruction (crowning every tooth) or jaw surgery, many patients do not want to take the medical risks or incur the costs that accompany such procedures. In these cases patients must allow the orthodontist to work with the anatomy that they have in spite of their less than ideal sizes and shapes.

I wish I had a body like the guys in Men’s Health magazine. Unfortunately I can’t spend enough time in the gym to look like them and I love chips and salsa with my dinner. I also wish I had more hair! I’ve looked into hair plugs, but they are expensive and look kind of painful. Likewise, you must realize that most orthodontists generally do the best they can with the teeth you bring them. If you do your part and Mother Nature cooperates a little, you can end up with a beautiful smile that will serve you a lifetime!

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.