Orthodontics

Children and adults can both benefit from dental braces, because healthy teeth can be moved at almost any age. Because monitoring growth and development is crucial to managing some orthodontic problems well, it is recommended that children have an orthodontic screening before the age of 7. Some orthodontic problems may be easier to correct if treated early. Waiting until all the permanent teeth have come in, or until facial growth is nearly complete, may make correction of some problems more difficult.

An orthodontic evaluation at any age is advisable if a parent, family dentist or the patient’s physician has noted a problem.

Most malocclusions are inherited, but some are acquired. Inherited problems include crowding of teeth, too much space between teeth, extra or missing teeth, and a wide variety of other irregularities of the jaws, teeth and face.

Acquired malocclusions can be caused by trauma (accidents), thumb, finger or dummy (pacifier) sucking, airway obstruction by tonsils and adenoids, dental disease or premature loss of primary (baby) or permanent teeth. Whether inherited or acquired, many of these problems affect not only alignment of the teeth but also facial development and appearance as well.

In general, active treatment time with orthodontic appliances (dental braces) ranges from one to three years. Interceptive, or early treatment procedures, may take only a few months. The actual time depends on the growth of the patient’s mouth and face, the cooperation of the patient and the severity of the problem. Mild problems usually require less time, and some individuals respond faster to treatment than others. Use of rubber bands and/or headgear, if prescribed by the orthodontist, contributes to completing treatment as scheduled.

While orthodontic treatment requires a time commitment, patients are rewarded with healthy teeth, proper jaw alignment and a beautiful smile that lasts a lifetime. Teeth and jaws in proper alignment look better, work better, contribute to general physical health and can improve self-confidence.

Estimates of treatment time can only be that – estimates. Patients grow at different rates and will respond in their own ways to orthodontic treatment. The orthodontist has specific treatment goals in mind, and will usually continue treatment until these goals are achieved. Patient cooperation, however, is the single best predictor of staying on time with treatment. Patients who cooperate by wearing rubber bands, headgear or other needed appliances as directed, while taking care not to damage appliances, will most often lead to on-time and excellent treatment results.

In their entirety, dental braces work by applying continuous pressure over a period of time to slowly move teeth in a specific direction. As the teeth move, the bony tooth socket reabsorbs and changes shape as pressure is applied.

Dental braces are made up of the following components:

• Brackets are the small squares that are bonded directly to each tooth with a special dental bonding agent or are attached to orthodontic bands. Brackets act like handles, holding the arch wires that move the teeth.
• Orthodontic bands are stainless steel, clear or tooth-colored materials that are cemented with dental bonding agents or cement to teeth. They wrap around each tooth to provide an anchor for the brackets. The clear or tooth-colored bands are more cosmetically appealing options but are more expensive than stainless steel. They are not used in all patients. Some people have only brackets and no bands.
• Spacers are separators that fit between teeth to create a small space prior to placement of orthodontic bands. 
  Arch wires attach to the brackets and act as tracks to guide the movement of the teeth. Arch wires can be made of metal or be clear or tooth-colored.
• Ties are small rubber rings or fine wires that fasten the arch wire to the brackets. They can be clear, metal or colored. 
  A buccal tube on the band of the last molar holds the end of the arch wire securely in place.
• Tiny elastic rubber bands, called ligatures, hold the arch wires to the brackets.
• Springs may be placed on the arch wires between brackets to push, pull, open or close the spaces between teeth.
• Two bands on the upper teeth may have headgear tubes on them to hold the facebow of the headgear in place. (A headgear is another tool used by orthodontists to aid in correcting irregularities of the teeth; see below)
• Elastics or rubber bands attach to hooks on brackets and are worn between the upper and lower teeth in various ways. They apply pressure to move the upper teeth against the lower teeth to achieve a perfect fit of individual teeth.
• Facebow headgear is the wire gadget that is used to move the upper molars back in the mouth to correct bite discrepancies and also to create room for crowded anterior teeth. The facebow consists of an inner metal part shaped like a horseshoe that goes in the mouth, attaching to buccal tubes, and an outer part that goes around the outside of the face and is connected to a headgear strap.

Your orthodontist will want to see you about every month to 6 weeks or so in order to make sure that the braces are exerting steady pressure on your teeth. To create more tension and pressure on your teeth, your orthodontist will make adjustments in the wires, springs, or rubber bands of your braces. In some cases, dental braces alone aren’t enough to straighten the teeth or shift the jaw. In these situations, an external appliance, such as a headgear may need to be worn at home in the evening or through the night.

Some of the adjustments your orthodontist may make to your braces may make your mouth feel sore or uncomfortable. When needed, over-the-counter pain relievers like Motrin or Tylenol can help relieve the pain. If you always experience a lot of pain after your dental braces are adjusted, talk to your orthodontist about it; he or she may be able to make the adjustments a bit differently.

Pulling baby teeth may be necessary to allow severely crowded permanent teeth to come in at a normal time in a reasonably normal location. If the teeth are severely crowded, it may be clear that some unerupted permanent teeth (usually the canine teeth) will either remain impacted (teeth that should have come in, but have not), or come in to a highly undesirable position. To allow severely crowded teeth to move on their own into much more desirable positions, sequential removal of baby teeth and permanent teeth (usually first premolars) can dramatically improve a severe crowding problem. This sequential extraction of teeth, called serial extraction, is typically followed by comprehensive orthodontic treatment after tooth eruption has improved as much as it can on its own.

After all the permanent teeth have come in, the pulling of permanent teeth may be necessary to correct crowding or to make space for necessary tooth movement to correct a bite problem. Proper extraction of teeth during orthodontic treatment should leave the patient with both excellent function and a pleasing look.

After your dental braces are taken off, your teeth will be thoroughly cleaned. Your orthodontist may want to take another set of x-rays and bite impressions to check how well the braces straightened your teeth and to see if any wisdom teeth have developed. If wisdom teeth are beginning to come in after your braces have been removed, your orthodontist may recommend the wisdom teeth be pulled to prevent your newly straightened teeth from shifting position in your mouth.

Your orthodontist will also fit you with a retainer. A retainer is a custom-made, removable appliance that help teeth to maintain their new position after braces have been removed. Retainers can also be used to treat minor orthodontic problems. The use of a retainer is a very important part of post-braces care. Retainers, which are typically made of rubber or clear plastic and metal wires that cover the outside surface of the teeth, need to be worn all the time for the first 6 months and then usually only during sleep. The time frame for wearing a retainer will vary from patient to patient. The reason why a retainer is needed is that even though braces may have successfully straightened your teeth, they are not completely settled in their new position until the bones, gums, and muscles adapt to the change. Also, after long periods of time, teeth tend to shift.

Correcting jaw-growth problems is done by the process of dentofacial orthopedics. Some of the more common orthopedic appliances used by orthodontists today that help the length of the upper and lower jaws become more compatible include:

Headgear: This appliance applies pressure to the upper teeth and upper jaw to guide the rate and direction of upper jaw growth and upper tooth eruption. The headgear may be removed by the patient and is usually worn 10 to 12 hours per day.

Herbst: The Herbst appliance is usually fixed to the upper and lower molar teeth and may not be removed by the patient. By holding the lower jaw forward and influencing jaw growth and tooth positions, the Herbst appliance can help correct severe protrusion of the upper teeth.

Bionator: This removable appliance holds the lower jaw forward and guides eruption of the teeth into a more desirable bite while helping the upper and lower jaws to grow in proportion with each other. Patient compliance in wearing this appliance is essential for successful improvement.

Palatal Expansion Appliance: A child’s upper jaw may also be too narrow for the upper teeth to fit properly with the lower teeth (a crossbite). When this occurs, a palatal expansion appliance can be fixed to the upper back teeth. This appliance can markedly expand the width of the upper jaw.

The decision about when and which of these or other appliances to use for orthopedic correction is based on each individual patient’s problem. Usually one of several appliances can be used effectively to treat a given problem. Patient cooperation and the experience of the treating orthodontist are critical elements in success of dentofacial orthopedic treatment.