Braces (Dental)

The results of dental braces can be very rewarding and outweigh the temporary discomfort.

Dental braces are devices that are placed directly on teeth to move them. For most of us, braces are the most common method for achieving optimally aligned teeth. Aside from straightening teeth, braces are used to improve the relationship of how our teeth come together between the upper and lower jaws.

Braces for tooth movement fall under the dental specialty of “orthodontics” which is the study and treatment of improper bites (malocclusion). Orthodontic treatment with braces is used for cosmetic as well as functional improvement concerning teeth position.

The “braces” are the actual devices that are attached to teeth.

• They usually consist of “brackets” that are bonded to the teeth and a metal wire that is inserted into the brackets.
• The metal wires are “tightened” and work together with the brackets to move teeth into the desired positions.
• Other components are also used in conjunction with braces to move teeth, jaw, and bone such as headgear and expansion devices.

While orthodontics work on teeth movement, it sometimes involves working with one's facial bone growth to achieve favorable jaw dimensions and relationships.

Braces can be for any age group, but there are optimal times to begin treatment. These days, it is recommended that children have an orthodontic evaluation at the age of 7 to determine if early intervention is needed or advantageous. If recommended, early intervention optimizes results by taking advantage of a child's skeletal bone growth and may require two-phase orthodontic treatment.

Phase-One Treatment

The first phase (“phase-one”) is considered interceptive orthodontic treatment as it addresses overcrowding of teeth or bite problems at an early age.

• As an example of interceptive treatment, a narrow upper jaw that has crowded teeth and does not fit correctly with the lower jaw can be widened with an expansion device called a “palatal expander.”
• This lets the upper jaw line up better with the lower jaw and allows room for upper teeth to fit in alignment.
• Widening the palate can only occur during a small window of time in a growing child before the bone becomes too developed to change.

During “phase one,” braces may or may not be used depending on the specific situation. After “phase one,” there is a resting period to allow most or all of the permanent teeth to come in.

Phase-Two Treatment

Around the age of 12 or 13, “phase-two” treatment may begin. During this phase, the alignment of all the permanent teeth is addressed using full braces.

• If the window of time for two-phase orthodontic treatment has already passed, results can still be achieved with only one phase of treatment. However, if there is significant crowding of teeth, dental extractions may be required to create room for teeth to move into alignment.
• Another method for creating room for teeth movement is called “interproximal reduction” (IPR). IPR involves minimal removal of tooth structure on the sides of the teeth to create more room. This method is limited to mild teeth crowding.

Essentially, anyone who desires to have straighter teeth or improve their bite may be a good candidate for braces. A thorough evaluation with a qualified clinician is very important in determining whether one is a good candidate for braces.

There are various types of braces available today. Choosing the right type depends on various considerations such as aesthetics, cost, and allergy concerns.

• Metal-wired braces: These are the most common and traditional types of braces. They are typically made out of stainless steel. Metal brackets are fixed (bonded) onto the teeth and secured on a wire with elastic ties made out of rubber. As an alternative to using elastic ties, “self-ligating” brackets are used to clip onto the wire.
• Ceramic wired braces: Also called “clear braces,” these provide a cosmetic alternative to metal wired braces. The brackets are ceramic to match the shade of the teeth and clear elastic ties are used. Self-ligating ceramic brackets are also available. The downside to ceramic braces is that they are more prone to breakage compared to metal braces.
• Lingual braces: These are braces that are placed on the lingual surface (backside) of the teeth and are not easily visible. This is mainly for cosmetic purposes and usually lengthens the time for treatment.
• Other metal braces: Gold-plated stainless steel or titanium brackets are usually used for those with nickel allergies.
• Clear aligners: These braces are made of clear plastic that is custom-made without the use of brackets or wires on the teeth. These are also known as “clear braces” and present a very comfortable option for treatment. However, there are limitations to this method. Clear aligners can only tilt and rotate teeth in their position. Conversely, the use of brackets with traditional braces enables the whole bodily movement of a tooth (and its root) into the desired position.

Braces work by a slow and controlled process using force and constant pressure. For traditional braces, the wire that is attached to the brackets works to put pressure on the teeth to move in a specified direction.

Teeth move through a biomechanical process called “bone remodeling.” When braces put pressure on a tooth, the “periodontal membrane” and bone surrounding this tooth are affected.

• The periodontal membrane surrounds a tooth in its socket and it essentially helps anchor the tooth to the bone.
• With pressure from braces, the periodontal membrane of a tooth is stretched on one side and compressed on the other side. This effectively loosens the tooth out of its socket.
• The compressed side (the direction of pressure) is where the bone is broken down to accommodate the new position of the tooth while the stretched side is where new bone is made.

This process needs to be done very slowly and explains why wearing braces can take some time to achieve the desired results.

The initial step for obtaining braces involves a thorough evaluation and record-taking with an experienced clinician. Dental impressions (molds) are taken to make models for study and X-rays are taken to look at teeth positions. Measurements are taken in the mouth as well. Once thoroughly evaluated, a treatment plan is created. This plan will specify what has been diagnosed for correction, treatment recommendations, and an estimated time for how long treatment will take. A discussion between the clinician and patient takes place where all the risks, benefits, and alternatives of treatment are reviewed.

If necessary, all dental extractions are performed before the placement of braces or other orthodontic appliances. For the two-phase process, appliances such as palatal expanders and headgear are used during the “phase-one” treatment to correct any developing skeletal growth problem.

Traditional Braces

• For the placement of traditional braces, brackets are bonded with special dental cement to all the teeth in the arch.
• For some clinicians, elastic spacers are placed between the molars for 1 to 2 weeks before placement of the brackets to make room for metal bands with attached brackets.
• These metal bands are typically placed around the last molars and can withstand the forces of chewing better than bonded brackets in the back teeth.

After the brackets and/or metal bands are in place, a metal wire (or “archwire”) is placed in the brackets and secured with elastic rubber bands (or clipped into place with self-ligating brackets). Of note, elastic rubber bands come in various colors and can be an appealing component of a child's orthodontic experience.

Clear Aligner Braces

• For clear aligner braces, accurate dental impressions (molds) are taken to have a set of aligners made.
• The aligners are clear trays that fit over the teeth to achieve movement.
• Each tray is worn for some time before progressing to the next tray.

Placement of traditional braces is usually pain-free, but the teeth and jaws will feel sore afterward. This is due to the slow movement of teeth that is taking place. This initial soreness usually lasts for about a week and then for a couple of days after each adjustment of the archwire during treatment. This discomfort also applies to clear aligners as tooth movement is taking place.

• During this time, it helps to have a soft food diet and use over-the-counter (OTC) pain medications such as ibuprofen or acetaminophen when appropriate.
• Initially, orthodontic wax can be used to cover rough areas that rub against the cheeks until the mouth becomes more accustomed to the brackets and wires.

The cost of treatment varies by the individual as every mouth is different. The cost will depend on treatment time, and steps involved and will vary by location.

• An estimated cost range for “phase-one” treatment is $2,000 to $4,000.
• For “phase-two” treatment, an estimated cost range is $2,000 to $7,000.
• Clear aligner treatment costs more by about 20 to 50 percent.

Orthodontic treatment can be a covered benefit through dental insurance. Limitations may exist depending on the dental insurance plan.

There is no doubt that braces can initially be uncomfortable and be a cosmetic concern.

Aside from the teeth soreness, the inconveniences of wearing braces include:

• Constantly getting food stuck when eating
• Having to spend more time cleaning the teeth
• Having to be cautious of the types of food that can be eaten

However, more often than not, individuals are happy to have gone through the process of orthodontic treatment to improve their smile or correct their bite. The results of treatment can be very rewarding.

Once braces come off, more records (molds and X-rays) are taken to evaluate the result. Additionally, plans for a dental retainer are made to keep the newly-positioned teeth in place. Without a retainer, the teeth can shift. There are usually two types of retainers -- removable or fixed.

• A removable retainer is made of acrylic and metal wires or a clear rigid plastic tray and can be easily removed for ease of brushing and flossing the teeth.
• A fixed retainer is usually bonded to the back ("lingual") side of the teeth. The advantages of this type of retainer are that it cannot be lost and is more effective in retaining the position of the teeth.

Typically, retainers need to be worn full-time after braces are removed for some time and then, for removable retainers, followed by part-time wear at night indefinitely. For adults completing orthodontic treatment, retainers usually must be worn for a lifetime. The dentist or orthodontist will recommend how long to wear the retainers as each case differs.