Also called: Orthodontic Braces, Orthodontic Appliances, Dental Braces, Tooth Braces, Removable Appliances
Andrew M. Sicklick, D.D.S.
Braces are devices designed to correct crooked, crowded or misaligned teeth. They are most often made of stainless steel, but may also be made of ceramic or plastic. A combination of brackets and connecting wires are affixed to the teeth so that light pressure is continuously applied to the teeth until they shift into proper position. Treatment times vary, but usually last between one and three years.
An orthodontist oversees treatment with braces. Orthodontists are dentists who specialize in the diagnosis and treatment of bite or alignment problems. Braces are used to correct malocclusions, or conditions that result in a “bad bite.” These include crooked or crowded teeth, extra or missing teeth, and size differences between the upper and lower jaw.
Braces are often used purely for cosmetic purposes. Patients may find that having straighter teeth or a more exact bite improves their appearance. However, braces can also be used to correct medical or dental problems related to malocclusions, such as improving a person’s ability to chew or talk. Straightening a patient’s teeth may prevent or correct abnormal wear of teeth, stress on gum tissue and bone that supports the teeth, and misalignment of the jaw.
Contemporary braces usually consist of small stainless steel, ceramic or plastic brackets that are bonded onto the teeth. Thin wires known as arch wires are threaded through the brackets and used to pull the teeth into position. As teeth shift position, the wires are periodically adjusted so that the braces continue to apply adequate pressure on the teeth.
Once treatment with braces has ended, the brackets and wires are removed and the patient is asked to wear a retainer. This is a small piece of hard plastic that contains metal wires and is specially molded to fit the patient’s teeth. Retainers may be removable or fixed inside the mouth. Retainers are designed to give the bone and gums additional time to stabilize around repositioned teeth.
Treatment of malocclusions with braces usually takes place during childhood, when a patient is young. At this age, the jaw is still growing and can better accommodate the changes that take place. However, adults are increasingly choosing to have braces to correct malocclusions.
While wearing braces, patients may have to make certain lifestyle adjustments. For example, patients are urged to avoid eating certain types of foods (e.g., hard or sticky candy), because they may stick to the braces or may cause brackets or wires to become damaged. Patients also are urged to be vigilant about regularly brushing and flossing their teeth.
The U.S. Food and Drug Administration (FDA) has approved an alternative to braces that uses a series of clear, removable aligners that gradually readjust a patient’s teeth. Approximately 18 to 30 aligners are worn over a period of nine to 15 months. This product is not intended for young children whose teeth are still developing. However, it may be a good option for adults whose orthodontic problem is less severe.
About dental braces
Braces are dental devices designed to move crooked, crowded or misaligned teeth into proper position. These stainless steel, ceramic or plastic devices are placed on the teeth. They apply light pressure to the teeth over long periods of time. As this pressure is applied, the teeth gradually shift into a more normal alignment.
Braces are a treatment associated with a specialy of dentistry called orthodontics. Orthodontics focuses on malocclusion, a term that means “bad bite.” Braces are used to correct improper alignment of the teeth in order to straighten teeth, correct a bite, close gaps in the teeth, or bring the teeth and jaw into proper alignment. About 6 million people in the United States and Canada receive orthodontic care each year, according to the American Association of Orthodontists.
Malocclusion causes a variety of problems with the teeth and jaws. Some of the most common include:
- Crossbite. The most common type is when the upper teeth sit inside (rather than outside) the lower teeth during biting. This can cause biting and chewing problems.
- Crowded or crooked teeth. Poor alignment of teeth can occur as the result of a dental arch that is too small, teeth that are too large or a combination of these factors. Teeth may become impacted or a patient’s bite may be affected. Crowded or crooked teeth also can be cosmetically unappealing.
- Open bite. Occurs when upper and lower incisor teeth do not touch during biting. This places all chewing pressure on the back teeth, making chewing less efficient and causing excessive wearing of the teeth.
- Overbite. The upper jaw is larger than the lower jaw, leading to discomfort, bone damage and excessive wear of the front teeth.
- Protruding upper teeth. These teeth are more prone to injury and may indicate unevenness in jaw growth. They also may indicate a poor bite of the back teeth.
- Spacing. A wide dental arch, missing teeth or teeth that are small can cause gaps between the teeth, which may be considered cosmetically unappealing.
- Underbite. When the lower jaw is bigger than the upper jaw, resulting in lower front teeth that protrude and a possible crossbite.
In most cases, malocclusions are genetic. However, some can be acquired through certain situations, including:
- Accidents. Teeth that are fractured or knocked out may fuse with the bone around them (ankylosis) following replacement. This prevents the teeth from lining up properly in the jaw of a growing child, resulting in an irregular bite.
- Illness and other problems. Conditions that develop after birth (e.g., air obstruction due to swollen tonsils or adenoid) can cause malocclusions.
- Prolonged thumb sucking or use of a pacifier. Children who engage in either of these habits after their permanent teeth erupt (about age 6 or 7) can force the upper teeth to protrude over the lower teeth.
- Premature loss of baby teeth. When a primary tooth is lost too early, it can cause the emerging permanent tooth to drift or erupt incorrectly. In some cases, adjacent primary teeth may move into the gap left by the tooth that was lost early. This can prevent the permanent tooth from coming in.
- Tongue-thrusting. A habit of pushing the tongue onto the back of the front teeth during swallowing can cause the teeth to protrude.
Braces can help correct many of these dental problems. Malocclusions are most often corrected for cosmetic reasons, such as improving one’s appearance with aligned teeth or a more exact bite.
Braces may also be used to correct medical or dental problems related to malocclusions, such as improving a person’s ability to chew or to talk. For example, straightening a patient’s teeth may prevent or correct:
- Abnormal wear of teeth (including accidents such as chipped teeth)
- Stress on gum tissue and bone that supports the teeth
- Misalignment of the jaw (which can trigger headaches and neck or facial pain)
Braces can be an extremely effective treatment for straightening a patient’s teeth or correcting a misaligned bite. However, braces can cost several thousand dollars, and insurance may only cover part of the cost. Some plans do not cover any of the cost.
Using braces to treat orthodontic problems early in life can help prevent more costly and time-consuming treatment later. The effectiveness of braces depends on how well a patient follows the treatment plan.
Types of dental braces and arch wires
Braces were previously made of thick bands of steel that were wrapped and cemented around the teeth. Advances in modern dentistry now allow orthodontists to use smaller brackets in place of the thick bands, at least on the front teeth. Metal bands are still frequently used on back teeth, but they are smaller and lighter than earlier versions.
Most often, the brackets used in contemporary braces are made out of stainless steel. Patients may prefer ceramic or plastic brackets for cosmetic reasons, but these materials have significant drawbacks compared to stainless steel. Plastic brackets sometimes stain or discolor over the course of treatment, while both plastic and ceramic braces tend to create more friction between the brackets and connecting wires. This can increase a patient’s treatment time. Research is ongoing in the development of more effective, cosmetically pleasing brackets.
Thin connecting wires, known as arch wires, are used to pull the teeth into position. They are thinner and more effective than wires used in the past. Arch wires may be made of stainless steel or alloys (mixtures) of nickel, titanium, copper and cobalt.
In most cases, braces are affixed to the front of the teeth. However, in some cases, they may be placed behind the teeth (lingual appliances), where they are less visible. These braces may be more cosmetically appealing, but are often more bothersome to patients because they can hamper speech and irritate the tongue.
When to get dental braces
Treatment of malocclusions with braces usually takes place during childhood because the jaw is still growing and can better accommodate the changes that take place. The American Dental Association recommends that all children have an orthodontic evaluation by the age of 7, when the first permanent molars and incisors typically have erupted.
A branch of orthodontics called interceptive orthodontics focuses on preventing malocclusions that may require braces. This involves examining and treating children before the eruption of all of the adult teeth, while their teeth and jaws are still developing. For example, a device called a palatal expander may be used to expand the child’s upper arch to its proper size, which encourages permanent teeth to erupt normally in the mouth. In some cases, interceptive orthodontics may take just a few months to complete.
Early signs and symptoms of malocclusion in a child include:
- Baby teeth that are lost early or late
- Chewing or biting difficulties
- Biting the cheek or roof of the mouth
- Crowded teeth
- Jaws and teeth out of proportion to the rest of the face
- Jaws that shift or make sounds
- Mouth breathing
- Upper and lower teeth do not meet or are improperly aligned
Although treatment with braces traditionally has been performed on children, it is increasingly being used on adults. About one in five orthodontic patients is an adult, according to the American Association of Orthodontists. The use of braces in adults is often more complicated due to their higher susceptibility to gum disease and skeletal problems that may require additional procedures (e.g., gum surgery, jaw surgery) before braces can be placed.
Before, during and after placement of dental braces
Before braces are placed on the teeth, patients undergo an examination by an orthodontist. This usually includes collecting a patient’s medical and dental history, physically examining the mouth and teeth, as well as creating plaster models of the teeth. More recently, computers are used to create digital models of the teeth. Photographs of the face and teeth and x-rays of the mouth and head may also be taken.
Treatment with braces consists of two phases:
- Active phase. This involves the use of braces or another device to move the teeth into proper position. In most cases, this phase lasts between one and three years. It tends to last longer for adults than children. During treatment, the braces are occasionally adjusted as the teeth shift position.
- Retention phase. Once the teeth are properly aligned, a device called a retainer is used to hold the teeth in proper position over the long term.
When braces are first placed, tiny brackets are affixed to each tooth using a special bonding agent. Some bonding agents are designed to continuously release fluoride, which helps protect tooth enamel under the brackets from tooth decay.
Once the brackets are in place, arch wires made of stainless steel or metal alloys (mixtures) are threaded through the brackets. Wires may also be made of clear or tooth-colored materials for cosmetic purposes, although these are typically more expensive than the metal wires.
Contemporary arch wires are very flexible at room temperature so they can be attached to teeth more easily. Once the wires are threaded through the brackets, body heat causes the wire to warm and apply constant pressure on the teeth to move into place. These more flexible wires both speed up the treatment process and make it more comfortable for patients. Wires require periodic adjustment to maintain continual pressure on the teeth as teeth begin to change position.
Tiny elastic bands called ligatures are used to hold the arch wires to the brackets. These are now available in many different colors, and children may choose different colored bands as a fashion statement. For example, patients who are having their braces adjusted during the fall may choose orange and black ligatures to celebrate Halloween.
Bands made of surgical latex also may be applied to the teeth to provide more pressure than arch wires can apply on their own.
Patients typically experience some discomfort for a few days following the procedure. Teeth are often sore, and the tongue, cheeks and lips may experience irritation as a result of the braces and wires. However, this usually disappears within a week and only recurs when the braces are adjusted. Pain-relief medications can help alleviate this discomfort. However, patients should never take any medication without first consulting their orthodontist or physician.
Treatment time will vary depending on several factors, including the type of problem being corrected, the patient’s age and how well the patient follows the orthodontist’s recommendations. Usually, treatment with braces takes between one and three years. An orthodontist may recommend removing wisdom teeth after the braces are removed to prevent any future complications.
Once treatment with braces has ended, the brackets and wires will be removed and the patient will need to wear a retainer. This is a small piece of hard plastic that contains metal wires and is specially molded to fit the patient’s teeth. It is designed to give the bone and gums additional time to stabilize around the repositioned teeth. Photographs of the teeth and jaws will be taken for comparison with the initial patient photographs.
In some cases, retainers are fixed to the teeth and not removed until the retainer is no longer needed. In other cases, the retainer is removable. Some patients require a retainer until their early 20s, although the actual length of time that a patient is required to wear a retainer can vary anywhere from a few months to the rest of their lives. Wearing a retainer for this extended amount of time may be important because teeth may continue to move throughout life, regardless of previous orthodontic treatment. Retainers are available in different colors and designs and can often be personalized with items such as a picture of a pet or a favorite sports team’s logo.
Patients with braces will be urged to avoid eating certain types of foods, as they are likely to stick to the braces and may even cause brackets or wires to become damaged. Prohibited foods include gum, popcorn, and hard or sticky candies. Many orthodontists urge patients to avoid sugary sodas and juices because sugar tends to stay longer on the teeth of patients who wear braces, which can lead to tooth decay. At the very least, patients should brush soon after consuming these drinks.
Chewing on items such as pens, pencils or fingernails also can damage braces. This type of damage requires repair by the orthodontist and often results in extended treatment time for the patient.
Food particles and sugary substances that stick to braces increase the buildup of dental plaque, which encourages tooth decay, gum disease and bad breath. For this reason, patients with braces have to be vigilant about regularly brushing and flossing their teeth. A toothbrush with soft bristles may help patients reach areas within their mouth that are hard to get to due to their braces. Certain types of mouthwash may also help patients with braces to maintain good oral hygiene. However, patients with braces should check with their orthodontist to see if use of mouthwash is appropriate for them.
An orthodontist may provide special flossing equipment that facilitates flossing in and around braces. In addition, an assistant at the orthodontist office will instruct the patient in the proper procedure for flossing around braces.
From time to time, patients may find that a bracket or wire comes loose, or that a wire is poking them. When this occurs, an appointment with the orthodontist should be scheduled. The most common problems associated with braces include:
- Broken or protruding wires. Wires sometimes break or protrude in a way that pokes into the cheek, tongue or gum. If the wire is protruding, a pencil eraser sometimes can be used to push the wire into a less bothersome position until patients can see their orthodontist. Orthodontic wax can also be used to cover the sharp end. Patients should never cut these wires, as bits of metal may be swallowed or inhaled into the lungs and cause additional problems. Patients who develop a mouth sore due to a protruding wire are urged to rinse with an antiseptic solution or warm saltwater until they can see their orthodontist.
- Loose brackets. The bond of a bracket may loosen, particularly if patients chew on something hard or sticky. A broken bracket may poke at gum tissues or soft tissues such as the tongue or cheek. Patients are urged to cover any sharp ends with orthodontic wax until they are able to see the orthodontist.
- Loose bands. The metal rings that are cemented around the back teeth sometimes will come loose. Patients are urged to save the band and schedule an appointment with their orthodontist.
- Loose spacers. These tiny circular spacers are made of rubber and are inserted between teeth to open a small gap between teeth that helps orthodontic bands to slip into place more easily. If a spacer slips out of place, an appointment should be made to have it replaced by an orthodontist.
In addition, some patients with braces may have allergic reactions to the metal or latex used in the braces and bands. Also, people with braces who have certain diseases (e.g., type 1 diabetes) may be at higher risk for periodontal problems.
Patients with braces can participate in most activities, but may have to take special precautions such as wearing mouth guards while participating in contact sports. Other activities may require a period of adjustment. For example, patients who play wind or brass musical instruments will probably need to practice and adapt to any changes in their ability to expel air due to the braces before they feel comfortable playing these instruments.
Patients advised to wear a removable retainer are urged to clean the device daily with a toothbrush and toothpaste. It is particularly important to clean the side that has contact with the roof of the patient’s mouth. Hot water should not be used to clean the retainer, as it can distort the shape of the retainer. Patients are urged to store the retainer in its case and to keep it away from pets.
Some patients prefer to soak the retainer in a solution intended for dentures. Patients are urged to consult with their orthodontist about the best denture cleaners for this purpose, as some may corrode metallic areas of the retainer.
Alternatives to dental braces
The U.S. Food and Drug Administration (FDA) has approved an alternative to braces that uses a series of clear, removable aligners to move a patient’s teeth. They can be used by patients who already have their second molars, which usually erupt by a person’s late teens.
Use of this product requires an impression of the patient’s teeth, which is sent to a laboratory where a computer simulates how the teeth should move in order to be corrected. A series of custom-made aligners are then created based on this simulation. Patients wear each aligner for a couple of weeks and can remove them when eating, and while brushing and flossing their teeth. Generally, approximately 18 to 30 aligners are worn over a period of nine to 15 months. However, in some cases as few as 10 aligners may be used for as few as 5 months with good results.
This product is not intended for young children whose teeth are still developing. However, it may be a good option for adults whose orthodontic problem is less severe.
Questions for your doctor regarding braces
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to braces:
- What type of malocclusion do I have?
- Why do you think braces are the most effective treatment for me?
- Do I have other options?
- How much will my braces cost?
- How often will I need to return for adjustments to my braces?
- How long do you estimate my treatment will last?
- What foods should I avoid while wearing braces?
- Will I need other treatments in addition to my braces?
- How long will I have to wear a retainer?
- Will the retainer be removable or fixed in my mouth?
- Is there a chance that my treatment will fail?
- Am I a candidate for clear, removable aligners? What are the pros and cons of this product?