Some frequently asked questions about orthodontics or braces and their answers based on scientific literature and evidences published.
Click on the ref number [*] for references or the underlined words for more info on that subject.
What is the right age for braces? Some dentist said that 12 years is ideal!
You cant pinpoint any particular age for correcting all the problems related to orthodontics. Cleft lip and palate needs orthodontic treatment early in the childhood such as neonatal maxillary orthopedics in an infant.[41] Sometimes malocclusion can present even while the milk teeth are present. Issues like crossbites in early childhood can develop into skeletal issues in the future if early interventions are not done.[4] Treatment for a prolonged digital or pacifier habit should be initiated between the ages of 4 and 6 years.
Anterior crossbile corrected using simple PBP appliance before the premolars are erupted
Same patient with improvement in the face and lip posture
There are malocclusions resulting from or affecting jaw growth. In such situations, the treatment should be done when the patient is growing so that the growth of the jaws can be corrected. In girls, the peak skeletal growth spurt [33] happens around their menarche. Menarche could be used as an indicator that the pubertal growth peak has been exceeded and to predict the end of the pubertal growth.[34]
So, if an orthopedic treatment of the jaw is needed for a girl, it will be ideal not to depend on the chronological age [32] of 12 years or other nonreliable methods like an increase in body height,[48] menarche or voice changes[49] dental development and eruption[50] but to look for skeletal maturity indicators like Hand wrist assessment [31] [35] [37 or CVMI method [30] [47] and treat them during their circum pubertal growth spurt. But some studies have found that obese girls who have reached the sexual maturity early were skeletally less mature with respect to the overall skeletal growth.[29] This is also considered by the orthodontist while treating girls.
Assessing skeletal maturity using cervical vertebra in a lateral cephalogram
To summarize, the effects of therapies aimed to enhance/restrict mandibular growth appear to be of greater magnitude at the circumpubertal period (CS3 or CS4) during which the growth spurt occurs in comparison to early treatment, while effects of therapies aimed to alter the upper jaw orthopedically (maxillary protraction/maxillary expansion) are greater at prepubertal stages. (CS1 or CS2). [47]
The reason for popular belief that the chronological age of 12 is the right age for braces is because a typical orthodontic treatment involving the removal of premolar teeth needs those teeth to be erupted in the mouth so that it can be removed.[38] This may not be the case with your child. Many of the malocclusion corrections should be carried out as soon as the problem is identified or when the patient is motivated to get the treatment or based on their growth pattern. So orthodontic treatments based on chronological age may not be truly effective.
The American Association of Orthodontists advocates the first orthodontic consultation of a child should be carried out at the age of 7. [1a] This is because some problems that could lead to complex issues could be lessened of corrected without much expenses if identified earlier.[1] One such example is tongue blade therapy for correcting anterior crossbite, where a simple wooden stick is used to correct the developing anterior crossbite. [39]
Tounge blade therapy for correcting a developing single tooth anterior crossbite. photo by Akhilesh Sharma
So the weight of evidence points to reserving early treatment for localized problems and specific situations while comprehensive treatment typically initiated in the late mixed or early permanent dentition. [6]
Hence, It is always wise not to wait till the age of 12 as per your dentists advice.
What can possibly happen if braces treatment is not done in spite of having malocclusion?
The answer depends of many factors such as age, severity of the problem and living standards etc.
Crowded, irregular, and protruding teeth have been a problem for some individuals since ancient times, and attempts to correct this disorder go back at least to 1000 B.C. [2]
One of the major problems with malocclusion is that it can substantially affect the psycho-social development of the child. People with visible malocclusion lack the confidence to show their smiles or teeth. [13] This factor is region specific. In some cultures mild to moderate teeth problems are considered normal while in some countries smaller issues are noticed much earlier on.[3]
Some malocclusions like crossbites affect the way the teeth function and the person can take longer time to finish the meal and/or swallow rather than chew the food leading to gastric issues or developing a dislike towards certain food items. This can also lead to Tempero Mandibular Joint problems (TMD) as well, [4] but orthodontics as the primary treatment for TMD which is established, almost never is indicated, except in special circumstances.[5]
If there is anterior or lateral openbite with tongue thrust is present it can result in lisping, which is a speach disorder. [40] A frontal lisp, Interdental lisping or lateral lisp can occur. Involvement of tongue tie should be ruled out before assessing this problem [43]
One of the other problems with protruded teeth is the chance of getting them broken in minor accidents like hitting on the door or the wall. (See the Picture)
Fracture of front teeth can happen with protruded teeth
Some malocclusions such as crowding can impede the ability to clean the teeth adequately and this can lead to dental caries, discoloration, and/or periodontal problems. [7]
Crowded teeth can’t be reached with regular brushing and can become discolored (photo by Dr. Vipin Challiyil)
What are some advantages of early treatment?
According to the Diplomates of American Board of Orthodontics there are some perceived advantages of early orthodontic treatments.[18]
- The ability to modify skeletal growth is one of the strongest perceived benefits of early treatment.
- Better and more stable treatment results [51] – By correcting the malocclusion as soon as it develops, we are establishing more normal function and development.
- Less iatrogenic tooth damage -The less developed roots of permanent teeth may mean more favorable biologic responses to orthodontic forces.
- Better cooperation -Patients may be more cooperative if they are treated before they reach high school.
- Improved patient self esteem and parental satisfaction -There is a clear correlation between improved esthetics and psychosocial well-being. Malocclusion is listed as one of the most common reasons for teasing in children. Moreover, parents, teachers, and peers are more likely to respond positively to attractive children. Researchers have found that good-looking students get higher grades from their teachers than students with an ordinary appearance [54]
What are the perceived disadvantages of early treatment?
- Variation in results and stability.
- Increased financial cost.
- Patient “burnout”. means that patient may loose interest and may not turn up for treatments.
- Iatrogenic problems – these are problems created by the clinician’s bad judgments or by poor patient co-operation such as bad hygiene. [18]
What is the most common malocclusion and why does that happen?
The most common malocclusion is the crowding of the teeth.[8] The jaw size and the tooth size discrepancy is the reason for dental crowding and many factors such as genetic, environmental are attributed to this problem. However, the reasons for overcrowding have not completely been comprehended till now. Some researchers have theorized that adaptation to the modern world and processed food have diminished the size of the jaws and it has resulted in crowding of teeth. [9] The condition has been described as the “malady of civilization”
My child takes a long time to finish his meal and chews only on one side. What could be the problem?
One of the problems you should expect is the presence of deep dental caries and the child may be having pain while chewing. This could be a reason. Some children do have psychological aversion towards food which should be ruled out too.
Malocclusions such as posterior crossbite or lateral open bite can affect the child’s efficiency in chewing and they take longer time to finish their meals and they tend to swallow their food rather than chew it.
Crossbite which is not treated in the childhood presenting with facial asymmetry. Such patients have chewing difficulty but may never realize that they have a problem. It is found during the first orthodontic consultation. This is why first orthodontic consultation should be at the age of 7. Photo by Dr. Vipin Challiyil
Crossbites can impede the child’s efficiency in chewing food. It can also lead to skeletal deformation which can affect the symmetry of the face. A functional posterior crossbite (mandibular guidance with midline deviation) is associated with headache, temporomandibular joint and muscular pain, and clicking. Such type needs orthodontic treatment to rehabilitate the asymmetric muscular activity between the crossbite and non-crossbite sides. [4]
Segmental crossbite in child with obvious facial asymmetry, corrected during the milk teeth period. Photo by Dr. Vipin Challiyil
How can we know for sure that braces are required?
Some reasons [10] why you should seek orthodontists help are:
- Early or Late Loss of Baby Teeth. ( due to decay)
- Difficulty Chewing or Biting
- Crowded, Misplaced or Blocked-Out Teeth
- Biting The Cheek or Roof of The Mouth (Traumatic bite)
- Protruding teeth where the child cant close the mouth
- Bad Bite ( Deep bite where lower teeth cant be seen or Open spaces between teeth)
- Facial Imbalance or Asymmetry
- Mouth breathing or sleep apnoea. [55]
A lot of times the person will feel the need for the treatment due to peer pressure. Girls get beauty conscious at an early age compared to boys. The awareness of the patient is one of the major factors in deciding the treatment timing. [11]
The lips of a normal person at repose are competent. Which means that the lips will be touching each other normally. If there is a proclination or retrognathic lower jaw then the lips tend to be apart, and are called incompetent lips. Lip posture can be taken as a guidance factor for determining treatment needs.[44] But there are differences in how dentists, orthodontists, and laypeople evaluate smiles and in what arch form each group prefers. [17]
Who Needs Orthodontic Treatment?
Protruding, irregular, or maloccluded teeth can cause three types of problems for the patient: (1) discrimination because of facial appearance; severe malocclusion is likely to be a social handicap. (2) problems with oral function, including difficulties in jaw movement (muscle incoordination or pain), TM joint dysfunction (TMD), and problems with mastication, swallowing, or speech such as lisping;[40] and (3) greater susceptibility to trauma, periodontal disease, or tooth decay.[11] Appearance can and does make a difference in teachers’ expectations [54] and therefore in student progress in school, in employability, and in competition for a mate.
There is no doubt that social responses conditioned by the appearance of the face and teeth can severely affect an individual’s whole adaptation to life. Current data suggest that in a low-income population without dental insurance coverage, early partial treatment to improve rather than totally correct obvious malocclusions does produce psychosocial benefits.[12]
There are many indices that suggest when the treatment is required. These indices have categorized malocclusions based on severity like the IOTN index,[14] peer views index like the PAR index [15] or Salzmann Index
Does all braces treatment need extraction of teeth? If yes how many teeth are needed to be removed?
Not all cases require the extraction of teeth. If the space requirement is less than 4 mm, or if spaces are already present or if the jaws can be widened to accommodate teeth, then extraction is not necessary in a patient with a normal or retrusive soft tissue profile. Space requirement from 4-8 mm can be managed with Interproximal Reduction [45] procedure with some expected side effects.
If there is a tooth size and arch length discrepancy of more than 8 mm, then there is an indication for the removal of teeth.[16] Latest anchorage techniques such as TADs (Mini implants) can correct severe protrusions without premolar extractions but third molar extractions will invariably needed. [46]
Also if the front teeth have to be pushed back more than 2 to 4 mm, the extractions, arch expansions or IPR are indicated. If the dental arch is narrow and/or the soft tissue profile is retrusive, arch expansion can be carried out successfully instead of extractions, and in cases where there is a mild requirement, space can be obtained from downsizing the teeth.
In cases where there are problems in both jaws, then 4 teeth are generally considered for extractions, and if it’s only one jaw affected, then 2 teeth are removed. In some rare cases, 1 front tooth from the lower front is removed. [16]
Can self ligating brackets like Damon avoid extractions?
No.The inventor of the Damon brackets describes that the system is capable of increasing the appointment intervals, and possibly reducing the overall treatment time and rapid levelling due to less friction.[22] He never claimed that extractions could be avoided.
One of the biggest study on SLB (Self Ligating Brackets) by Colling Jacobs et al. showed no difference between SLB and conventional bracket systems. [9] Many Self ligating bracket system are marketed utilizing the fear of extraction of the teeth. A case that requires extractions based on analyses doesn’t become extraction-less simply by changing the bracket system. The manufacturer probably is showing cases which is borderline or doesn’t require extractions as an extraction case to market their system. The correction that is achieved by the Self Ligating Bracket system can be achieved by the traditional system at a lower cost with no significant increase in time. Advantages of SLB seems to be lighter force, more torque expression [20] decreased amount of external apical root resorption, increased molar width and high self esteem among the peer groups but cons are higher cost, bulkiness and less aesthetically pleasing, short tie wings. Maybe less chair side time but no other tangible benefits to the patient.[21] These brackets tend to be costly to replace if broken or lost.
Regarding patients, self-ligating brackets do not reduce the pain, the
number of extractions, the incidence of resorption or the risk for caries.[23]
Will there be any side effects in removing good teeth? Such as persistent headaches or eye problems?
No headaches or eye problems have been associated with extraction of teeth. In fact the teeth are secured on to the bone by means of fibers called periodontal fibers. These fibers are severed when a tooth is removed. So no bone breaks while the tooth is being extracted. Usually the wound heals in a couple of days and new bone fills up the socket where the tooth was situated. [24]
Some unknown authors have theorised that removing 4 teeth and pushing the front teeth front teeth back increases the chances of snoring or sleep apnea but this has not been proven clinically. Some dental clinic-website, marketing themselves as no extraction clinics speaks against extractions without showing any evidence. They often accuse that the treatment with extractions take away the space for the tongue which is only true if there is macroglossia which means big tongue and associated malocclusion. There is no case report or study that shows that there is any side effects whatsoever.
The other side effects of extraction are minimal, like pain and tenderness which fades away in couple of days or a week. Spaces of extractions can be visible until they are closed and this is reported as a transient side effect. This can be avoided with riding pontics [25] ( See the picture below)
In the first picture the missing tooth are was filled with a riding pontic which is a false tooth photo. In the second photo the extracted premolar is replaced using a false tooth (riding pontic) which will be trimmed monthly according to the tooth movement and finally will be abandoned when the gap fills. photo by Dr. Vipin Challiyil
Can braces cause Snoring?
No. There is no evidence to proove this claim. The American Association of Orthodontists performed a two-year review of 4,000 scientific studies and found no correlatation and no evidence that supports the claim that moving front teeth backwards causes sleep apnea. On the contrary orthodontic treatment can improve sleep anoea [55],[56] Many physicians and dentists are unaware of the role dentistry, particularly orthodontics, may play in the interdisciplinary management of these disorders.
What will happen to the spaces created by the extraction? Will I need artificial teeth?
The extractions are planned based on the space requirements and spaces are utilized for procedures such as decrowding or retraction of the front teeth. when spaces are available more than the requirement, the posterior teeth are brought forward to close the space. You will never need to place artificial teeth unless the treatment plan suggest placement of a tooth in an already missing area.
How can I treat missing teeth in the front?
There are three treatment options that exist for replacing missing lateral incisors. They include canine substitution, [57] a tooth-supported restoration like maryland bridge [58] [59] or a single-tooth implant.
Can braces hurt me all the time?
Braces don’t hurt if light forces are used. That is why Invisalign do not hurt as much as traditional braces do. It uses only mild force. For Traditional braces there may be discomfort for a day or two after 2 4hours of braces adjustments and it is well tolerated by most patients. Mild painkillers can help alleviate the pain but regular use is not advised as it can delay bone formation and tooth movement.[27] Paracetamol is the preferred medication for orthodontic pain. [26],[27] Persistent pain is abnormal and needs clinical evaluation and you should inform the doctor about it. Any breakage of the brackets or wire can irritate the cheeks and can lead to pain in the surrounding tissues and may require protection or correction by the orthodontist. Orthodontic relief wax can be used to protect the cheek in case of irritation.
What is a space maintainer and why do we need it?
If pre mature extractions of milk teeth are done an appliance called as space maintainer is used which prevent the other teeth from moving to that space and closing before the permanent successor tooth erupt. If the spaces are closed by the forward movement of the permanent back teeth, the teeth that have to erupt at that space will not do so and can erupt in abnormal locations or may not erupt at all. [28]
What are the problems that can be treated in the primary dentition?
- Treatment for a prolonged digit sucking or pacifier habit should be initiated between the ages of 4 and 6 years, before the eruption of the permanent incisors. Keep in mind that front and back dental and skeletal changes are not likely to self-correct than are the vertical dental changes. Anterior open bites in milk teeth resulting from digit sucking do not generally need to be treated because they will correct spontaneously if the habit ceases before 9 years of age. Skeletal open bite and distal step molar relationship, on the other hand, may worsen unless treated early.[18]
- It is important that a posterior crossbite with the presence of a functional shift be treated as soon as it is diagnosed to prevent the asymmetrical positioning and growth of the condyles [18]
My teeth are not protruding but my smile is not good. What could be wrong?
The front teeth should form a curve that is parallel to the lower lip to form a beautiful smile. Sometimes the front teeth may form flat line and may not look appropriate while smiling. An orthodontist can position the teeth so that they follow the smile line. [52]
Flat smile line which is offensive and parellel smile which is attactive
Highly preferred smiles have a high or medium anterior smile line, a parallel smile arc, and a straight or upturned upper lip curve
Can I start my braces treatment in my home country and follow up on the treatment in another country?
Yes. It is absolutely possible and does happen to a lot of people who migrate during their treatment period. You have to make sure to see an orthodontist and get all the records needed for the transfer of cases from one orthodontist to another. [60]
Can I develop allergy to the orthodontic braces?
Very rarely some people develop allergy to the contents of fixed or removable appliances. For example allergy to the nickel in the stainless steel bracket or wire or allergy to the acrylic plates can happen. Nickel is a powerful sensitizer metal and a common allergen. In such cases Nickel less brackets and wire materials are used. [53] nickel allergy usually manifest in women wearing nickel containing jewelry. You should report to your doctor about your allergy conditions so that the materials can be changed accordingly. Brackets and archwire materials without nickel should be used.
What is Invisalign? How is it different from traditional braces?
Invisalign is an advanced treatment modality called clear aligners [61] which can be used to treat mild to moderate malocclusions. This technological advancement uses computer prediction methods and creates stages of teeth movement and prints the molds using 3d printing technology. Clear plastic sheets are wrapped around these models as trays and a series of trays are made which have to be worn by the patient for certain periods of time. These trays are capable of moving the teeth incrementally. Hence the teeth can be brought into new positions by means of wearing such trays. Since 2004, aligners have been recognized as an efficient way for the treatment of malocclusion. [62]
In the Invisalign® system, the practitioner controls the treatment plan initially, and when needed, requests a modification of the virtual setup. In case the suggested setup steps gain the physician’s approval, the 3-D models will be “printed” for each step using stereolithography. In this manner, a series of clear, custom-made appliances is created.
What are the advantages of Invisalign or clear aligner treatments?
Esthetics: They are almost invisible because they are transparent and are preferred by older patients who don’t want to show their braces to others. Invisalign aligners are undetectable from a distance of 2 feet. Of course, one can remove them at will in anticipation of close encounters or lisping.
Comfort: Traditional pain or soreness associated with fixed appliances is not experienced with Invisalign.
Bonding problems avoided: In patients with amelogenesis imperfecta or prosthetic crowns with porcelain surfaces or bridges, the clinician does not worry about securing brackets onto such surfaces. Also, with the aligner, even patients with less than perfect oral hygiene do not exhibit white enamel spots or decalcification.
Lack of root resorption: There are no reported studies of noticeable root resorption in patients treated with the Invisalign System. This is probably due to less than 0.25 mm of tooth movement per tray with mild forces. This distance does not obstruct the periodontal ligament (PDL) blood flow and avoids formation of necrotic regions.
Oral hygiene: Compared with fixed appliances and untreated control patients, the periodontal tissue health as measured by papillary bleeding score and periodontal pocket depth improves with use of Invisalign during orthodontic treatment.[62] [63]
No emergencies: Normally, the Invisalign aligners do not break. But even if they do, patients need to simply move to the next aligner.
Special patients: Musicians or athletes benefit greatly from Invisalign. If the aligner interferes with the wind instrument, it can be removed—just as an athlete would. But in most instances the Invisalign trays may function as mouth guards.
Vertical correction: The Invisalign aligner can intrude the posterior teeth and close the anterior openbite. Conversely, it can effectively intrude the anterior teeth to open the bite.
Bruxism: The aligner is a good substitute for bite splints. It will also reposition the mandible to read the correct centric relation.
Bleaching: The Invisalign tray may be used for bleaching, but it is critical not to bleach if there are attachments present because color will not change to the same extent under the attachments.
ClinCheck is a diagnostic tool: The clinician can create innumerable “what if” scenarios without messy wax setups and can also fine-tune the desired final tooth positions with overcorrections.
What are the disadvantages of Invisalign or clear aligners?
The major disadvantage is that they tend to be costly compared to traditional braces. But the competitive market has made them cheaper.
Another disadvantage is that the treatment requires high patient compliance. Complex malocclusions cannot be easily handled by clear aligners and they are good for mild to moderate complex cases.
Aligners cannot pull a tooth and it is designed to push the tooth only which makes it difficult to treat complicated malocclusions.
How much time does it take for braces to correct malocclusions?
A regular 4×4 premolar extraction treatment may take 18 to 24 visits and non extractions cases may take 12 to 16 visits. Again these durations are based on the severity of the cases and patient compliance. Some cases which may require correction of the jaw bones are done in stages and requires even more time. If the patient does not turn up for appointments or breaks the attachments, the treatment time may get elapsed. Treatment for anterior crossbites using catalans appliance only last for weeks.
Can braces bring the trapped teeth into position?
Yes. If the trapped or impacted teeth are favorably placed, the orthodontic treatment can bring them into normal position slowly by applying forces to them. [64] [65]
Until what age can the braces be worn?
There is no particular age limit for braces as such. If the teeth and bone health are adequate even older people can have them. [66] [68] particularly the Clear aligners. The maintenance of healthy periodontal tissues throughout active orthodontic treatment and not worsening the exisiting periodontium during orthodontic treatment is mandatory.
What are the main things that should be taken care of while wearing braces?
Diet and oral hygiene are the main things to be taken care of. The diet should be such that it does not break the attachments. Cookies, wafers, popcorn, and cold chocolates should be avoided.
Hygiene is important and brushing frequency should be raised to keep the teeth free of debris. If needed brushing the teeth should be done after each meal. Poor oral hygiene can enlarge the gingival tissue around the teeth and it may need surgical interventions. Teeth can also get white spots of deminaralization or can get yellowish due to bad oral hygiene habits.
My gum grows in between the braces. what could be the reason?
Poor oral hygiene can enlarge the gingival tissue around the teeth and it may need surgical interventions. In many patients, proper oral hygiene is sufficient to achieve normal, healthy gingiva. In some situations, however, gingival
overgrowth is drug induced or can be a manifestation of a genetic disorder. Gingival overgrowth occurs in about 50% of persons taking Phenytoin (Dilantin). Gingival enlargement is also seen in several blood dyscrasias such as acute monocytic, lymphocytic, or myelocytic leukemia. Thrombocytopenia and thrombocytopathy can also cause gingival enlargement and spontaneous bleeding.
Depending on home care and the relationship between the gingival tissue and the crown of the tooth, gingival hyperplasia is frequently reversible, especially after orthodontic appliances have been removed.[69] Alternatively, Graber and Vanarsdall [70] suggest that some patients may benefit from the removal of excessive gingival tissue around the crowns of the teeth, and this may add to the stability of the orthodontic correction.
Which brush is better? electric or normal?
From existing studies, it can be concluded that compared with a manual
toothbrush, orthodontic patients using a powered toothbrush will show a mild, statistically significant reduction for bleeding on probing and plaque accumulation. The electric toothbrush, with either brush head, demonstrated significantly greater plaque removal over the manual brush. The orthodontic brush head was superior to the regular head. [67]
Can braces hurt my cheeks?
Modern brackets and attachments used today are designed in such a way that they do not irritate the soft tissue around them. However, some discomfort may be expected initially, which will be settled after a couple of weeks. If there are any broken attachments or wire elements then they can impinge the mucosa and because of friction, the cheeks can get bruised. This should be corrected by visiting the office as early as possible.
Are there braces that are worn inside the teeth?
There are braces that can be fitted onto the inside part of the teeth. These are called lingual braces and tend to be costly than traditional braces. They have the advantage that they are invisible but occupy the space of the tongue and thereby affect speech.
