What is orthodontic treatment?

Orthodontic treatment is a branch of dentistry that deals with the alignment of the teeth and jaws. Many people of all ages seek orthodontic treatment to improve the appearance, health and function of their teeth and jaws. Your smile is often the first thing other people notice about you. There are many different types of orthodontic treatment available today.

Reasons for orthodontic treatment

Some reasons people seek orthodontic treatment include:

  • Difficulty chewing - teeth that are in the wrong position can cause problems with chewing. They may not meet correctly, or can rub against your lips or cheeks when eating;
  • Poor appearance - many people can be self-conscious about their crooked teeth or uneven jaws. An attractive smile with straight teeth and a symmetrical jaw can boost self-confidence and create a positive impression on other people;
  • Difficulty cleaning teeth - overlapping and crowded teeth can be difficult to clean;
  • Excessive tooth wear - when teeth are not in their correct positions, they may wear against each other and cause unnatural chipping and wearing-down of teeth;
  • Speech problems - some people can have difficulty speaking when their teeth or jaws are in the wrong positions;
  • Gum damage - when teeth are severely crooked, they sometimes bite against the gums instead of the opposing teeth. This will damage the gums over time and may strip them off nearby teeth. Moving the teeth into better positions is the best solution to this problem, and;
  • Incorrect bite - teeth and jaws are designed to bite together in a certain way. If the bite is incorrect, the teeth and jaw joint can deteriorate over time and cause problems such as jaw pain, worn-down and chipped teeth, gum problems and poor appearance. 

When to seek treatment

Orthodontic problems are best treated in childhood. Most problems can be detected at around 7-9 years of age. Some become obvious even earlier and can be corrected easily while the child is still growing. Ask your dentist to check your child for orthodontic problems, or refer you to an orthodontist for an assessment. An orthodontist is a dentist who has studied further to specialise in correcting irregularities in the teeth or jaws.

Treatment for children

Early examination of the teeth, jaws and growth pattern of the face allows for early detection and treatment of orthodontic problems. Problems with jaw alignment and size can often be easily corrected in children who are still growing. Treatment in children is usually shorter and less complicated that in adulthood, as jaw alignment problems usually worsen with age.

Where jaw alignment and size is normal in children, but only the teeth are crooked, orthodontic treatment is usually started when the last baby teeth are about to be lost. This is usually around 12 years of age. Correcting crooked teeth at an early age is often simpler and quicker than in adulthood, when problems resulting from crooked teeth may have already caused damage and the bone around the teeth is thicker and denser, making the teeth harder to move.

Treatment for adults

Orthodontic treatment is possible at any age. In the past, treatment was mainly restricted to children and teenagers, but nowadays, with less visible alternatives to metal braces, it is can be performed in people of all ages. 

Some severe bite problems in adults cannot be corrected with braces alone. As the jawbones are no longer growing, they cannot be manipulated into different shapes. Often surgery, together with orthodontic treatment, is needed to correct the problem. This is called orthognathic surgery and is performed by an oral and maxillofacial surgeon in consultation with an orthodontist.

Maxillofacial

An broad term that refers to the maxilla (the bone of the upper jaw) and the face.

What happens before the procedure?

Before starting any treatment, a thorough examination is essential to assess your orthodontic problems and to ensure your mouth and teeth are free from any other problems that may hamper your treatment. First, your dentist will check that your gums and teeth are healthy and free from decay or gum disease. They will clean any tartar or stains from your teeth and ensure that your mouth is in good condition and ready for orthodontic treatment.

Your dentist may then refer you to an orthodontist for treatment, or treat you themselves. Some dentists have had training in orthodontics and although they have not specialised in this field, are competent to manage simple cases. If you are unsure, it is wise to seek a second opinion from another dentist or orthodontist before making a decision.

At your initial orthodontic appointment, a thorough assessment will be made of your mouth and jaws to analyse and diagnose your condition accurately.

Your dentist or orthodontist will record the following:

  • X-rays of the mouth and jaws. These often include a orthopantomogram (OPG) that gives a panoramic X-ray of your jaws;
  • An X-ray of your face in profile is often also taken. This is called a lateral cephalogram;
  • Impressions are taken of your upper and lower jaws from which plaster models are then made. This creates an exact replica of your teeth and jaws and allows the dentist or orthodontist to see your teeth from all angles and plan your treatment, and;
  • Photographs are taken of your teeth and face from different angles.

Once these records are taken and assessed, you will be advised on your treatment options, how long treatment is likely to take, its cost and the best time to start it.

Gum disease

A chronic, progressive disease of the gums caused mainly by bacteria and poor oral hygiene. Early stages are generally asymptomatic, with the advanced stages characterised by loss of gum tissue, supporting bone and eventual loss of teeth.

X-rays

A scan that uses ionising radiation beams to create an image of the body’s internal structures.

What happens during the procedure?

There are many different types of orthodontic treatments available. They range from early treatment and altering growth patterns in children to minor tooth movements in adult patients.

Preventive treatment

The aim of early treatment in young children, who still have mostly baby teeth, is to give them the best chance of proper growth and tooth development and prevent future orthodontic problems. For example, a baby tooth may be removed if it is preventing proper growth of a permanent tooth. If a baby tooth has been lost prematurely, an appliance may be fitted to hold the space for the permanent tooth that will follow.

Interceptive treatment

In young children, it is sometimes necessary to intervene when a problem is developing. Modification of an unfavourable growth pattern is easily done while the child is still growing. Sometimes appliances are used to expand a narrow upper jaw to make room for future permanent teeth. A crossbite or underbite can be corrected, or at least the severity reduced through the use of appliances to change growth patterns. 

An appliance can also be fitted to discourage a thumb-sucking habit that is distorting the shape of the jaws and causing teeth to protrude. The aim of interceptive orthodontic treatment is to prevent future problems and ensure any further treatment the child needs is straightforward.

Comprehensive treatment

This is aimed at correcting an existing problem with the bite or position of the teeth. It can be started at a young age as the permanent teeth begin to develop, or delayed until most permanent teeth are present. It involves the use of fixed braces or other devices to move teeth into their correct positions.

Surgical treatment

In some difficult cases, surgery may also be needed. For example, jaws that are protruded or recessed in an adult, who is no longer growing, may need to be surgically repositioned to create a proper bite and a normal appearance. This type of surgery is done by an oral and maxillofacial surgeon in collaboration with the orthodontist. 

A tooth can sometimes lose its path when growing and may need to be surgically exposed to allow the orthodontist to move it into its correct position. Once again, the oral surgeon will perform this surgery as part of the treatment plan.

Tooth extractions

If your teeth are severely crowded, you may need to have one or more permanent teeth removed. This usually happens before orthodontic treatment starts. In the past, tooth extraction was the only solution for crowded teeth. Nowadays, early intervention in childhood can encourage small jaws to grow wider to accommodate all the permanent teeth when they erupt. 

Braces and appliances

Growth-modifying appliances

These are used in children who are still growing. They can be either fixed appliances that are glued onto the teeth or removable appliances that are taken out to clean the teeth and eat. They work by applying forces on the jaws to stimulate growth and modify undesirable growth patterns.

Headgear is also a type of growth-modifying appliance used in children to change undesirable growth of the jaws. It attaches the teeth to the outside of the head by way of straps and wires, and gently pushes the jaws into a better position. It must be worn consistently during the night and evenings for at least 10-12 hours to be effective.

Removable appliances

These are often referred to as 'plates'. They are made of a plastic base with a wire component to correct relatively simple tooth alignment problems. It is worn at all times except when eating or brushing the teeth. Multiple visits to the orthodontist may be needed to tighten the appliance as the tooth moves into place.

Fixed braces

Braces are ceramic or metal brackets that are glued to the teeth and connected by wires that are held in place by elastics or clips. The braces exert a gentle and consistent force on the teeth, which moves them into position. Visits to the dentist or orthodontist are required usually every 4-6 weeks to adjust the braces and make changes as the teeth move.

There are different types of fixed braces:

  • Metal braces are made of stainless steel and other metals, usually nickel titanium. They are the most common type of braces and the most economical. The metal brackets are bonded to the front of the teeth and have a wire that runs through them. The wire is held in place by a small rubber band that can be coloured or plain. Metal braces are sturdy and very effective although they are not suitable for people with nickel allergies;
  • Ceramic braces are also called 'clear' braces because they are white and blend into the colour of the teeth. They are less visible than metal brackets although usually more expensive. People who are concerned about their appearance often prefer these braces. Ceramic brackets are more brittle than metal braces, so are not suitable for heavy forces as they may break;
  • Lingual braces are bonded to the inside surfaces of the teeth, so they are not visible from the outside. This approach conceals the braces, but is not suitable for all orthodontic problems. The tongue is in constant contact with the braces and can suffer cuts and ulceration. Speech can also often be affected. Lingual braces are more expensive that regular braces and require an orthodontist specially trained in these appliances, and;
  • Self-ligating braces are a relatively new type of braces that consist of brackets glued to the teeth and a wire that runs through them. However, instead of the wire being held in place by a rubber band or 'ligature', it is contained within the bracket. This makes the brackets appear less bulky. Treatment is also faster and requires fewer appointments. The system is more comfortable than regular braces.

Braces, orthodontic treatment.Metal braces can be used to correct crooked teeth. 

With any type of fixed braces, hard or sticky foods such as toffees, candy or nuts are best avoided as they can damage the braces, bend the wires or dislodge the brackets.

Removable aligners

Removable aligners are a series of clear, plastic trays that are changed every two weeks to slowly move the teeth into a more aligned position. They are worn for 20-22 hours per day and are removed only to eat or drink and brush the teeth. Removable aligners are usually more expensive than regular braces. 

Tooth-coloured attachments are usually needed to help the aligners move specific teeth. These are bonded onto the teeth and remain for the duration of treatment. Visits to the orthodontist are usually required every six weeks, although this varies for each person.

The dentist or orthodontist will decide whether to fit you with fixed or removable appliances based on your needs and ability to comply with treatment. In the case of children, fixed appliances are often best as they cannot be removed and so will not be lost, damaged or forgotten. Treatment will not work if the appliances are left out of the mouth for long periods of time.

Dental retainers

Dental retainers are orthodontic appliances that are used to hold the teeth in their new position after the orthodontic treatment is completed. Once the teeth are in their desired position, it takes time for the bone and soft tissue around the teeth to adapt and re-form, so retainers help to prevent teeth from moving back into their old positions.

Retainers are a very important part of your orthodontic treatment and need to be worn as directed or the teeth may move out of position. Teeth can still move out of position many years after orthodontic treatment is completed, so retainers are kept forever and worn occasionally at night to ensure no tooth movement has occurred. Lost or damaged retainers need to be replaced as soon as possible.

How long will treatment take?

The length of your orthodontic treatment depends on the severity of your case. A person with minor crowding of the front teeth may only need six months of treatment while a person with complex bite problems who requires orthognathic surgery may take two years to complete treatment. Your orthodontist will advise you how long your treatment is expected to take and which treatment is best for you.

Once you have started treatment, avoid delays by following all instructions carefully, taking good care of your teeth and attending all appointments. 

Hygiene during orthodontic treatment

Orthodontic treatments can make it harder to clean the teeth and maintain good oral hygiene. Carefully follow any cleaning instructions you are given to reduce your risk of tooh decay and gum disease.

Tooth brushing

If you have braces, it is best to brush your teeth three times a day, or after every meal. Food becomes easily trapped around brackets and under wires and must be removed. Special orthodontic brushes are available with longer bristles around the edge and shorter ones in the middle to clean around brackets. Electric toothbrush attachments are also available for braces.

Interdental brushes are also used to clean under the wires and around the brackets where a normal toothbrush cannot reach. These look like a small bottlebrush and can be bent to help reach around back teeth.

Flossing

It is recommended that you floss once a day when wearing braces. Special floss threaders and flossing products are available to feed the floss under the wires and clean between the teeth and around the gum line. Your orthodontist or dentist will show you how to use these products.

Mouthwash

Mouthwash is useful for reducing the number of bacteria in the mouth that can potentially cause tooth decay or gum disease.

Water irrigators

Water irrigators can also be useful in flushing food debris and plaque out from under brackets and wires and keeping the mouth clean.

Regular dental visits

It is important to keep attending your regular dentist for check-ups and cleaning while you are undergoing orthodontic treatment to monitor the health of your teeth and gums and address any problems as early as possible. Check-ups every six months are usually recommended.

Gum disease

A chronic, progressive disease of the gums caused mainly by bacteria and poor oral hygiene. Early stages are generally asymptomatic, with the advanced stages characterised by loss of gum tissue, supporting bone and eventual loss of teeth.

Maxillofacial

An broad term that refers to the maxilla (the bone of the upper jaw) and the face.

Plaque

A thick, sticky, soft mass that adheres to the surface of the teeth and gums and is the primary cause of tooth decay. It is composed of bacteria, food particles and mucin derived from the saliva. It cannot be rinsed off with the flow of water or saliva.

Ulceration

The formation of an ulcer, which is an open sore in the skin or mucous membranes, such as those of the stomach lining, intestine or mouth.

Potential complications

While orthodontic treatment can greatly improve the function, health and appearance of the teeth and jaws, there are some possible side effects and complications. These include:

Pain and discomfort

The process of moving teeth will cause some degree of tenderness or pain. This usually occurs for the first 24 hours after braces are tightened or new aligners are inserted. A soft diet is recommended and pain-relief medications, such as paracetamol and ibuprofen, can be taken to reduce the discomfort.

Regular braces will often rub against the cheeks and lips and cause ulceration when first fitted. You will be given orthodontic wax to put over the brackets where they rub, to ease the pain and allow any ulcers to heal.

Damage to teeth 

When wearing braces, food particles can become trapped around the brackets and wires. If the teeth are not cleaned properly, the tooth enamel can be damaged and eventually decay. The best way to avoid this is with recommended oral hygiene practices and by avoiding food or drinks high in sugar.

Inflammation of the gums 

When wearing fixed braces or orthodontic appliances, some gum inflammation and redness is common. This is usually mild and quickly clears up once treatment is completed. However, in some people the inflammation may persist and lead to gum disease. This requires special treatment by your dentist or gum specialist (periodontist). Adults are more at risk of this than children.

Maintaining good oral hygiene and regularly attending check-ups with your regular dentist will help prevent this complication. If you have suffered from gum disease in the past, you may be at a greater risk of this complication.

Damage to tooth roots 

Rapid movement of teeth can result in a slight shortening of the roots. This does not usually cause any problems, but in a very small percentage of people, some roots may be significantly shortened. This means the teeth are less secure in the bone and may be more likely to be lost or require root-canal treatment. A tooth that has been previously damaged by trauma (such as a blow to the mouth), or extensive dental work, is more likely to suffer problems during orthodontic treatment.

Allergic reactions

In rare cases, some people may develop an allergic reaction to the materials used in orthodontic treatment. This can be caused by the nickel in stainless steel braces, wires or headgear. Allergies to the latex in rubber bands and elastics used with braces can also occur. Allergies to the adhesives used to bond braces to the teeth are possible, but very rare.

Failure of treatment

In some cases, orthodontic treatment may not produce the desired effect. One measure to prevent this is to strictly follow the advice of your dentist or orthodontist, in maintaining good oral hygiene. Also, talk to your dentist or orthodontist about any concerns you may have about orthodontic treatment.

Allergic reaction

A problematic physiological response to an allergen that comes into contact with the body.

Gum disease

A chronic, progressive disease of the gums caused mainly by bacteria and poor oral hygiene. Early stages are generally asymptomatic, with the advanced stages characterised by loss of gum tissue, supporting bone and eventual loss of teeth.

Tooth enamel

The outer layer of the tooth. Typically 1-2mm thick, this is the whitest part of the tooth, forming a protective shell over the underlying dentine.

Ulceration

The formation of an ulcer, which is an open sore in the skin or mucous membranes, such as those of the stomach lining, intestine or mouth.

Latex

A milky fluid from the rubber tree that is used to make natural rubber. Many people are allergic to rubber latex.