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What are Braces?Braces have been around for a very long time. In fact, a simple form of orthodontic appliances has been documented as early as 1000 B.C. The design and components have changed and been improved over the years, but the basic idea has remained largely the same. The basic idea behind braces is to produce a force on a tooth in a specific, controlled amount and direction to move a tooth (the biology of just how a tooth moves when a force is applied will be discussed later). BracketA photo of a bracket, or a single brace, that is attached to the front side of a tooth is shown below. The diagram below shows the basic components of a bracket, which are the wings, slot, and base. The slot is where the wire is placed. Wings provide a means to hold a wire into the slot with a small rubber band. The base is used to attach the bracket to the tooth.
BandA band is also a part of the braces, currently used primarily on the back molar teeth. It was commonplace to band all of the teeth even as recent as 20 years ago. With the introduction of newer bonding materials, bands have become less common except for the back molars. Bands are sometimes used for the teeth in front of the molars (premolars), though most orthodontists will bond brackets to these teeth. A picture of a band on a molar is shown below. The bands provide the same type of attachments as a bracket that is glued to the teeth, except the wire slides into a tube. The tube provides added support for tooth movement with the wires, and the band surrounding the tooth provides added structural support and security against breakage.
What are Clear Braces?
In recent years, many orthodontists have seen a dramatic increase in the number of adults interested in orthodontic treatment. Much of this surge is related to an increased awareness and importance placed on cosmetics and dental health. Clear or "invisible" braces have also contributed to this increase in demand. "Metal Mouth" or "Railroad Tracks" were commonly used phrases to describe those who had braces in the past - especially since it was common to place bands or metal rings around all the teeth, including the front teeth. Recent advances in bonding techniques have permitted the use of braces bonded directly to the teeth, resulting in much less of a metallic looking mouth. Ceramic braces have improved within the last 10-15 years, providing a more esthetic alternative to the traditional metal braces. Plastic braces and older ceramic braces were prone to staining and changing colors. They also had a greater tendency towards breakage. Ceramic braces are still more prone to fracture than metal, but this has improved significantly in recent years. The clear braces had an increased risk of damaging enamel upon removal in the past. While this is a risk when removing any bracket (especially from an already weak tooth), manufacturers have changed how the braces are bonded and have provided braces that are easier to remove, which has decreased the risk of enamel damage.
Ceramic braces provide an excellent choice for greater esthetics and are less visible on the teeth. However, the following points should be considered. First, clear braces are more prone to breakage and fracture than metal braces. Therefore, even greater care must be taken to avoid hard/sticky foods and activities that may damage the braces. This problem has been reduced in recent years with the development of better and stronger brackets. Second, ceramic causes more friction with the wire. Some have claimed that this may slow down the treatment time, since friction may slow down the speed of tooth movement. Some clear braces have been manufactured with a metal slot built into the ceramic, purportedly helping to reduce this problem. The actual clinical effect of the friction or of the metal slot may be questionable, and it may not be a significant factor on the time in braces. Last, and perhaps most importantly, ceramic can wear away enamel if teeth are allowed to contact the brackets when biting. Therefore, ceramic braces on lower teeth may not be recommended in some patients. Placing ceramic braces on upper teeth and metal braces on the lower teeth will reduce the possibility of enamel wear, and generally will not adversely affect the esthetic value of the clear braces (most people do not show their lower teeth very much when they smile). The increased demand for a better smile and the recent advances in esthetic braces has attracted more adults and patients to consider orthodontic treatment than ever before. Most seem to be concerned about showing too much metal, which makes the ceramic braces a perfect solution. InvisalignTM, which is discussed in a future chapter, is also an alternative option. However, as will be discussed later in more detail, the limitations of the aligners make the clear braces a better choice for some patients. How do Teeth Move?The way the body produces tooth movement is quite an amazing and complicated process. It involves many different tissues, cells, and cell signaling substances. When a force is applied to the roots of the teeth through the braces and the wire, cells in the bone and tissues surrounding the root are stimulated to act. Cells in the body called Osteoblasts and Osteoclasts add and remove bone, respectively. Pressure at the bracket produces pressure and tension (pulling) at the root of the tooth, causing remodeling of bone and tooth movement. This type of force combination is called a couple, which is defined as two equal and opposite forces acting on a mass. A couple is a necessary way to move teeth since the braces are attached at the crowns of the teeth, and not at their center of resistance. The center of resistance would be the most ideal position from which to apply forces and move teeth. However, the center of resistance is located at the roots and would therefore be an impossible place to attach a bracket and apply a force.
There is a time lag from the moment pressure and forces are applied until actual tooth movement occurs. The delay in tooth movement is mainly due to how the body removes bone adjacent to the tooth. Bone is many times not removed immediately next to the tooth, but rather a distance away from the root. Therefore it may take the cells a period of 1-2 weeks before bone is removed close to the tooth. After the initial phase of nearly no tooth movement, the bone then undergoes significant changes, and the tooth begins to move more rapidly. This will usually occur over the next 2-3 weeks, and is also dependant on the amount of force still active on the tooth. While there are other factors involved in determining the frequency of appointments, the process just described is often the basis for how often appointments are made. Early in treatment, the orthodontist may use a flexible wire that also has a longer activation time. The wire provides a way to keep a gentle force active over a long period of time. Therefore, appointments could be scheduled anywhere from 4-12 weeks apart. Later in treatment, as the wires become less flexible, the time between appointments may be scheduled 4-6 weeks apart for more frequent activation and to keep the forces active. The length of orthodontic treatment is also related to how the teeth move. There are many variables that may contribute to variation in the length of treatment, including growth, cooperation, and differences in the speed of tooth movement. However, since there is a biological limit on the rate of movement, many patients that have similar problems with crowding and a bite that is off will tend to have similar treatment times. What is a Malocclusion?The word occlusion refers to the bite, or how the teeth come together (occlude). Mal refers to bad or incorrect. Therefore, malocclusion is simply defined as a “bad bite.” The bite can be off in a number of ways. To be able to describe the different types of bites, a classification system was developed to help define three main categories of bites, or malocclusion: Class I malocclusion - the upper and lower teeth are in the proper front-back position, but may have other problems (crowding, rotations, misalignment etc.) Class II malocclusion – the upper teeth are too far ahead of the lower teeth (commonly referred to as an “overbite”) Class III malocclusion – the lower teeth are forward of the upper teeth (commonly seen as an “underbite”). The three main classification systems define how a bite may be off in a front to back direction. Althouth the class I malocclusion may have a good front to back bite position, there may be other features that characterize the malocclusion. For example, a class I malocclusion patient may have significant crowding, spacing, midline asymmetry, crossbites, rotated teeth, or other problems. An overbite, or excessively deep overlap of the front teeth, may also be seen on some patients. While an overbite may not always be an esthetic concern to the patient, there is evidence that an excessively deep overbite increases the incidence of wear on the front teeth. Overjet is the distance between the top and bottom front teeth in a front-back direction. “Buck” teeth would be considered excessive overjet. Although there have been studies that do not show a correlation, most studies have shown an increased risk of trauma to the top front teeth in patients that have an excessively large amount of overjet. This is mainly due to an increased prominence of the teeth, making them more prone to injury. An open-bite refers to a malocclusion where the teeth do not touch when fully biting together. This may occur in the front teeth (anterior open bite) or in the back teeth (posterior open bite). Many times an open bite is more likely to be related to a jaw position problem rather than just a tooth position problem. Jaw position and jaw growth problems can contribute to open bite, underbite, severe overjet, and asymmetrical issues. The x-rays and other records taken in the initial stages of treatment will help the orthodontist better discern the cause and best treatment options. Class I Malocclusion
Class II Malocclusion and Excess Overjet
Class III Malocclusion and Front Crossbite (Underbite)
Back Crossbite and Front Deep Overbite
Midline Discrepancy
Crowding/Rotation
Open Bite
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What is orthodontics? Orthodontics is the area of dentistry that specializes in the diagnosis, supervision, guidance and correction of problems involving the alignment of the teeth and jaws. The technical term for these problems is “malocclusion,” which means “bad bite.” The practice of orthodontics requires professional skill in the design, application and control of corrective appliances, such as braces, to bring teeth, lips and jaws into proper alignment and to achieve facial balance.1 What causes orthodontic problems (malocclusions)? Many malocclusions are inherited, which means genetics plays a key role in their appearance. Inherited problems include; crowding of teeth, too much space between teeth, or the improper alignment of the teeth to each other. Another cause of malocclusion is acquired characteristics. This happens by trauma (accidents), thumb; finger or pacifier sucking causes some acquired malocclusions. Whether inherited or acquired, many of these problems affect not only permanent alignment of the teeth but facial development and appearance as well.2 Is orthodontic treatment important? Crooked and crowded teeth are hard to clean and maintain. This may contribute to conditions that cause not only future tooth decay but also eventual periodontal disease and potential tooth loss. Orthodontic problems can also contribute to abnormal wear of tooth surfaces, inefficient chewing or misalignment of the jaw joints, which can result in chronic headaches or facial pain. If left untreated, many orthodontic problems may become worse. Orthodontic treatment to correct the problem, is often less costly than dental care to treat the problems that can develop in later years.3 At what age can people have orthodontic treatment? Children and adults can both benefit from orthodontics, because healthy teeth can be moved at almost any age. Because monitoring growth and development is crucial to managing some orthodontic problems, the American Association of Orthodontics recommends that all children have an orthodontic screening no later than age 7.4 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 orthodontic 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. How is treatment accomplished? How do braces feel? Many people have some discomfort after their braces are first put on their teeth or when adjustments are made during treatment. After braces are placed or adjusted, teeth may become sore and may be tender to biting pressures for two to three days. The orthodontist may recommend pain medication commonly used for a headache. The lips, cheeks and tongue may also become irritated for two to three days as they become accustomed to the surface of the braces, and can be alleviated or controlled by wax that your orthodontist will provide and proper rinsing. Overall, orthodontic discomfort is Are there alternatives to metal braces? Today’s braces are generally less noticeable than those of the past when a metal band with bracket (the part of the braces that hold the wire) was placed around each tooth. Now the front teeth typically have only the bracket bonded directly to the tooth, minimizing the “tin grin”. Brackets can be metal, clear or colored ceramic, depending on the patient’s preference. In some case, brackets may be bonded behind the teeth (lingual or tongue side braces). Modern wires are made of “space age” materials that exert a steady, gentle pressure on the teeth, so that the Do teeth with braces need special care? The orthodontist and staff will teach patients how to best care for their teeth, gums and braces during treatment. The orthodontist will instruct patients (and/or their parents) how to brush, floss, and, if necessary, suggest other cleaning aids that might help the patient maintain good dental health. Keeping the teeth and the braces clean requires more precision and time than normal cleaning, and must be done two to three times every day if the teeth and gums are to be remain healthy during orthodontic treatment. Patients with braces must be careful to avoid hard and sticky foods. They must not chew on pens, pencils or fingernails because chewing on hard things can damage the braces. Damaged braces will almost always cause treatment to take longer, and will require extra trips to the orthodontist’s office. If the patient plays contact sports the orthodontist may recommend a special mouth guard to protect the braces and the patient’s lips, tongue and teeth. Braces usually do not interfere with the playing of musical instruments, but practice and a period of adjustment may be necessary.
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