Facts About Orthodontics

1. What is orthodontics?
   Orthodontics is the branch of dentistry that specializes in the diagnosis, prevention and treatment of dental and facial irregularities. 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.
2. What is an orthodontist?
   All orthodontists are dentists, but only about 6 percent of dentists are orthodontists. An orthodontist is a specialist in the diagnosis, prevention and treatment of dental and facial irregularities. Orthodontists must first attend college, and then complete a four-year dental graduate program at a university dental school or other institution accredited by the Commission on Dental Accreditation of the American Dental Association (ADA). They must then successfully complete an additional two- to three-year residency program of advanced education in orthodontics. This residency program must also be accredited by the ADA. Through this training, the orthodontist learns the skills required to manage tooth movement (orthodontics) and guide facial development (dentofacial orthopedics).
   
   Only dentists who have successfully completed this advanced specialty education may call themselves orthodontists.
3. What is the American Association of Orthodontists?
   The American Association of Orthodontists is the national organization of dental specialists who limit their practice to orthodontics and dentofacial orthopedics. Founded in 1900, the AAO is the oldest and largest dental specialty organization in the United States and Canada. To date, the AAO has more than 14,600 members, including more than 2,000 international members from outside North America. This membership consists of approximately 94 percent of all orthodontists who currently practice in the United States.
   
   The AAO is dedicated to advancing the art and science of orthodontics and dentofacial orthopedics, improving the health of the public by promoting quality orthodontic care, and supporting the successful practice of orthodontics. All members must meet the specialty educational requirements as defined by the Commission on Dental Education of the American Dental Association.
   
   The American Dental Association has recognized that "specialists are necessary to protect the public, nurture the art and science of dentistry, and improve the quality of care."
4. 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 well, the American Association of Orthodontists recommends that all children have an orthodontic screening no later than age 7. 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 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.
5. What causes orthodontic problems (malocclusions)
   Most malocclusions are inherited, but some are acquired. Inherited problems include crowding of teeth, too much space between teeth, extra or missing teeth, and a wide variety of other irregularities of the jaws, teeth and face.
   
   Acquired malocclusions can be caused by trauma (accidents), thumb, finger or dummy (pacifier) sucking, airway obstruction by tonsils and adenoids, dental disease or premature loss of primary (baby) or permanent teeth. Whether inherited or acquired, many of these problems affect not only alignment of the teeth but also facial development and appearance as well.
6. What are the most commonly treated orthodontic problems?
   Crowding: Teeth may be aligned poorly because the dental arch is small and/or the teeth are large. The bone and gums over the roots of extremely crowded teeth may become thin and recede as a result of severe crowding. Impacted teeth (teeth that should have come in, but have not), poor biting relationships and undesirable appearance may all result from crowding.
   
   Overjet or protruding upper teeth: Upper front teeth that protrude beyond normal contact with the lower front teeth are prone to injury, often indicate a poor bite of the back teeth (molars), and may indicate an unevenness in jaw growth. Commonly, protruded upper teeth are associated with a lower jaw that is short in proportion to the upper jaw. Thumb and finger sucking habits can also cause a protrusion of the upper incisor teeth.
   
   Deep overbite: A deep overbite or deep bite occurs when the lower incisor (front) teeth bite too close or into the gum tissue behind the upper teeth. When the lower front teeth bite into the palate or gum tissue behind the upper front teeth, significant bone damage and discomfort can occur. A deep bite can also contribute to excessive wear of the incisor teeth.
   
   Open bite: An open bite results when the upper and lower incisor teeth do not touch when biting down. This open space between the upper and lower front teeth causes all the chewing pressure to be placed on the back teeth. This excessive biting pressure and rubbing together of the back teeth makes chewing less efficient and may contribute to significant tooth wear.
   
   Spacing: If teeth are missing or small, or the dental arch is very wide, space between the teeth can occur. The most common complaint from those with excessive space is poor appearance.
   
   Crossbite: The most common type of a crossbite is when the upper teeth bite inside the lower teeth (toward the tongue). Crossbites of both back teeth and front teeth are commonly corrected early due to biting and chewing difficulties.
   
   Underbite or lower jaw protrusion: About 3 to 5 percent of the population has a lower jaw that is to some degree longer than the upper jaw. This can cause the lower front teeth to protrude ahead of the upper front teeth creating a crossbite. Careful monitoring of jaw growth and tooth development is indicated for these patients.
7. Why is orthodontic treatment important?
   Crooked and crowded teeth are hard to clean and maintain. This may contribute to conditions that cause not only tooth decay but also eventual gum disease and tooth loss. Other orthodontic problems can contribute to abnormal wear of tooth surfaces, inefficient chewing function, excessive stress on gum tissue and the bone that supports the teeth, or misalignment of the jaw joints, which can result in chronic headaches or pain in the face or neck.
   
   When left untreated, many orthodontic problems become worse. Treatment by a specialist to correct the original problem is often less costly than the additional dental care required to treat more serious problems that can develop in later years.
   
   The value of an attractive smile should not be underestimated. A pleasing appearance is a vital asset to one?s self-confidence. A person's self-esteem often improves as treatment brings teeth, lips and face into proportion. In this way, orthodontic treatment can benefit social and career success, as well as improve one?s general attitude toward life.
8. How do I find someone to treat an orthodontic problem?
   Ask your family dentist for a referral to an orthodontist, or call 1-800-STRAIGHT (787-2444) for the names of orthodontists near you.
9. I recently took my child to an orthodontist for an orthodontic screening. The orthodontist recommended treatment. Should I seek a second opinion?
   Review the recommended treatment with your family dentist. If you would still like to compare your comfort level with another orthodontic office or simply hear another orthodontist's assessment of your child's problem, arrange for a second opinion. You may have already had more than one orthodontist recommended to you by family, friends, your dentist or the AAO?s referral service. Seeking out a member of the AAO assures that your second opinion is from an educationally qualified orthodontic specialist. You should feel confident in the orthodontist and his or her staff, and trust their ability to provide you the care and lifetime orthodontic value you seek.
10. What does orthodontic treatment cost?
    The actual cost of treatment depends on several factors, including the severity of the patient?s problem and the treatment approach selected. You will be able to thoroughly discuss fees and payment options before any treatment begins. Most orthodontists offer convenient payment plans to patients. Generally, treatment fees may be paid over the course of active treatment. Arrangements commonly offered in orthodontic offices may include an initial down payment with monthly installments, credit card payment, finance company agreements, and other innovative ways to make treatment affordable. Insurance plans or other employer-sponsored payment programs, such as direct reimbursement plans, may be helpful.
    
    Dental schools with graduate orthodontic programs usually offer treatment to a limited number of patients at a reduced cost. The Dental School Listing includes telephone numbers and Web site addresses for dental schools with orthodontic graduate programs.
11. How long will orthodontic treatment take?
    In general, active treatment time with orthodontic appliances (braces) ranges from one to three years. Interceptive, or early treatment procedures, may take only a few months. The actual time depends on the growth of the patient?s mouth and face, the cooperation of the patient and the severity of the problem. Mild problems usually require less time, and some individuals respond faster to treatment than others. Use of rubber bands and/or headgear, if prescribed by the orthodontist, contributes to completing treatment as scheduled.
    
    While orthodontic treatment requires a time commitment, patients are rewarded with healthy teeth, proper jaw alignment and a beautiful smile that lasts a lifetime. Teeth and jaws in proper alignment look better, work better, contribute to general physical health and can improve self-confidence.
12. What are orthodontic study records?
    Diagnostic records are made to document the patient?s orthodontic problem and to help determine the best course of treatment. As orthodontic treatment will create many changes, these records are also helpful in determining progress of treatment. Complete diagnostic records typically include a medical/dental history, clinical examination, plaster study models of the teeth, photos of the patient?s face and teeth, a panoramic or other X-rays of all the teeth, a facial profile X-ray, and other appropriate X-rays. This information is used to plan the best course of treatment, help explain the problem, and propose treatment to the patient and/or parents.
    
    The profile X-ray, or cephalometric film, shows the facial form, growth pattern, and inclination of the front teeth (if teeth are tipped or tilted), which are essential in planning comprehensive treatment. Panoramic or other dental X-rays are used to locate impacted teeth, missing teeth, and shortened or damaged tooth roots, to determine the amount of bone supporting teeth, and to evaluate position and development of permanent teeth that have not yet come in, among other things. From the necessary records, a custom treatment plan is created for each patient.
13. How is treatment accomplished?
    Custom-made appliances, or braces, are prescribed and designed by the orthodontist according to the problem being treated. They may be removable or fixed (cemented and/or bonded to the teeth). They may be made of metal, ceramic or plastic. By placing a constant, gentle force in a carefully controlled direction, braces can slowly move teeth through their supporting bone to a new desirable position.
    
    Orthopedic appliances, such as headgear, bionator, Herbst and maxillary expansion appliances, use carefully directed forces to guide the growth and development of jaws in children and/or teenagers. For example, an upper jaw expansion appliance can dramatically widen a narrow upper jaw in a matter of months. Over the course of orthodontic treatment, a headgear or Herbst appliance can dramatically reduce the protrusion of upper incisor teeth (the top four front teeth) or retrusion of the lower jaw (a lower jaw that is too far behind the upper jaw), while making upper and lower jaw lengths more compatible.
14. Are there less noticeable braces?
    Today's braces are generally less noticeable than those of the past when a metal band with a 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, depending on the patient's preference. In some cases, brackets may be bonded behind the teeth (lingual braces). Modern wires are also less noticeable than earlier ones. Some of today's wires are made of "space age" materials that exert a steady, gentle pressure on the teeth, so that the tooth-moving process may be faster and more comfortable for patients. A type of clear orthodontic wire is currently in an experimental stage.
15. How have new "high tech" wires changed orthodontics?
    In recent years, many advances in orthodontic materials have taken place. Braces are smaller and more efficient. The wires now being used are no longer just stainless steel. They are made of alloys of nickel, titanium, copper and cobalt, and some of the wires are heat-activated. (The nickel-titanium alloy was originally engineered by NASA to automatically activate antennae or solar panels of spacecraft orbiting into the sun's rays.) These new kinds of wires cause the teeth to continue to move during certain phases of treatment, which may reduce the number of appointments needed to make adjustments to the wires.
16. How do braces feel?
    Most people have some discomfort after their braces are first put on or when adjusted during treatment. After the braces are on, teeth may become sore and may be tender to biting pressures for three to five days. Patients can usually manage this discomfort well with whatever pain medication they might commonly take for a headache. The orthodontist will advise patients and/or their parents what, if any, pain relievers to take. The lips, cheeks and tongue may also become irritated for one to two weeks as they toughen and become accustomed to the surface of the braces. Overall, orthodontic discomfort is short-lived and easily managed.
17. Do teeth with braces need special care?
    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.
    
    Keeping the teeth and braces clean requires more precision and time, and must be done every day if the teeth and gums are to be healthy during and after orthodontic treatment. Patients who do not keep their teeth clean may require more frequent visits to the dentist for a professional cleaning.
    
    The orthodontist and staff will teach patients how to best care for their teeth, gums and braces during treatment. The orthodontist will tell patients (and/or their parents) how often to brush, how often to floss, and, if necessary, suggest other cleaning aids that might help the patient maintain good dental health.
18. How important is patient cooperation during orthodontic treatment?
    Successful orthodontic treatment is a "two-way street" that requires a consistent, cooperative effort by both the orthodontist and patient. To successfully complete the treatment plan, the patient must carefully clean his or her teeth, wear rubber bands, headgear or other appliances as prescibed by the orthodontist, and keep appointments as scheduled. Damaged appliances can lengthen the treatment time and may undesirably affect the outcome of treatment. The teeth and jaws can only move toward their desired positions if the patient consistently wears the forces to the teeth, such as rubber bands, as prescribed. Patients who do their part consistently make themselves look good and their orthodontist look smart.
    
    To keep teeth and gums healthy, regular visits to the family dentist must continue during orthodontic treatment. Adults who have a history of or concerns about periodontal (gum) disease might also see a periodontist (specialist in treating diseases of the gums and bone) on a regular basis throughout orthodontic treatment.

1. Why should children have a check-up with an orthodontic specialist?
   By age 7, enough permanent teeth have come in and enough jaw growth has occurred that the dentist or orthodontist can identify current problems, anticipate future problems and alleviate parents' concerns if all seems normal. The first permanent molars and incisors have usually come in by age 7, and crossbites, crowding and developing injury-prone dental protrusions can be evaluated. Any ongoing finger sucking or other oral habits can be assessed at this time also.
   
   Some signs or habits that may indicate the need for an early orthodontic examination are:
   • early or late loss of baby teeth,
   • difficulty in chewing or biting,
   • mouth breathing,
   • thumb sucking,
   • finger sucking,
   • crowding, misplaced or blocked out teeth,
   • jaws that shift or make sounds,
   • biting the cheek or roof of the mouth,
   • teeth that meet abnormally or not at all, and
   • jaws and teeth that are out of proportion to the rest of the face.

A check-up with an orthodontic specialist no later than age 7 enables the orthodontist to detect and evaluate problems (if any), advise if treatment will be necessary, and determine the best time for that patient to be treated.

2. What are the benefits of early treatment?
   For those patients who have clear indications for early orthodontic intervention, early treatment presents an opportunity to:
   • guide the growth of the jaw,
   • regulate the width of the upper and lower dental arches (the arch-shaped jaw bone that supports the teeth),
   • guide incoming permanent teeth into desirable positions,
   • lower risk of trauma (accidents) to protruded upper incisors (front teeth),
   • correct harmful oral habits such as thumb- or finger-sucking,
   • reduce or eliminate abnormal swallowing or speech problems,
   • improve personal appearance and self-esteem,
   • potentially simplify and/or shorten treatment time for later corrective orthodontics,
   • reduce likelihood of impacted permanent teeth (teeth that should have come in, but have not), and
   • preserve or gain space for permanent teeth that are coming in.
3. What is a space maintainer?
   Baby molar teeth, also known as primary molar teeth, hold needed space for permanent teeth that will come in later. When a baby molar tooth is lost, an orthodontic device with a fixed wire is usually put between teeth to hold the space for the permanent tooth, which will come in later.
4. Why do baby teeth sometimes need to be pulled?
   Pulling baby teeth may be necessary to allow severely crowded permanent teeth to come in at a normal time in a reasonably normal location. If the teeth are severely crowded, it may be clear that some unerupted permanent teeth (usually the canine teeth) will either remain impacted (teeth that should have come in, but have not), or come in to a highly undesirable position. To allow severely crowded teeth to move on their own into much more desirable positions, sequential removal of baby teeth and permanent teeth (usually first premolars) can dramatically improve a severe crowding problem. This sequential extraction of teeth, called serial extraction, is typically followed by comprehensive orthodontic treatment after tooth eruption has improved as much as it can on its own.
   
   After all the permanent teeth have come in, the pulling of permanent teeth may be necessary to correct crowding or to make space for necessary tooth movement to correct a bite problem. Proper extraction of teeth during orthodontic treatment should leave the patient with both excellent function and a pleasing look.
5. How can a child's growth affect orthodontic treatment?
   Orthodontic treatment and a child's growth can complement each other. A common orthodontic problem to treat is protrusion of the upper front teeth ahead of the lower front teeth. Quite often this problem is due to the lower jaw being shorter than the upper jaw. While the upper and lower jaws are still growing, orthodontic appliances can be used to help the growth of the lower jaw catch up to the growth of the upper jaw. Abnormal swallowing may be eliminated. A severe jaw length discrepancy, which can be treated quite well in a growing child, might very well require corrective surgery if left untreated until a period of slow or no jaw growth. Children who may have problems with the width or length of their jaws should be evaluated for treatment no later than age 10 for girls and age 12 for boys. The AAO recommends that all children have an orthodontic screening no later than age 7 as growth-related problems may be identified at this time.
6. What kinds of orthodontic appliances are typically used to correct jaw-growth problems?
   Correcting jaw-growth problems is done by the process of dentofacial orthopedics. Some of the more common orthopedic appliances used by orthodontists today that help the length of the upper and lower jaws become more compatible include:
   
   Headgear: This appliance applies pressure to the upper teeth and upper jaw to guide the rate and direction of upper jaw growth and upper tooth eruption. The headgear may be removed by the patient and is usually worn 10 to 12 hours per day.
   
   Herbst: The Herbst appliance is usually fixed to the upper and lower molar teeth and may not be removed by the patient. By holding the lower jaw forward and influencing jaw growth and tooth positions, the Herbst appliance can help correct severe protrusion of the upper teeth.
   
   Bionator: This removable appliance holds the lower jaw forward and guides eruption of the teeth into a more desirable bite while helping the upper and lower jaws to grow in proportion with each other. Patient compliance in wearing this appliance is essential for successful improvement.
   
   Palatal Expansion Appliance: A child's upper jaw may also be too narrow for the upper teeth to fit properly with the lower teeth (a crossbite). When this occurs, a palatal expansion appliance can be fixed to the upper back teeth. This appliance can markedly expand the width of the upper jaw.
   
   The decision about when and which of these or other appliances to use for orthopedic correction is based on each individual patient's problem. Usually one of several appliances can be used effectively to treat a given problem. Patient cooperation and the experience of the treating orthodontist are critical elements in success of dentofacial orthopedic treatment.
7. I've just heard about the Herbst appliance. How could it help my son who has an underdeveloped lower jaw?
   For patients who have an underdeveloped lower jaw, it is important to begin orthodontic treatment several years before the lower jaw ceases to grow. One method of correcting an underdeveloped jaw uses an orthodontic appliance that repositions the lower jaw. These appliances influence the jaw muscles to work in a way that may improve forward development of the lower jaw. There are many appliances used by orthodontists today to treat underdeveloped lower jaws - such as the Frankel, headgears, Activator, Twin Block, bionator and Herbst appliances. Some are fixed (cemented to the teeth) and some are removable. You and your orthodontist can discuss which appliance is best for your child.
8. Can my child play sports while wearing braces?
   Yes. Wearing a protective mouthguard is advised while playing any contact sports. Your orthodontist can recommend a specific mouthguard.
9. Will my braces interfere with playing musical instruments?
   Playing wind or brass instruments, such as the trumpet, will clearly require some adaptation to braces. With practice and a period of adjustment, braces typically do not interfere with the playing of musical instruments.
10. Why does orthodontic treatment time sometimes last longer than anticipated?
    Estimates of treatment time can only be that - estimates. Patients grow at different rates and will respond in their own ways to orthodontic treatment. The orthodontist has specific treatment goals in mind, and will usually continue treatment until these goals are achieved. Patient cooperation, however, is the single best predictor of staying on time with treatment. Patients who cooperate by wearing rubber bands, headgear or other needed appliances as directed, while taking care not to damage appliances, will most often lead to on-time and excellent treatment results.
11. Why are retainers needed after orthodontic treatment?
    After braces are removed, the teeth can shift out of position if they are not stabilized. Retainers provide that stabilization. They are designed to hold teeth in their corrected, ideal positions until the bones and gums adapt to the treatment changes. Wearing retainers exactly as instructed is the best insurance that the treatment improvements last for a lifetime.
12. Will my child's tooth alignment change later?
    Studies have shown that as people age, their teeth may shift. This variable pattern of gradual shifting, called maturational change, probably slows down after the early 20s, but still continues to a degree throughout life for most people. Even children whose teeth developed into ideal alignment and bite without treatment may develop orthodontic problems as adults. The most common maturational change is crowding of the lower incisor (front) teeth. Wearing retainers as instructed after orthodontic treatment will stabilize the correction. Beyond the period of full-time retainer wear, nighttime retainer wear can prevent maturational shifting of the teeth.
13. What about the wisdom teeth (third molars) - should they be removed?
    In about three out of four cases where teeth have not been removed during orthodontic treatment, there are good reasons to have the wisdom teeth removed, usually when a person reaches his or her mid- to late-teen years. Careful studies have shown, however, that wisdom teeth do not cause or contribute to the progressive crowding of lower incisor teeth that can develop in the late teen years and beyond. Your orthodontist, in consultation with your family dentist, can determine what is right for you.