Dental braces (also known as orthodontic braces, or simply braces) are devices used in orthodontics that align and straighten teeth and help to position them with regard to a person's bite, while also working to improve dental health. They are often used to correct underbites, as well as malocclusions, overbites, cross bites, open bites, deep bites, crooked teeth, and various other flaws of the teeth and jaw. Braces can be either cosmetic or structural. Dental braces or orthodontic braces are often used in conjunction with other orthodontic appliances to help widen the palate or jaws and to otherwise assist in shaping the teeth and jaws.
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According to many scholars and historians, braces date back to ancient times, coming into existence around 2022–2030 BC. Around 400-300 BC, Hippocrates and Aristotle contemplated about ways to straighten teeth and to fix various dental conditions. Archaeologists have come to discover numerous mummified ancient individuals with the appearance of metal bands wrapped around their teeth. It has been perceived that catgut, a type of cord made from the natural fibers of an animal's intestines, did the work that is done by today’s orthodontic wire used to close gaps in the teeth and mouth.[1] The Etruscans, seen as the early Romans, buried their dead with dental appliances in place to maintain space and prevent collapse of the teeth during afterlife, most likely before the start of our era. A Roman tomb was found with a number of teeth bound with gold wire documented as a ligature wire, a small elastic wire that is used to affix the arch wire to the bracket. In the early years of the common era, philosopher and physician Aurelius Cornelius Celsus first recorded the treatment of teeth by finger pressure.[1] Unfortunately, due to lack of evidence, the poor preservation of bodies, and primitive technology, not much research was done on dental braces until around the 17th century, although dentistry as a profession was making great advancements.
Orthodontics truly began developing in the 17th, 18th, and 19th centuries. In 1728, French dentist Pierre Savagn, who took modernized orthodontics, published a book entitled "The Surgeon Dentist" on methods of straightening teeth. Savagn, in his practice, used a device called a "Blandeau", a horseshoe-shaped piece of precious iron that helped expand the arch. In 1754, another French dentist, Louis Bourdet, dentist to the King of France, followed Savagn's book with “The Dentist’s Art", which also dedicated a chapter to tooth alignment and application. He perfected the "Blandeau" and was the first dentist on record to recommend extraction of the premolar teeth to alleviate crowding and to improve jaw growth. Patients were often told to eat grapes, as the acid in the grapes would stop the iron going rusty in the mouth.
Although teeth straightening and pulling was used to improve alignment of remaining teeth and had been practiced since early times, orthodontics, as a science of its own, did not really exist until the mid-19th century. Several important dentists helped to advance dental braces with specific instruments and tools that allowed braces to be improved.
In 1819, Delabarre introduced the wire crib, which marked the birth of contemporary orthodontics, and gum elastics were first employed by Maynard in 1843. Tucker was the first to cut rubber bands from rubber tubing in 1850. Dentist, writer, artist, and sculptor Norman W. Kingsley in 1858 wrote the first article on orthodontics and in 1880, his book, "Treatise on Oral Deformities", was published. A dentist named J. N. Farrar is credited for writing two volumes entitled, "A Treatise on the Irregularities of the Teeth and Their Corrections" and was the first to suggest the use of mild force at timed intervals to move teeth.
In the early 20th century America, Edward Angle devised the first simple classification system for malocclusions, such as Class I, Class II, and so on. His classification system is still used today was a way for dentists to describe how crooked teeth are (what way teeth are pointing) and how teeth fit together. Angle contributed greatly to the design of orthodontic and dental appliances, making many simplifications. He founded the first school and college of orthodontics, organized the American Society of Orthodontia in 1901 which became the American Association of Orthodontists (AAO) in the 1930s, and founded the first orthodontic journal in 1907. Other innovations in orthodontics in the late 19th and early 20th centuries included the first textbook on orthodontics for children, published by J.J. Guilford in 1889, and the use of rubber elastics, pioneered by Calvin S. Case, along with H. A. Baker.
The application of braces moves the teeth as a result of force and pressure on the teeth. There are four basic elements that are needed in order to help move the teeth. In the case of traditional metal or wire braces, one uses brackets, bonding material, arch wire, and ligature elastic, also called an “O-ring”[2] to help align the teeth. The teeth move when the arch wire puts pressure on the brackets and teeth. Sometimes springs or rubber bands are used to put more force in a specific direction. Braces have constant pressure, which over time, move teeth into their proper positions. Occasionally adults may need to wear headgear to keep certain teeth from moving. When braces put pressure on ones teeth, the periodontal membrane stretches on one side and is compressed on the other. This movement needs to be done slowly otherwise the patient risks losing his or her teeth. This is why braces are commonly worn for approximately two and a half years and adjustments are only made every three or four weeks.
This process loosens the tooth and then new bone grows in to support the tooth in its new position which is technically called bone remodeling. Bone remodeling is a biomechanical process responsible for making bones stronger in response to sustained load-bearing activity and weaker in the absence of carrying a load. Bones are made of cells called osteoclasts and osteoblasts. Two different kinds of bone resorption are possible which are called direct resorption, starting from the lining cells of the alveolar bone, and indirect or retrograde resorption, which takes place when the periodontal ligament has become subjected to an excessive amount and duration of compressive stress.[3] Another important factor associated with tooth movement is bone deposition. Bone deposition occurs in the distracted periodontal ligament and without bone deposition, the tooth will loosen and voids will occur distal to the direction of tooth movement.[4] A tooth will usually move about a millimeter per month during orthodontic movement, but there is high individual variability. Orthodontic mechanics can vary in efficiency, which partly explains the wide range of response to orthodontic treatment.
Traditional braces are mostly used in treating children, as well as adults. They consist of a small bracket that is glued to the front of each tooth and the molars are adjusted with a band that encircles the tooth. An advantage is one can eat and drink while wearing the brace but a disadvantage is that one must give up certain foods and eating habits while wearing them, such as, chewing gum and potato chips. Another disadvantage is they have to be periodically tightened by your orthodontist causing increased amounts of discomfort.
Orthodontic services may be provided by any licensed dentist trained in orthodontics. In North America most orthodontic treatment is done by orthodontists, dentists in diagnosis and treatment of malocclusions—malalignments of the teeth, jaws, or both. A dentist must complete 2–3 years of additional post-doctoral training to earn a specialty certificate in orthodontics. There are many general practitioners who also provide orthodontic services.
The first step is to determine whether braces are suitable for the patient. The doctor consults with the patient and inspects the teeth visually. If braces are appropriate, a records appointment is set up where X-rays, molds, and impressions are made. These records are analyzed to determine the problems and proper course of action. The use of digital models is rapidly increasing in the orthodontic industry. Digital treatment starts with the creation of a three-dimensional digital model of the patient's arches. This model is produced by laser-scanning plaster models created using dental impressions. Computer-automated treatment simulation has the ability to automatically separate the gums and teeth from one another and can handle malocclusions well. This software enables clinicians to ensure, in a virtual setting, that the selected treatment will produce the optimal outcome, with minimal user input.[10]
Typical treatment times vary from six months to two and a half years depending on the complexity and types of problems. Orthognathic surgery may be required in extreme cases. About 2 weeks before the braces are applied, orthodontic spacers are required to spread apart back teeth in order confirm enough space for the bands.
Teeth to be braced will have an adhesive applied to help the cement bond to the surface of the tooth. In most cases the teeth will be banded and then brackets will be added. A bracket will be applied with dental cement, and then cured with light until hardened. This process usually takes a few seconds per tooth. If required, orthodontic spacers may be inserted between the molars to make room for molar bands to be placed at a later date. Molar bands are required to ensure brackets will stick. Bands are also utilized when dental fillings or other dental work make securing a bracket to a tooth infeasible.
An archwire will be threaded between the brackets and affixed with elastic or metal ligatures. Elastics are available in a wide variety of colors. Archwires are bent, shaped, and tightened frequently to achieve the desired results. Brackets with hooks can be placed, or hooks can be created and affixed to the archwire to affix the elastic to. The placement and configuration of the elastics will depend on the course of treatment and the individual patient. Elastics are made in different diameters, colors, sizes, and strengths.
Modern orthodontics makes frequent use of nickel-titanium archwires and temperature-sensitive materials. When cold, the archwire is limp and flexible, easily threaded between brackets of any configuration. Once heated to body temperature, the archwire will stiffen and seek to retain its shape, creating constant light force on the teeth.
When applying another type of dental brace, such as Invisalign, the process is quite different but there are similarities like the initial steps of molding the teeth before application. With Invisalign, impressions of the patient's teeth are sent for evaluation. After viewing and determining the best course of action for the patient, their series of trays are created. The patients dentist or orthodontist receives the trays which fit to the patients mouth almost like a protective mouthpiece.
There are some forms of braces in which the brackets are placed in a special form which are customized to the patients mouth. This reduces the application time for the traditional type of braces. The form contains the metal brackets which are placed in the patients mouth like a mouth guard, drastically reducing the application time.
In many cases there is insufficient space in the mouth for all the teeth to fit properly. There are two main procedures to make room in these cases. One is extraction: teeth are removed to create more space. The second is expansion: the palate or arch is made larger by using a palatal expander. Expanders can be used with both children and adults. Since the bones of adults are already fused, expanding the palate is not possible without surgery to unfuse them. An expander can be used on an adult without surgery, but to expand the dental arch, and not the palate.
Each month or two, the braces must be adjusted. This helps shift the teeth into the correct position. When they get adjusted the orthodontist takes off the colored rubber bands keeping the wire in place. The wire is then taken out, and may be replaced or modified. When the wire has been placed back into the mouth, the patient may choose a color for the new rubber bands, which are then fixed to the metal brackets. The adjusting process may cause some discomfort, which is normal.
In order to avoid the teeth moving back to their original position, retainers may be worn once the treatment with braces is complete.
Patients may need post-orthodontic surgery, such as a fiberotomy or alternatively a gum lift, to prepare their teeth for retainer use and improve the gumline contours after the braces come off.
In order to prevent the teeth moving back to their original position, retainers may be worn once the treatment with braces is complete for the patient depending on their specific needs. If the patient does not wear the braces appropriately for the right amount of time, the teeth may move towards their previous position. For regular traditional braces Hawley retainers are used. They are made of metal hooks that surround the teeth and are enclosed by an acrylic plate shaped to fit the patient's palate. For invisalign braces an Essix retainer is used. They are similar to the regular invisalign braces and is a clear plastic tray that is form fitted to the teeth that stays in place. There is also a bonded retainer where a wire is permanently bonded to the lingual side of the teeth, usually the lower teeth only. Doctors will sometimes refuse to remove this retainer, and it may require a special orthodontic appointment to have it removed.
The pre-finisher is molded to the patient's teeth by use of extreme pressure to the appliance by the person's jaw. The product is then worn a certain amount of time with the user applying force to the appliance in their mouth for 10 to 15 seconds at a time. The goal of the process is to increase the exercise time in applying the force to the appliance. If a person's teeth are not ready for a proper retainer the orthodontist may prescribe the use of a preformed finishing appliance such as the pre-finisher. This appliance fixes gaps between the teeth, small spaces between the upper and lower jaw, and other minor smaller problems.
Changes in the shape of the face, jaw and cheekbones may occur as a result of braces. It is important for a patient to discuss the potential changes with an orthodontist, as these changes may not be positive.
Plaque forms easily when food is retained in and around braces. It is important to maintain proper oral hygiene by brushing and flossing thoroughly when wearing braces to prevent tooth decay, decalcification, or unpleasant color changes to the teeth.
There is a small chance of allergic reaction to the elastics or to the metal used in braces. In even rarer cases, latex allergy may result in anaphylaxis. Latex-free elastics and alternative metals can be used instead. It is important for those who believe that they are allergic to their braces to notify the orthodontist immediately.
Mouth sores may be triggered by irritation from components of the braces. Many products can increase comfort, including oral rinses, dental wax or dental silicone, and products to help heal sores.
Braces can also be damaged if proper care is not taken. It is important to wear a mouth guard to prevent breakage and/or mouth injury when playing sports. Certain sticky or hard foods such as taffy, raw carrots, hard pretzels, and toffee should be avoided because they can damage braces. Frequent damage to braces can prolong treatment. Some orthodontists recommend sugar-free chewing gum in the belief that it may expedite treatment and relieve soreness; other orthodontists object to gum chewing because it is sticky and may therefore damage the braces.
In the course of treatment orthodontic brackets may pop off due to the forces involved, or due to cement weakening over time. The orthodontist should be contacted immediately for advice if this occurs. In most cases the bracket is replaced.
When teeth move, the end of the arch wire may become displaced, causing it to poke the back of the patient's cheek. Dental wax can be applied to cushion the protruding wire. The orthodontist must be called immediately to have it clipped, or a painful mouth ulcer may form. If the wire is causing severe pain, it may be necessary to carefully bend the edge of the wire in with a spoon or other piece of equipment (e.g. tweezers, clean eraser side of a pencil) until the wire can be clipped by an orthodontist.
Patients with periodontal disease usually must obtain periodontal treatment before getting braces. A deep cleaning is performed, and further treatment may be required before beginning orthodontic treatment. Bone loss due to periodontal disease may lead to tooth loss during treatment.
In some cases, teeth may be loose for a prolonged period of time. One may be able to wiggle one's teeth for a year or two after treatment or longer.
The dental displacement obtained with the orthodontic appliance determines in most cases some degree of root resorption. Only in a few cases is this side effect large enough to be considered real clinical damage to the tooth. In rare cases, the teeth may fall out or have to be extracted due to root resorption.[11][12]
Pain and discomfort are common after adjustment and may cause difficulty eating for a time, often a couple days. During this period, eating soft foods can help avoid additional pressure on teeth.
Removal of the cemented brackets can also be painful. The cement must be chipped and scraped off which can cause severe pain in patients with sensitive teeth. Often molar bands have been installed for an extended period of time and they may be embedded in the gums at the time of removal.
The metallic look may not be desirable to some people, although transparent varieties are available. According to a survey published in the American Journal of Orthodontics and Dentofacial Orthopedics, dental braces with no visible metal were considered the most attractive. Ceramic braces with thin metal or clear wires were a less desirable option, and braces with metal brackets and metal wires were rated as the least aesthetic combination.[13]
Typical treatment time is from six months to six years, depending on the severity of the case, location, age, etc., although research has shown that the average duration is 1 year and 4 months. Treatment can be accelerated using state-of-the-art technology, novel planning, and positioning techniques.
The typical cost of braces ranges widely in various regions. The cost depends on whether both arches are being treated and the length of treatment. Typical orthodontic treatment comprises metal braces on both arches for 12 to 24 months. The 2007 orthodontic practice study done by the Journal of Clinical Orthodontics showed the United States national average cost of braces for comprehensive orthodontic treatment to be $2,000 for children and $5,354 for adults. Some cases in the United Kingdom cost £3,500, although they can much of the time be provided free on the NHS, providing the patient is under 18.[14]
In some European countries (e.g. Germany, Norway, Finland, Sweden, Slovenia, Slovakia, Croatia or Denmark) orthodontic treatment is available without charge to patients under 18 (or for treatment to start at 16, such as Republic of Ireland and the UK) as benefits for orthodontic treatment are provided under government-run health care systems. However, in the UK, the National Health Service will not pay for braces if the teeth do not a have protrusion of over 5mm; if there is not a protrusion, it is classed as cosmetic. In some countries (e.g. Ireland), adults can also get treatment at a discounted rate, or claim tax relief after paying a full cost with a private practitioner.
Costs also depends on the type of braces and the type of city the patient is in. In India this treatment can cost anywhere between INR 20000 to INR 80000. In Saudi Arabia the price of treatment ranges between 3500SR to 15000SR. In Serbia brace for one part of the jaw (upper or lower) is 700 euros or 800 euros if clear braces are used. In the Philippines, the price of dental braces costs Php25000 to Php70000. In Singapore, the price of dental braces ranges from SGD$2000 to SGD$4000. In Indonesia, the price of dental braces ranges from IDR 5.000.000 to IDR 10.000.000. In South Africa, the cost of treatment ranges from ZAR 13,000.00 to ZAR 25,000.00 for standard metal braces, or ZAR 22,000.00 to ZAR 30,000.00 if clear braces are used, depending on the duration of treatment and severity of the case.
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