When Do I Get My Braces Off?

The absolute, single most most common question I get as an orthodontist is this:  “When do I get my braces off?” 
Although treatment is unique for every patient, there are some basic objectives and steps of orthodontic treatment that are similar for the majority of the patients I see in my office.  If you have braces now and want to know how you are progressing, please read on…
 

In my office there are three distinct phases of treatment through which every patient must pass. Although their order may be switched or there may be some overlap between them, the three steps of orthodontic include resolving the crowding/spacing, aligning the teeth, and correcting the bite.

In the first step, crowding is corrected by either expanding the arches or by removing teeth through extractions. Teeth cannot be aligned if there is simply not enough room for them. The decision to expand or extract is determined by a number of variables including the size of the teeth, the size of jaws, the amount of bone and gum tissue supporting the roots, and the profile and facial esthetics. The first step is to create room so that the teeth can be aligned. If a patient has extra space at the start of treatment, that space must be closed during this step.  If the teeth are crowded, then space must be created for them.

Once there is room, the second step is to align or straighten the teeth. Aligning the arches is accomplished using wires, elastic chains, springs, and other auxiliaries that rotate, tip, torque, tweak and tease the teeth into their desired positions. Another common step in the alignment process is “repositioning” individual brackets. Sometimes brackets cannot be put in the right place on the first day because of the bite, the alignment, or the shape of the teeth. After the teeth have been partially aligned however, the brackets can then be moved to better positions.

The third step of treatment is correcting the bite or making the upper teeth fit the lower ones. This must be accomplished in all three planes or dimensions of space, front to back (overbite or underbite), side to side (crossbites), as well as top to bottom (open bite or deep bite). Making the upper match the lower is accomplished with wires, rubber bands, springs, or in extreme cases surgery. When the bite is right, the backs of the top teeth rest lightly on the fronts of the bottom ones and the teeth should interdigitate nicely, such as how the teeth of a zipper fit together.

 

The “When do I get my braces off?” question usually arises during the third or “bite step” of treatment. By that time the crowded, crooked teeth are gone, the smile looks great, and the patient is generally happy with how things look. I have to admit that the first half of treatment exhibits more dramatic changes and is more exciting than the last half. But I must stress that it is during the final phase however where the overall bite is corrected so that the results will be healthy and stable.  I admit, this can be a hard sell to some people.  But rest assured that these small tweaks and adjustments are very important.  I am a big believer that the best long-term retainer is a good bite.

If you are wondering if you’re getting close to getting your braces off, compare what you see in your mouth with this quick checklist:

        1. Are the teeth straight?
        2. Are the spaces between the teeth closed completely?
        3. Do the upper front teeth overlap the lower front teeth appropriately (not too deep, but no visible   space between them)?
        4. Are the outer cusps of the upper teeth resting on the outside of the corresponding ones in the lower?
         5. Is the overbite or underbite corrected?

If it is obvious that your teeth are still crooked, have spaces between them, or you still have a deep bite or overbite, you probably still have some time remaining. If your treatment time is longer that was originally estimated, check out another article I wrote about that at http://wheelerortho.blogspot.com/ entitled Dr. Wheeler’s Formula for Successful Orthodontic Treatment.  If you have specific questions about your smile or your treatment, ask me to explain what objectives remain in your treatment.  Rest assured that your braces will come off when the best result is achieved and not before. 

--- Doc W

Content used with permission by Dr. Greg Jorgensen

http://www.gregjorgensen.com/blog

Two-Phase Orthodontic Treatment: Everything You Need to Know

Two-phase orthodontic treatment (also known as early, preventative, or interceptive orthodontics) seems to be more popular today than ever before. It is not uncommon to see braces on elementary school children.  Why is this so?  

The American Association of Orthodontists, The American Dental Association, and the American Academy of Pediatric Dentstry all recommend that all children be seen by an orthodontist by age 7 so that the growth and development of their teeth and smile can be evaluated. By age 7 most children have grown in all four of their 6-year-molars as well as all four of their permanent upper and lower incisors. With these teeth in place, your doctor can identify most of the orthodontic problems your child may have, and can predict how growth will impact your child’s overall dental development, and can counsel you on whether early treatment would be beneficial.

What kinds of dental problems should be addressed early when your child still has lots of baby teeth?

The first type of problem has to do with the amount of space available. Crowded and crooked teeth overlap each other and they cannot be lined up straight. Teeth with too much space or with excessive flaring may actually prevent other permanent teeth from coming into the mouth. Crowding in the front of the mouth is obvious. Crowding in the back of the mouth is not so obvious, and may only be visible with the aid of an x-ray radiograph. Moderate crowding and spacing problems should be addressed at an early age so that the remaining permanent teeth can come in correctly.  If treatment is delayed, some of the teeth may become impacted (do not erupt) or can damage the root of adjacent teeth.  I am a believer that if you make room for the permanent teeth to erupt, you give those teeth the best chance to erupt where they belong.  This I feel leads to long-term stability.

The second type of problem has to do with upper and lower jaw coordination and harmony.  Normally, the teeth of the upper are positioned on the outside of the lower teeth, when lined up correctly. When the top back teeth sit inside of the lower ones (crossed-over), we call that a posterior crossbite. When the upper front teeth are behind the lower front teeth, we call this an anterior crossbite, negative overjet, or an underbite. Teeth in crossbite may reveal an underlying jaw problem that is best addressed at a young age.

The opposite of an underbite is an “overbite” (also called excessive overjet) where the upper teeth stick to far out, often making it difficult to chew or even to close the lips together. Mild overbites are common and not a concern until all the permanent teeth are in. Moderate to severe overjets can cause significant social problems for young patients and make them more susceptible to dental injuries because the teeth stick out. Although overbites cannot be totally eliminated until a child has finished growing, it is advisable to “get a head start” to reduce their severity for safety and self-esteem reasons.

Ideally the top front teeth vertically overlap the bottom front teeth about half way. If they overlap too much, we call this a deep overbite or deep bite. If they don’t overlap at all, we call this an open bite. Both conditions may hint that there may be underlying jaw problems that need attention at a young age. An open bite may also be due to oral habits such as thumb- or finger-sucking that can harm your child’s dental development.  Orthodontists can help young patients break such harmful habits.

Finally, it should be noted that in the past, extractions of bicuspids were often required for an orthodontist to be able to correct the bite.  Simply the patient waited too long to start treatment, and had to accept the pre-existing, and usually constricted skeletal dimensions.    There has been some recent scientific evidence that shows that expansion of the upper jaw actually opens up the nasal passages to aid in clearer breathing.  A more open airway can vastly reduce snoring or heavy night-time breathing, and can reduce incidences of ear and sinus infections.  Scientific evidence also shows that a constricted upper jaw can have a significant restraining-effect on the way the lower jaw grows.  In essence, a narrow upper jaw prevents the lower jaw from growing forward normally, resulting in a deficient or weak chin.  Think of this analogy:  Have you ever tried on shoes that were too narrow?  The narrowness of the shoe prevents the foot from sliding forward to be fully sitting inside the shoe.  

 

What is involved with the first phase of treatment?

Many first phase treatments use some type of growth modification device like a palatal expander, habit appliance (to stop thumb or finger sucking), or a functional appliance (to reduce an overbite). First phase treatments allow your orthodontist to take advantage of your child’s inherent growth potential, to harness it into a way to resolve dental issues before they truly become a problem.  Following the first phase of treatment, retainers are used to maintain the results achieved, and to help guide the eruption of the remaining permanent teeth.

Will early treatment guarantee that a child will not need treatment later?

The answer is almost always no. Early treatment is commonly called two-phase treatment because more than 90 percent of children who undergo treatment at age seven or eight must finish when the remaining permanent teeth are in place. The typical Phase 1 patient finishes the first phase of treatment with 12 primary teeth still remaining. The second phase cannot begin until all of those remaining primary teeth are gone and the permanent ones have come in fully (around age 11-13). If a child has problems so severe at age 7 that they need interceptive care, the chances are pretty good that he or she will need to have the second phase of treatment to finish their smile.

The best way to look at two-phase treatment is this. Instead of waiting until your child is a 13 years old and then putting him or her through two to three years of difficult treatment, your orthodontist is recommending an easier approach. Why not let him help your child over some of the biggest hurdles now, so that when all the adult teeth are in (junior high and high school) treatment will be easier, better, and faster? That is the goal of early treatment.

Between the two phases of treatment, patients are seen at regular intervals so that the orthodontist can check the condition of the retainers, the loss of the baby teeth, and the arrival of the remaining permanent ones. Periodic x-rays help your doctor make sure that everything is developing as desired. It is also an opportunity for the orthodontist to repair the retainers and refer you back to your general dentist if primary teeth are not being lost on schedule.

The second phase of treatment begins ideally after the last primary tooth is lost, about the same time the 12-year-molars make their appearance. Treatment may begin earlier if the patient is having social problems due to their smile, the orthodontic problems are severe, or there are teeth that cannot take their place without help. Treatment will take too long if started too soon, and it will not be finished before the end of high school if started too late.  It is all about timing!

So doesn’t two-phase treatment cost more?

The answer is yes, for most offices.  Putting braces on twice, making two sets of retainers, as well as the extra observation visits all cost money.  However, at Wheeler Orthodontics, I consider two-phases of treatment as being two parts of one treatment—just divided over two different time periods.  Our fees for the 2 phases of treatment, when added together, will cost the same as doing one long phase later.  We do not want to make doing a two-phase treatment approach to be a financial disadvantage to our patients and parents.  We want our patients to benefit from the upside of two-phases of treatment, when indicated for the reasons aforementioned.

The key factor is we want to take advantage of growth (which we can orthodontically direct in our favor).  Waiting too long for all permanent teeth to erupt may disqualify us from being able to orthopedically expand the dental arches. Early treatment allows the orthodontist to achieve results he cannot get in a single treatment later. Many girls, who tend to mature faster than boys, finish growing before their second molars are in place. Teeth that erupt into the wrong place, through the wrong tissue, may never look as good even if their position is corrected later on.  Furthermore, overall long-term stability of teeth that erupt out of alignment is less than if the teeth are allowed to erupt through good tissue in the arch.   Extractions and surgery that might have been avoided with early intervention may become necessary—which in itself is an added expense that can be quite pricey. Most important however is the improvement in self-esteem that occurs when a child is given a pretty smile to go with them through the socially awkward junior high years. How much is your child’s self-esteem worth to you?

--- Doc W

Content used with permission by Dr. Greg Jorgensen

http://www.gregjorgensen.com/blog

Dr. Wheeler’s Formula for Successful Orthodontic Treatment

Getting your braces on is exciting, but getting them off is the best day ever!!! So you may be asking yourself, “How can I help my orthodontist help me get to that ‘best day ever,’ with the best result possible in the most efficient way available”? 

  

The answer is simple... 

Consistency and compliance.      

Let me elaborate…

You (the patient) are a significant variable that affects your treatment time. Your orthodontist may have the perfect diagnosis and treatment plan designed and prepared for you, but he cannot succeed without your cooperation. Some things you might be doing can sabotage your own treatment time.  These include 1) Missing, changing, or spreading out your appointments, 2) Arriving late to appointments so the chair-side technicians do not have sufficient time to perform all planned procedures, 3) Not getting other necessary procedures done in a timely manner (surgeries, extractions, restorative work, etc.), 4) Breaking or bending your wires or brackets between visits, or 5) Not following instructions regarding rubber band wearing, aligners, and oral hygiene. Consistently doing your part will not only help keep your treatment on schedule, it will give you the best final results too.

At the start of treatment, we gave you an estimated time of how long your braces would be on. This estimated time considers and assumes that you as a patient are being 100% consistent and compliant with what we have recommended for you to do. 

The intervals for adjustment visits we set up range from 3 to 8 weeks—although typically it’s every 6 weeks.  This interval is determined by the goals we have for that particular interval, and considers the bio-mechanical properties of the particular wires and ties we have selected for use.  We set up the following visit to coincide when the previous adjustment’s activation is about to “run out of gas”.  It has been proven scientifically that teeth move most efficiently under light, steady, and continuous forces.  If that application of a continuous force is ever interrupted, it takes a bit of time to get back into the “sweet spot” of efficient tooth movement.  We just don’t want an activation to ever “run out of gas”.  In fact, even just rescheduling an appointment just 1 week longer than ideal can easily add 3-4 weeks to your treatment time.  If you have been given rubber bands to wear—wearing them only 80% of the time causes the job to be done in twice the time, and wearing them only 50% of the time causes them to take 8 times as long for the treatment to be done.

Let me give you analogy.  Have you ever had to push a stalled car?  You might have noticed that it takes a little bit of strength and effort to get the car to start rolling; however, once it is rolling it is so much easier to push.  This is true with tooth movement as well.  All of what I am talking about occurs on the biological/physiological level within the supportive tissue around the roots of the teeth.  Once orthodontic treatment starts, special cells are recruited by the body to migrate around the root of the teeth and respond only to the stimuli of pressure…some remove old bone (osteoclasts), some make new bone (osteoblasts). When forces are added to the teeth in a consistent manner, this process works smoothly.  However, if these forces are interrupted by missing appointments, poor compliance with rubber band wear, or having broken appliances that need to be constantly repaired, then these cells get confused by the mixed signals they receive.  This, at a minimum causes a stop in the tooth movement (which takes a while to “get back up to speed”), but worse tends to cause the patient to experience an elevated level of tooth discomfort.  In rare cases, these cells get so confused they can actually start resorbing other hard tissue like tooth root structure, instead of remodeling bone.

Another important factor is to be consistent and compliant with your oral hygiene.  Keeping your teeth and gums free of bacteria-laden plaque keeps the supportive gum tissue strong and healthy.  If plaque is allowed to accumulate, then the gum tissues can get rather inflamed as they try to fight off the infection of the bacterial plaque.  Teeth simply do not move in areas of active inflammation.  To combat this you must be vigilant and consistent with your hygiene including, brushing and flossing twice or more times daily, and in seeing your family dentist regularly for thorough check-ups and cleanings (at least every 6 months or sooner, if advised to do so by your family dentist).  It’s a war against plaque!!

If you are in treatment now and are concerned by your prolonged treatment time, consider these three factors: Are you really doing your part and is there any room for improvement? Have you discussed your treatment progress with your orthodontist to see if anything has changed from his perspective? If you’re confident that both of you are doing your best, it may be that your body’s response to treatment is just slow.  Sometimes, it’s the individual’s biology that limits tooth movement to a slow pace. 

Also consider this as well…Not all orthodontists are the same.  Some are really focused and invested personally on making sure your treatment is complete.  Isn’t it comforting to know your orthodontist Dr. Wheeler has the integrity to finish the job he started, as opposed to one cutting corners just to say he finished “on time”?  Any treatment less that completed is unsuccessful treatment in my mind.

So to help your orthodontist help you get the most out of your treatment …be consistent and compliant with…

      1)     Making all your scheduled appointments

      2)     Making it to your appointments on time

      3)     Following all of our instructions regarding rubber band wear, aligner or appliance wear, and in following through with referrals for any adjunctive procedures (extractions, surgeries, etc)

      4)     Keeping your teeth clean through good oral hygiene practices

      5)     Making your treatment a team approach—having both the parent and patient—be active participants in the treatment.  Ask questions, be engaged in your investment of orthodontic care--come into the office, sit chairside for your child’s visit and not just sit in the car.

--- DocW

Content used with permission by Dr. Greg Jorgensen

http://www.gregjorgensen.com/blog