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Misaligned teeth, crowded teeth, and rotated teeth make good oral hygiene difficult. They put you at risk for tooth decay and periodontal disease, increase your chances of a chipped tooth, cracked tooth, and TMJ dysfunction. Poorly aligned teeth can also affect your smile and self-confidence. Orthodontia is often the best solution to prevent or alleviate these conditions.

Orthodontia is a dental specialty that diagnoses, prevents, and corrects misaligned teeth, jaws, and bite patterns. It involves placing gentle, controlled forces on the teeth over time to move them into proper alignment using braces and other appliances. Orthodontia can address either functional or cosmetic needs.

Some general dentists can perform orthodontic procedures. Usually, they will refer you to an orthodontist.

The primary need for orthodontic treatment is hereditary. You are born with jaws that are not properly aligned, or teeth come in at odd angles, are crowded, or spaced too far apart. However, there are other issues and habits that can result in the need for orthodontia, such as congenitally missing teeth, thumbsucking, facial trauma, or simply changes in bite or teeth alignment over time.

The complexity of orthodontic cases can vary significantly depending on many factors. In some cases, complex orthodontic issues may require additional treatment such as an occlusal adjustment or even surgery to achieve the desired result. In these cases, treatment planning and communication should be coordinated by the entire dental team: the general dentist, orthodontist, and oral surgeon.

When is orthodontia recommended?

Dentists usually recommend that children start treatment to improve their jaw and teeth alignment while still young, and their bones and muscles are more flexible. Adults typically consider orthodontia if they have not had orthodontic treatment in the past if there has been a change in their bite over time, or to make cosmetic improvements.

There are several situations where orthodontic treatment is suggested. These conditions are typically first seen in children. Generally, these conditions will not correct themselves on their own and tend to get worse over time without treatment.¹

• Underbite: The lower front teeth close together in front of the upper teeth. This can occur for dental or skeletal reasons.
• Crossbite: Normally, the upper teeth are positioned to overlap the lower teeth on the cheek side when biting. Crossbite occurs when the teeth overlap the opposite way, with the lower teeth overlapping the upper teeth. It can be caused by misalignment of teeth (including baby teeth) or a misalignment of the jawbones. It can affect a single tooth or specific groups of teeth. In some cases, all of the teeth are affected, most commonly when there is a discrepancy in the size of the jawbones.
• Open bite: When the back teeth are together and the upper and lower front teeth do not overlap. Open bite also refers to a condition where the front teeth meet, but the back teeth do not.
• Deep bite: When the bite is closed, and the upper front teeth cover the bottom teeth too much.
• Crowding: This can result from unusually large teeth, the presence of extra teeth, inadequate space in the jaw, or all of these. Crowding results in teeth that overlap, move into the wrong location, become rotated, or have a crooked appearance.
• Spacing: The condition of having too much space between teeth. Spacing can result from missing teeth, undersized teeth, oversized jaws, or a combination of any of these.
• Protrusion: Front teeth that stick out. Protrusion may occur because the upper jaw is too far forward, the lower jaw is too far back, the teeth grew in at an angle, or a combination of these conditions. People who have protrusive front teeth may also have a deep bite. Protruding front teeth are at higher risk for injury, which is why this condition should be evaluated as early as possible.

Advantages of orthodontic treatment include:

• Establishing a proper bite relationship between the upper and lower teeth and jawbones.
• Evenly distributing bite forces to minimize tooth wear, chipped teeth, and cracked teeth.
• Improved accessibility to properly clean teeth and gums, so they are less prone to tooth decay and periodontal disease.
• Providing proper support for your jaw joints and a proper balance of muscle forces when chewing.
• Producing appealing smiles without the need to alter natural tooth structure.
• Raising self-confidence and self-esteem by bringing teeth, lips, and face into proper proportion.
• Correcting speech issues due to misaligned teeth.

Types of braces

There are several types of braces. Not all of them may be effective choices to achieve your desired goal. Your orthodontist can suggest the best option for you or your child. Keep in mind that an orthodontist may not use each of these methods. It may be worth getting additional opinions before committing to a treatment strategy.

• Metal braces: Often called "traditional" braces, metal braces have two primary components — metal brackets applied to the teeth and metal wires threaded through the brackets that apply pressure to move the teeth. These are most commonly used with children. They are the least expensive fixed appliance option and are often the most efficient at moving teeth into their proper locations.
• Ceramic braces: Ceramic braces are similar to metal braces, except the brackets are made of ceramic material with a similar color and texture to natural teeth. The wires also match your tooth color. This makes them less noticeable than metal braces. Ceramic braces are typically more expensive, can stain, and are more likely to break. If a ceramic brace breaks, it may cause damage to tooth enamel.
• Lingual braces: Lingual braces are similar to metal braces, except they adhere to the lingual (inner) side of teeth. They are just as effective as traditional or ceramic braces but are less intrusive and visible. Lingual braces are typically more expensive than traditional braces, are more difficult to clean, and may cause speech difficulties. They are usually not a good option for severe orthodontic conditions.
• Self-ligating braces: Self-ligating braces also make use of a bracket and wire system. Unlike traditional elastic bands used with metal and ceramic braces to exert forces on the teeth, self-ligating braces use brackets with clips to hold the wire. These braces tend to capture fewer food particles and be less painful than other types of braces.
• Clear plastic aligners: An alternative to fixed braces are a progression of clear plastic trays (aligners) that are worn over your teeth. These aligners apply forces that cause your teeth to move. Tooth-colored attachments are often placed on specific teeth to give the aligners a better grip. Aligners are worn in a series until the teeth have moved to the point the aligner fits comfortably and then progress to the next aligner. The process is repeated until the teeth are in the desired location.

Types of orthodontic appliances

There are a wide variety of other orthodontic appliances that may be used before, during, or after braces have been placed. Some of the most common include:

• Elastics ("rubber bands"): Elastics help correct the bite relationship between the upper and lower teeth when worn as instructed. You generally attach them to the braces by yourself and cross from one arch to the other. Elastics can be used for other reasons depending on how the teeth need to move.
• Headgear: Headgear is used to treat an overbite or an underbite. Headgear gently applies a force that restricts the upper teeth and jaw from growing forward. This allows the lower jaw to move to a more ideal position. "Reverse pull headgear" corrects underbites by applying pressure in the opposite direction.
• Palatal expander: Palatal expanders widen the horizontal space between the left and right back teeth of the upper jaw. This is achieved by putting outward pressure on the upper molars and adjusting the expanders over time. Expanders are typically used before the two halves of the upper jaw fuse together so the pressure can separate the two halves of the jaw. The orthodontist will provide instructions on when and how to adjust the expander. When the desired expansion is achieved, the appliance is worn for several months to prevent the palate from moving back to its original position.
• Positioners: Positioners are usually the final appliances needed to move teeth. They are worn over the teeth and are removable. When used correctly, positioners are typically only worn for four to eight weeks.
• Retainers: Once braces are removed, retainers are used to hold teeth in their correct positions. Retainers may be removable or fixed. The orthodontist will provide instructions on how to care for the retainer and how long to wear it. Wearing retainers as directed is critical to keep teeth from moving back into their prior positions.
• Separators or spacers: Separators look like small rubber doughnuts. They are placed between teeth to push them apart and allow orthodontic bands to be placed more easily.
• Twin block appliance: A twin block appliance is unique from other functional appliances. It uses two appliances (one for the upper arch and one for the lower arch) that work together to move the lower jaw forward and stabilize the jaw joint. The appliances are worn full time, even while eating. They are removable to make it easier to clean the teeth and the appliance.

Today's orthodontia isn't the same experience as it was in the past. Orthodontia is more comfortable, less noticeable, and less time-consuming than it was years ago. Braces are smaller today, and new technologies have created wires and appliances that move teeth more efficiently with less pain. Today's braces also enable you to choose the color of rubber bands around each bracket so they can look stylish.

When to see an orthodontist

A general dentist is usually the first person to recognize issues that may require orthodontic treatment. With periodic exams and X-ray images, your dentist can identify issues such as crowding, misalignment, or congenitally missing teeth. Identifying these issues early on and working together with an orthodontist, your dentist can develop a plan to prepare you or your child for braces.

The American Association of Orthodontists (AAO) recommends that children get an evaluation at the first sign an orthodontic issue may exist, but no later than age seven. By this age, children usually have enough permanent teeth to allow an orthodontist to determine if a problem exists or is likely to develop. An orthodontic evaluation provides a baseline for the orthodontist to recommend the appropriate treatment at the proper time.²

Most of the time, orthodontic treatment begins when children have both primary and permanent teeth. This is typically around puberty. In some cases, earlier treatment is recommended to prepare for future treatment that may be more difficult once a child's face and jaws have finished growing. Other times, treatment may continue for many years after growth and development is complete.

Treatment strategies

There are a wide variety of strategies to address orthodontic needs and goals. An orthodontist's experience with different approaches will factor into the recommended treatment strategy.³

Once a course of treatment has been developed, always follow that treatment plan until it is complete. Some factors that may differ between orthodontists include:

• When treatment should start.
• Whether the goal is functional or cosmetic.
• If tooth removal or other treatment prior to orthodontics is required.
• How to address issues with jaw realignment.

Orthodontic treatment is often completed in one continuous phase that can last for up to five years or more, depending on the severity of the condition. The treatment may require tooth removal. It may also consist of appliances to prepare the teeth and jaw for braces to bring the teeth into proper alignment. Once teeth are in the correct position, retainers are used to keep the teeth from moving back to their original positions.

Orthodontic treatment may also be completed in two phases. Orthodontists may recommend this when a developmental condition is readily apparent at a younger age. Two-phase orthodontia may also be recommended in cases of severe trauma. The first phase typically focuses on moving the jaws and some teeth into a proper position and uses retainers to hold them from moving until all of the permanent teeth have erupted. Phase two may not start until a few years later. Braces placed in phase two remain until the treatment objectives are achieved.

There is no general consensus among orthodontists whether one-phase or two-phase orthodontic treatment is more effective. The decision is based to a significant extent on individual needs. Be sure to discuss all options with a general dentist and orthodontist before deciding on a course of treatment.⁴

Before treatment begins

The first visit to an orthodontist is often a screening and consultation appointment to assess whether treatment is necessary.

The orthodontist will evaluate:

• Health history and current health status.
• Congenital or acquired conditions that may indicate abnormalities in the face or skull.
• The bite relationships between the teeth.
• Any issues related to the alignment of the jaws.
• The number of decayed, missing, or restored teeth.
• The health of the gums and teeth.
• Oral hygiene habits.

The orthodontist will take various X-ray images, along with a digital bite analysis or tooth impression casts that are used to construct needed appliances. Based on this diagnostic information, the orthodontist will recommend a treatment strategy and discuss what to expect.

How long will orthodontic treatment last

Moving teeth is best accomplished by applying light forces over as much time as is required to move them into the proper position. It can take a few months to move a few teeth or years to move them all (particularly if the jawbones have to be re-positioned). The time it takes is also affected by how well you comply with the orthodontist's instructions. To make treatment as quick and successful as possible:

• Maintain good oral hygiene.
• Wear appliances and elastics as instructed.
• Keep scheduled appointments.
• Continue to see a general dentist for routine exams and cleanings every six months, or more often if recommended.
• Avoid hard, sticky, and crunchy foods.
• Avoid sugary, acidic soft drinks, fruit juices and drinks, and sports drinks.

In general, a full course of orthodontic treatment includes:

• Preparation (pre-banding): May include an occlusal adjustment, tooth removal, palate expansion, and jaw realignment.
• Active treatment: The placement of braces, elastics, and other appliances.
• Post-treatment: Retainers to hold the teeth in place after braces are removed.

During treatment

Once the teeth and jaws are ready for braces, fixed-wire orthodontic patients are "banded." At the banding appointment, an orthodontist places the brackets and wires to begin to move the teeth.

Follow-up appointments with the orthodontist normally occur about every six to ten weeks. This enables the orthodontist to evaluate how well the teeth are moving. The time between appointments may be less for some people. Adjustments to braces or appliances are made as necessary. The orthodontist also monitors oral hygiene to ensure that teeth and gums remain healthy. It's important to maintain excellent oral hygiene at home and to continue to see a general dentist as often as recommended. It is commonly recommended that patients (particularly adolescents) in fixed-wire braces have at least one additional professional cleaning each year.

After treatment (orthodontic retention)

Moving teeth through the jaws during active treatment loosens the ligament attachments between the teeth and the jawbone. When the jaws and teeth have been moved into the correct position, the braces are removed, and the post-treatment phase begins. Once braces are removed, the teeth need to be held in place long enough for the ligaments to re-attach. This is accomplished with retainers.

If teeth have been rotated, the orthodontist may recommend a fiberotomy. This dental procedure prevents teeth from rotating back to their original position.

Orthodontists commonly retain the lower front teeth with a retaining wire that is bonded onto the teeth. It can only be removed by a dentist. This is a long-term way of holding those teeth in position. Other teeth are usually held in place with a removable retainer.

Oral hygiene during orthodontic treatment

Maintaining good oral hygiene helps to minimize treatment time and contributes to a healthier result. When plaque and trapped food remain on teeth and braces, tooth decay, swollen gums, bad breath, and permanent marks on the teeth can occur. It is generally most effective to brush for two minutes after every meal or snack, before bed, and to floss at least once a day. If brushing after eating or drinking is not possible, rinse teeth and gums with water to help remove food or traces of beverages. Other items to consider are:

• Interproximal brushes to dislodge plaque and food particles trapped between teeth and on brackets and wires.
• Water irrigators can help flush out food particles.
• Electric toothbrushes which are more efficient at cleaning teeth compared to manual toothbrushes.
• Fluoride treatment or fluoride mouth rinse (over-the-counter or prescription-strength) strengthens tooth enamel and helps prevent white marks (decalcification).

• Oral hygiene: Maintaining good oral hygiene while wearing braces can be difficult, but not properly caring for teeth can lead to tooth decay and periodontal disease. Patients with untreated periodontal disease, tooth decay, or poor oral hygiene should not undergo orthodontic treatment until the disease is successfully treated and oral hygiene is shown to be satisfactory.⁵
• Tooth movement: Applying strong forces to teeth or moving them too rapidly may cause tooth root resorption. In rare situations, this can result in damage to a tooth's pulp.
• Additional procedures: Your dentist may need to perform surgical procedures, such as tooth removal or jaw surgery, before, during, or after orthodontic treatment. These procedures have risks of their own, which include infection, bruising, bleeding, swelling, nerve injury, and pain.
• Latex allergies: Some people are allergic to latex gloves and elastic bands often used in treatment. Be sure to discuss this with an orthodontist before starting treatment.
• Speech issues: Braces can cause temporary changes in speech, creating lisps or "whistles." In rare cases, moving teeth can cause changes that require speech therapy once treatment is completed.
• Cost: Orthodontic treatment can be costly. Be sure to ask for a complete list of expenses and payment plan options before starting treatment.
• Discomfort: It is typical to experience temporary discomfort after braces are placed or adjusted. Teeth may be sore for a day or two, especially when biting. The cheeks and tongue may also become tender from rubbing against the braces or appliances. Orthodontists will provide wax to place on the braces or appliances to shield irritated areas. Over-the-counter pain relievers may help relieve short-term discomfort. Only use medication if it is safe to take it.
• Athletics: Ask about special mouthguards to reduce the chance of injury or broken braces or appliances while participating in sports or activities.
• Use your teeth properly: Using your teeth improperly can loosen brackets and wires.
• Adults: Since an adult's jaw and mouth are no longer growing, the treatment may take longer. Also, tooth decay, periodontal disease, some medications, tobacco use, or grinding or clenching may require additional treatments that can extend the course of treatment.

There are no alternatives to orthodontic treatment to straighten natural teeth and restore a properly functioning bite.

• Getting orthodontic treatment when facial bones are still developing is often the best time to begin. This can simplify the treatment plan and provide the best treatment outcome. Delaying treatment until after teeth and bones are fully developed can result in more complicated treatment.
• Not treating crowded dental arches or misaligned teeth can create "food traps" that increase the risk of tooth decay and periodontal disease.
• Poorly aligned teeth can lead to excessive tooth wear on the teeth which bear the most force. This may increase the risk of a cracked tooth or chipped tooth.
• Misaligned teeth may increase the forces on jaw joints, which can increase the risk of jaw pain and TMJ dysfunction.
• Misaligned teeth can lead to grinding or clenching.
• Crooked or poorly aligned teeth can lead to being self-conscious and lead to confidence issues.

Questions for a general dentist

• When should I first have my child examined by an Orthodontist?
• Which orthodontist do you recommend? Why? Should I also get a second opinion?
• Will you and the orthodontist work together through the course of treatment?
• You just took X-rays. Does the orthodontist need to take more, or will you share them?

Questions for an orthodontist

• When is the best time to perform orthodontic treatment for my child?
• What needs to be done to adjust the jaw and/or straighten the teeth?
• Would my or my child's treatment be possible with removable aligners? If so, what are the pros and cons?
• Will any teeth need to be removed? What issues may that cause?
• Are there any specific risks with this course of treatment given my or my child's unique dental or medical history?
• Is a one-phase or two-phase course of treatment more appropriate?
• How long do you estimate each phase of treatment to take? What can be done to make that timeframe shorter?
• Are there other options to consider? What if the goal is only cosmetic?
• What steps should be taken to ensure good oral hygiene while wearing braces?
• What should I do if a bracket or wire comes loose?
• When and for how long should the retainers be worn?
• How much will the course of treatment cost, and what will dental insurance cover?
• Do you have payment plans for my family's share of the cost?
• What is your policy on broken braces or wires? What about lost appliances?