Straight teeth help an individual to effectively bite, chew and speak. Straight teeth contribute to healthy teeth and gums. Properly aligned teeth and jaws may alleviate or prevent physical health problems. Teeth that work better also tend to look better. An attractive smile is a pleasant “side effect” of orthodontic treatment. It contributes to self-esteem, self-confidence and self-image—important qualities at every age. You may be surprised to learn that straight teeth are less prone to decay, gum disease and injury. Straight teeth collect less plaque, a colorless, sticky film composed of bacteria, food and saliva. Decay results when the bacteria in plaque feed on carbohydrates (sugar and starch) we eat or drink to produce acids that can cause cavities. Plaque can also increase the risk for periodontal (gum) disease.

When teeth are properly aligned, and less plaque collects, these risks decline. And when teeth are properly aligned it is easier to keep teeth clean. As for injuries to teeth, protruding upper teeth are more likely to be broken in an accident. When repositioned and aligned with other teeth, these teeth are most probably going to be at a decreased risk for fracture. Untreated orthodontic problems may become worse. They may lead to tooth decay, gum disease, destruction of the bone that holds teeth in place, and chewing and digestive difficulties. Orthodontic problems can cause 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, sometimes leading to chronic headaches or pain in the face or neck. Treatment to correct a problem early may be less costly than the restorative dental care required to treat more serious problems that can develop in later years.

Some children as early as 5 or 6 years of age may benefit from an orthodontic evaluation. Although treatment is unusual at this early age, some preventive treatment may be indicated. The advantage for patients of early detection of orthodontic problems is that some problems may be easier to correct if they are found and 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. For these reasons, the American Association of Orthodontists recommends that all children get an orthodontic evaluation no later than age 7.

Some common orthodontic problems seen in children can be traced to genetics, that is they may be inherited from their parents. Children may experience dental crowding, too much space between teeth, protruding teeth, and extra or missing teeth and sometimes jaw growth problems. Other malocclusions (literally, “bad bite”) are acquired. In other words, they develop over time. They can be caused by thumb or finger-sucking, mouth breathing, dental disease, abnormal swallowing, poor dental hygiene, the early or late loss of baby teeth, accidents or poor nutrition. Trauma and other medical conditions such as birth defects may contribute to orthodontic problems as well. Sometimes an inherited malocclusion is complicated by an acquired problem. Whatever the cause, most conditions are usually treated successfully.

Early treatment may prevent more serious problems from developing and may make treatment at a later age shorter and less complicated. For those patients who have clear indications for early orthodontic intervention, early treatment presents the opportunity to:

• Influence jaw growth in a positive manner
• Harmonize width of the dental arches
• Improve eruption patterns
• Lower risk of trauma to protruded upper incisors
• Correct harmful oral habits
• Improve esthetics and self-esteem
• Simplify and/or shorten treatment time for later corrective orthodontics
• Reduce likelihood of impacted permanent teeth
• Improve some speech problems
• Preserve or gain space for erupting permanent teeth

An early orthodontic evaluation can ease a parent's concerns about crooked teeth or facial development and about orthodontic treatment. Some conditions are best treated early for biological, social or practical reasons, whereas others should be deferred. Final treatment decisions should be made among the parent and the child’s orthodontic provider.

• 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
• Jaws and teeth that are out of proportion to the rest of the face

If any of these problems are noted by parents, regardless of age, it is advisable to obtain a consult.  It is not necessary to wait until age 7 for an orthodontic check-up.

This is a time to listen to patient concerns and to provide an orthodontic examination. It will be determined whether or not treatment is needed and if needed, when the best time would be to start treatment. Typical steps prior to beginning treatment include gathering orthodontic records to provide specific information to tailor a treatment plan for that patient (see orthodontic records below).

Often, this is a time when the doctor and staff discuss fees for orthodontic care, general payment options, and insurance benefits.

Diagnostic records include x-rays, photographs, and impressions made of the teeth. These “molds” are used to develop models for closer examination of the teeth and how the upper and lower teeth relate to each other. X-rays are taken to look at the root structure of the teeth and how the jaw bones and teeth relate to each other. At times additional imaging of the temporomandibular joints is helpful. Typically facial photographs and intra-oral photographs are taken to evaluate facial proportions, facial aesthetics and the health of the teeth and gums. These diagnostic records collectively enable the doctor to develop an appropriate treatment plan for the patient.

Preventive orthodontic treatment is intended to keep a malocclusion (“bad bite” or crooked teeth) from developing in an otherwise normal mouth. The goal is to provide adequate space for permanent teeth to come in. Treatment may require a space maintainer to hold space for a primary (baby) tooth lost too early, or removal of primary teeth that do not come out on their own so to create room for permanent teeth.

Interceptive orthodontic treatment is performed for problems that, if left untreated, could lead to the development of more serious dental problems over time. The goal is to reduce the severity of a developing problem and eliminate the cause. The length of later comprehensive orthodontic treatment may be reduced. Examples of this kind of orthodontic treatment may include correction of thumb- and finger-sucking habits; guiding permanent teeth into desired positions through tooth removal or tooth size adjustment; or gaining or holding space for permanent teeth. Interceptive orthodontic treatment can take place when patients have primary teeth or mixed dentition (baby and permanent teeth). A patient may require more than one phase of interceptive orthodontic treatment.

Comprehensive orthodontic treatment is undertaken for problems that involve alignment of the teeth, how the jaws function and how the top and bottom teeth fit together. The goal of comprehensive orthodontic treatment is to correct the identified problem and restore the occlusion (the bite) to its optimum. Treatment can begin while patients have primary teeth, when they have a mix of primary and permanent teeth, or when all permanent teeth are in. Treatment may consist of one or more phases, depending on the nature of the problem being corrected and the goals for treatment.

Orthodontic care may be coordinated with other types of dental treatment that may include oral surgery (tooth extractions or jaw surgery), periodontal (gum) care and restorative (fillings, crowns, bridges, tooth size enhancement, implants) dental care. When finished with comprehensive treatment, the patient must wear retainers to keep teeth in their new positions.

What is two-phase treatment? Two-phase treatment simply means that the treatment is carried out in two stages. The first is the interceptive orthodontic phase (see above) and the second is the comprehensive orthodontic phase (see above).

Removing 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 that some unerupted permanent teeth (usually the canine teeth) will either remain impacted (teeth that should come in, but do 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 eruption of permanent teeth has brought about as much improvement as it can on its own.

After all the permanent teeth have come in, the extraction of selected 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.

Orthodontic treatment and your child’s growth can complement each other. A common orthodontic problem to treat is protrusion of the upper front teeth. Quite often this problem is due in part to the lower jaw being shorter than the upper jaw. Upper teeth may also be the primary cause of the protrusion if they stick out too far.  While the upper and lower jaws are growing, orthodontic appliances can be beneficial in reducing these discrepancies.  A severe jaw growth discrepancy may require orthodontics and corrective surgery after jaw growth has been completed, although this is rare.

The American Association of Orthodontists recommends that all children have an orthodontic evaluation no later than age 7 so that growth-related problems may be identified and so that treatment can be commenced at the appropriate time for each patient.

What kinds of orthodontic appliances are typically used to reduce the severity of jaw-growth problems?

A process of dentofacial orthopedics (guiding the growth of the face and jaws) with orthodontic appliances may be used to correct jaw-growth problems. The decision about when and which appliances to use for this type of correction is based on each individual patient's problem. Some of the more common orthopedic appliances include:

• Headgear (see image): This appliance applies pressure to the upper teeth and upper jaw to guide the direction of upper jaw growth and tooth eruption. The headgear may be removed by the patient and is usually worn 10 to 12 hours per day.
• Fixed functional appliance: The appliance is usually fixed (glued) to the upper and lower molar teeth and may not be removed by the patient. By holding the lower jaw forward, it reduces the protrusion of the teeth while the patient is growing and helps bring the teeth together.  The appliance can help correct severe protrusion of the upper teeth.
• Removable functional appliance: 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 to each other. Patient compliance in wearing this appliance is essential for successful improvement; the appliance cannot work unless the patient wears it.
• Palatal Expansion Appliance: A child’s upper jaw may 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.  For some patients, a wider jaw may prevent the need for extraction of permanent teeth.

Although every case is different, generally speaking, patients wear braces from one to three years. Treatment times vary with factors that include the severity of the problem, patient growth, gum and bone response to tooth moving forces and how well the patient follows the instructions on dental hygiene, diet and appliance wear (patient cooperation). Patients who brush and floss thoroughly and regularly; avoid hard, sticky, crunchy and sticky foods; wear their rubber bands and/or headgear as instructed; and keep their appointments usually finish treatment on time with good results. After the braces are removed, most patients wear a retainer for some time to keep or “retain” the teeth in their new positions.

After braces are removed, the teeth can shift out of position if they are not stabilized. Retainers 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 longer. It is normal for teeth to change with increasing age.

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 a lifetime 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 and can prevent most of this change.

Good “patient cooperation” means that the patient not only follows the instructions on wearing appliances as prescribed and tending to oral hygiene and diet, but is also an active partner in orthodontic treatment.

Successful orthodontic treatment is a “two-way street” that requires a consistent, cooperative effort by both the doctor 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 prescribed, avoid foods that might damage braces 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.

To keep teeth and gums healthy, regular visits for check-ups and cleanings must continue during orthodontic treatment.

Extra time is needed with tooth brushing to make sure that all areas around the braces have been cleaned properly. Specialized brush tips are available to help get in between the braces and under the wires. Floss-threaders are helpful in passing floss under archwires to facilitate flossing of the teeth. Oral irrigators are often helpful to dislodge food debris from around the teeth. Over-the-counter mouth rinses can be used in conjunction with oral irrigators to help reduce the level of bacteria around the teeth. The goal is to remove plaque from around the teeth and gums. It is the bacteria in plaque that is responsible for causing inflamed gum tissue (gingivitis), permanent scarring of enamel (decalcification), as well as tooth decay. Remember, braces don’t cause these problems, they just make cleaning the teeth more difficult. Avoiding hard, sticky, crunchy and chewy foods will also keep your braces intact and help to make your treatment flow smoothly.

Teeth can develop white spots, called “decalcification,” when an individual’s teeth are susceptible or when oral hygiene has been poor. If plaque is not regularly removed, the patient can develop gum disease.

This is why the dentist and dental hygienist stress dental hygiene—for the good of the patient’s dental health. (See photos of decalcification and gum disease below)

Note the white decalcification spots on these teeth


Note the reddened areas of gum where the gum meets the teeth. This is gingivitis.

Follow the instructions you are given with regards to oral hygiene (keeping your teeth and gums clean) and wearing your appliances (e.g.: elastics, headgear, etc.) Your cooperation may help speed up your treatment. Keeping braces from breaking or wires from getting bent will speed treatment. Avoiding hard, sticky, and chewy foods, including ice, will go a long way in preventing broken braces. Pen and pencil chewing should also be avoided.

Many common orthodontic “emergencies” can be handled easily at home.  To help you accurately describe an emergency situation, use the diagram at the end of this section, which illustrates and names each part of a typical set of braces.  A list of supplies to keep on hand is also posted at the bottom of this section.

• A Bracket is Knocked Off: Brackets (see diagram below) are the parts of braces attached to teeth with a special adhesive.  They are generally positioned in the center of each tooth.  If the bracket is off center and moves along the wire, the adhesive has likely failed.  Call the office to determine the course of action. If the loose bracket has rotated on the wire and is sticking out, attempt to turn it back into its normal position and schedule an appointment to have it reattached.  You may wish to put orthodontic wax around the area to minimize the movement of the loose brace.  If you are in pain, please call the office and inform us of the circumstance.  If you are not in pain, this is not a true emergency.  Please call the office at your earliest convenience to schedule an appointment to reattach the brace to the tooth. Remember, brackets can become loose as a result of chewing on hard, sticky or chewy foods or objects as well as from physical contact from sports or rough housing. Be sure to wear a protective mouth guard while playing sports!
• The Archwire is Poking: If the end of an orthodontic archwire (see diagram) is poking in the back of the mouth, attempt to put wax over the area to protect the cheek.  Call to schedule an appointment and have the archwire clipped.  In a situation where the wire is extremely bothersome and the patient will not be able to seen immediately, as a last resort, the wire may be clipped with an instrument such as fingernail clippers. Reduce the possibility of swallowing the snipped piece of wire by using folded tissue or gauze around the area to catch the piece you will remove.  Use a pair of sharp clippers and snip off the protruding wire.  Relief wax may still be necessary to provide comfort to the irritated area.
• “Ligature Wire” is Poking Lip or Cheek: Use a Q-tip or pencil eraser to push the wire (see diagram) so that it is flat against the tooth.  If the wire cannot be moved into a comfortable position, cover it with relief wax.  (See “Irritation of Cheeks or Lips” below for instructions on applying relief wax.)  Notify the office.
• Loose Brackets, Wires or Bands: If the braces have come loose in any way, call the office to determine appropriate next steps.  Save any pieces of your braces that break off and bring them with you to your repair appointment.
• Irritation of Lips or Cheeks: Sometimes new braces can be irritating to the mouth.  A small amount of orthodontic wax makes an excellent buffer between the braces and lips, cheek or tongue.  Simply pinch off a small piece and roll it into a ball the size of a small pea.  Flatten the ball and place it completely over the area of the braces causing irritation. If possible, dry off the area first as the wax will stick better.  The patient may then eat more comfortably.  If the wax is accidentally swallowed it’s not a problem.  The wax is harmless.
• Mouth Sores: People who have mouth sores during orthodontic treatment may gain relief by applying a small amount of topical anesthetic (such as Orabase or Ora-Gel) directly to the sore area using a cotton swab.  Reapply as needed.
• Discomfort: It’s normal to have discomfort for three to five days after braces or retainers are adjusted.  Although temporary, it can make eating uncomfortable.  Encourage soft foods.  Have the patient rinse the mouth with warm salt water.  Over-the-counter pain relievers, acetaminophen or ibuprofen, may be effective.
• Lost Ligature (Rubber or Wire): Tiny rubber bands known as elastic ligatures (see diagram), are often used to hold the archwire into the bracket or brace.  If an elastic ligature is lost, contact the office, who will advise you whether the patient should be seen. The same holds true for wire ligatures.
• What if the Lip Gets Caught on a Brace? Call the office immediately. Apply ice to the affected area until you have the opportunity to been seen.
• I Can’t Open My Mouth: Potential causes – problems with lower jaw joint or swelling around the soft tissues in the mouth. Call the office and inform them of your symptoms.
• Food Caught Between Teeth: This is not an emergency.  It can be resolved with a piece of dental floss.  Try tying a small knot in the middle of the floss to help remove the food.  Or use an interproximal brush to dislodge food caught between teeth and braces.

Diagram of Braces
To help you accurately describe an emergency situation, use the diagram below, which illustrates and names each part of a typical set of braces.

A. Ligature
The archwire is held to each bracket with a ligature, which can be either a tiny elastic or a twisted wire.
B. Archwire
The archwire is tied to all of the brackets and creates force to move teeth into proper alignment.
C. Brackets
Brackets are connected to the bands, or directly bonded on the teeth, and hold the archwire in place.
D. Metal Band
The band is the cemented ring of metal which wraps around the tooth.
E. Elastic Hooks & Rubber Bands
Elastic hooks are used for the attachment of rubber bands, which help move teeth toward their final position.

Supplies: With these supplies on hand, you will be prepared to handle the most common problems with braces.

• Non-medicated orthodontic relief wax
• Dental floss
• Sterile tweezers
• Small, sharp clippers suitable for cutting wire (such as a fingernail clipper)
• Q-tips
• Salt
• Interproximal brush
• Non-prescription pain reliever (acetaminophen or ibuprofen or any over-the-counter medication typically used for a headache)
• Oral topical anesthetic (such as Orabase or Ora-Gel)