Frequently asked questions
About orthodontic treatment

Orthodontic treatment does involve a certain amount of discomfort, with almost all patients experiencing some pain. However, pain is not normally something that should put people off having braces.

The actual fitting of fixed braces is usually relatively painless, although you may feel some pressure when fitting some parts. When you go home though, you may find that some pain or soreness starts and the teeth are usually tender for up to 7 days following fitting of braces. This tends to be worst in the first 3 days and the teeth may feel sore when you bite on them and when you are eating/chewing. The braces may also rub on the gums and cheeks especially over the first couple of weeks; this may feel better if you put some soft wax over certain parts of the braces and your orthodontists will show you how to use this.

Painkillers, are useful if you do get pain; people often use ibuprofen or paracetamol (Monk et al., 2017). Both children and adults get pain during treatment and there is some evidence to suggest that adults may experience more prolonged pain than children (Johal et al., 2014) (But maybe kids are just braver than grown-ups?!).

Once the initial pain settles down, it is normal for the teeth to feel a bit sore for 2 or 3 days after the braces are adjusted each time but most people feel that the benefits of treatment are worth that short term discomfort.

In summary, almost everyone experiences some pain with orthodontics, with teeth being tender and braces prone to rubbing the cheeks at the start of treatment.

Headgear is a type of orthodontic brace which fits outside the mouth. There is a “headcap” that is fitted to the back of the patient’s head and this is attached to a wire framework (using some elastic bands) that then goes into the mouth.

When it is it used?
This is used mostly to help with moving the top teeth backwards so that the orthodontist can correct crowded teeth or sticking out teeth and help with making sure that the side teeth meet together. Young people having orthodontic treatment wear this for about a year of their treatment, but they sometimes have to wear it for longer.

Patients are asked to wear their headgear for between 10 and 14 hours a day depending on what tooth movements are needed. This usually means wearing the headgear when a patient comes home from school and then through the night when they are sleeping. Orthodontists and dentists do not expect this to be worn during the day. Your orthodontist/dentist will explain to you how many hours wear is needed, if they decide to use headgear in your treatment.

What are the risks of having headgear treatment?
There have been reports of headgear coming loose at night and the metal parts of the device causing damage to the eyes. This is obviously a severe problem occurs very rarely and headgear is very carefully designed to reduce these risks.

Mini-screws or Temporary Anchorage Devices are a relatively new development in orthodontics. They are small screws that the orthodontist or dentist screws into the bone around the teeth. They are used to help with treatment and are used as “anchors” to move other teeth against – this reduces the chance of tooth movement that is not wanted. They are sometimes used instead of headgear braces. Springs and elastics are attached to the TAD to move the teeth.

How are they put in?
This is simple. Your orthodontist or dentist freezes up your gum with a small injection. This is much quicker than injections used for fillings or having teeth taken out. They then use a special screwdriver to put the screw into the bone near your teeth. Other young people who have had this done say they can feel a bit of pushing but it does not hurt.

How are they taken out?
This is also easy. The orthodontist or dentist, just unscrews them. You do not need to have an injection in your gum when they are taken out.

Do they work?
Yes, they work for most people. There have been several research studies that show that they are a very useful tool for the orthodontist to straighten teeth (Jambi et al., 2014). The studies also show that there are no real risks of having this treatment and patients prefer it to having other types of treatment like headgear. Occasionally they do come loose and have to be replaced or your orthodontist/dentist needs to find an alternative way of moving your teeth.

Over the past ten years there have been many developments in the design of braces. Scientists and dentists have succeeded in making the metal brackets smaller and more accurate so that the orthodontist has good control of the movement of teeth.

However, there have been some developments in the design of braces which people have said makes treatment faster, more comfortable and avoids the need to take teeth out. These braces are called self-ligating braces.

Do they work?
The research into self-ligating braces has shown that treatment is not shorter or less painful than when an orthodontist uses a standard brace (Chen et al., 2010). There is also no proof that the braces change the shape of the jaws to such an extent that removing teeth are not needed to make space for crooked teeth.

If your orthodontist suggests that you think about these braces, or they talk about them being better than other braces or you have seen advertisements on websites, then you may want to ask about the scientific evidence that they are any better than other braces.

This is a type of orthodontic treatment where the orthodontist or dentist attempts to correct an orthodontic problem by moving the teeth along with a series of muscle exercises to change the way that the muscles in the face work. The theory behind this is that the muscles cause the orthodontic problem and they need to correct the muscles as part of their treatment.

When is this carried out?
This treatment starts when children are quite young (about 7-8 years old) and can last a number of years. So, it needs a lot of commitment, as for any form of orthodontics. In the UK this type of treatment is not provided on the National Health Service and can be rather expensive, it would have to be done privately.

This form of treatment is considered by many orthodontists not to be usual and is regarded as unconventional.

Does this work?
We do not really know if this type of treatment works There is no scientific proof that this type of treatment works and there is a need for research still to be done in this area. . We feel that there needs to be a lot of research done in this area before this treatment is widely accepted. We suggest that if you are offered this type of treatment, you should discuss the benefits and risks with the orthodontist or dentist and ask them if this treatment really works. You can also ask for a second opinion from another orthodontist.

AcceleDent is a new development in orthodontic treatment. It is a hands free device that applies a vibration to your teeth while you are wearing braces. The manufacturers suggest that this speeds up orthodontic treatment and also reduces the amount of discomfort that patients may feel.

Your orthodontist can sell you the AcceleDent device..

Does it work?
The company have carried out several small studies that show that this device may work. There have also been two larger studies. One of these studies showed that the appliance did have a small effect but the study was sponsored by the company which makes the brace.

The other study was carried out by an independent team and was published in a high quality dental research journal. This showed that the AcceleDent device did not speed up the initial stages of orthodontic treatment or reduce the amount of discomfort that the patients experienced.

Should I use AcceleDent?
This is a decision which you need to make after asking your orthodontist/dentist about the scientific evidence. At the moment scientific research has shown us that we do not know if it works.

There is no one ideal time to start brace treatment, and there are some factors which might affect this. Treatment for certain types of problems and bites can be started earlier than others, and some patients reach growth maturity at an earlier stage than others which can affect these decisions.

Early treatment is sometimes called ‘interceptive’ treatment; this is usually carried out to correct specific problems and is often followed by a longer course of treatment at an older age to deal with any other problems with the alignment or the bite .

For some problems, the timing of treatment is not critical (for example, correcting crooked teeth can often be done at any age), but for other problems it is essential. These include:

Reversed bite:

A reversed bite where the lower teeth bite in front of the upper teeth may be treated at a younger age than usual – for example; it may be possible to treat as early as eight years of age. If your child has a bite like that, it is sensible to ask your dentist to refer you for an opinion regarding what age they would start treatment.

If the front teeth bite edge-to-edge before sliding into a complete reversed bite, then this may lead to wear on the teeth and gum problems, and it may be sensible to start treatment relatively early. If a slide is not present the treatment may best be started in adolescence or even in late teenage years as growth of the lower jaw can cause the bite to become worse.

Prominent/Sticking out upper front teeth

Treatment to correct sticking out teeth is often recommended between the ages of 10-13 years in girls and 11-14 years in boys. This is because the procedure is thought to work most effectively when a child is around their peak growth spurt. Treatment may be started earlier in certain cases especially if the appearance of the teeth is linked to bullying; however, treatment may then take longer, and there is no evidence it is more effective than later treatment (O’ Brien et al., 2003).

Crowding:

Crooked teeth are generally not corrected until the early teens when the permanent teeth are all present – this is normally after 12 years of age.

A reversed (or Class III) bite is where the lower teeth bite in front of the upper teeth and this can be challenging to correct.

If there is a significant Class III bite in a child or adolescent it is likely that there may be a difference in the rate of growth between upper and lower jaws, with the lower jaw growing slightly faster than the upper jaw. While your orthodontist may try to correct your bite when you are growing, this may be very difficult as the lower jaw continues to grow forward until the late teens in females and even longer in males.

If the lower jaw grows significantly, it may not be possible to correct the bite with braces by themselves and it may only be possible to correct the bite with braces combined with jaw surgery. It is important to say that nobody HAS to have this type of treatment – there are rarely any long term problems due to leaving a reverse bite but some patients may have problems biting or chewing because of the way their teeth bite or people may feel very self-conscious due to how the teeth/face look.

If you orthodontist thinks there is a possibility that orthodontics and jaw surgery could be required then they may not want to do any treatment until that decision has been made. This is because the type of tooth movement needed to prior to jaw surgery is opposite to that needed to improve the bite without surgery. It is often, therefore, better to wait so that your orthodontist has a better idea of exactly what type of correction is required.

A crossbite means that that lower teeth bite on the outside of your upper teeth. This can affect the front teeth (in which case it is called an anterior crossbite) or the side teeth (in which case it is called a posterior crossbite).

Occasionally, crossbites can cause some harm to the teeth. For example, if the lower teeth slide off the upper teeth before meeting fully. This sliding movement (or displacement) can sometimes cause wear on the teeth or it may cause damage to the gums (gum recession). This happens more often with crossbites of the front teeth than the back teeth. Some dentists also think that untreated slides are not particularly healthy for the jaw joints in the long-term, although the evidence regarding that is weak. However, it is important to say that many people with perfectly normal bites do not have healthy jaw joints and most people with poor bites still have healthy jaw joints.

Often crossbites are not associated with slides/displacements and can be left without treatment, without risking wear of the teeth, gum problems or jaw joint problems (Luther et al., 2010).

Most people do not have a perfect bite. A malocclusion (or incorrect bite) is very common, and most people still function very well despite this. Indeed, patients who are missing some teeth do not necessarily have any problems with chewing or speech (Witter et al., 2001). It is also known that many people with perfectly normal bites do not have healthy jaw joints and most people with poor bites still have healthy jaw joints (Luther et al., 2010).

However, some bites can potentially cause problems and may lead to possible wear of the teeth, gum problems or jaw joint problems. Those bites which may be a particular risk of creating these problems are those where there is a significant slide (or displacement) on biting together.

Orthodontists aim to get the bite as good as they possibly can so that the teeth meet together in the best possible way; a normal (or Class I) bite may also lead to slightly more stable long term treatment results. It is known, however, that the teeth do tend to settle and “mesh together” somewhat better once the braces have been removed, particularly over the first 6-12 months.

You must never feel that you “have to have orthodontic treatment” – this is a treatment decision for you to make with the orthodontist/ dentist who is treating you and it is essential that you ask what the benefits and risks of having treatment are.

Often the bite feels a little bit strange with the braces on. The teeth are probably changing position quite a bit and are being held in a slightly false position. It is also challenging to control the way that the teeth meet when a brace is fitted to just one arch of teeth (upper or lower).

Your orthodontist/ dentist will try to achieve the best bite that they can and may make small adjustments to your brace or ask you to wear elastics between your upper and lower braces to make the bite as good as possible

However, the teeth do also “settle in” and often “mesh together” better one the braces have been removed. As a result, your orthodontist may decide that it is sensible to remove your braces to allow the bite to settle further once the braces are taken off. If you have any doubts, explain why you are worried and ask the orthodontist/ dentist to justify their decision to you.

Marks can develop on teeth for many reasons and may be white, or sometimes even brown, in colour. It is possible that these marks were present before your treatment and that you are only now noticing these as your teeth are straight, and your braces are off.

However, white marks can develop during brace treatment. This is due to a process known as demineralisation or decalcification and happens where the tooth brushing and the diet are not as good as they should have been during brace treatment. These white marks often become less noticeable over time, and some disappear entirely. Proper toothbrushing is helpful, as is the regular use of fluoride toothpaste, mouth rinses and other gels (Benson et al., 2013). Your dentist may recommend additional products to use to improve the appearance of these marks, and some of them (for example, Tooth Mousse) have been shown to have beneficial effects. Your dentist may also be able to carry out some treatment to make these spots look better if they do not improve after using these products.

Teeth can become wobbly during brace treatment for many reasons, and it is particularly common to feel this just after your braces are fitted or after they have been adjusted – they have to become a little bit loose to move to the new, improved position. This settles typically down in time.

If you notice that your teeth are getting loose, you should mention this to your orthodontist/ dentist though. Root shortening (or root resorption) is a risk of brace treatment; however, this does not usually happen until some months into treatment, and the shortening has to be quite severe to cause problems – and reassuringly severe root shortening is not common.

In summary, it is likely that the wobbly teeth are nothing to worry about, but it is nevertheless a good idea to mention this to your orthodontist so that they can keep this under review for you.

Either fixed or removable retainers can be used after brace treatment, and your orthodontist/dentist will discuss with you which they think would be best in your situation. There is very little evidence to show that one type of retainer is better than another, although there is limited research in this area. We do know that, if some kind of retainer is not used, your teeth are likely to move after treatment, so retainers are a vital part of orthodontic treatment.

Fixed retainers do have advantages; you will not need to wear your removable retainers as much as those patients wearing only removable retainers, and this can be an advantage for some people. We also know that some problems (such as spaces between the teeth at the start of treatment) are particularly likely to relapse and your orthodontist might recommend a fixed wire in cases such as this.

However, you will be aware of your fixed retainers at first as you can feel them on the back of your teeth and they do require additional effort to keep them clean. Your orthodontist will consider how good your tooth brushing is before deciding on the best type of retainer for you.

Fixed retainers can also break or fall off and need to be maintained both by you and your orthodontist/ dentist in the long term. This will have cost implications associated with it.

If you have doubts about having a fixed retainer, it would be wise to discuss this with your orthodontist/dentist. You should also be aware that if you decide not to have a wire, you will need to wear your removable retainers several nights a week for as long as you want to keep your teeth perfectly straight.

There has been a lot of interest in methods to speed up orthodontic treatment over the last decade or so. Everybody would like treatment to go faster – patients and orthodontists/ dentists!

Studies have looked into these methods in detail, and there is little evidence to suggest that non-surgical approaches (e.g. AcceleDent) are useful in speeding up your treatment (Woodhouse et al., 2015).

Surgical procedures also appear to have minimal benefit in most cases; there are also risks associated with any surgical treatment, including the chance that the treatment may need to be undertaken on more than one occasion and may be quite invasive to have a significant impact (Uribe et al., 2017).

Therefore, if either surgical or non-surgical methods are suggested to speed up your treatment, it would be worth discussing this in detail with your orthodontist and discussing the evidence for the technique being proposed.

Crowding does not tend to improve as we get older. Having gaps between the baby teeth is normal. As the adult teeth come through, crowding of the front teeth is common. Occasionally, this may improve very slightly as the last few baby teeth are lost.

However, once the adult teeth come through, crowding does not usually get better. This may seem surprising as children and teenagers are growing at that time. However, the width of the jaws does not increase much after the age of 12 years, and this is why crowding does not usually get better.

Indeed, as we get older (particularly in our 20s and later), crowding of the lower front teeth tends to get worse. This seems to be part of the “ageing process” in the same way that our eyesight may become poorer, and our hair turns grey. This is one reason why most orthodontists now recommended some form of orthodontic retainer for many, many years after braces are removed. If we want to have straight teeth for life, we also need to wear retainers for life.

A gap (increased overjet) can develop between the upper and lower teeth for many reasons. Usually, jaw position and lip position are the leading causes; finger or thumb sucking can cause a gap to form or may make the gap bigger.

A protrusion (sticking out) of the upper teeth does not usually get better during adolescence, even though the lower jaw grows slightly faster than the upper jaw at this time. The way that the teeth meet does not change very much despite these differences in jaw growth. Sometimes the protrusion of the teeth may get slightly worse, especially if the lower lip rests behind the upper teeth when somebody is talking, smiling etc.

A reverse bite (reverse overjet), where the lower teeth bite in front of the upper teeth, can develop for some reasons but jaw position is the most likely cause of this problem, where the lower jaw is larger than the upper jaw.

Sometimes a reverse bite in the primary (baby) dentition will correct itself as the adult teeth come through. However, if the reverse bite remains once the adult teeth have erupted, this does not usually get better.

Reverse bites tend to get worse during childhood/ adolescence/ late teenage years, mainly if the reverse bite is caused by a mismatch in jaw position. This is because the upper jaw stops growing quite a long time before the lower jaw growth stops. This is one reason why orthodontists sometimes decide to not to start any treatment and to monitor reverse bites during the teenage years.

An open bite is where there is a vertical gap between the front teeth and they do not overlap. In many patients, an open bite will not cause problems, but it may make it more difficult to bite into certain foods. Each patient is different, and your orthodontist will make a judgement as to whether it might be best to accept the bite as it is, or whether it should be corrected with braces alone or with a combination of braces and jaw surgery.

1. Do nothing

Sometimes your dentist will tell you that the risks of treatment outweigh the benefits and suggest that you accept the open bite. This is particularly the case where the open bite is relatively small or the potential for the open bite opening again after treatment is unusually high.

2. Treatment with orthodontic braces only

If an open bite is going to be corrected just using braces, then this may also involve, for example, wearing elastic bends between the teeth to allow the teeth to come together and meet. It may also require something called mini-screws, mini-implants or temporary anchorage devices – these are all very similar, but you may see different terms used.

One way of improving open bites is by moving the upper molar teeth (back teeth) upwards. Mini-implants (small screws inserted into the bone usually for a few months during treatment) may help to do this. These are generally quite simple to place, and this is just done in the dental chair, usually with a small injection to make you feel a bit more comfortable. There is relatively little pain. However, they may come loose, and there is a low risk that they can touch the roots of nearby teeth risking damage to them.

3. Treatment with braces and jaw surgery

The other option is using orthognathic surgery – which is a combination of fixed brace treatment and then jaw surgery. This treatment is for more severe anterior open bites and moves both the teeth and the jaws into a better position. While this type of treatment is now undertaken more commonly, there are risks associated with both the braces (see the risk and benefits of braces section) and also with the surgery. The surgery is done under general anaesthetic (that means you will be asleep) and you will usually need to stay in the hospital for 1 or 2 nights. There is also pain, swelling, a risk of bleeding, need for stitches and possible damage to nerves to the lips and tongue. The jaws also have to be fixed in the new position with metal plates and screws – these are buried under the gum and are intended to stay there permanently, but sometimes they do get infected and need to be taken out. Most orthodontists will aim to correct anterior open bites without the need for surgery where possible. More information on jaw surgery can be accessed via the following link: https://www.bos.org.uk/Public-Patients/Your-Jaw-Surgery1

One of the main problems when treating open bites is that teeth may move following orthodontic treatment due to either natural changes as people grow or relapse after treatment (See retaining braces). Open bites are known to be challenging to treat mainly in the long term and the open bite may re-open after treatment. It is essential, therefore, that retainers are worn well following treatment to have the best chance of a good outcome.

In summary, open bites are difficult to correct fully, especially when the jaw position is a significant cause of the open bite. There are some options, but solutions which don’t involve surgery are preferred wherever possible. Retainers should be worn correctly to produce the best long-term outcomes.