Introduction

Has it ever crossed your mind that something can be done to straighten your crooked teeth, or for your child's "buck" teeth that were often the butt of jokes? The answer lies in the dental specialty of Orthodontics. Simply put, orthodontics is the art and science of aligning teeth.

Many people have sought orthodontic help for a variety of reasons. Some are conscious of their looks and how others view them. As the mouth is often the area of focus in our daily interaction with others, there is no doubt that a well-aligned set of teeth complements a pleasant-looking face. While looks are a priority for some, many live to eat and eat to live. Difficulties with chewing, arising from irregularities of teeth positioning can make eating one's favorite food a chore. Crooked teeth may also give rise to oral hygiene problems. These crooked teeth interfere with proper tooth brushing, and with time, tooth decay and gum problems develop. A social nuisance arising from these problems is bad breadth.

Orthodontic treatment has helped many people, be it improving their personal confidence, enjoying their food or having a healthier set of teeth. Orthodontic treatment is available to help you, your family and friends.

Here are some questions you might ask?

• Is there an age limit for orthodontic treatment?
• What is the right time for orthodontic treatment?
• What are some orthodontic services available for young children and teenagers?
• What are some orthodontic services available for late teenagers and adults?
• What does a combined orthodontic-surgical treatment involve?
• Besides correcting jaw growth problems, how may orthodontic treatment help the adult?
• How many types of fixed braces are available in the market?
• What are some common problems associated with orthodontic treatment?

Is there an age limit for orthodontic treatment?

What is the right time for orthodontic treatment?

The irregularities of teeth position and how the upper and lower sets of teeth relate to each other is called a malocclusion. There is no "right time" for orthodontic treatment. Similarly, age is not a limit for treating malocclusions. It all depends on the type and severity of an individual's malocclusion. Children with a cleft lip and palate anomaly have been treated a few weeks after birth with orthodontic plates, while grandparents in their sixties have undergone limited orthodontic treatment to align their teeth so that dentures or bridges may be fitted.

Malocclusion

Recent trends in orthodontic care show an increased number of young adults in their twenties and thirties seeking orthodontic treatment. This has been due to an increased awareness of what orthodontics can do and to rising affluence. Still, the majority of orthodontics is carried out in the younger age group. Many children are excited at the idea of having braces. With the liberal use of colours on elastic rings for fixed braces or in the design of removable plates, orthodontic treatment becomes the hot topic of conversation for students and parents. It has become an in-thing to wear braces.

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What are some orthodontic services available for young children and teenagers?

Alleviation of crowding

Orthodontic treatment is tailored for each child depending on the type and severity of the malocclusion. If a child develops or has the potential of developing irregularity or crowding in the mixed dentition period from 6 to 11 years of age, extraction of primary teeth may be recommended to relieve crowding. In some cases where the crowding is expected to be severe in the teenage years, some permanent teeth may be recommended for extraction to prevent severe crowding from developing.

Extraction of Primary Teeth

Space maintenance

A range of treatment methods can be employed to intercept and treat malocclusion problems in the younger age group. If a child happens to lose his primary tooth prematurely before the permanent tooth is due to come out, space maintenance is recommended to preserve space in the dental arch for the eruption of future permanent teeth.

Space Maintenance

Modifying jaw growth

Occasionally, abnormalities in jaw growth influence the relationship between the upper and lower sets of teeth. In one instance, retarded growth in the lower jaw may result in the appearance of a small and deficient chin. The child may find his lower lip trapped behind the upper teeth, while the lower front teeth bites completely on the gums behind the upper front teeth. When growth problems are encountered, the child will be placed on a treatment programme involving the use of removable orthodontic plates. This may come in the form of a single plate attached to the upper teeth or a functional appliance engaging both upper and lower teeth. Sometimes, a headgear may be used to facilitate treatment. Essentially, the headgear comprises a neck strap or a head cap that is connected to the upper teeth through a face bow. Elastic traction applied to the teeth from the headgear helps to withhold growth in the upper jaw. Treatment with functional appliances and headgear are effective during the stage of active growth in a young child. The window of growth is usually two to three years, and takes place around the time of puberty.

Functional Appliance

Alignment of teeth with sectional fixed braces

A child may require fixed braces for a limited time period if there are irregularities to his permanent front teeth. Children with permanent incisors that are rotated, displaced or protruded may undergo 6 to 9 months of sectional fixed braces. A sectional fixed brace refers to a set of braces on the child's front teeth and molars only, instead of attaching braces on all the teeth. The benefits of such short-term treatment is significant as this helps to improve the child's self-image, and is also likely to reduce the risk of injury to the front teeth when his protruding front teeth are retracted.

Sectional Fixed Braces
Before Treatment	After Treatment

Alignment of teeth with full fixed braces

In the adolescent years, many teenagers undergo orthodontic treatment with full fixed appliances. This commonly used method of orthodontic treatment has gained wide recognition as an effective and efficient way of treating malocclusions. Treatment duration ranges from 12 to 36 months, again depending on the severity of the problem, and cooperation of the individual. If extraction of permanent teeth is needed to facilitate the correction of the malocclusion, the length of treatment will be longer than a treatment that does not require the extraction of permanent teeth. Accordingly, on average, non-extraction treatment regimens may last from 12 to 15 months, while extraction treatments from 18 to 36 months.

What are some orthodontic services available for late teenagers and adults?

Correction of jaw relationship problems

Generally, treatment recommendations for late teenagers and adults do not differ from those of early teenage years. The exception lies in individuals whose abnormal jaw growth has created a severe malocclusion where the correction of the problem is not possible with orthodontic treatment alone. You would have read in the preceding paragraphs that the potential for growth in children and early teenagers is utilised in functional appliance treatment to correct jaw relationships. In contrast, an individual's growth potential is significantly reduced in the late teenage years, and little or no growth takes place in adulthood. If abnormal jaw growth resulted in jaw deficiency or protrusion, surgery and orthodontics must be employed to move the jaws and teeth into a good position.

Take the example of a young lady who had excessive lower jaw growth that resulted in a long lower jaw. She was unable to eat properly with her front teeth, and was conscious of herself and what others thought about her. Surgery of the lower jaw with orthodontic treatment was recommended, and after 20 months, a new and positive self-image emerged.

Before Treatment Profile	Before Treatment X-Ray
End of Treatment Profile
Before Treatment Occlusion	End of Treatment Occlusion

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What does a combined orthodontic-surgical treatment involve?

If an individual's malocclusion is severe to the extent that surgery is required, the orthodontist will work together with an oral surgeon to draw up a comprehensive plan for the patient's orthodontic and surgical needs. Using the previous example, let me explain. Prior to surgery, a patient will have to undergo 12 to 15 months of fixed braces to correct any teeth irregularity. During this period, teeth are also moved into a proper relationship with the jawbone. At the end of the pre-surgical period, surgery, under general anaesthesia, is carried out to move one or both jawbones into a pre-planned position. A patient may be warded for three to four days, and is fit for light work after 14 days. Three weeks after surgery, orthodontic treatment continues for a further 3 to 5 months after which the braces are removed.

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Besides correcting jaw growth problems, how may orthodontic treatment help the adult?

The use of fixed braces remains the main method of treating malocclusions in late teenage and adulthood. Other than its use in the correction of crooked teeth and surgical problems, fixed braces are used to change teeth positions so as to facilitate subsequent denture or crown and bridgework. When a tooth in the dental arch is lost earlier in life, the neighbouring teeth tilt into the space. Restoring the space with bridgework or a denture requires that supporting teeth be parallel to each other. If a tooth has tilted, a limited form of orthodontic treatment with a spring mechanism is used to upright the tooth in question.

Spring Mechanism

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How many types of fixed braces are available in the market?

The key components of the fixed braces or appliance system are the attachments and arch wires. The attachments on the molar teeth are the bands and buccal tubes. Those attached to each tooth in front of the molar teeth are called brackets. When wires are attached to these brackets, teeth can be moved in a controlled manner in three dimensions of space. Until the late seventies, brackets were welded onto bands (metal collars) wrapped around each individual tooth. Orthodontic treatment was unsightly, and many who had treatment in the 70s were unkindly called "Jaws" after the rogue character in the James Bond movie "The spy who loved me". Presently, brackets are bonded onto the teeth surfaces with an adhesive. A newer generation of brackets, produced in the nineties, is smaller in size and less obtrusive.

Orthodontic brackets are commonly made from stainless steel. However, when they are bonded onto the teeth, they are highly visible. Many children and students do not mind the visibility. However, it is different with adults. Due to the high visibility of stainless steel brackets, many working adults become conscious of their teeth. To improve acceptance of fixed appliance treatment, bracket manufacturers use a glass-based material called ceramic. Brackets made from ceramic offer aesthetic advantages over the stainless steel brackets. Ceramic brackets are translucent. When these brackets are bonded onto the teeth, they blend with the teeth remarkably well, and from a distance, one would not be able to tell if an individual is having fixed braces. The only visible component with fixed ceramic braces is the metallic arch wire. If looking good and free of visible attachments are essential in one's job, a truly invisible set of fixed appliances is available. The Lingual Appliance system applies brackets onto the inner tongue-side of the upper and lower teeth, hence the term "lingual". With the brackets hidden away from the eye, wires applied to these brackets move teeth to their corrected positions.

Types of Fixed Braces
Stainless Steel	Ceramic
Lingual Appliance

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What are some common problems associated with orthodontic treatment?

Speech difficulties

Speech problems are encountered when a removable orthodontic appliance is worn initially. The coverage of the palate by the plastic component of the removable appliance interferes with the normal positioning of the tongue. This makes pronouncing words difficult, especially those with 's', 'f' and 'th' sound, for example 'Mississippi'. Regular and persistent wear of the removable appliance in the first week after placement allows the tongue to adapt quickly to its new environment. Normal speech patterns will return shortly.

Ulceration and pain

After the initial placement of the fixed appliances, ulceration of the lips and cheeks are common findings in the first and second week. Pain, arising from the ulcers and from the teeth, is a major concern raised by patients in the first two weeks. The use of the painkiller, Panadol, is usually sufficient in helping the patient cope with the discomfort. Another medication, Oracort, comes in a paste, and is effective in alleviating the pain from ulcers.

Difficulty in plaque control

As with any foreign substance attached to the teeth, the control of bacterial plaque becomes increasingly more difficult. Brackets act as a trap for food. Bacteria thrive and multiply easily in the areas around each bracket. Enamel-dissolving acids are produced from the bacteria "feeding" off the trapped food debris around the brackets. For the teeth and gums to be in excellent health, an individual with fixed braces must undertake to practise a regular and consistent oral hygiene routine such as daily brushing and flossing. Failure to maintain good oral hygiene will result in extensive tooth decay, chronic gum inflammation and bad breadth.

Fracture of ceramic brackets

Ceramic brackets are made from aluminum oxide or silica. Inherent in silica is its brittle nature and hardness. Hence, there is a higher likelihood of fracture than metal brackets, and when it does, the sharp edges may cut your lip. Furthermore, ceramic is a harder substance than the enamel of natural teeth. If ceramic brackets are placed on the lower front teeth, the upper natural teeth may be worn down due to continual contact with the ceramic brackets. In addition, studies have shown that teeth move slower when ceramic brackets are used due to a higher frictional resistance between the arch wire and the ceramic surface. Apart from the advantage of improved aesthetics, the liability of ceramic brackets outweighs the benefits.

Poor tolerance of lingual braces

While the Lingual Appliance appears to be the solution for those who demand invisible braces, it is unfortunate not all malocclusions can be treated with this method. Due to the proximity of lingual brackets to the tongue, some individuals may find it unbearable due to frequent ulceration and interference with speech.

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In conclusion...

The specialty of orthodontics has made great and important strides over the last two decades. Many patients have benefited from the advances made in orthodontic materials, and from clinical research on treatment methods. Treatment techniques have evolved, been tried and tested. Therefore, there is no better time than the present to seek help for your orthodontic needs. Your orthodontist will be able to make treatment recommendations based on your condition and expectations, and provide you with quality orthodontic care.

Beautiful Smile

Contributed by A/Prof Kelvin Foong Weng Chiong

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