Contemporary Orthodontics & Dentofacial Orthopedics
Board Certified Treatment for Children, Teens and Adults
Why am I (or why is my child) still in braces?
Probably the most frequently asked question in any orthodontic practice is “how much longer?” If I dared to count how many times this is asked on a daily basis I would likely have to use two hands. There are certainly times where we may be a little further than the original estimated time however many times it is akin to the back-seat child or passenger asking “are we there yet?” and asking every 10 miles on a 500 mile trip.
To address this question however, we must first realize that initial estimates are just that, an estimated time based on similar cases and experience with other patients. Of course every patient is different and treatments between one patient and another may be dependent on growth, compliance (rubber band wear, oral hygiene, breakage and/or loss of appliances during treatment and making appointments as scheduled), bone quality, severity of crowding, nutrition, anatomy of the teeth and bone, impacted and/or missing teeth, and even oral musculature such as mouth-breathing or adverse tongue activity during swallowing. As an analogy, consider exactly how long it will take to build a large backyard playhouse or put together that set of cabinets that is always missing a part or gets a stripped screw. Now imagine a project that is expected to take anywhere from 18mo to 24mo and you can imagine how it is possible that the project may not finish exactly as first estimated.
Also, remember that good Orthodontists are perfectionists by nature; they are always trying to balance perfection with realistic expectations and time in treatment. Moving teeth around (on a moving platform) that all have multiple cusps fitting against multiple cusps is more complex than simply changing wires. Good Orthodontists are also using “potential growth” and “expected growth” in children when there is excessive overjet (a big overbite) or other discrepancies between upper and lower jaws/teeth. Kids mature at different times; they go through pre-puberty growth spurts differently and because we can’t completely predict when this will happen, many times we have to be in braces a little early to make sure we don’t miss the growth. When growth is slow, the correction can take longer. If growth does not materialize as expected, the treatment plan could change to compensate accordingly.
“Good Orthodontists are perfectionists by nature”
Beyond the physiologic and anatomic specifics we may be unable to control or completely predict, there are a few things that the patient and Orthodontist can control. To summarize some of the pitfalls that can delay Orthodontic treatment, I am listing some of the more predictable (and preventable) issues that will add time to Orthodontic treatment:
Breakage of Brackets
Breakage of brackets is a particular problem that can add significant time to treatment. When braces are first placed, there may be some teeth that hit brackets prematurely and can dislodge a bracket; as long as these are replaced in a timely matter, there should be no real loss of time. But consider that appointments are 4 to 8 weeks apart; if a bracket breaks free and the Orthodontist does not know for 1 to 2 months, once it is repaired the patient may lose up to 2 months of treatment. If this happens several times, you can start to see why a treatment extends 6 months past the estimate.
Missing Scheduled Appointments
Orthodontics can take two years or more in a moderately crowded case; appointments are set to allow enough time for a wire to work but not too long for the wire to lose strength. Also, even if the wire will be working for several months it is important to make sure nothing is broken while the wire works; if a bracket comes off without the patient knowing and the patient does not return for 3 months, then the tooth without the bracket can shift out of alignment to the point that the patient actually goes backward in treatment, adding not only the lost time but possibly another few months to an already extended treatment.
Not Wearing Rubber Bands/Elastics as Prescribed
Rubber bands, or elastics, are worn for several reasons but essentially they are used to use one set of teeth (or one arch) to move another set of teeth, usually in the opposing arch (i.e. using lower teeth to move the upper teeth and vice-versa). Because the lower jaw moves and grows separately, Orthodontists can use the elastics to “enhance” growth of the lower jaw but only during growth. These elastics are usually anchored on one end to the upper teeth (which are all tied together to provide maximum anchorage) and the other side attaches to the back teeth on the lower jaw to “pull” the lower jaw forward. In truth, we are simply placing forces in the mouth opposite of the natural muscle forces that pull backward and limit jaw growth. This forward pressure allows more growth than would otherwise occur but only if the elastics are worn full-time.
Elastics are also worn to de-program a backward shift in the bite after the front teeth are corrected and the jaw can now fit forward. If the front teeth lean backward, this will cause the lower jaw to bite backward which compresses the TMJ’s (jaw joints) and can lead to trauma and jaw pain with headaches over time (TMD). Even after the front teeth are uprighted in adults, it sometimes takes elastic wear to stop the lower jaw from pulling back; muscles have a memory and after years it takes some time to de-program this bite and relieve the joints. Without these elastics, it may take a year or longer for the lower jaw to return forward.
Remember whatever force is causing a resistance to growth (muscle forces, habits, etc.) is present throughout treatment; if we cannot overcome these forces with rubber bands, braces alone may not be able to fully correct the bite and we have to work longer to compensate for the jaws being out of alignment. If the lower jaw is even 2mm off, then every tooth in the lower jaw will be 2mm off (2mm is 25% the width of a normal tooth) making the final correction take much longer to finish.
Poor Oral Hygiene During Treatment
It is important to brush and floss when in braces! Plaque can build up around brackets and between the brackets and the gums causing demineralization (white spots) and even cavities over time. If the oral hygiene is poor, the guns become inflamed making it difficult to work with the braces and difficult sometimes to see the inclination of adjacent teeth. If an Orthodontist sees that oral hygiene is insufficient to continue care, he or she may remove the braces and delay completion (at additional cost) at a later date when the oral hygiene is improved.
Timing can still extend beyond the estimated time but with good compliance, good oral hygiene and good attention during treatment, it is likely that treatment will proceed as expected and the patient will have a beautiful and lasting smile to show for the effort and time.
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001. He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics. Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin. You can learn more about Dr. Waters at BracesAustin.com.
1814 W. 35th Street
Austin, TX 78703
4302 N. Quinlan Park
Austin, TX 78732