Contemporary Orthodontics & Dentofacial Orthopedics
James
R. Waters,
DDS, MSD , PA
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.
Central Austin
1814 W. 35th
Street
Austin, TX 78703
(512) 451-6457
Steiner Ranch
4302 N. Quinlan Park
Austin, TX 78732
(512) 266-8585
BracesAustin.com
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