Brace yourself to smile

    20 October 2016

    There they are, all over the press and social media: people with beautiful, straight, white teeth, oozing confidence with their lovely smiles. Most of my patients ask if this can be realistically achieved and the answer is often that their own smiles can be made much more attractive without damaging their teeth and still retaining a natural appearance. This is where adult orthodontic-appliances (braces) come in. Just like the ones that teenagers often wear, they straighten the teeth and avoid alternative treatments that may be too aggressive.

    Of course many adults have a negative image of-braces, but they are usually surprised by how-discreet a modern set can be. The hideous metal-monstrosities of their teenage years are long gone, superseded by a generation of high-tech, aesthetically improved and often custom-made appliances that can help them achieve superb results (see Figure 1 below)

    Initial consultation

    What you need is an orthodontic specialist, which means a dentist who has completed further training, usually a Master of Science degree (MSc) plus a Royal College of Surgeons Membership in Orthodontics (MOrth). This is an eight-year training pathway which leads candidates into careers as fully trained and well-informed clinicians. A specialist will check that you are in good dental health with no cavities or active gum disease, and will often recommend that you first see your regular dentist for a check-up, a hygienist appointment and any urgent work.

    With that out of the way, there are decisions to be made about what kind of braces you need, and this depends on what you would like the result to be. It pays to have an ideal end-point in mind and your specialist will be able to tell you whether it is achievable; inevitably there may have to be a little compromise because the shape and arrangement of teeth is unique to the individual. Listen to all the options open to you.

    Treatment options

    Braces on the front of the teeth These are, of course,-visible, but they are less unsightly that you might expect. Most of my patients say that people notice their upper brace but rarely a lower one. They may ask about the-braces, but more out of curiosity than because they are shocked by anything unsightly. You can eat, talk and use an-electric toothbrush in the usual way. All that is-needed is a little extra care. Advances in the manufacturing methods of fixed braces have resulted in smaller, more-compact attachments and better adhesives. For the patient this means that the brace is less obvious, and that it does not rub the inside of the mouth so much.

    The attachment options are normally either clear (ceramic, see Figure 2) or metal (stainless steel, see-Figure 3). Thanks to technical advances it is now possible to selectively and carefully control how each tooth moves and ensure a very precise result. Names to look out for are Gemini, Victory, Clarity Advanced (all made by 3M), plus Damon Braces. These are all fantastic American appliances that can help achieve a broad, wide smile. Fees for simple or single-arch treatments start from £3,500.

    Aligner braces These are relatively invisible and are a good compromise in terms of aesthetics, comfort and minimal disruption to your daily routine. The market is flooded with many brands and dental laboratories each offering their own aligner braces. My own clinical preference is to use Invisalign, a proven system manufactured in the USA (see Figure 4). Simple records such as impressions of the teeth, X-rays and photographs are taken and I also arrange for a Clincheck (a 3D animation of the treatment) to show the patient before they commit to it. Once approved and custom-made, these braces are worn for approximately 20 hours per day, so good patient willpower is a pre-requisite. Fees start from £3,500 for single-arch treatment.

    Lingual braces These are hidden on the back of the teeth: nothing can be seen from the front. Brands such as Win and Incognito (see Figure 5) are fully custom-made in Germany using highly accurate technology to match the shape of the inside surfaces of your teeth. The downside is that they can be slightly more uncomfortable in the way they rub on the tongue, they cost a little more and they take more time to move the teeth because of where the force is applied. However, they really are the ultimate in discretion. On average, fees start from £7,500.

    General issues and contraindications

    Most people wonder if they are not too old for their teeth to move about and ask how it actually works. Well, orthodontic forces move the teeth within the jaw bones, and because bone is a living entity that can remodel under pressure, the simple answer is that age makes-little difference. Think about the way fractures mend — bone heals in the same way when we are older but it may take a little longer. With adult braces, to achieve the desired result can take between six and 24 months. To keep the timeframe shorter sometimes we compromise: for example, accepting the bite as it is and aligning only the front teeth according to the patient’s needs. My average treatment plans are 12 to 18 months — I find patient motivation often reduces with anything longer.

    Although teeth are incredibly strong, treatment can put them at risk. Too much sugar in the diet, especially from drinks, can cause permanent white/brown decay marks when the braces are removed. Careful brushing and regular hygienist checks are recommended. Hard foods eaten carelessly can break fixed-braces, so patients need to eat more slowly and avoid really tough items.

    Gums need to be in a healthy condition before treatment and without careful cleaning they can become inflamed. Treatment for some patients with gum-recession needs careful planning to make sure it does not get worse. Seeing a gum specialist before the plan begins is a wise step in many cases.

    There is some discomfort and a little rubbing after braces have been-fitted and each time they are-adjusted, but this is often far less than patients expect. The ends of the tooth roots can become a little shorter after treatment (root resorption) but this is a rarely a significant issue if carefully checked. Heavily filled teeth can require further treatment as they are moved but this should be highlighted to the patient at the start.

    Alternatives to braces

    Braces are not always the right answer to improve the appearance of teeth, especially if they are already reasonably straight with an even bite. Some people simply want a quicker option. I often work with colleagues to look into alternative treatments tailored to individual needs. These can include:

    Tooth whitening When carried out by a trained professional this is very different from the heavily advertised whitening products you can buy over the counter. The basic options are to use a whitening gel which is either put into customised trays and worn at home, or applied in the surgery using a light to activate the gel. This way the concentration is stronger but the application is controlled and safe. When factors such as the health of individual teeth and selective whitening are taken into account the end result is better.

    Composite bonding Adding a dental resin to hide small chips and misshapen areas results in major aesthetic improvement without cutting into the teeth.

    Veneers and crowns Veneers are porcelain facings and crowns are full covers over the tooth. Preparation of the tooth underneath is needed, and patients need to understand why the treatment is being done, how long the results will last and to be aware of any alternatives.

    A word of warning

    A variety of quick-fix treatments are now available. One is the ‘smile make-over’, which involves cutting the teeth to align them. Be wary of any plan that involves tooth tissue being significantly cut down solely for aesthetic reasons. Another quick fix is ‘short-term’ orthodontic treatment. There may be scientific evidence to support certain shorter techniques but from my clinical viewpoint the latter stages of comprehensive orthodontics really matter. They ensure that teeth are locked into good parallel positions with an even bite, and give the bone time to remodel around the new tooth positions.

    One point to bear in mind is the need for retainers. Teeth naturally want to be in their original places and once this has been changed something needs to hold them in the new positions. This can be achieved quite simply with a combination of fine fixed retainer wires stuck to the back of the teeth and a night-time removable retainer. But they do need to be worn long-term.

    Final advice

    Ask if the treatment you are being offered is really needed, make sure it is what you want, and consider the alternatives, which may include doing nothing. Sometimes I actively discourage patients from pursuing treatment — health is not a suitable area for the hard sell.

    I am often asked if it is worth it or ‘What would you do?’ My answer is that our teeth are one of our most personal assets and it is important to have them the way we would like. There is no one prescription for all — it really is a personal decision. Orthodontics may take longer that other treatments but a little patience can lead to a major beneficial change that will last for years.