Years ago, few teens had a positive attitude about braces. Orthodontic appliances triggered taunts like "metal mouth" and "tin grin." But today, braces are almost a status symbol among middle-class American teenagers. About three million teenagers in the United States and Canada have braces, an increase of about 30 percent in the last 10 years, according to the American Association of Orthodontists. Teeth aren't any more crooked than in the past. It's just that more teenagers want the perfect smiles that braces can give them, and more parents are willing to foot the bills. Today there are more orthodontic devices than ever before, allowing more choices in how braces look and how long the patient must wear them.

"In general, people get braces for aesthetic reasons," says D. Gregory Singleton, D.D.S., a senior dental officer with FDA's Center for Devices and Radiological Health and an orthodontist in private practice. "But that doesn't mean they won't get a functional benefit in the process," he adds. A better bite and fewer jaw problems are often the byproducts of what begins as a cosmetic procedure.

The crooked smile

Anyone who's spent time in an orthodontist's chair has seen pictures and plaster molds of the "ideal" mouth. The top front teeth extend over the lower front teeth slightly, while the molars line up and meet on both sides of the mouth, top and bottom. The teeth are straight and not crowded, spaced close together like a string of pearls. But in most mouths, variations on this theme are more common. Some problems affect chewing or speaking, but most are simply cosmetic issues. Improper tooth alignment is called malocclusion. Malocclusion is not a disease, but crooked teeth can decay faster than straight ones because people have more trouble keeping them clean. Severe misalignments may require extra flossing and brushing. But malocclusion doesn't always cause jaw problems or pain, and many people have lived long and healthy lives with misaligned teeth. Nevertheless, malocclusions can be embarrassing.

There are three types of malocclusions, plus a number of other bite problems. The malocclusion types are:

Class I: Teeth line up correctly top to bottom, but they are spaced too far apart or are crooked, crowded or turned.

Class II: Upper teeth protrude and the lower teeth are too far back. This is also called an "overbite."

Class III: Lower teeth are too far in front and the upper teeth are too far back. This is also called an "underbite." This is the most difficult problem to correct, says Singleton, and may require surgery.

Other orthodontic problems include:

Open bite: Front teeth stay open even when biting down with back teeth. This can make chewing food difficult or impossible.

Closed bite: When biting down, upper teeth cover the lower teeth completely. This is also called a "deep bite."

Cross bite: When biting down, some upper teeth close inside or outside lower teeth.

Causes

Bite problems stem from a number of causes. Most are inherited, but others are behavioral. Habits such as a reverse swallow, tongue thrust, or sucking the thumb, fingers or the lower lip can apply pressure to teeth. Over time, teeth spread. If these habits aren't corrected before treatment, the teeth may spread even after the braces are removed. Babies who suck their thumbs or pacifiers aren't generally at risk, says Singleton. As long as they break those habits by age five or six, they usually don't cause malocclusion in their permanent teeth. Baby teeth can greatly affect the look and health of permanent teeth. If a baby tooth falls out too early or decays, the other teeth may move to fill in the space, blocking permanent teeth from coming in when they are ready. Similarly, if a baby tooth does not fall out soon enough, the bigger tooth behind it may come in crooked. And if a permanent tooth is lost to decay or trauma and is not replaced, the other teeth will drift to fill up the space, sending them out of alignment. The size of teeth can affect their alignment as well. Teeth that are too small can drift, and teeth that are too large will crowd. Mouth size can also cause drifting or crowding.

Bands and brackets

Braces and other orthodontic appliances can solve most bite problems. Braces apply gentle pressure to teeth, moving them slowly over a period of 12 to 36 months. As teeth move, the jaw bones around them grow to fill in spaces left by the tooth roots. The main advancement for braces in the last 15 years has been the elimination of metal bands around front teeth. Today, small brackets are bonded onto the front teeth instead, greatly reducing the "metal mouth" look. The brackets are tiny devices that attach each tooth to an archwire. The wire acts as a track to guide teeth along. Metal bands are now used only around the back teeth, which are stronger and more difficult to move.

Today's brackets can also be made of more aesthetically pleasing materials. Clear or tooth-colored materials can be used to create almost invisible braces, although they tend to be more expensive and difficult to work with. Some braces can even be hidden on the insides of teeth, although these are much more difficult for the orthodontist to place and adjust. They can also irritate the patient's tongue, which may hit them repeatedly. Most teens and children get stainless steel brackets because they're durable and less expensive than other kinds. Another development has been "space age" wires. These wires, made of nickel titanium alloys developed through the NASA space program, hold their shape better than stainless steel wires. As a result, they require fewer replacements and trips to the orthodontist, often shortening treatment time. Other appliances include elastics, small rubber bands that apply extra pressure between the jaws.

Headgear, which fits around the head or neck, helps move jaws into a new position, and functional appliances, worn sort of like a football player's mouth guard, help align jaws and chewing muscles. Retainers help keep teeth straight after treatment. Special-purpose appliances can correct specific problems, such as the roof of the mouth being too small. Most patients wear a combination of two or more appliances over the course of treatment. Some patients can even make a fashion statement with their braces, getting multi-colored ligatures--the small wires or elastics that hold the arch wires to the brackets. Elastics and retainers also come in an array of colors. It's even possible to put a logo or mascot on a retainer.

The latest development, although not widely used, is magnets attached along the archwire to the upper or lower molars. Encased in stainless steel and placed with opposing or attracting forces, the magnets can help create or close spaces between teeth. In some cases, they can replace headgear, one of the most conspicuous orthodontic appliances. The Food and Drug Administration reviews all new materials and orthodontic devices before they go on the market. Manufacturers must file a pre-market notification, showing through laboratory or clinical tests that their device is substantially equivalent to others already in use. Most older orthodontic devices were already on the market in 1976, the year device regulations went into effect. Unless FDA receives evidence to the contrary, those devices are assumed to be safe and effective

Keeping braces clean

Perhaps the biggest challenge of living with braces is keeping them clean. The nooks and crannies formed by braces create ideal hiding spots for bacteria that lead to cavities and gum problems. Patients who don't take care of their teeth risk even more dental decay than they would have without the braces. "This is a problem especially for patients around 11 and 12 years old," says Singleton. Flossing and brushing for them is often not a priority, he explains. Orthodontic patients should brush thoroughly after every meal and before bed. Flossing is more of a challenge because the wires make maneuvering difficult. A floss threader, available from an orthodontist or pharmacy, helps the floss slip behind the archwire and get to the gums.

Certain foods can damage braces. Sticky food, hard food, crunchy food, and sweets are the four troublemakers for those who wear braces. Sticky foods like gum, taffy and caramels can loosen cement and damage the brackets. Hard food like apples and carrots must be cut into bite-sized pieces so they won't break appliances. Crunchy foods like corn chips, popcorn and nuts should be avoided for the same reason. And sweets, because they feed bacteria when caught between braces, should be avoided as much as possible. Teeth should be brushed soon after eating sweets to prevent decay. In fact, many orthodontists say that much of the success of braces depends on the willingness of the patient to stay away from harmful foods, keep teeth clean, and wear appliances faithfully.

What cost beauty?

The cost of braces varies with the patient, but typically treatment runs from $1,800 to $4,500. Some insurance plans cover a portion of the cost. Aside from cost, braces can be physically uncomfortable. A day or two of soreness is not unusual after every visit to the orthodontist because of adjustments to the archwire. Also, some patients must have teeth extracted to make room for others. In addition to pain and expense, orthodontic patients must keep track of extra equipment daily. Elastics, retainers, headgear--school lockers are full of orthodontic devices. More than a few teens make the mistake of wrapping their retainers in paper napkins while they eat and then accidentally tossing them out.

Just because braces weren't fashionable or affordable when you were a kid doesn't mean you have to go through life with a major malocclusion. In 1979, 17 percent of orthodontic patients were adults. By 1992, that number had risen to 23 percent. Of those, 70 percent are women. Braces are increasingly popular among adults. They have even gotten good press from famous patients: Cher, Diana Ross, and Phyllis Diller have all sported "tin grins" and beautiful smiles later.

Source: 

Williams RD. Orthodontic braces: perfect smile replaces tin grin. US Food and Drug Administration website. Available at: http://www.fda.gov/bbs/topics/CONSUMER/CON00297a.html. Accessed November 3, 2005.

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