Orthodontic Braces:
Perfect Smile Replaces Tin Grin

by Rebecca D. Williams

     When her four children, ages 9 to 16, all had braces at the
same time several years ago, Wanda Brown of Knoxville, Tenn.,
always knew what she'd be doing on her days off work.
     "I knew it was Tuesday because we were at the orthodontist,"
she says with a laugh.
     Today her children smile at the results of all those
appointments: The three oldest have straight, perfect teeth,
while the youngest has had some treatment but still awaits full
braces.
     "I really wanted braces," says daughter Diana, 17. "I'm glad
I had them because I feel a whole lot better about myself. I'm
always smiling now."
     Years ago, few teens had such 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 3 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 5 or 6, 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.
     FDA 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. 
     "It wasn't as high as I'd expected," Wanda Brown remembers.
"I guess I thought we'd have to sell the house to pay for it. The
cost was absolutely worth it--without question." 
     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. 
     Fifteen-year-old Michael Brown, for example, had to have 11
teeth extracted before getting braces. Most of them were baby
teeth that hadn't come out on their own. 
     "That was pretty painful," he remembers. "Compared to that,
the braces weren't bad."
     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. 
     "We've been through a few restaurant trash bins," Brown
remembers. 
     Did they find the missing retainer?
     "Oh yes!" she says. "I'm sure some people thought we were
crazy, but we always searched till we found it." 

Rebecca D. Williams is a writer in Oak Ridge, Tenn.

Braces: Not Just for Kids
     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.
     Orthodontists have made adult braces more palatable by
fashioning them out of plastic and ceramic, which are clear or
tooth-colored. Some appliances can fit on the inside of teeth,
completely out of sight. Called "lingual braces," these devices
may not be appropriate for everyone. They are not as strong as
traditional braces so they usually have to be worn longer. They
are also more difficult to adjust, and they can be uncomfortable
because the patient's tongue hits them.
     FDA has found new appliances to be substantially equivalent
to older stainless steel brackets. Many of them, however, are
more expensive.
     Nevertheless, 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. 

--R.D.W.