Bracing for Braces? What You Should Know if Orthodontics Are in Your Family’s Future

Braces: They’re a rite of passage for most teenagers—including me, back in 1991. In fact, American orthodontists treat roughly 3.15 million kids each year. But things have changed since the 1990s, both in technology and style.

Shankar Venugopalan is the chair and program director of orthodontics at Tufts University School of Dental Medicine. He’s also a clinician who’s adjusted thousands of smiles. Meanwhile, I’m a mom with a teenager on the brink of needing braces, just like his mom once did 30-something years ago. Venugopalan explains what parents like me need to know about the new world of braces, retainers, and yes, even head gear, and answers questions from youngsters who are new to having braces.

At what age should a kid typically see an orthodontist?

Most often, I see patients who were referred from either a pediatric or general dentist for a particular problem around 9 years old, when most kids have a combination of baby teeth and adult teeth.

Between 8 and 9 is a critical age when kids should see an orthodontist or pediatric dentist to get evaluated for the proper development of adult teeth and the falling out of baby teeth. (Before that, kids should see their pediatric dentist or their family dentist to make sure their oral health is up to the mark.) 

Oftentimes, I’ll see kids when a tooth isn’t tracking properly or if there’s a developmental problem such as a posterior crossbite. That’s when the upper jaw is narrower than the lower jaw. For these problems, we can intervene with some type of an orthodontic treatment, which we call early treatment or phase one treatment, to correct developmental dental problems to ensure that all adult teeth erupt into the mouth. (“Eruption” is the dental term for a process in which the teeth cut through the gum and become visible in the mouth.) In most situations, I can predict if there’s going to be a significant amount of crowding and if teeth will need to come out based on radiographic and clinical findings. 

Can’t parents just wait and see at this age?

In some situations, you really have to do early treatment to correct certain dental problems. For example, all top front teeth should be ahead of bottom front teeth. If that’s reversed, we call it an “anterior crossbite” (underbite). When there’s an anterior crossbite—and if the top teeth are banging on the bottom teeth—it could result in a condition called “traumatic occlusion.” This means bottom front teeth are taking more than their optimal load. As a result, the bone around the teeth starts breaking down, and the gum starts receding. 

Another example is a “posterior crossbite,” where the upper jaw is narrower than the bottom jaw. The orthodontist could correct this problem with a palatal expander to make the jaw wider. There’s a critical time in which the expanders can produce what orthodontists call “skeletal expansion.” These are some examples of things that an orthodontist can focus on in early treatment.

When do braces enter the picture?

Typically around 12 or 13, when kids have a full set of adult teeth, is ideal to start orthodontic treatment. It’s a good idea, around age 9, to make an appointment with an orthodontist as a starting point. The orthodontist might take an X-ray and do a clinical exam and determine whether everything is tracking well in terms of eruption and wait for adult teeth to come in to start braces—or identify early developmental dental problems and intervene sooner.

In general, how long do kids wear braces? What’s the lifespan?

The early treatment, or phase one treatment, typically lasts six months to a year. The phase two treatment or full braces varies depending on the severity of the problem. If the problems aren’t as severe—let’s say, you’re not taking teeth out—treatment tends to be shorter, like a year-and-a-half. If it’s a complex situation where you’re taking teeth out, it can take up to 24 months. If there’s a need for jaw surgery, it could take up to 36 months or more. 

I remember getting the wires on my braces tightened as a kid, and it hurt. Have things improved over the years?

There is some level of discomfort in the first few days of putting the braces on or immediately after monthly adjustment visits. For the most part, patients gets adjusted to this rather quickly. However, if there is a severe problem and complex procedures involved, such as severely crowded teeth with tooth extractions or a tooth locked inside the bone requiring a surgical procedure, then there may be discomfort. Regardless, most patients get accustomed to it.

Today, we have increased understanding of the biology of tooth movement. Our average treatment time has gone from seeing a patient every four weeks to every six to eight weeks, and we have newer technology where we can 3D print and customize braces for a particular patient. Compared with 30 years ago, there are a lot more options to make the patient experience a lot more comfortable.

Let’s say we’ve signed up for braces. What does the treatment plan look like?

I’ll walk you through a typical sequence: The patient sees an orthodontist. The orthodontist examines and takes records. Typically, these records include photographs of the face, photographs of the teeth, and 3D scans of the teeth, and then two X-rays: one X-ray from the side of the face (lateral cephalometric radiograph) where the orthodontist can see the position of the jaws and the teeth, and another X-ray where the orthodontist can see all the teeth (panoramic radiograph). 

Next, we develop a customized treatment plan for the patient, and present it to the patient, or a parent or legal guardian. In this appointment, the orthodontist will go over the dental problems and potential treatment options, the sequence, and the timing. This provides an opportunity for patients to ask questions. 

Then, the patient will sign a consent form. At some point between a treatment plan consult and putting the braces on, the office will submit paperwork to insurance for pre-authorization. Most offices also provide payment plan options for the patient portion of the fee. When all this is taken care of, the next appointment is where braces are put on, which can range anywhere between 45 minutes to an hour-and-a-half. 

Once the braces are put on, I’ll see patients anywhere between every six to eight weeks to tighten and readjust. In a span of 24 months, you’ll see the orthodontist anywhere between 16 to 18 times for adjustments. 

I remember having the dreaded retainers, which I would always manage to put on my lunch tray and throw out in the cafeteria. Then there was head gear. Could you walk us through the other equipment involved when someone gets braces?

Absolutely. Retainers are essential to be worn as advised by the orthodontist. After orthodontic treatment, teeth are to be maintained in the final treatment position to allow for bone and the periodontal/gingival fibers surrounding the teeth to be remodeled to the new position. As the name indicates, “retainers” help to maintain the position of the teeth while all this happens. Another way to look at it is: retainers help to maintain your smile, and they achieve good results if worn properly. 

Another common appliance is a palate expander, which is used to widen the top jaw. Sometimes, when patients come in with either minimal crowding or a narrow palate, the orthodontist will start them with a palate expander and then put braces on. I use them in situations where someone has a narrow palate or to make space when there is a little bit of crowding. This lasts for two to three weeks; then, there’s a waiting period of anywhere between eight to 12 weeks.

Headgear is still in use today, although not as much as before. Headgear delivers what we call “orthopedic forces” to the bones. For example, say the position of the upper jaw is in an ideal location or within the range of normal, but the lower jaw is rather small. In that scenario, the orthodontist may give headgear to hold the upper jaw in place to allow the natural growth of the lower jaw to catch up. Headgear mainly delivers orthopedic forces to attempt to modify growth. 

There are also times when the upper jaw is way behind the lower jaw. We call this an underbite. We use “reverse pull headgear” or a “facemask” to bring the upper jaw forward to a normal position, typically worn at night time. Headgear does have a role to play, and if it’s worn properly, it could make a difference. However, the challenge is compliance. 

Bone screws are reserved for complex orthodontic tooth movements. The analogy that I give to patients is: It’s like a push pin that you put on a wall. It can be put in any region where you have adequate bone available. It serves as an anchor to move or facilitate certain challenging types of orthodontic tooth movements.

That sounds painful. Is it?

When an orthodontist puts in bone screws, they numb the gums. You might feel a little bit of a pressure, but there’s not going to be any pain. We ensure that the patient is as comfortable as possible when these procedures are performed.

What other questions do patients and parents ask?

People ask: Do I have to treat now, or can I delay the treatment? I say: Let’s think about this on a continuum: one to ten. One means the benefit from orthodontic problem is low and 10 means the benefit is very high. An example of a one would be: All teeth are reasonably well aligned, there are no functional issues, and there are one or two teeth slightly out of alignment; in this case, the benefit of braces is mostly cosmetic. So I’ll say, “Hey, you fall around 1 or 2, and if you want to delay braces, that’s totally OK, or you’re going to be fine without it.”

Some patients are on the other side of the continuum. For example, their top teeth are banging on their bottom teeth. This could have a significant impact on the health of the dentition. Another example is if an erupting adult tooth is going in the wrong direction and damaging the roots of neighboring teeth. You want to treat it when you see it and be proactive about it. One question to ask an orthodontist might be: “In that continuum, where does my kid fall?” Finance is a big deal for most of us, so it’s worth asking whether you can wait, or if you need to treat immediately.

The other follow-up question is: “How long can I wait?” I go back to that continuum: If they are somewhere around 2 or 3, if they want to wait few years, it doesn’t matter. But if they’re around 5 or 6, I won’t delay more than a year or two. If they’re somewhere around 8 or 9, I’d want to treat ASAP.

I have adult friends who use clear aligners like Invisalign. Is that an option for teenagers?

 It’s an option for teenagers. The main thing is compliance. Think about it this way: In traditional braces, you wear them all the time and go to an orthodontist to get them tightened. With clear aligners, if you don’t wear the aligners, it’s not going to work. You need to wear it at least 20-plus hours a day to remodel the bone and move a tooth. 

Let’s say you wear it three hours in the morning and two hours in the evening, and then you forget one day. The force levels aren’t continuous. You’re not going to see any change. In the patient’s mind, they may think they’ve been wearing aligners for two years, but they won’t see a change because the frequency and consistency is suboptimal. That’s the limitation that parents have to keep in mind.

They also tend to be on the pricier side because as there’s an associated lab fee, and the practitioner charges that out to patients. You’re going to spend a bit more money than for traditional braces. 

Nightmare scenarios: Do you ever get into a situation where the braces come off, teeth move again, and you need a do-over?

As I mentioned before, wearing retainers is essential to maintain good results. If the retainers are not worn as advised, teeth tend to shift. The most comfortable position for the teeth is where Mother Nature has placed them. With orthodontic treatment, teeth are moved out of their comfort zone. Think about this: Somebody fractures their arm. The doctor stabilizes the two broken fragments with a cast or rigid fixature. The bone is going to heal by forming a new bone, and that initial new bone is going to be soft. Over time, it gets fully mineralized and matures to be stronger. 

If that new bone hasn’t fully matured, and you start activities that you shouldn’t, like boxing or weightlifting, then the fragment is going to be misaligned. In a similar fashion, when you’re moving teeth in the mouth, the bone around each tooth is being remodeled, and the new bone is being formed. There are also soft tissue fibers that run underneath the gums and between the bone and the tooth. This remodeling is going to take some time. This is where retainers come into play. If you don’t wear the retainer, they’ll tend to relapse a significant amount. The only way to fix it is by redoing treatment.

It’s very important to wear retainers as advised. You buy a phone; you have to take care of it. You buy a car; every six months, you have to go change the oil. You get a smile; you have to take care of it, too.