What is Orthodontics?

Orthodontics is the branch of dentistry that specializes in the diagnosis, prevention and treatment of dental mal-alignment and facial disharmony. The use of corrective appliances can move teeth into proper alignment, improve the "Bite" and re-establish good facial balance.

Who is an orthodontist?

An orthodontist goes through an additional 3-year full-time residency training programme focused on diagnosing and treating a patient's bite problems, crooked teeth, and aligning jaws when working together with an Oral & maxillofacial surgeon. They are regulated by the Singapore Dental Council, with an additional accreditation examination required for registration as an Orthodontic specialist.

Why should you consider orthodontic treatment?

Orthodontic treatment may be suitable for you if you have concerns about the aesthetics of your smile, if you have problems chewing and biting your food, or if you have much difficulty cleaning around teeth which are crooked. Some common reasons for seeking orthodontic treatment include "my teeth protrude out too much", "I don't like my long lower jaw", "I have problems biting on noodles as my front teeth don't meet when I bite". Orthodontic treatment seeks to correct these problems with your teeth and jaws, to address the concerns you have and to bring about an all-rounded improvement to your dental health, aesthetics and self-esteem.

When do you see an orthodontist?

The Association of Orthodontists (Singapore) encourages children to be screened by an Orthodontist around the age of 7-8 years old. This allows the orthodontist to pick up any problems as the permanent teeth erupt in the mouth and to intercept them before they escalate into serious problems in the growing child. Such interceptive treatment reduces treatment complexity of braces treatment in the future.

Some common issues that parents can look out for include underbites or crossbites (where the lower teeth bite in front of the upper teeth), extra or missing teeth, very crowded teeth and bad habits such as thumb/finger/pacifier sucking.

Examples of cases that may require interceptive treatment:

Am I too old for orthodontics?

Although orthodontic treatment is commonly associated with adolescence, it is most certainly not limited to that particular age group. However, treatment may sometimes be more complex in adults when compared to teenagers, as adults may have tooth loss, underlying severe gum disease and other health issues that come with age. An Orthodontist is able to diagnose and formulate an individualized treatment plan to address your concerns, and to treat your bite effectively.

Orthodontic treatment may also be an adjunct, in which the straightening of teeth facilitates the replacement of missing teeth with prosthetic teeth (in conjunction with prosthodontics), or in other cases straightening of teeth can also remove areas of crowding, allowing a patient to clean his or her teeth better to prevent gum disease (periodontal disease) and improve gum health.

Fixed Appliances (Braces)

Types of Braces

Braces are appliances used to bring about tooth movement in the mouth. They consist of two components: brackets and wires. Wires are made of metal and slotted into the brackets which are attached to the teeth.

Temporary Anchorage Device (TAD)

It is a small titanium screw which is temporarily inserted into the jaw bone. It is indicated for the purpose of enhancing orthodontic anchorage, especially where large movements of teeth are needed. TADs are also used for tooth movements that could not otherwise have been performed with traditional braces, at times reducing the need for jaw surgery.

It will be felt as a metal piece that protrudes through the gums. As it is a foreign material, it may occasionally cause irritation to the gums around it. Your dentist will instruct you on the care of the implant to reduce the possibility of this happening.

How long does it stay in my mouth?

As soon as orthodontic movement has been achieved, the TAD will be removed. Its removal is done by simply turning it out.

What if it loosens?

The TAD may become loose in the course of tooth movement. This may require reinsertion. How firm the implant sticks to the bone depends on the density of your bone as well. Patients with loose textured bone are more prone to implant loosening. However, this is not an insurmountable problem. Leave the management of this with your dentist!

The Braces Treatment Process

Your first orthodontic visit

During this visit, your orthodontist will address your dental problems and explain the need for braces to correct them. Diagnostic records like digital X-rays, clinical photographs, and moulds of your teeth will be obtained to formulate a customized treatment plan for each patient.

The length of your treatment depends on each person’s bite, age, response to treatment, and compliance with treatment instructions.

What Can I Expect When I Start Braces Treatment?

A set of three consecutive visits is required to start the actual process of orthodontic appliance therapy. These three appointments are spaced out weekly.

First Visit: Separator Placement

Separators are small rubber rings inserted between the molars to open up space to aid the fitting of orthodontic bands.

Second Visit: Banding

During this visit, the doctor will remove the separators and fit the molar bands (stainless steel rings) over your teeth. These molar bands serve as anchors for your braces.

Third Visit: Bonding

During this visit, the doctor will fully install your orthodontic appliance onto your teeth. An orthodontic wire will tie the braces together.

Expect some degree of discomfort from the appliance, as your mouth is experiencing, for the very first time, the pressure from actual tooth movement.

Care During Braces Treatment

Braces treatment is a team effort between you and your orthodontist to ensure a successful outcome. The following care for your fixed braces is highly expected:

• Avoid foods that will damage the orthodontic appliance
• Maintain a high level of oral hygiene
• Attend your adjustment visits every 4–6 weeks, or as instructed by your orthodontist, to ensure proper progress
• Strictly follow your doctor’s instructions on elastic wear to move your teeth in the correct direction

Risks of Braces Treatment

Orthodontic treatment has limitations and potential risks. In some instances, it may be worthwhile to consider the option of limited orthodontic treatment or no orthodontic treatment at all by accepting your present oral condition. You are encouraged to discuss your expectations and treatment alternatives with your orthodontist prior to commencing treatment.

Relapse

Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to maintain your teeth in their new positions following orthodontic treatment. You must wear the retainers as instructed or your teeth may shift.

Decalcification and Dental Caries

Excellent oral hygiene and regular visits to your general dentist are essential during orthodontic treatment. Poor oral hygiene could result in cavities, discoloured teeth, periodontal disease and/or decalcification. These problems may be aggravated with the frequent consumption of sweetened beverages or foods. Deep dental caries can also cause your tooth to die, requiring root canal treatment. The restoration of decayed teeth or root canal management can be costly, especially if it involves several teeth. Your orthodontist may advise you to discontinue treatment if you are unable to maintain good oral hygiene.

Periodontal Disease

Poor oral hygiene may also cause periodontal (gum) disease, which can result in gum loss and, in worse cases, shaky teeth and tooth loss. While periodontal therapy can improve the condition, a perfect result is seldom achievable in advanced cases with significant tissue loss.

Black triangles

Crowded teeth prevent gum tissue from forming between the teeth. When the teeth are aligned, a black triangle forms. The risk becomes higher if you have triangular-shaped teeth or if you already have gum recession present.

Root Resorption

The roots of your teeth may become shorter during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. If root resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or discontinuation of treatment. You may have to accept a less than perfect result in such instances. However, many patients have retained teeth with severely shortened roots throughout life.

Injury from Orthodontic Appliances

You must take care of your orthodontic appliance by avoiding hard and chewy food. Activities and habits which could damage, loosen and dislodge the orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled, swallowed or cause soft tissue injury to the surrounding areas. You should inform your orthodontist of any unusual symptoms, loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to an existing restoration (crown, veneers or fillings) is possible during the removal of orthodontic appliances.

Temporomandibular (Jaw) Joint Dysfunction

Some patients may experience problems with their jaw joints during orthodontic treatment. Most of these cases are coincidental in nature. Its presence could be related to past trauma (blows to the head or face), arthritis, hereditary predisposition, excessive teeth grinding or clenching, poor diet and many medical conditions. You should report any jaw symptoms (pain, difficulty in opening/closing and joint sounds) to your orthodontist promptly. Treatment by other dental or medical specialists may be necessary at additional cost.

Removable Appliances

Clear aligners

What are Clear Aligners?

Clear aligners are a form of clear, plastic removable braces which gradually move your teeth into their desired position. This is achieved through wearing a sequence of aligners, which incrementally move your teeth over time. Clear aligners are an alternative to fixed metal or ceramic braces to straighten your teeth and form one of the many tools an Orthodontist has to move your teeth.

These aligners are made after a thorough examination by your orthodontist, who individualizes the treatment to correct a patient’s bite and straighten their teeth.

The advantages & disadvantages of Clear Aligners

Clear aligners bring with them certain advantages. One major advantage is its superior aesthetics, being almost entirely invisible when worn, with the difference especially stark when compared to traditional metal braces. The aligners are also removable, facilitating the maintenance of oral hygiene and eating.

However, clear aligners have their own set of disadvantages. Although being removable, aligners only work when worn, and therefore require good compliance with wear. They are also prone to misplacement, since they can be easily removed. Dietary changes will be required as liquids can seep between the teeth and the aligners, predisposing the patient to stains or tooth decay if sugary and coloured drinks are frequently consumed. Clear aligners are not suitable for every patient, as some bites can only be fixed with conventional braces.

Can I be treated with clear aligners?

It is strongly advised to seek the professional opinion of an Orthodontist who is familiar with the various types of braces, who can advise you on the most suitable type of braces for your needs.

Functional appliances

Early treatment for growth modification is needed for children with deficient upper or lower jaws and is usually indicated when the child is still growing.

Functional appliances are used in orthodontics to correct bite and support proper teeth movements and aid in jaw corrections.

How often should I be wearing them?

Functional appliances need to be worn for at least 12 to 14 hours per day to achieve desired teeth movement and growth modification. Therefore, this form of treatment requires good patient compliance for favourable results.

Precautions?

Patients need to be taught to be careful while putting on and wearing such extra oral devices, as improper care may result in injury to the face. While wearing such devices, patients should avoid playing with young children together.

Upper removable appliance

Active upper removable appliances are indicated for the correction of certain aspects of malocclusion in the young patient at mixed dentition stage. Crossbites, as seen in the above picture (the lower incisors biting in front of the upper), for example, if left untreated, will worsen and cause damage to teeth and gums. Hence upper removable appliance (URA), as seen below, may be indicated for its correction.

Retainers

Congratulations on finishing your braces treatment! After your braces are removed, it is very important to wear your retainers to ensure that your new smile is well-maintained.

There are two main groups of retainers: 1) Fixed and 2) Removable.

Fixed retainers

A fixed retainer is a metal wire that is glued to the back surface of your upper/lower front teeth with bonding material, frequently from the canine tooth on one side to the other. This type of retainers is fixed on your teeth permanently to keep them from moving, and does not require removal by you.

Fixed retainers are often indicated by your Orthodontist if you had very severe crowding of the front teeth, or if the front teeth were leaned forward on purpose as part of treatment.

A common issue of fixed retainers is increased difficulty with brushing and flossing in the region, as well as dislodgement of the bonding material/metal wire. Regular six-monthly reviews with your Orthodontist/Dentist will be helpful to examine for issues with your fixed retainers.

Your Orthodontist might also suggest the need for both fixed and removable retainers for you.

Removable retainers

At KTPH, your first set of removable retainers are included in your braces package. Removable retainers are highly recommended to be worn full time (except during brushing and mealtimes) for the first six months to a year after your braces have been removed, as your teeth require time to stabilise and get used to their new positions. Your teeth will move if you do not comply with retainer wear.

Removable retainers come in a few types:

• Thermoplastic

• Protection against grinding however durability may be affected due to increased wear

• Acrylic base attached to wire
• Clear plastic strap replaces the metal wire at the region of the front teeth for clearbow
• Acrylic plate might interfere with speech initially. The presence of metal components allow for activation and slight tightening if required.

Ultimately, your Orthodontist will discuss with you the best option for your case – be it a combination of fixed and removable retainers, removable retainers only, and the type of removable retainers. Your orthodontist will recommend an option that suits your lifestyle while ensuring that it is best suited for maintaining the corrections achieved by your braces treatment.

What can I expect during braces treatment?

How do I brush?

Proper brushing will take extra time and effort. Your teeth are yours to keep forever. Read the following instructions carefully and follow them and you will have a bright shiny smile!

• Always use a small- or medium-sized soft-bristled toothbrush
• Brush with water and fluoride toothpaste
• Start from the back of the mouth on the outside of the upper teeth. Use small circular motion and concentrate on each tooth individually. Make sure the bristles of your toothbrush clean between your gums and teeth at the gum line, as well as over, under and around your brackets. Continue to work slowly around the other teeth, not missing out the inner surfaces of your teeth.
• Use an interdental brush to clean in between your brackets
• The amount of pressure you apply to your brush is also very important. Too heavy pressure will cause injury to your gums. Not enough pressure and you will see plaque stuck in and around your bands and brackets.
• Rinse your mouth thoroughly and inspect your teeth in a well-lit mirror. Pull your lips back and get a close enough look to see places you may have missed. Be sure to pay attention to your gums also. They should be a healthy pink colour.
• Brush a second time the areas you have missed without toothpaste and rinse again. Keep your teeth and braces clean, especially along the gum line, or they may become sore and swollen, which in turn will make brushing more difficult.

Wearing orthodontic appliances can cause dental decay if your tooth brushing is not thorough, as the brackets will trap plaque that causes tooth decay. Remember that you want straight teeth that are cavity-free. So make sure to brush, rinse and look to check that your teeth and braces are spotlessly clean.

Flossing with your braces on will take more effort, but it is worth it! It is recommended to use waxed floss to reduce the chances of the floss getting caught on the components of your braces.

You can use either:

• Regular floss with/without a floss threader
• Superfloss

When using regular floss, the recommended length is about 30 cm long. With your fingers, thread one end of the floss behind the main wire. Using the other hand, gently pull the end that has been threaded through in between your teeth towards the inside of your mouth. Floss as you would normally do without braces, with an up-down motion while wrapping against the side surface of the tooth.

You can also use a floss threader to help thread the floss behind the main wire. Do so until you are able to hold each end of the floss in both hands.

The superfloss has a stiffened end that is similar to that of the floss threader. This will help you to manoeuvre the floss behind the main wire more easily, without the use of a floss threader.

What foods should I avoid?

You will have to adjust your diet while you are on braces. Avoid hard foods or cut them into bite-sized pieces to reduce the likelihood of breakages.

Try to avoid the following groups of food:
Hard food — might result in components of your braces breaking
Sticky and chewy food — gets stuck in between your braces and teeth, increasing risk of decay
Any type of bony food — can cause breakage of wires/brackets if not careful
High sugar content food and carbonated drinks — causes decay and permanent change in the structure of your teeth not “protected” by your braces

Taking proper care of your braces will ensure that treatment progresses smoothly, and unscheduled appointments can be avoided.

You must take on an active role in caring for your braces and teeth. Aside from proper care during mealtimes, good brushing habits after meals and in the morning and night will help to keep your teeth in the best possible condition as we straighten them. Ensuring that plaque build-up is kept to a minimum will help to prevent decay.

How do I care for my URA?

Orthodontic removable appliances are indicated for the correction of certain aspects of malocclusion in the young patient at mixed dentition stage. Crossbites as seen in the above picture (the lower incisors biting in front of the upper) for example, if left untreated, will worsen and cause damage to teeth and gums. Hence upper removable appliance (URA) as seen below may be indicated for its correction.

Treatment Outcome

Your cooperation is important in keeping to appointments, following instructions, maintaining good oral hygiene and care of the appliance. As teeth move only when the appliance is worn, it is largely the responsibility of the wearer in ensuring treatment result will be good.

Treatment Duration

Adjustment to the appliance is required every 4 to 6 weeks. Treatment spans over 6 to 12 months with some variation depending on the severity of the condition and the level of cooperation given. If compliance on appliance wear is poor, your orthodontist may decide to terminate the treatment and re-evaluate you for possibility of other options of treatment.

Any discomfort?

You will experience some minor discomfort or soreness of the teeth for the next 3 to 5 days after each adjustment. Return to the clinic if the discomfort becomes unbearable. If you have to leave it out, put it on for at least 2 hours before being seen, as this will help leave clues to the cause or source of discomfort. You may need some getting used to speaking with the appliance in place. Salivation may be stimulated, requiring more frequent swallowing. It should return to normal after a few days.

Do I remove the appliance at all?

The appliance should be worn at all times. Remove only for that moment of cleaning it. Remove it when you are swimming. Do not bite the appliance in or click it in and out with your tongue. This will cause the wires in the appliance to break.

How do I keep the appliance clean?

The same way you’d brush your teeth with toothpaste. Brush across it gently, taking care not to damage the wires.

Can I eat normally?

Have your appliance in whilst eating unless specifically instructed otherwise by your orthodontist. Remove and rinse it clean after food. Avoid sticky or hard foods to prevent dislodgement and breakages.

How do I care for my retainers?

Your orthodontic retainers have been carefully designed to hold your teeth in their corrected position and maintain your new smile after braces treatment. Our teeth are never 100% stable, hence there is a risk that your teeth will move if you do not wear your retainers as instructed.

Wear your retainers all the time, until your orthodontist instructs otherwise.

Initially, you may find it difficult to speak. To hasten adaptation, you are encouraged to speak, read or sing out loud. Practice makes perfect!

Your retainers should be in your mouth all the time, except for when you are:

• Eating
• Brushing your teeth
• Swimming
• Playing contact sports

Take out your retainers while eating and always put your retainers in its case. Try to avoid wrapping them in tissue paper, as you might accidentally throw them away.

Always remove your retainers before brushing your teeth. Clean your retainers thoroughly with a toothbrush and toothpaste after every meal or minimally at night before you wear them to sleep.

Retainers are breakable, so treat them with proper care. Do not “click” them in and out with your tongue. This will weaken the wires and may cause them to break.

Call us immediately if you have lost, broken or distorted your retainers. Do not try to adjust them yourself.

You must bring your retainers every time you visit your orthodontist.

Always remember, retainer replacement is expensive. With proper care, your retainer will last longer.