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How are braces attached?
The process of attaching braces to the teeth has changed significantly in the last 30 years. This is mainly due to the introduction of materials and methods that allow effective bonding of the braces directly to the enamel. As recently as 20 years ago, it was common for orthodontists to place bands, or rings, around each and every tooth. This provided an effective means of attachment, but tended to show quite a bit of metal.
In 1955, Dr. Buonocore published an article detailing his observation that conditioning the enamel before bonding increased the effectiveness of the attachment. It was found that the pretreatment caused microscopic changes in the enamel, allowing the bond materials to flow into the enamel, giving a micromechanical attachment. This concept was mostly used for dental fillings, but was later applied to orthodontics.
The back sides of the braces have a mesh design. When glue is placed onto the bracket and against the tooth, the combination of the conditioned enamel and the mesh base of the bracket provide a very good attachment.
The placement of the braces and the bonding procedure as used today generally follows these steps:
The teeth are polished with a non-flavored paste (this is similar to a dental polish after a cleaning).
A cheek retractor is placed to provide a dry field and make it easier to visualize the teeth.
The teeth are lightly air-dried, and the conditioner is placed onto the front surfaces of the teeth for about 30 seconds.
The conditioner is rinsed and the teeth are again dried using suction and air. A primer is painted onto the teeth.
The bonding cement is placed onto the back sides of the braces, which are then placed onto the teeth.
The brackets are placed in a very precise position onto the teeth, and excess bonding cement is removed.
If the bonding cement is light sensitive, a bright blue light is used to “cure” the glue. Some bonding agents do not require a light since they have a chemical cure.
The cheek retractor is removed and the wires are placed
The entire bonding procedure can take anywhere between 10-20 minutes. The length is primarily due to the time required to properly position the braces, and time required for the curing light. Recent advances in the curing lights have allowed use of LED lights, which narrow the wavelength of the light. This reduces the time needed to cure the glue. Older Halogen lights require about 15-20 seconds for each bracket, whereas an LED light would require only half of the time. Plasma lights require even less time (about 3 seconds per bracket).
Bonding braces is quite painless, although the length of time required for the procedure is perhaps a bit annoying. The cheek retractors, which are so essential to a successful bonding procedure, can stretch the cheeks and lips and make the whole mouth feel very dry when the bonding is completed. The lips and cheeks recover very quickly, however, and the dryness can be remedied with a rinse (which also helps to remove the bad taste).
A dry field is very important since the materials used for bonding require a clean enamel surface. Many of the primers and some types of glue are water tolerant (hydrophilic), but do not perform very well with saliva contamination. Proteins in saliva have a tendency to bind very quickly to the enamel surface and forms a layer know as a pellicle. The pellicle interferes with proper bonding. Consequently, the enamel surface needs to remain protected from the tongue, cheeks, and lips during the entire bonding procedure.
Many orthodontists will still place bands (rings) on the back molars. The bands were the treatment of choice for all teeth as recently as 30+ years ago. Despite the advances in the bonding materials and effectiveness, many find there are still advantages to using bands on the molar teeth.
An advantage of using molar bands includes an increased stability of attachment on a large tooth in a very highly active part of the mouth. They also provide additional attachments on the tongue side of the band, as well as attachment tubes for headgear and other appliances. The process of placing bands on the molars involves the following:
Separators are placed 1 week prior to the appointment of band placement.
The separators are removed, revealing space between the back molar teeth.
Bands, which come in a variety of sizes, are selected to fit each individual tooth.
A bite stick is used to help properly place and position the band on the tooth. By having the patient bite together with the stick, less strain is placed on the jaw while positioning the band. The orthodontist will first position the stick, and then let the patient know when and how hard to bite.
Once the bands are selected and fit to the molars, they are removed and dried.
The inner portion of the band is lined with band cement, and then it is positioned on the tooth
If the cement is light sensitive, a light will be used to cure it.
Braces Adjustment Appointment
Once the braces have been placed, wires are attached into the braces with very small rubber bands (elastic ties). These are most commonly seen as the colors on the braces, although clear elastic ties can also be used if the desire is to have the braces be less noticeable.
The wires used today are very flexible and return to their original shape, thereby applying a continuous and gentle force on the teeth. The pressure applied to the teeth through the braces will reduce over time as the elastic ties holding the wire into the brackets weaken and stretch. Regular “adjustment” appointments are therefore needed to replace the weakened elastic ties and re-establish the forces necessary to move the teeth.
The appointments also give the orthodontist an opportunity to evaluate the tooth movement and make the necessary recommendations in treatment. Usually the original treatment plan predicts the process throughout the whole treatment time. Since the teeth are constantly moving during treatment, every adjustment presents a new set of circumstances for the orthodontist to evaluate. The patient is essentially re-diagnosed at each appointment throughout the treatment plan, following the original plan as a guide.
Since the changes in tooth movement require a minimum of 3 weeks to take effect (the biological requirement for tooth movement), most adjustment appointments are made in the 3-8 week range. Longer times between appointments may be recommended in some patients since many of the wires used today have a very long working range, and more frequent visits may not be necessary. A normal adjustment appointment may include the following:
- Remove the colored ties that hold the wire into the braces
- Remove the wires
- Allow the patient to brush and floss (
- The orthodontist will check the patient and recommend treatment (i.e. new wires, rubber bands, etc)
- Replace the new colors onto the braces
It is not unusual for a patient to feel tightness during and immediately after the adjustment appointment. The tightness tends to progress into soreness about 4-6 hours after the adjustment. The tightness and soreness is usually a result of wire changes or adjustments in the wires that eventually result in additional tooth movement. The recommendations for managing the pain are the same as when braces are first placed (i.e. over the counter pain medication). The pain will usually decrease over the next 3-5 days.
Rubber Bands for Braces
Rubber bands, or elastics, are generally used to help improve how teeth fit together. They are also often used to help close spaces, or make sure spaces are closing in the right direction, and improve cross-bites and midlines.
They are simply small rubber bands that are attached to the braces. They are attached by the patient to little hooks that are a part of the braces. Since they need to be placed by the patient, cooperation with instructions for wear is critical to make progress and achieve a good outcome.
There are many different types and sizes of elastics. They are generally classified by the problem that is to be corrected. For example, Class II elastics are worn in such a way to help correct a Class II malocclusion. Illustrations of the different ways elastics can be worn are shown below.
Class II Elastics (to correct an overbite)
Class III Elastics (to correct an underbite)
Vertical Elastics (to keep teeth together)
Front Cross Elastics (to correct a midline)
In addition to the shape and direction, there are also differences in the sizes of the elastics. The size differences are necessary since adequate force levels are needed for various positions on the teeth. For example, if a patient is wearing a long Class II elastic, a very small, tight elastic may not allow the patient to open their mouth very well. It may also place too much force on the teeth. Therefore, the orthodontist will advise each patient to wear properly sized elastics. This may vary depending on the configuration and circumstances.
Elastic wear instructions are generally either recommended as full-time or night-time wear. Full-time wear is usually prescribed in those situations when tooth and bite movement is desired. Whereas night-time wear is effective for holding a correction. The difference between full-time and night-time wear is significant, since the teeth and bite will only move if pressure is constant. Therefore, if instructions are not followed, and a patient wears the elastics less than required, the teeth and bite will not move properly. This can slow down the treatment progress and may result in a compromised final result.
Some patients try to compensate for poor rubber band wear by wearing double elastics. This tends to be ineffective for movement, since the length of time a force is present is more important than the amount of force. Double elastics also tend to increase soreness. The best advice for effective movement is to follow the instructions of the orthodontist.
Be aware that some patients may have a latex allergy. Since rubber bands are usually made from latex, ask the orthodontist for an alternate rubber band material. There are rubber bands manufactured from vinyl rather than latex, which will still provide effective movement without a potential reaction.
Besides the larger rubber bands just described to help move the bite, smaller elastics are also used for braces. These tiny rubber bands are used to hold the wire into the brackets (as shown below) and are what most people talk about when they choose colors for their braces. These rubber ties get changed every visit since they will stretch and weaken over time. This also allows for changing up different color combinations throughout the braces treatment. Special instruments are used to place and remove each tie at the orthodontic adjustment appointments. There are also ties that are all linked together. These “chains” are used to help hold the wire in, but they also pull between the teeth to close spaces