Orthodontics

Dental braces.

Braces are usually placed on the front side of the teeth, but may also be placed on the side facing the tongue (called lingual braces). Brackets made out of stainless steel or porcelain are bonded to the center of the teeth using an adhesive. Wires are placed in a slot in the brackets which allows for controlled movement in all three dimensions.

Apart from wires, forces can be applied using elastic bands, and springs may be used to push teeth apart or to close a gap. Several teeth may be tied together with ligatures and different kinds of hooks can be placed to allow for connecting an elastic band.[8]

Clear aligners are an alternative to braces, but insufficient evidence exists to determine their effectiveness.[9]

The time required for braces varies from person to person, depending on the severity of the problem; the amount of room available; the distance the teeth must travel; the health of the teeth, gums, and supporting bone; and how closely the patient follows instructions. On average, however, once the braces are put on, they usually remain in place for one to three years. After braces are removed, most patients will need to wear a retainer all the time for the first six months, then only during sleep for many years.[10]

Orthodontic headgear—sometimes referred to as an "extra-oral appliance"—is a treatment approach that requires the patient to have a device strapped onto his or her head to help correct malocclusion—typically used when the teeth do not align properly. Headgear is most often used along with braces or other orthodontic appliances. While braces correct the position of teeth, orthodontic headgear—which as the name suggests is worn on or is strapped onto the patient's head—is most often added to orthodontic treatment to help alter the alignment of the jaw, although there are some situations in which such an appliance can help move teeth, particularly molars.

Whatever the purpose, orthodontic headgear works by exerting tension on the braces via hooks, a facebow, coils, elastic bands, metal orthodontic bands, and other attachable appliances directly into the patient's mouth. It is most effective for children and teenagers because their jaws are still developing and can be easily manipulated. (If an adult is fitted with headgear, it is usually to help correct the position of teeth that have shifted after other teeth have been extracted.) Thus Headgear is typically used to treat a number of jaw alignment or bite problems such as overbite and underbite.[11]

Palatal expansion can be achieved using either fixed or removable appliances.[12]

Jaw surgery may be required to fix severe malocclusions. The bone is broken during surgery and is stabilised with titanium (or bioresorbable) plates and screws to allow for healing to take place.[13] After surgery, regular orthodontic treatment is used to move the teeth into their final position.[14]

To reduce pain during the orthodontic treatment, low level laser therapy (LLLT), vibratory devices, chewing adjuncts, brainwave musics or cognitive behavioral therapy can be used. However, the supporting evidence is of low quality and the results are inconclusive.[15]

After orthodontic treatment has completed, there is a tendency for teeth to return, or relapse, back to their pre-treatment positions. Over 50% of patients have some reversion to pre-treatment positions within 10 years following treatment.[16] To prevent relapse, the majority of patients will be offered a retainer once treatment has completed, and will benefit from wearing their retainers. Retainers can be either fixed or removable.

Removable retainers are made from a clear plastic, and they are custom-fitted for your mouth. It has a tight fit and holds all of your teeth in position. There are many types of brands for clear retainers including, Zendura Retainer, Essix Retainer and Vivera Retainer.[17] Hawley retainer is also a removable orthodontic appliance made from a combination of plastic and metal that is molded custom to fit your mouth. Removable retainers will be worn for different periods of time depending on patient need to stabilise the dentition.[18]

Fixed retainers are a simple wire fixed to the tongue-facing part of the incisors using dental adhesive and can be specifically useful to prevent rotation in incisors. Other types of fixed retainers can include labial or lingual braces, with brackets fixed to the teeth.[18]

• 
  Palatal expander
• 
  Orthodontic headgear
• 
  An X-ray taken for skull analysis
• 
  Top and bottom retainers

In Canada, obtaining a dental degree, such as a Doctor of Dental Surgery (DDS) or Doctor of Medical Dentistry (DMD), would be required before being accepted by a school for orthodontic training.[20] Currently, there are 10 schools in the country offering the orthodontic specialty.[20] Candidates should contact the individual school directly to obtain the most recent pre-requisites before entry.[20] The Canadian Dental Association expects orthodontists to complete at least two years of post-doctoral, specialty training in orthodontics in an accredited program, after graduating from their dental degree.

Similar to Canada, there are several colleges and universities in the United States that offer orthodontic programs. Every school has a different enrollment process, but every applicant is required to have graduated with a DDS or DMD from an accredited dental school.[21][22] Entrance into an accredited orthodontics program is extremely competitive, and begins by passing a national or state licensing exam.[23]

The program generally lasts for two to three years, and by the final year, graduates are to complete the written American Board of Orthodontics (ABO) exam.[23] This exam is also broken down into two components: a written exam and a clinical exam.[23] The written exam is a comprehensive exam that tests for the applicant's knowledge of basic sciences and clinical concepts.[23] The clinical exam, however, consists of a Board Case Oral Examination (BCOE), a Case Report Examination (CRE), and a Case Report Oral Examination (CROE).[23] Once certified, certification must then be renewed every ten years.[23] Orthodontic programs can award the Master of Science degree, Doctor of Science degree, or Doctor of Philosophy degree depending on the school and individual research requirements.[24]

Dhaka Dental College in Bangladesh is one of the many schools recognized by the Bangladesh Medical and Dental Council (BM&DC) that offer post-graduation orthodontic courses.[25][26] Before applying to any post-graduation training courses, an applicant must have completed the Bachelor of Dental Surgery (BDS) examination from any dental college.[25] After application, the applicant must take an admissions test held by the specific college.[25] When successful, selected candidates undergo training for six months.[27]

Throughout the United Kingdom, there are several Orthodontic Specialty Training Registrar posts available.[28] The program is full-time for three years, and upon completion, trainees graduate with a degree at the Masters or Doctorate level.[28] Training may take place within hospital departments that are linked to recognized dental schools.[28] Obtaining a Certificate of Completion of Specialty Training (CCST) allows an orthodontic specialist to be registered under the General Dental Council (GDC).[28] An orthodontic specialist can provide care within a primary care setting, but to work at a hospital as an orthodontic consultant, higher level training is further required as a post-CCST trainee.[28] To work within a university setting, as an academic consultant, completing research toward obtaining a PhD is also required.[28]

In Pakistan to be enrolled as a student or resident in postgraduation orthodontic course approved by Pakistan medical and dental council, the dentist must graduate with a Bachelor of Dental Surgery (BDS) or equivalent degree. Pakistan Medical & Dental Council (PMDC) has a recognized program in orthodontics as Master in Dental Surgery (MDS) orthodontics and FCPS orthodontics as 4 years post graduate degree programs, the latter of which is conducted by CPSP Pakistan.[29]

In Australia, to obtain an accredited three-year full-time university degree in orthodontics you will need to be a qualified dentist (complete an AHPRA registered general dental degree) with a minimum of two years clinical experience. There are several universities in Australia that offer orthodontic programs: University of Adelaide, University of Melbourne, University of Sydney, University of Queensland, University of Western Australia, University of Otago.[30] Orthodontic Courses are accredited by the Australian Dental Council and reviewed by the Australian Society of Orthodontists (ASO). Prospective applicants should obtain information from the relevant institution before applying for admission.[31] After completing a degree in orthodontics, specialists are required to be registered with the Australian Health Practitioners Regulation Agency (AHPRA) in order to practise.[32][33]